Defining and recognising clinical deterioration in the prehospital setting (PRECLuDE study): a systematic scoping review

Emma Bourke-Matas,Kelly-Ann Bowles,Paul Gowens,Karen Smith,Emma Bosley

doi:10.32378/ijp.v5i1.245

Abstract

IntroductionEarly identification of high-risk patients in the prehospital environment is crucial as it enables early intervention, transportation, and may determine the trajectory of future care. Although early warning systems (EWS) in-hospital are well established, it remains unclear whether adaptations of these systems can simply be extrapolated to prehospital care. This scoping review aims to explore how the current literature defines and recognises clinical deterioration in the prehospital setting. MethodsIn December 2019, a systematic search of five databases using a combination of terms describing ‘paramedic’, were integrated with terminology relating to ‘recognition’ of ‘clinical deterioration’. Additional reference chaining was also undertaken. ResultsA total of eight papers met the inclusion criteria. Seven out of eight studies included a definition, however these were primarily ad-hoc and fundamentally formed to support the creation of varying EWS. The prevalence of prehospital clinical deterioration is poorly explored in the literature, with only two studies discussing the frequency deterioration (5.1%). Furthermore, studies reported that paramedics were inadequate at identifying clinical deterioration due to medical aetiology by comparison to trauma. Additionally, a number of articles reported an association between clinician experience and recognition of clinical deterioration. As the topic of prehospital clinical deterioration has rapidly moved to focus on the potential implementation of EWS, with few studies providing fundamental description of the concept and its characteristics, there is no standardised operational definition available in the literature. The development of this definition is crucial to assessing clinical deterioration and improving the efficacy of EWS. Not only could this lead to improving early identification of risk factors, but it can lay the foundations for the development of an effective EWS. ConclusionThis review has found that further quality research in this understated space is warranted to increase understanding and early identification of the deteriorating patient, prevent unnecessary harm, and ultimately, improve patient outcomes.

Highlights

Identification of high-risk patients in the prehospital environment is crucial as it enables early intervention, transportation, and may determine the trajectory of future care
This review aimed to identify how paramedics define clinical deterioration, what is the prevalence of deteriorating patients, and how clinical deterioration is currently recognised
Definitions were based on iatrogenesis and medical neglect, the concept of clinical deterioration continued to evolve alongside adverse events and was defined as “one or more discrete complications”[37], p

Summary

Introduction

Identification of high-risk patients in the prehospital environment is crucial as it enables early intervention, transportation, and may determine the trajectory of future care. Early warning systems (EWS) in-hospital are well established, it remains unclear whether adaptations of these systems can be extrapolated to prehospital care. This scoping review aims to explore how the current literature defines and recognises clinical deterioration in the prehospital setting. In 2012, the Australian Commission on Safety and Quality in Health Care (ACSQHC) established clinical deterioration as one of ten key National Safety and Quality Health Service Standards[1]. Identifying those that are declining into a critically ill state can be challenging[2,3]. There is a lack of knowledge surrounding clinical deterioration for the broader, more diverse general population[6]

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