Evaluation of a patient and family activated escalation system: Ryan's Rule

IntroductionPatients experience physiological changes in the hours preceding adverse medical events, and patients or their family can be the first to identify ominous signs of clinical deterioration that have gone undetected by health professionals. Patient and family activated escalation systems provide consumers access to a referral system that can address their concerns. In Queensland, this escalation system is called Ryan's Rule and once activated, triggers an independent clinical review. This study aimed to access clinicians' and activators' experiences to develop an understanding of the incidence, contributing factors, and outcomes surrounding Ryan's Rule activations.MethodThe study involved a retrospective chart review of Ryan's Rule (n = 57) activations in a regional hospital, over a 24-month period.ResultsOn average, there were 2.4 activations a month. There are three major findings: first, communication issues were central to more than half the activations, 35% of cases required no clinical intervention, with communication alone sufficient to achieve resolution. Second, this initiative was valued with 65% of activators stating that they would be comfortable calling again and having access to the escalation process was reassuring and improved communication between clinicians and patients. While clinicians doubted the appropriateness of activators use of the escalation tool, 15% of patients were transferred to receive a higher level of care. Lastly, clinicians labelled activations as a ‘complaints’ as opposed to a ‘concern’ and reasoned that a ‘complaint’ did not justify a full review of the consumer's perspective for the activation.ConclusionConsumers who activated a Ryan's Rule were satisfied and valued the process. It provides a reassuring safety net, empowering them to speak up and initiate a clinical review. Clear communication among clinicians and between clinicians and consumers is essential. Clinicians are hesitant to fully embrace Ryan's Rule, and this discordance contributes to the failure to fully evaluate reasons for call activation.     

A call for better doctor–nurse collaboration: A qualitative study of the experiences of junior doctors and nurses in escalating care for deteriorating ward patients

BackgroundDespite the widespread implementation of medical emergency teams (METs) in hospitals to provide immediate interventions to deteriorating ward patients, little is known about how junior doctors and nurses escalate care for deteriorating ward patients in hospitals with established MET services.ObjectivesThe objective of this research study was to explore the experiences of junior doctors and nurses in escalating care for clinically deteriorating patients in general wards.MethodsTwenty-four individual interviews were conducted with 10 junior doctors and 14 registered nurses of a 1000-bed acute general hospital with the most established MET service in Singapore. Interviews were transcribed verbatim and analysed using an interpretive thematic analysis approach.FindingsThree salient themes emerged from thematic analysis: (1) MET activations versus the primary team doctors' reviews, (2) challenges in obtaining medical reviews, and (3) unspoken rules of the escalation of care. Participants' decisions to call the MET or to escalate to the primary team doctors not only depended on the severity of a patient's deterioration and their perceptions of the primary team doctors' capacity to manage the patient but also were largely influenced by sociocultural factors that were shaped by the hierarchy of medical professions. Key challenges faced by nurses in obtaining medical reviews from junior doctors for patients with early deterioration included presenting “convincing” evidence of patient deterioration and “packaging” information about patient deterioration.ConclusionsThe decision to call a MET or the primary team doctors is a complex judgement that is greatly influenced by the dynamics of perceived hierarchy between the medicine and nursing professions and within the medicine profession. Educational and organisational changes that enhance doctor–nurse interprofessional and intraprofessional collaboration among all levels of doctors may improve the process of the escalation of care for deteriorating patients and thus improve patient safety for hospitalised patients.     

End-of-life care for older people in subacute care: A retrospective clinical audit

Background

With an ageing population and chronic illness the leading cause of death, challenges exist in meeting the healthcare needs of older people. For older people, care may be provided in subacute care services where, although the focus is on rehabilitation and optimisation of functioning, many older people will die.

Clinicians’ attitudes towards escalation and management of deteriorating patients: A cross-sectional study

BackgroundInternationally, rapid response systems have been implemented to recognise and categorise hospital patients at risk of deterioration. Whilst rapid response systems have been implemented with a varying amount of success, there remains ongoing concern about the lack of improvement in the escalation, and management of the deteriorating patient. It also remains unclear why some clinicians fail to escalate concerns for the deteriorating patient.ObjectiveThe objective of this study was to explore clinicians’ attitudes towards the escalation, and management of the deteriorating patient.MethodsA cross-sectional online survey of conveniently sampled clinicians from the acute care sector in a regional health district in Australia was conducted. The Clinicians’ Attitudes towards Responding and Escalating care of Deteriorating patients scale, was used to explore attitudes towards the escalation and management of the deteriorating patient.ResultsSurvey responses were received from medical officers (n = 43), nurses (n = 677), allied health clinicians (n = 60), and students (n = 57). Years of experience was significantly associated with more confidence responding to deteriorating patients (p < .001) and significantly less fears about escalating care (p < .001). Nurses (M = 4.16, SD = .57) and students (M = 4.11, SD = .55) in general had significantly greater positive beliefs that the rapid response system would support them to respond to the deteriorating patient than allied health (M = 3.67, SD = .64) and medical (M = 3.87, SD = .54) clinicians, whilst nurses and medical clinicians had significantly less fear about escalating care and greater confidence in responding to deteriorating patients than allied health clinicians and healthcare students (p < .001).ConclusionNurses and medical officers have less fear to escalate care and greater confidence responding to the deteriorating patient than allied health clinicians and students. Whilst the majority of participants had positive perceptions towards the rapid response system, those with less experience lacked the confidence to escalate care and respond to the deteriorating patient.     

Patient Concerns about Medical Errors in Emergency Departments

OBJECTIVE: Despite large numbers of emergency encounters, little is known about how emergency department (ED) patients conceptualize their risk of medical errors. This study examines how safe ED patients feel from medical errors, which errors are of greatest concern, how concerns differ by patient and hospital characteristics, and the relationship between concerns and willingness to return for future care. METHODS: Multiwave telephone interviews of 767 patients from 12 EDs were conducted. Patients were asked about their medical safety, concern about eight types of medical errors, and satisfaction with care. RESULTS: Eighty-eight percent of patients believed that their safety from medical errors had been good, very good, or excellent; 38% of patients reported experiencing at least one specific error-related concern, most commonly misdiagnosis (22% of all patients), physician errors (16%), medication errors (16%), nursing errors (12%), and wrong test/procedure (10%). Concerns were associated with gender (p < 0.01), age (p < 0.0001), ethnicity (p < 0.001), length of stay (p < 0.001), ED volume (p < 0.0001), day of week (p < 0.0001), and hospital type (p < 0.0001). Concerns were highly related to a patient's willingness to return to the ED. CONCLUSIONS: The majority of ED patients felt relatively safe from medical errors, yet a significant percentage of patients experienced concern about a specific error during their emergency encounter. Concerns varied by both patient and hospital characteristics and were highly linked to patient satisfaction. The selective nature of concerns may suggest that patients are attuned to cues they perceive to be linked to specific medical errors, but efforts to involve patients in error detection/prevention programs will be challenging given the stressful and intimidating nature of ED encounters.     

Effect of gender on prehospital refusal of medical aid

Background

“Refusal of medical aid” (RMA) is the term commonly used by emergency medical technicians (EMTs) when someone calls 911 for care (usually the patient or a family member) but, after the initial encounter with the EMTs, the patient refuses emergency medical services transport to the hospital. Some intervention may have been performed, such as taking vital signs or an electrocardiogram, before the RMA. Although there have been multiple studies of the characteristics and outcomes of patients who RMA, little analysis has been done of the role of EMTs in these cases.

Objective

To analyze the association between EMT gender and the patient’s decision to refuse medical aid in the prehospital setting.

Methods

The study was performed using data from one hospital-based ambulance service in an urban setting that participates in the 911 system. This was a case control study that examined the data from consecutive patients who refused medical aid for a 1-year period compared to a control group of non-RMA patients.

Results

There was a significantly higher representation of all-male EMT teams in the RMA group (p < 0.0001). Using propensity score-matching methodology to control for other factors, all-male EMT teams were 4.75 times more likely to generate an RMA as compared to all-female and mixed-gender EMT teams (95% confidence interval 1.63–13.96, p = 0.0046).

Conclusion

We found that the gender of the EMTs was one of the most important factors associated with RMA, with a much higher frequency of RMAs occurring when both members of the team were male.     

Understanding how medications contribute to clinical deterioration and are used in rapid response systems: A comprehensive scoping review

BackgroundIn hospitals, rapid response systems (RRSs) identify patients who deteriorate and provide critical care at their bedsides to stabilise and escalate care. Medications, including oral and parenteral pharmaceutical preparations, are the most common intervention for hospitalised patients and the most common cause of harm. This connection between clinical deterioration and medication safety is poorly understood.ObjectivesTo inform improvements in prevention and management of clinical deterioration, this review aimed to examine how medications contributed to clinical deterioration and how medications were used in RRSs.Review methodsA scoping review was undertaken of medication data reported in studies of clinical deterioration or RRSs in diverse hospital settings between 2005 and 2017. Bibliographic database searches used permutations of “rapid response system,” “medical emergency team,” and keyword searching with medication-related terms. Independent selection, quality assessment, and data extraction informed mapping against four medication themes: causes of deterioration, predictors of deterioration, RRS use, and management.ResultsThirty articles were reviewed. Quality was low: limited by small samples, observational, single-centre designs and few primary medication-related outcomes. Adverse drug reactions and potentially preventable medication errors, involving sedatives, analgesics, and cardiovascular agents, contributed to clinical deterioration. While sparsely reported, outcomes included death and escalation of care. In children, administration of antibiotics or nebulised medications appeared to predict subsequent deterioration. Cardiovascular medications, sedatives, and analgesics commonly were used to manage deterioration but further detail was lacking. Despite reported potential for patient harm, evaluation of medication management systems was limited.ConclusionsMedications contributed to potentially preventable clinical deterioration, with considerable harm, and were common interventions for its management. When assessing deteriorating patients or caring for patients who require escalation to critical care, clinicians should consider medication errors and adverse reactions. Studies with more specific medication-related, patient-centred end points could reduce medication-related deterioration and refine RRS medication use and management.     

Family members’ experiences of “wait and see” as a communication strategy in end-of-life decisions

Purpose

The aim of this study is to examine family members’ experiences of end-of-life decision-making processes in Norwegian intensive care units (ICUs) to ascertain the degree to which they felt included in the decision-making process and whether they received necessary information. Were they asked about the patient’s preferences, and how did they view their role as family members in the decision-making process?

Methods

A constructivist interpretive approach to the grounded theory method of qualitative research was employed with interviews of 27 bereaved family members of former ICU patients 3–12 months after the patient’s death.

Results

The core finding is that relatives want a more active role in end-of-life decision-making in order to communicate the patient’s wishes. However, many consider their role to be unclear, and few study participants experienced shared decision-making. The clinician’s expression “wait and see” hides and delays the communication of honest and clear information. When physicians finally address their decision, there is no time for family participation. Our results also indicate that nurses should be more involved in family–physician communication.

Conclusions

Families are uncertain whether or how they can participate in the decision-making process. They need unambiguous communication and honest information to be able to take part in the decision-making process. We suggest that clinicians in Norwegian ICUs need more training in the knowledge and skills of effective communication with families of dying patients.

     

A review of rapid response team activation parameters in New Zealand hospitals

Objective

To review current systems for recognising and responding to clinically deteriorating patients in all New Zealand public hospitals.

Design

A cross-sectional study of recognition and response systems in all New Zealand public hospitals was conducted in October 2011. Copies of all current vital sign charts and/or relevant policies were requested. These were examined for vital sign based recognition and response systems. The charts or policies were also used to determine the type of system in use and the vital sign parameters and trigger thresholds that provoke a call to the rapid response team.

Setting

All New Zealand District Health Boards (DHBs).

Main outcome measures

Physiological parameters used to trigger rapid response, the weighting of any early warning score assigned to them, type of system used, values of physiological derangement that trigger maximal system response.

Results

All DHBs use aggregate scoring systems to assess deterioration and respond. A total of 9 different physiological parameters were scored with most charts (21%) scoring 6 different parameters. All scored respiratory rate, heart rate, systolic blood pressure and conscious level. 86% scored oliguria, 14% polyuria, 33% oxygen saturation and 24% oxygen administration. All systems used either aggregate scores or a single extreme parameter to elicit a maximal system response. The extremes of physiological derangement to which scores were assigned varied greatly with bradypnoea having the greatest range for what was considered grossly abnormal.

Conclusion

A large variance exists in the criteria used to detect deteriorating patients within New Zealand hospitals. Standardising both the vital signs chart and escalation criteria is likely to be of significant benefit in the early detection of and response to patient deterioration.     

Collaboration between family physicians and nurse clinicians: Opinions of graduates in family medicine

Objective

To determine whether graduating family physicians are exposed to collaboration between family physicians and nurse clinicians during their training, as well as their opinions about shared care between doctors and nurse clinicians in the delivery of patient care.

Design

Anonymous online survey.

Setting

Two French-Canadian university family medicine residency programs.

Participants

The 2010 and 2011 graduating family physicians (N = 343) from the University of Montreal and Laval University in Quebec.

Main outcome measures

The extent to which nurse clinicians in graduating family physicians’ training milieu were involved in preventive and curative patient care activities, and graduates’ opinions about nurse clinicians sharing care with physicians.

Results

Of 343 graduates, 186 (54.2%) participated in the survey. Although as residents in family medicine their exposure to shared care with nurse clinicians was somewhat limited, respondents indicated that they were generally quite open to the idea of sharing care with nurse clinicians. More than 70% of respondents agreed or strongly agreed that nurse clinicians could adjust, according to protocols of clinical guidelines, the treatment of patients with diabetes, hypertension, and asthma, as well as regulate medication for pain control in terminally ill patients. By contrast, respondents were less favourable to nurse clinicians adjusting the treatment of patients with depression. More than 80% of respondents agreed or strongly agreed that nurse clinicians could initiate treatment via a medical directive for routine hormonal contraception, acne, uncomplicated cystitis, and sexually transmitted infections. Respondents’ opinions on nurse clinicians initiating treatment for pharyngitis and otitis were more divided.

Conclusion

Graduating family physicians are quite open to collaborating with nurse clinicians. Although they have observed some collaboration between physicians and nurses, there are areas of shared clinical activities in which they would benefit from further exposure and training.     

Medical emergency teams: a strategy for improving patient care and nursing work environments

AIM: This paper reports a study of nurses' perceptions about medical emergency teams and their impact on patient care and the nursing work environment. BACKGROUND: In many acute care hospitals, nurses can summon emergency help by calling a medical emergency team, which is a team of expert critical care professionals adept at handling patient crisis scenarios. Critical care nurses form the core of such teams. In addition, of all the healthcare professionals, nurses are the ones who most often need and call for medical emergency team assistance. METHODS: A simple anonymous questionnaire distributed amongst 300 staff nurses at two sites of an acute care teaching hospital in the United States of America in mid-January of 2005. RESULTS: A total of 248 nurses responded to the survey (response rate = 82.7%). Ninety-three per cent of the nurses reported that medical emergency teams improved patient care and 84% felt that they improved the nursing work environment. Veteran nurses (with at least 10 years of experience) and new nurses (<1 year's experience) were more likely to perceive an improvement in patient care than other nurses (P = 0.025). Nurses who had called a medical emergency team on more than one occasion were more likely to value their ability to call a team (P = 0.002). Nearly sixty-five per cent of respondents said they would consider institutional medical emergency team response as a factor when seeking a new job in the future. Only 7% suggested a change in the team response process, and 4% suggested a change in activation criteria. CONCLUSIONS: Most nurses surveyed had a favourable opinion of the medical emergency team. Our findings suggest that other institutions should consider implementing a medical emergency team programme as a strategy to improve patient care and nurse working environment.     

The impact of a modified New Zealand Early Warning Score (M–NZEWS) and NZEWS on ward patients triggering a medical emergency team activation: A mixed methods sequential design

IntroductionLimited research exists on the effectiveness of the New Zealand Early Warning Score (NZEWS).AimTo determine the impact of a modified NZEWS (M–NZEWS) and NZEWS on ward patients’ medical emergency team activation triggers.Research designMixed methods sequential design.MethodsThree phases included: 1) review of M–NZEWS electronic data to determine the effect of a M–NZEWS and NZEWS on ward patients; 2) an in-depth review of 20 Māori patients allocated to lower escalation zones if the NZEWS were adopted and 3) the number of electronic medical emergency team activation triggers compared to the number of actual medical emergency team activations.Results1255 patients and 3505 vital sign data sets were analysed. Adopting the NZEWS would result in 396 (26.8%) fewer patients triggering a medical emergency team activation. The biggest impact would be on Māori, with 38.6% of Māori allocated to a lower escalation zone. Only 51.2% of patients with a medical emergency team activation had vital signs triggering the response electronically documented.ConclusionChanging from the M–NZEWS to NZEWS will reduce the number of medical emergency team activation triggers, with the biggest impact on Māori. Electronic vital sign data does not accurately reflect the number of ward medical emergency team triggers or activations.     

Key High‐efficiency Practices of Emergency Department Providers: A Mixed‐methods Study

Objective

The objective of this study was to determine specific provider practices associated with high provider efficiency in community emergency departments (EDs).

Methods

A mixed‐methods study design was utilized to identify key behaviors associated with efficiency. Stage 1 was a convenience sample of 16 participants (ED medical directors, nurses, advanced practice providers, and physicians) identified provider efficiency behaviors during semistructured interviews. Ninety‐nine behaviors were identified and distilled by a group of three ED clinicians into 18 themes. Stage 2 was an observational study of 35 providers was performed in four (30,000‐ to 55,000‐visit) community EDs during two 4‐hour periods and recorded in minute‐by‐minute observation logs. In Stage 3, each behavior or practice from Stage 1 was assigned a score within each observation period. Behaviors were tested for association with provider efficiency (relative value units/hour) using linear univariate generalized estimating equations with an identity link, clustered on ED site.

Results

Five ED provider practices were found to be positively associated with efficiency: average patient load, using name of team member, conversations with health care team, visits to patient rooms, and running the board. Two behaviors, “inefficiency practices,” demonstrated significant negative correlations: non–work‐related tasks and documentation on patients no longer in the ED.

Conclusions

Average patient load, running the board, conversations with team member, and using names of team members are associated with enhanced provider productivity. Identification of behaviors associated with efficiency can be utilized by medical directors, clinicians, and trainees to improve personal efficiency or counsel team members.

     

Closing the loop: best practices for cross-setting communication at ED discharge

Purpose

This study aimed to develop emergency department best practice guidelines for improved communication during patient care transitions.

Basic Procedures

To our knowledge, there are no specific guidelines for communication at the point of transition from the emergency department to the community. In Rhode Island, we used a multistage collaborative quality improvement process to define best practices for emergency department care transitions. We reviewed the medical literature, consensus statements, and materials from national campaigns; gathered preferences from emergency medicine and primary care clinicians; and created guidelines that we vetted with emergency medicine clinicians and other key stakeholders.

Main Findings

Because we did not find any guidelines that globally addressed care transitions from the emergency department, we drew from studies on patient discharge instructions and extrapolated from the evidence base available for other, related settings. Our key outcome is a set of care transition best practices for emergency departments, which can be implemented to establish measurable, communitywide expectations for cross-setting clinician-to-clinician communication. They include obtaining information about patients' outpatient clinicians, sending summary clinical information to downstream clinicians, performing modified medication reconciliation, and providing patients with effective education and written discharge instructions.

Principal Conclusions

The best practices provide feasible standards for evaluating and improving how patients transition out of the emergency department and can provide a framework for emergency department leaders expanding their collaboration with community partners, particularly in the context of emerging payment models. They also catalyze introspection and debate about how to improve communication and accountability across the care continuum.     

Medical Emergency Team syndromes and an approach to their management

Introduction  

Most literature on the medical emergency team (MET) relates to its effects on patient outcome. Less information exists on the most common causes of MET calls or on possible approaches to their management.