Management Of Deteriorating Patients Research Articles

Review article: Use of the Team Emergency Assessment Measure in the rating of emergency teams' non-technical skills: A mapping review.

The present study aims to explore the utility of the Team Emergency Assessment Measure (TEAM) in relation to the enhancement of emergency team non-technical skills based on research conducted over the last decade. In this mapping review, a citation mining process identified 22 primary studies for inclusion, published between 2012 and 2022. It provides outcome data on emergency teams' non-technical skills following team training and/or real-life patient emergencies. Emergency team studies related to resuscitation teams (adult, paediatric, newborn and obstetric cases) and medical emergency team (MET) management of patient deterioration. Team performance ratings varied, ranging from approximately 90% for experienced clinical teams down to 38% for students. Statistically significant improvements in performance were notable following training and/or repeated practice. Validity evidence, across 11 studies that provided change data described positive learning outcomes and moderate intervention effects. However, according to Kirkpatrick's model of educational evaluation the studies were limited to professional development phases of learning and immediate post-training assessments rather than care quality improvement. The review highlights a lack of studies evidencing quality improvement or clinical impact such as change of patient care practice or health service performance. There is a need to conduct well-designed studies that explore both technical and non-technical skills of resuscitation teams and METs. Currently, non-technical skills training and repeated performance evaluations using the TEAM contribute immensely to the proficiency of emergency teams.

Exploring interdisciplinary communication pathways for escalating pre-medical emergency team deterioration: a mixed-methods study.

Objective To explore clinicians' use and perceptions of interdisciplinary communication pathways for escalating care within the pre-medical emergency team (pre-MET) tier of rapid response systems. Method A sequential mixed-methods study was conducted using observations and interviews. Participants were clinicians (nurses, allied health, doctors) caring for orthopaedic and general medicine patients at one hospital. Descriptive and thematic analyses were conducted. Results Escalation practices were observed for 13 of 27 pre-MET events. Leading communication methods for escalating pre-MET events were alphanumeric pagers (61.5%) and in-person discussions (30.8%). Seven escalated pre-MET events led to bedside pre-MET reviews by doctors. Clinician interviews (n = 29) culminated in two themes: challenges in escalation of care, and navigating information gaps. Clinicians reported deficiencies in communication methods for escalating care that hindered interdisciplinary communication and clinical decision-making pertaining to pre-MET deterioration. Conclusion Policy-defined escalation pathways were inconsistently utilised for pre-MET deterioration. Available communication methods for escalating pre-MET events inadequately fulfilled clinicians' needs. Variable perceptions of escalation pathways illuminated a lack of of a shared mental model about clinicians' roles and responsibilities. To optimise timely and appropriate management of patient deterioration, communication infrastructure and interdisciplinary collaboration must be enhanced.

Exploration of a rapid response team model of care: A descriptive dual methods study

BackgroundAvoidable in-patient clinical deterioration results in serious adverse events and up to 80% are preventable. Rapid response systems allow early recognition and response to clinical deterioration. ObjectiveTo explore the characteristics of a collaborative rapid response team model. DesignDual methodology was used for this descriptive study. SettingThe study was conducted in a 500-bed tertiary referral hospital (Sydney, Australia). ParticipantsInpatients (>17 years) who received a rapid response team activation were included in an electronic medical audit. Participants were rapid response team members and nurses and medical doctors in two in-patient wards. MethodsA 12-month (January-December 2018) retrospective electronic health record audit and semi-structured interviews with nurses and medical doctors (July-August 2019) were conducted. Descriptive statistics summarised audit data. Interviews were transcribed and analysed thematically. ResultsThe rapid response team consulted for 2195 patients. Mean patient age was 67.9 years, and 46% of the sample was female. Activations (n = 4092) occurred most often in general medicine (n = 1124, 70.8%) units. Overall, 117 patients had >5 activations. The themes synthesised from interviews were i) managing patient deterioration before arrival of the rapid response team; ii) collaboratively managing patient deterioration at the bedside; iii) rapid response team guidance at the bedside; and iv) ‘staff concern’ rapid response activation. ConclusionsSome patients received many activations, however few required treatment in critical care. The rapid response model was collaborative and supportive. The themes revealed a focus on patient safety, optimising early detection, and management of patient deterioration.

Nurses' cognitive and perceptual bias in the identification of clinical deterioration cues

BackgroundPerception and processing of clinical cues have rarely been investigated in the nursing literature despite their relevance to the early identification and management of clinical deterioration. AimThis study used a hypovolemic shock scenario from the Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends (FIRST2ACT) virtual simulation program, equipped with an eye tracker, to investigate cue processing during the management of patient deterioration. ResultThe study revealed that attention deviation distorted interpretation of subsequent cues, causing 63% of participants to exhibit a cognitive bias (heightened sensitivity to specific but noncritical cues) and 65% to exhibit at least one episode of nonfixation on clinically relevant cues. Attention deviation and distorted interpretations of clinical cues will have an impact on patient safety. ConclusionThe findings are likely to have important implications for understanding error and associated training implications.

Emergency Room Safer Transfer of Patients (ER-STOP): a quality improvement initiative at a community-based hospital to improve the safety of emergency room patient handovers

ObjectivesEnsure early identification and timely management of patient deterioration as essential components of safe effective healthcare. Prompted by analyses of incident reports and deterioration events, a multicomponent organisational rescue from...

The educational impact of web-based and face-to-face patient deterioration simulation programs: An interventional trial

BackgroundThere are international concerns relating to the management of patient deterioration. The “failure to rescue” literature identifies that nursing staff miss cues of deterioration and often fail to call for assistance. Simulation-based educational approaches may improve nurses' recognition and management of patient deterioration. ObjectivesTo investigate the educational impact of the First2Act web-based (WB) and face-to-face (F2F) simulation programs. Design & SettingA mixed methods interventional cohort trial with nursing staff from four Australian hospitals. ParticipantsNursing staff working in four public and private hospital medical wards in the State of Victoria. MethodsIn 2016, ward nursing staff (n = 74) from a public and private hospital completed three F2F laboratory-based team simulations with a patient actor in teams of three. 56 nursing staff from another public and private hospital individually completed a three-scenario WB simulation program (First2ActWeb) [A 91% participation rate]. Validated tools were used to measure knowledge (multi-choice questionnaire), competence (check-list of actions) and confidence (self-rated) before and after the intervention. ResultsBoth WB and F2F participants' knowledge, competence and confidence increased significantly after training (p ≤0.001). Skill performance for the WB group increased significantly from 61% to 74% (p ≤ 0.05) and correlated significantly with post-test knowledge (p = 0.014). No change was seen in the F2F groups' performance scores. Course evaluations were positive with median ratings of 4/5 (WB) and 5/5 (F2F). The F2F program received significantly more positive evaluations than the WB program (p < 0.05), particularly with regard to quality of feedback. ConclusionWB and F2F simulation are effective education strategies with both programs demonstrating positive learning outcomes. WB programs increase ease of access to training whilst F2F enable the development of tactile hands on skills and teamwork. A combined blended learning education strategy is recommended to enhance competence and patient safety.

The effectiveness of virtual simulation in improving student nurses' knowledge and performance during patient deterioration: A pre and post test design

BackgroundPreparing nursing students to perform competently in complex emergency situations, such as during rapid patient deterioration, is challenging. Students' active engagement in such scenarios cannot be ensured, due to the unexpected nature of such infrequent events. Many students may consequently not experience and integrate the management of patient deterioration into their knowledge and practical competency by the end of their studies, making them unprepared to manage such situations as practicing nurses. This study investigated the effectiveness of virtual simulation in improving performance during rapid patient deterioration. ObjectiveTo investigate the effectiveness of virtual simulation in improving student nurses' knowledge and performance during rapid patient deterioration. DesignA pre- and post-test design was used. SettingNursing students at a university in Malta were invited to participate in a virtual simulation program named FIRST2ACTWeb™, using their own computer devices. ParticipantsA total of 166 (response rate=50%) second and third year diploma and degree nursing students participated in the study. MethodsThe simulation included three scenarios (Cardiac-Shock-Respiratory) portraying deteriorating patients. Performance feedback was provided at the end of each scenario. Students completed pre- and post-scenario knowledge tests and performance during each scenario was recorded automatically on a database. ResultsFindings showed a significant improvement in the students' post-scenario knowledge (z=−6.506, p<0.001). Highest mean performance scores were obtained in the last scenario (M=19.7, median: 20.0, s.d. 3.41) indicating a learning effect. Knowledge was not a predictor of students' performance in the scenarios. ConclusionsThis study supports virtual simulation as an effective learning tool for pre-registration nursing students in different programs. Simulation improves both knowledge about and performance during patient deterioration. Virtual simulation of rare events should be a key component of undergraduate nurse education, to prepare students to manage complex situations as practicing nurses.

Early warning systems and rapid response to the deteriorating patient in hospital: A systematic realist review.

To determine the Rapid Response System programme theory and investigate how the mechanisms of implementation and the characteristics of context combine to enable or constrain the implementation of Rapid Response Systems and the achievement of desired outcomes. Rapid Response Systems have been implemented internationally to improve the recognition and management of patient deterioration, reduce the need for cardiopulmonary resuscitation and improve patient outcomes. Realist review. We searched DARE, CENTRAL, NHSEED, MEDLINE, Medline In Process, EMBASE, CINAHL, PubMed, Scopus, The Web of Science and PychInfo databases from 1997 - 2017 in addition to purposively searching the grey literature looking for articles supporting, refuting or explaining Rapid Response System programme theories. Included studies were critically appraised and graded using the Critical Appraisal Skills Programme tool. Data extraction and synthesis investigated the Rapid Response System theoretical propositions against the empirical evidence to refine Rapid Response System programme theories. The review found that the Rapid Response System programme theory achieved desired outcomes when there were sufficient skills mix of experienced staff, EWS protocols were used flexibly alongside clinical judgement and staff had access to ongoing, multiprofessional, competency-based education. However, ward cultures, hierarchical referral systems, workload and staffing resources had a negative impact on the implementation of the Rapid Response System. To improve the recognition and management of patient deterioration, policymakers need to address those cultural, educational and organizational factors that have an impact on the successful implementation of Rapid Response Systems in practice.

Mental Rehearsal Strategy for Stress Management and Performance in Simulations

BackgroundA mental rehearsal (MR) strategy using standardized patients was implemented for third-year nursing students in a simulation training on clinical deterioration. The study aimed to evaluate its efficacy, by comparing with a conventional approach using a mnemonic strategy with mannequin simulation, for improving the nursing students' performance and reducing their stress level in patient deterioration management. The study also explored the students' perspectives of using MR during their clinical practice. MethodA mixed methods design was used. Thirty-two third-year nursing students participated in a randomized posttest. They were assigned to either the MR group or mnemonic group. Performance was observed and measured using simulation-based assessment. Strait–Trait Anxiety Inventory, heart rate, systolic blood pressure, and skin temperature were used as stress measures. Twenty-one students participated in individual interviews after a nine-week clinical posting. ResultsPerformance between the MR group and the mnemonic group (p = .105) did not differ. The state (p = .524) and trait (p = .516) anxiety inventory, systolic blood pressure (p = .890), heart rate (p = .692), and skin temperature (p = .521) did not differ between the two groups. Three themes were generated from the application of MR on students' clinical practice: being mentally and emotionally prepared, recalling and visualizing the steps to be taken, and enhancing actual clinical practice. ConclusionsBoth MR and the mnemonic strategies had similar effects on performance and stress during patient deterioration management. However, the interviews suggested that MR still benefits learning and has value in health professions' training.

The impact of web-based and face-to-face simulation on patient deterioration and patient safety: protocol for a multi-site multi-method design

BackgroundThere are international concerns in relation to the management of patient deterioration which has led to a body of evidence known as the ‘failure to rescue’ literature. Nursing staff are known to miss cues of deterioration and often fail to call for assistance. Medical Emergency Teams (Rapid Response Teams) do improve the management of acutely deteriorating patients, but first responders need the requisite skills to impact on patient safety.Methods/designIn this study we aim to address these issues in a mixed methods interventional trial with the objective of measuring and comparing the cost and clinical impact of face-to-face and web-based simulation programs on the management of patient deterioration and related patient outcomes. The education programs, known as ‘FIRST2ACT’, have been found to have an impact on education and will be tested in four hospitals in the State of Victoria, Australia. Nursing staff will be trained in primary (the first 8 min) responses to emergencies in two medical wards using a face-to-face approach and in two medical wards using a web-based version FIRST2ACTWeb. The impact of these interventions will be determined through quantitative and qualitative approaches, cost analyses and patient notes review (time series analyses) to measure quality of care and patient outcomes.DiscussionIn this 18 month study it is hypothesised that both simulation programs will improve the detection and management of deteriorating patients but that the web-based program will have lower total costs. The study will also add to our overall understanding of the utility of simulation approaches in the preparation of nurses working in hospital wards. (ACTRN12616000468426, retrospectively registered 8.4.2016).

Piloting the feasibility of head-mounted video technology to augment student feedback during simulated clinical decision-making: An observational design pilot study

Clinical decision-making is a complex activity that is critical to patient safety. Simulation, augmented by feedback, affords learners the opportunity to learn critical clinical decision-making skills. More detailed feedback following simulation exercises has the potential to further enhance student learning, particularly in relation to developing improved clinical decision-making skills. To investigate the feasibility of head-mounted video camera recordings, to augment feedback, following acute patient deterioration simulations. Pilot study using an observational design. Ten final-year nursing students participated in three simulation exercises, each focussed on detection and management of patient deterioration. Two observers collected behavioural data using an adapted version of Gaba's Clinical Simulation Tool, to provide verbal feedback to each participant, following each simulation exercise. Participants wore a head-mounted video camera during the second simulation exercise only. Video recordings were replayed to participants to augment feedback, following the second simulation exercise. Data were collected on: participant performance (observed and perceived); participant perceptions of feedback methods; and head-mounted video camera recording feasibility and capability for detailed audio-visual feedback. Management of patient deterioration improved for six participants (60%). Increased perceptions of confidence (70%) and competence (80%), were reported by the majority of participants. Few participants (20%) agreed that the video recording specifically enhanced their learning. The visual field of the head-mounted video camera was not always synchronised with the participant's field of vision, thus affecting the usefulness of some recordings. The usefulness of the video recordings, to enhance verbal feedback to participants on detection and management of simulated patient deterioration, was inconclusive. Modification of the video camera glasses, to improve visual-field synchronisation with participants' actual visual field, is recommended to further explore this technology for enhancing student performance.

Comparison of standardized patients with high-fidelity simulators for managing stress and improving performance in clinical deterioration: A mixed methods study

The use of standardized patients in deteriorating patient simulations adds realism that can be valuable for preparing nurse trainees for stress and enhancing their performance during actual patient deterioration. Emotional engagement resulting from increased fidelity can provide additional stress for student nurses with limited exposure to real patients. To determine the presence of increased stress with the standardized patient modality, this study compared the use of standardized patients (SP) with the use of high-fidelity simulators (HFS) during deteriorating patient simulations. Performance in managing deteriorating patients was also compared. It also explored student nurses' insights on the use of standardized patients and patient simulators in deteriorating patient simulations as preparation for clinical placement. Fifty-seven student nurses participated in a randomized controlled design study with pre- and post-tests to evaluate stress and performance in deteriorating patient simulations. Performance was assessed using the Rescuing A Patient in Deteriorating Situations (RAPIDS) rating tool. Stress was measured using salivary alpha-amylase levels. Fourteen participants who joined the randomized controlled component then participated in focus group discussions that elicited their insights on SP use in patient deterioration simulations. Analysis of covariance (ANCOVA) results showed no significant difference (p=0.744) between the performance scores of the SP and HFS groups in managing deteriorating patients. Amylase levels were also not significantly different (p=0.317) between the two groups. Stress in simulation, awareness of patient interactions, and realism were the main themes that resulted from the thematic analysis. Performance and stress in deteriorating patient simulations with standardized patients did not vary from similar simulations using high-fidelity patient simulators. Data from focus group interviews, however, suggested that the use of standardized patients was perceived to be valuable in preparing students for actual patient deterioration management.

Managing patient deterioration: assessing teamwork and individual performance

ObjectiveTo assess the ability of rural Australian nurse teams to manage deteriorating patients.MethodsThis quasi-experimental design used pre- and post-intervention assessments and observation to evaluate nurses' simulated clinical performance. Registered nurses...

Patient deterioration simulation experiences: Impact on teaching and learning

Early recognition and management of patient deterioration are essential nursing skills, and can be improved through education and experience. However, both nursing students and registered nurses may have few opportunities to develop and maintain the emergency management skills necessary to ensure patient safety. Using both theory and empirical evidence, we have developed a simulation-based educational model, 'FIRST2ACT' (Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends), to provide nurses with a high-fidelity learning experience. The model has been tested in three different settings: it is highly acceptable to learners, adaptable to different training needs, and shows promise in improving actual clinical performance.

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Simulation-based education is helping students improve management of patient deterioration, says Penny Buykx

Managing the deteriorating patient in a simulated environment: nursing students’ knowledge, skill and situation awareness

To examine, in a simulated environment, the ability of final-year nursing students to assess, identify and respond to patients either deteriorating or at risk of deterioration. The early identification and management of patient deterioration has a major impact on patient outcomes. 'Failure to rescue' is of international concern, with significant concerns over nurses' ability to detect deterioration, the reasons for which are unknown. Mixed methods incorporating quantitative measures of performance (knowledge, skill and situation awareness) and, to be reported at a later date, a qualitative reflective review of decision processes. Fifty-one final-year, final-semester student nurses attended a simulation laboratory. Students completed a knowledge questionnaire and two video-recorded simulated scenarios (mannequin based) to assess skill performance. The scenarios simulated deteriorating patients with hypovolaemic and septic shock. Situation awareness was measured by randomly stopping each scenario and asking a series of questions relating to the situation. The mean knowledge score was 74% (range 46-100%) and the mean skill performance score across both scenarios was 60% (range 30-78%). Skill performance improved significantly (p < 0.01) by the second scenario. However, skill performance declined significantly in both scenarios as the patient's condition deteriorated (hypovolaemia scenario: p = 0.012, septic scenario: p = 0.000). The mean situation awareness score across both scenarios was 59% (range 38-82%). Participants tended to identify physiological indicators of deterioration (77%) but had low comprehension scores (44%). Knowledge scores suggest, on average, a satisfactory academic preparation, but this study identified significant deficits in students' ability to manage patient deterioration. This study suggests that student nurses, at the point of qualification, may be inadequately prepared to identify and manage deteriorating patients in the clinical setting.