The aim of the study was to examine the effectiveness of an early warning system to detect adult clinical deterioration within Queensland hospitals and health services and to identify the socio-cultural factors influencing health professional compliance in using the EWS.
Central Queensland Hospital Health Services
The study identified a number of socio-cultural factors that contributed to some doctors' and nurses' failure to monitor and escalate care of hospital patients' deterioration. Findings also suggested further refinements of monitoring charts at a state-wide level, and importantly, informing policy development – a major contribution to best evidence and best practice within clinical environments. When health professionals practice best practice, better health outcomes inevitably follow. With consumers expecting the best possible health care, the EWS study provides the potential to improve the delivery of this expectation, resulting in substantial social impact, shorter hospital stays and better quality of life.
Professor Trudy Dwyer, Dr Tracy Flenady, Professor Tania Signal, Professor Matthew Browne, Dr Danielle le Lagadec and Central Queensland Hospital and Health Service industry partner Ms Julie Kahl
A CQUniversity research team has established that an early warning system (EWS), designed to support nurses and doctors to quickly identify when a patient's condition is worsening and escalate care, does work when used correctly.
The team also identified the main factors that influenced nurses' and doctors' compliance and non-compliance when using these EWSs and found compliance improved hospital patient safety, resulting in fewer unexpected intensive care admissions, transfers to another hospital or even patient deaths.
In setting out to validate the extent EWS can predict patient clinical deterioration, researchers focused on how the most prevalent EWS were currently used in public hospitals across Queensland.
In total, 2474 patient charts and 12,399 sets of patient vital sign measurements from 13 different hospitals, found that abnormal respiratory or cardiac changes commonly preceded unexpected clinical deterioration.
Better still, when these individual abnormal vital signs were considered collectively as one total score, the system had a better than average chance of predicting clinical deterioration 24 hours preceding death.
Significantly, if early detection is acted upon, patient mortality rates are reduced, unplanned intensive care unit admissions are reduced, and the length of hospital stays is shorter.
The study was lead by Chief Investigators Professor Trudy Dwyer and Dr Tracy Flenady, both from CQUniversity Rockhampton; CQUniversity team members Professor Tania Signal, Professor Matthew Browne, Dr Danielle le Lagadec; and Central Queensland Hospital and Health Service industry partner Ms Julie Kahl.
Prof Dwyer explains that the study arose in response to the findings of a coronial inquiry into a hospital death because staff had not complied with the early warning system protocols.
"We found that staff don't have confidence that the early warning system charts in place are relevant to all patients on all occasions. As a result, they aren't used as intended," she says.
The early warning system examined comprises a single and multi-trigger tracking system that requires clinicians to collect and record patients' vital signs. The EWS allocates scores for each vital sign outside a healthy range, then the aggregate score determines escalation protocols for clinicians to enact once certain predetermined thresholds are met.
However, for the system to work at its optimum level, it's essential that the EWS accurately detects deterioration and that staff comply with escalation protocols.
Prof Dwyer stresses that given the validation of this early warning system, improving the confidence of those who used them was critically important in avoiding future patient deaths.
She says it was found that negative perceptions of EWS benefits related to the undermining of experience, inhibited clinical skills development and the fact there was no consequence for non-compliance.
Professional hierarchy, dissatisfaction with management training, plus insufficient and diverse training were negatively identified in regard to workplace satisfaction.
The perception of the current training for EWS indicated a diverse workforce required more diverse training as staff rated adequacy for training new staff poor and specific chart nuances such as blood pressure, modifications, pain and sedation required more in-depth training.
Overall, attention to three factors – education and training, practice changes, and future research – were identified as vital in ensuring EWS requirements and procedures were consistently complied with in all Queensland hospitals.
Regarding education and training, an urgent focus on completing patients' usual/default blood pressure and the correct use/fulfilment of the temporary and permanent modifications section, modification is required when symptoms related to a patient's chronic medical condition. For example, Chronic Obstructive Pulmonary Disease (COPD) has the potential to repeatedly trigger unnecessary clinical interventions and access to EWS training modules for casual staff and transient workers were outlined as key issues.
In relation to practice changes, it was noted that while the modification section allowed for medical officers' clinical judgement/reason, it provided limited scope for registered nurses. Also related to practice change, different models of response teams or tiers to reduce workload around responses to escalation and response were recommended.
Research recommendations further included that of a different sampling method (that of random sampling of patients as opposed to medical emergency team review (MET) and matching), a method which would potentially provide improved predictions for clinical deterioration. Professional tensions between the home team and the MET were also identified as an issue requiring attention and further research to improve partnerships between the teams to optimise patient outcomes was recommended.
"We have confirmed that EWS charts do predict deterioration, so knowledge and awareness are vital in improving the confidence of those who use the charts," says Prof Dwyer.
"In conclusion, complete compliance to these recommendations would no doubt significantly improve clinicians behaviour in EWS monitoring and escalation protocols compliance to the extent that unnecessary patient deaths due to cardiac or respiratory arrest are things of the past."
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