Recognizing and Responding to Patient Deterioration.

 

 

 

 

 

Recognizing and Responding to Patient Deterioration

 

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Abstract

Introduction

Various deaths recorded in healthcare facilities can be prevented (Kotwal, Montgomery, Miles, Conklin, Hall, & McChrystal, 2017). Rapid response teams are being implemented in many hospitals globally to ” rescue” deteriorating patients before their conditions move from bad to worse (Cho, Kwon, Kwon, Lee, Park, Jeon, & Oh, 2020). This paper aims to establish the changes in the views and characteristics of rapid response systems (RRS) from the moment Standard 9 of the NSQHS began to be implemented.

Findings

Since 2010, various changes in systems have been put into place to aid nurses in effectively recognizing and responding to patients’ deterioration, following the implementation of Standard 9 of the NSQHS.

Analysis/ Discussion

The findings indicate the significance of recognizing and responding to the deterioration of patients has been reinforced by Standard 9. More emphasis has been placed on evaluating results on how deteriorating patients are identified and responded to

Conclusion

A variety of evidence has shown that rapid response teams as being effective in helping nurses to recognize and respond to deteriorating patients. However, the Standard proved to be effective in ensuring that all hospitals regard this initiative as important as possible.

 

Recommendations

  • Increment in staffing and fund allocation.
  • Technology is to be embraced in aiding the nurse in getting an early warning on patient deterioration.

Introduction

Various deaths recorded in healthcare facilities can be prevented (Kotwal, Montgomery, Miles, Conklin, Hall, & McChrystal, 2017). Frequently, a given set of times follow after a patient’s condition is said to have deteriorated. Death can always be prevented if the deterioration of the patient is noticed early enough, and if necessary, interventions are made as soon as possible. Rapid response teams are being implemented in many hospitals globally to ” rescue” deteriorating patients before their conditions move from bad to worse (Cho, Kwon, Kwon, Lee, Park, Jeon, & Oh, 2020). The majority of hospital-based rapid response teams are set up in Australia, where a Medical Emergency Team (MET) being found in intensive care units of the 60% of Australian hospitals (Sethi & Chalwin, 2018).

Nonetheless, the hospitals in Australia did not have elaborate systems where clinical deterioration could be recognized and responded to. The developed MET was never fully incorporated into the hospital systems. Instead, some were only set up to handle only crises, like cardiac arrest, and not actively checking on the deterioration status of the patients. A set of ten National Safety and Quality Health Service (NSQHS) Standards was developed by the Australian Commission on Safety and Quality in Health Care in 2011 (Australian Commission on Safety and Quality in Health Care, 2022).  This paper aims to establish the changes in the views and characteristics of rapid response systems (RRS) from the moment Standard 9 began to be implemented.

Findings

Since 2010, various changes in systems have been put into place to aid nurses in effectively recognizing and responding to patients’ deterioration, following the implementation of Standard 9 of the NSQHS. First, various organizational systems have been developed to promote the recognition and response to deterioration. For instance, 85% of patients reported having a formal rapid response system in 2015, compared to 66% in 2010 (Chua, See, Legido-Quigley, Jones, Tee, & Liaw, 2017). Various rapid response teams were in operation during the period 2010-2015. Improvements were seen in the hospitals that provided room for the rapid response system to be initiated by the non-clinicians such as family and the patient.

Changes were also seen in terms of funding and allocation such that a huge percentage of hospitals in the year 2015 had put in place specialized staff whose responsibility was to implement and monitor how the rapid response systems (Heal, Silvest-Guerrero, & Kohtz, 2017). These systems were mostly being implemented by less than 0.5 full-time equivalents, only very few of them being allocated funds to support the rapid response systems.

By 2015, the training and education in managing the deterioration of patients had increased (McGaughey, O’Halloran, Porter, & Blackwood, 2017). Almost all hospitals were offering education and training to support staff on the better ways of recognizing and responding to the deterioration of patients in that year. This was not the case in 2010 when very few hospitals offered this training and education to their staff.

In most hospitals, governance was also set up in dedication to the recognition and response system in 2015, compared to the previous years. Most of the hospital staff were also giving regular feedback to the top management regarding recognizing and responding to deteriorating patients. As per the Standard, nurses need to collect information, provide feedback to the clinical staff, and track the results and any alterations in performance over a certain period. Hence it is not surprising that a majority of the hospitals in 2015 had nurses that collected specific information about the patients and how effective the system of recognizing and responding to deteriorating patients was (Anstey, Bhasale, Dunbar, & Buchan, 2019).

Most of the nursing staff in the year 2015 agreed that the Standard has succeeded in improving the activity of recognizing and responding to deteriorating patients (Anstey, Bhasale, Dunbar, & Buchan, 2019). These nurses who were positive about the impact of the Standard cited various reasons. These included that the Standard played a big role in improving how the deteriorating patients in the wards were being managed, changing the hospital culture, improvement in staffing, increasing frequency in the escalations of patients whose deterioration involved vital signs, increased awareness in the management level, and the nursing staff being highly empowered.

It is also important to note that these changes were seen in equal measure in public and private hospitals. The public and private hospitals never differed in their perception of the Standard’s impact in contributing to improved recognition and response to clinical deterioration. Nonetheless, the private hospitals had lower chances of reporting training on basic and advanced life support for doctors and nurses.

 

 

Analysis/ Discussion

It was established that the recognition and response to deteriorating patients had been improved through the Standard 9 of NSQHS. Based on the above findings, it is clear that the significance of recognizing and responding to the deterioration of patients has been reinforced by Standard 9 (Considine, Hutchison, Rawson, Hutchinson, Bucknall, Dunning, & Street, 2017). More emphasis has been placed on evaluating results in how deteriorating patients are recognized and responded to, on engaging nurses throughout the healthcare facility about recognizing and responding to deterioration, and on how they can improve on this task through learning.

Several factors contributed to changing the hospital culture to begin appreciating the significance of recognizing and responding to the clinical deterioration of patients. Some of such factors included increased efforts in training and education and the management of hospitals gaining interest in this issue (Jones, Bhasale, Bailey, Pilcher, & Anstey, 2018). The nurses’ involvement in recognizing and responding to deteriorating patients was impacted by the issue of limited funding and few staff dedicated to this issue.

It was very important for the NSQHS Standards to be introduced. Its introduction was actually for the benefit of nurses, who previously had limitations on how they could approach the issue of deteriorating patients in hospitals. Most hospitals began to put more priority on the issue of recognizing and responding to patients after the NSQHS Standards were introduced. Some hospitals had to re-assign tasks for the currently working nurses so that they could work on the Standard. This is why the number of hospitals that met the Standard’s requirement increased in the period between 2013-2015.

Since the number of hospitals implementing the Standard started to increase, positive health outcomes started to be recorded. These included reduced ICU admissions related to cardiac arrest, reduced in-hospital cardiac arrests, and low in-hospital mortality (Jones, Bhasale, Bailey, Pilcher, & Anstey, 2018; Haddeland, Slettebø, Carstens, & Fossum, 2018).  Patient safety cannot be implemented and achieved simply by writing down aspirational statements. Hence, organizations had to develop systems and processes in line with governance bodies.

Various hospitals positively embraced the system-wide mandated standard. This standard allowed rapids response teams to be developed throughout every acute hospital (Jung, Daurat, De Jong, Chanques, Mahul, Monnin, & Jaber, 2016). This standard was very impactive in ensuring that more nurses were deployed and that further organizational changes were made in hospitals so that care of the deteriorating patients in hospitals could be improved. It was impressive that this impact was achievable despite hospitals allocating limited funding for its support. The NSQHS Standards cut across every type of hospital. Therefore, even the hospital that lacks ICUs should incorporate the systems. The recognition tools like trigger tools, early warning track, and graded response protocols are currently being used by many hospitals to aid the nurses in recognizing and responding to deteriorating patients (McGaughey, O’Halloran, Porter, & Blackwood, 2017).

Nurses have also been making an effort to ensure their ability to recognize and manage wards with deteriorating patients is improved by adjusting their educational strategies. The nursing abilities to recognize and respond to a patient’s deterioration are mainly affected by their experience and knowledge (Dalton, Harrison, Malin, & Leavey, 2018). The models of decision making like IHM (intuitive-humanist model) and IPM (information processing model) have been used to explain the effects of such factors. As per the IPM, the short-term memory processes receive cues from the long-term memory knowledge.

For the short-term memory to interpret the patient’s cues, the nurse is required to have the pre-existing knowledge regarding the disease’s pathology stored in their long-term memory. Nurses can develop crucial clinical decision-making skills in recognizing and responding to deteriorating patients when the educational frameworks incorporate the models of decision-making. Nurses can also improve their efficiency in handling deteriorating patients by ensuring they collect as much information relating to them as possible. They also are aware that the early signs of deterioration may not be sensed by checking on the vital signs (Wood, Chaboyer, & Carr, 2019).

Conclusion

As discussed, a variety of evidence has shown that rapid response teams are effective in helping nurses recognize and respond to deteriorating patients. However, the Standard proved to be effective in ensuring that all hospitals regard this initiative as important as possible. The Standard requires many organizational systems to improve their operations towards recognizing and responding to patient deterioration. The ideas presented in this paper truly show that institutional changes were observed after the Standard was put into action. A valuable change leveler is provided when there is the specification of safety and quality standards that are mostly implemented when hospital accreditation is observed. This is even though the Australian health system faces various limitations on attaining standardization.

Additionally, improvision on the educational strategies used on nurses while training them on how to recognize and respond to clinical deterioration is crucial. The models of decision making like IPM and IHM must be put into good use so that nurses can be properly equipped to monitor the changes in the severity level of diseases and the exact measures that they ought to take. It was also crucial for hospitals to begin using tools like trigger tools and early warning tracks to help nurses be aware of any changes seen in patients.

Recommendations

One recommendation that can be made regarding the findings and analysis of this paper is about increment in staffing and fund allocation. There is a shortage of nurses employed globally, and Australia is not an exception. Nurses are the main factor behind the recognition and response to deteriorating patients. Hence, for this issue to be efficiently implemented, the management of all hospitals must allocate enough resources and funds to ensure that there is enough hospital personnel to serve the patients. This directive needs urgent attention so that hospitals can be sure of complying with the NSQHS Standards.

It is also recommended for the management of hospitals to embrace technology that would allow the patients to seamlessly offer feedback once they encounter an event where a patient’s condition is deteriorating. Technology can also prove useful where the hospitals will want to ease nurses’ jobs as they embrace more efficient tools that give signs and triggers. As such, the nurses will be able to recognize that a particular patient’s condition is about to deteriorate and be in a good position to call for appropriate intervention as soon as possible.

 

 

References

Anstey, M. H., Bhasale, A., Dunbar, N. J., & Buchan, H. (2019). Recognizing and responding to deteriorating patients: what difference do national standards make?. BMC health services research, 19(1), 1-7.

Australian Commission on Safety and Quality in Health Care. (2022). National Safety and Quality Health Service Standards. [Online]. Retrieved on 9th May 2022 from https://www.safetyandquality.gov.au/sites/default/files/migrated/NSQHS-Standards-Sept2011.pdf

Cho, K. J., Kwon, O., Kwon, J. M., Lee, Y., Park, H., Jeon, K. H., … & Oh, B. H. (2020). Detecting patient deterioration using artificial intelligence in a rapid response system. Critical care medicine, 48(4), e285-e289.

Chua, W. L., See, M. T. A., Legido-Quigley, H., Jones, D., Tee, A., & Liaw, S. Y. (2017). Factors influencing the activation of the rapid response system for clinically deteriorating patients by frontline ward clinicians: a systematic review. International Journal for Quality in Health Care, 29(8), 981-998.

Considine, J., Hutchison, A. F., Rawson, H., Hutchinson, A. M., Bucknall, T., Dunning, T., … & Street, M. (2017). Comparison of policies for recognizing and responding to clinical deterioration across five Victorian health services. Australian Health Review, 42(4), 412-419.

Dalton, M., Harrison, J., Malin, A., & Leavey, C. (2018). Factors that influence nurses’ assessment of patient acuity and response to acute deterioration. British Journal of Nursing, 27(4), 212-218.

Haddeland, K., Slettebø, Å., Carstens, P., & Fossum, M. (2018). Nursing students managing deteriorating patients: A systematic review and meta-analysis. Clinical Simulation in Nursing, 21, 1-15.

Heal, M., Silvest-Guerrero, S., & Kohtz, C. (2017). Design and development of a proactive rapid response system. CIN: Computers, Informatics, Nursing, 35(2), 77-83.

Jones, D., Bhasale, A., Bailey, M., Pilcher, D., & Anstey, M. H. (2018). Effect of a national standard for deteriorating patients on intensive care admissions due to cardiac arrest in Australia. Critical Care Medicine, 46(4), 586-593.

Jung, B., Daurat, A., De Jong, A., Chanques, G., Mahul, M., Monnin, M., … & Jaber, S. (2016). Rapid response team and hospital mortality in hospitalized patients. Intensive care medicine42(4), 494-504.

Kotwal, R. S., Montgomery, H. R., Miles, E. A., Conklin, C. C., Hall, M. T., & McChrystal, S. A. (2017). Leadership and a casualty response system for eliminating preventable death. Journal of trauma and acute care surgery, 82(6S), S9-S15.

McGaughey, J., O’Halloran, P., Porter, S., & Blackwood, B. (2017). Early warning systems and rapid response to the deteriorating patient in hospital: A systematic realist review. Journal of advanced nursing, 73(12), 2877-2891.

Sethi, S. S., & Chalwin, R. (2018). Governance of rapid response teams in Australia and New Zealand. Anesthesia and Intensive Care, 46(3), 304-309.

Wood, C., Chaboyer, W., & Carr, P. (2019). How do nurses use early warning scoring systems to detect and act on patient deterioration to ensure patient safety? A scoping review. International journal of nursing studies, 94, 166-178.

 

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