Does resuscitation status affect decision making in a deteriorating patient? Results from a randomised vignette study

Aims and objectives: The aim of this paper is to determine the influence of do not attempt cardiopulmonary resuscitation (DNACPR) orders and the Universal Form of Treatment Options (‘UFTO’: an alternative approach that contextualizes the resuscitation decision within an overall treatment plan) on nurses' decision making about a deteriorating patient. Methods: An online survey with a developing case scenario across three timeframes was used on 231 nurses from 10 National Health Service Trusts. Nurses were randomised into three groups: DNACPR, the UFTO and no-form. Statements were pooled into four subcategories: Increasing Monitoring, Escalating Concern, Initiating Treatments and Comfort Measures. Results: Reported decisions were different across the three groups. Nurses in the DNACPR group agreed or strongly agreed to initiate fewer intense nursing interventions than the UFTO and no-form groups (P < 0.001) overall and across subcategories of Increase Monitoring, Escalate Concern and Initiate Treatments (all P < 0.001). There was no difference between the UFTO and no-form groups overall (P = 0.795) or in the subcategories. No difference in Comfort Measures were observed (P = 0.201) between the three groups. Conclusion: The presence of a DNACPR order appears to influence nurse decision making in a deteriorating patient vignette. Differences were not observed in the UFTO and no-form group. The UFTO may improve the way nurses modulate their behaviours towards critically ill patients with DNACPR status. More hospitals should consider adopting an approach where the resuscitation decisions are contextualised within overall goals of care

Ten rules to assess and manage the acutely deteriorating patient: a practical mnemonic

The acutely deteriorating patient is a challenge to even the most seasoned provider. The ability to diagnosis the underlying condition quickly and accurately is vital to a successful outcome. We present a review of 10 critical aspects in the management of the crashing patient, based on up-to-date guidelines and organized as an easily remembered mnemonic. The A-A-B-B-C-C-D-D-E-E's of the deteriorating patient address many key pearls and current recommendations to give physicians an added advantage in the moment of crisis

First do no harm: Teaching and assessing the recognition and rescue of deteriorating patients to nursing students

Failure to recognise and appropriately rescue the deteriorating patient is a global issue which has the potential to cause serious harm to patients. Such recognition and rescue of a deteriorating patient requires both technical and non-technical skills and there are multiple points for potential failure. The taking and recording of vital observations is one of the cornerstones of recognising deterioration. However, such observations are often delegated to students and the least experienced staff. This paper explores the teaching and assessment of under-graduate nursing students to recognise and arrange the rescue of a deteriorating patient within the first 16 weeks of their course. The paper describes the development of an integrated Objective Structured Clinical Examination (OSCE) and the subsequent evaluation of this using survey data, student performance results and unobtrusive methods. The results suggest that it is possible to use an integrated OSCE to assess students even at such an early stage in their course. Although data from other Higher Education Institutions in the UK suggests that integrated OSCEs at such an early stage are rare. The appropriate teaching of vital observations, structured hand off and reporting enable students to contribute to safer care and to adhere to the maxim “First Do No Harm”

DEveloping a Complex Intervention for DEteriorating Patients using Theoretical Modelling (DECIDE study): study protocol

AIM: To develop a theory-based complex intervention (targeting nursing staff), to enhance enablers and overcome barriers to enacting expected behaviour when monitoring patients and responding to abnormal vital signs that signal deterioration. DESIGN: A mixed method design including structured observations on hospital wards, field notes, brief, un-recorded interviews and semi-structured interviews to inform the development of an intervention to enhance practice. METHODS: Semi-structured interviews will be conducted with nursing staff using a topic guide informed by the Theoretical Domains Framework. Semi-structured interviews will be transcribed verbatim and coded deductively into the 14 Theoretical Domains Framework domains and then inductively into 'belief statements'. Priority domains will be identified and mapped to appropriate behaviour change techniques. Intervention content and mode of delivery (how behaviour change techniques are operationalised) will be developed using nominal groups, during which participants (clinicians) will rank behaviour change techniques /mode of delivery combinations according to acceptability and feasibility. Findings will be synthesised to develop an intervention manual. DISCUSSION: Despite being a priority for clinicians, researchers and policymakers for two decades, 'sub-optimal care' of the deteriorating ward patient persists. Existing interventions have been largely educational (i.e., targeting assumed knowledge deficits) with limited evidence that they change staff behaviour. Staff behaviour when monitoring and responding to abnormal vital signs is likely influenced by a range of mediators that includes barriers and enablers. IMPACT: Systematically applying theory and evidence-based methods, will result in the specification of an intervention which is more likely to result in behaviour change and can be tested empirically in future research. This article is protected by copyright. All rights reserved

The response to patient deterioration in the UK National Health Service - A survey of acute hospital policies.

BACKGROUND: The assessment of acute-illness severity in adult non-pregnant patients in the United Kingdom is based on early warning score (EWS) values that determine the urgency and nature of the response to patient deterioration. This study aimed to describe, and identify variations in, the expected clinical response outlined in 'deteriorating patient' policies/guidelines in acute NHS hospitals. METHODS: A copy of the local 'deteriorating patient' policy/guideline was requested from 152 hospitals. Each was analysed against pre-determined areas of interest, e.g., minimum expected vital sign observations frequency, expected response and expected staff response times. RESULTS: In the 55 responding hospitals (36.2%), the documented structure and process of the response to deterioration varied considerably. All hospitals used a 12-hourly minimum vital signs measurement frequency. Thereafter, for a low-risk patient, the minimum frequency varied from '6-12 hourly' to 'hourly'. Frequencies were higher for higher risk categories. Expected escalation responses were highly individualised between hospitals. Other than repeat observations, only nine (16.4%) documents described specific clinical actions for ward staff to consider/perform whilst awaiting responding personnel. Maximum permitted response times for medium-risk and high-risk patients varied widely, even when based on the same EWS. Only 33/55 documents (60%) gave clear instructions regarding who to contact 'out of hours'. CONCLUSIONS: The 'deteriorating patient' policies of the hospitals studied varied in their contents and often omitted precise instructions for staff. We recommend that individual hospitals review these documents, and that research and/or consensus are used to develop a national algorithm regarding the response to patient deterioration

Strengthening Critical Thinking in the New Entry, New Graduate Registered Nurse Population

Abstract Background: Nursing students’ transition to professional practice is lengthy. Guidelines for best practices for nurse residency programs exist, but when guidelines are not followed, new nurses suffer from increased burnout, increased turnover, and worsening job satisfaction. These issues are tied to a lack of critical thinking and clinical reasoning skills, which also results in a lack of recognition of patient deterioration. Objective: To improve new nurse recognition of a deteriorating patient and institute a practice change through a Doctor of Nursing Practice (DNP) project. The project goal was to strengthen critical thinking and clinical reasoning in the specified population, thereby improving their recognition of a deteriorating patient. Method: The method was a pretest-posttest project design. The inclusion criterion was any NENGRN resident who started between July 1, 2021 and November 1, 2021. The sample size was 15. After the pretest, the initial concept mapping and problem-based learning intervention began the week of hire. Concept mapping of a deteriorating patient case study intervention occurred bi-weekly. In theory, this strengthens critical thinking, clinical reasoning, and self-confidence in the NENGRN population. Results: There was an overall increase in posttest scores when compared to pretest critical thinking scores. The overall increase in critical thinking scores was 7%. The Critical Care cohort had a larger increase in their scores when compared to the Acute Care cohort. There is enough evidence to suggest repeating the project with a larger population of participants to see if the same results can be achieved

How actionable are staff behaviours specified in policy documents? A document analysis of protocols for managing deteriorating patients

BACKGROUND: To optimise care of deteriorating patients, healthcare organisations have implemented rapid response systems including an "afferent" and "efferent" limb. Afferent limb behaviours include monitoring vital signs and escalating care. To strengthen afferent limb behaviour and reduce adverse patient outcomes, the National Early Warning Score was implemented in the UK. There are no published reports of how National Early Warning Score guidance has translated into trust-level deteriorating patient policy and whether these documents provide clear, actionable statements guiding staff. AIM: To identify how deteriorating patient policy documents provide "actionable" behavioural instruction for staff, responsible for actioning the afferent limb of the rapid response system. DESIGN: A structured content analysis of a national guideline and local policies using a behaviour specification framework. METHODS: Local deteriorating patient policies were obtained. Statements of behaviour were extracted from policies; coded using a behaviour specification framework: Target, Action, Context, Timing and Actor and scored for specificity (1 = present, nonspecific; 2 = present, specific). Frequencies and proportions of statements containing elements of the Target, Action, Context, Timing and Actor framework were summarised descriptively. Reporting was guided by the COREQ checklist. RESULTS: There were more statements related to monitoring than escalation behaviour (65% vs 35%). Despite high levels of clear specification of the action (94%) and the target of the behaviour (74%), context, timing and actor were poorly specified (37%, 37% and 33%). CONCLUSION: Delay in escalating deteriorating patients is associated with adverse outcomes. Some delay could be addressed by writing local protocols with greater behavioural specificity, to facilitate actionability. RELEVANCE TO CLINICAL PRACTICE: Numerous clinical staff are required for an effective response to patient deterioration. To mitigate role confusion, local policy writers should provide clear specification of the actor. As the behaviours are time-sensitive, clear specification of the time frame may increase actionability of policy statements for clinical staff

Responding to a Deteriorating Patient: An Educational Intervention for Outpatient Clinic Nurses

Responding to a Deteriorating Patient: An Educational Intervention for Outpatient Clinic Nurses Background: Dynamic and evolving healthcare practices require nurses to continually acquire knowledge and confidence to provide optimal care. Organizations that recognize nurses’ educational needs and develop strategies to meet them empower nurses to improve the quality and safety of patient care. Local Problem: The need for a continuing education program to improve outpatient clinic nurses’ knowledge, skills, and self-confidence prompted the implementation of this project. Method: Single cohort education intervention as a test of change to assess the knowledge and confidence participants acquired in a pre- and post-survey using Berning’s 2018 questionnaire on nurses’ knowledge and recognition of early signs of clinical deterioration. Intervention: Two discrete educational intervention sessions, including (1) one-hour didactic session that reviewed vital signs and signs and symptoms of hypoglycemia, stroke, and cardiac arrest and (2) two hours of mock code using case scenarios of a patient with changes in vital signs of hypoglycemia, stroke, and cardiac arrest. Result: Twenty-one participants responded to the pre-implementation questionnaire, and sixteen responded to the post-implementation questionnaire. A non-statistically significant five percent increase in knowledge and confidence scores suggests improvement. Conclusion: An effective educational process with the support of stakeholders is an ongoing opportunity to build on nurses’ knowledge and confidence in the outpatient care setting

Responding to a Deteriorating Patient: An Educational Intervention for Outpatient Clinic Nurses

Responding to a Deteriorating Patient: An Educational Intervention for Outpatient Clinic Nurses Background: Dynamic and evolving healthcare practices require nurses to continually acquire knowledge and confidence to provide optimal care. Organizations that recognize nurses’ educational needs and develop strategies to meet them empower nurses to improve the quality and safety of patient care. Local Problem: The need for a continuing education program to improve outpatient clinic nurses’ knowledge, skills, and self-confidence prompted the implementation of this project. Method: Single cohort education intervention as a test of change to assess the knowledge and confidence participants acquired in a pre- and post-survey using Berning’s 2018 questionnaire on nurses’ knowledge and recognition of early signs of clinical deterioration. Intervention: Two discrete educational intervention sessions, including (1) one-hour didactic session that reviewed vital signs and signs and symptoms of hypoglycemia, stroke, and cardiac arrest and (2) two hours of mock code using case scenarios of a patient with changes in vital signs of hypoglycemia, stroke, and cardiac arrest. Result: Twenty-one participants responded to the pre-implementation questionnaire, and sixteen responded to the post-implementation questionnaire. A non-statistically significant five percent increase in knowledge and confidence scores suggests improvement. Conclusion: An effective educational process with the support of stakeholders is an ongoing opportunity to build on nurses’ knowledge and confidence in the outpatient care setting