Abstract
BackgroundEarly warning systems (EWSs) are used to assist clinical judgment in the detection of acute deterioration to avoid or reduce adverse events including unanticipated cardiopulmonary arrest, admission to the intensive care unit and death. Sometimes healthcare professionals (HCPs) do not trigger the alarm and escalate for help according to the EWS protocol and it is unclear why this is the case. The aim of this qualitative evidence synthesis was to answer the question ‘why do HCPs fail to escalate care according to EWS protocols?’ The findings will inform the update of the National Clinical Effectiveness Committee (NCEC) National Clinical Guideline No. 1 Irish National Early Warning System (INEWS).MethodsA systematic search of the published and grey literature was conducted (until February 2018). Data extraction and quality appraisal were conducted by two reviewers independently using standardised data extraction forms and quality appraisal tools. A thematic synthesis was conducted by two reviewers of the qualitative studies included and categorised into the barriers and facilitators of escalation. GRADE CERQual was used to assess the certainty of the evidence.ResultsEighteen studies incorporating a variety of HCPs across seven countries were included. The barriers and facilitators to the escalation of care according to EWS protocols were developed into five overarching themes: Governance, Rapid Response Team (RRT) Response, Professional Boundaries, Clinical Experience, and EWS parameters. Barriers to escalation included: Lack of Standardisation, Resources, Lack of accountability, RRT behaviours, Fear, Hierarchy, Increased Conflict, Over confidence, Lack of confidence, and Patient variability. Facilitators included: Accountability, Standardisation, Resources, RRT behaviours, Expertise, Additional support, License to escalate, Bridge across boundaries, Clinical confidence, empowerment, Clinical judgment, and a tool for detecting deterioration. These are all individual yet inter-related barriers and facilitators to escalation.ConclusionsThe findings of this qualitative evidence synthesis provide insight into the real world experience of HCPs when using EWSs. This in turn has the potential to inform policy-makers and HCPs as well as hospital management about emergency response system-related issues in practice and the changes needed to address barriers and facilitators and improve patient safety and quality of care.
Highlights
Warning systems (EWSs) are used to assist clinical judgment in the detection of acute deterioration to avoid or reduce adverse events including unanticipated cardiopulmonary arrest, admission to the intensive care unit and death
National Clinical Guideline Update This qualitative evidence synthesis was conducted to inform the update of the Irish National Clinical Guideline No 1 Irish National Early Warning System (INEWS)
The findings are presented according to themes generated which were coded for each included study according to barriers and facilitators of escalation. For this qualitative evidence synthesis, there were 18 eligible studies, which focused on why health care professional (HCP) may fail to escalate as per the Early warning system/score (EWS) protocols
Summary
Warning systems (EWSs) are used to assist clinical judgment in the detection of acute deterioration to avoid or reduce adverse events including unanticipated cardiopulmonary arrest, admission to the intensive care unit and death. Sometimes healthcare professionals (HCPs) do not trigger the alarm and escalate for help according to the EWS protocol and it is unclear why this is the case. Recognition of clinical deterioration, followed by prompt and effective action, can minimise the occurrence of adverse events such as unanticipated cardiopulmonary arrest, [4] and may mean that a lower level of intervention, and resources, is required to stabilise a patient. Approaches include early warning systems (EWSs) which incorporate the recognition, escalation, response and clinical governance of the deteriorating patient; targeted education programmes for healthcare professionals, and standardised approaches to clinical and interdepartmental handover [5]. The track and trigger tool is used to assist, rather than over-ride HCPs clinical judgement and decision-making
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