Journal of Nursing Administration:
Departments: Spotlight on Leadership
Recognition of Clinical Deterioration: A Clinical Leadership Opportunity for Nurse Executive
Swartz, Colleen DNP, MBA, RN
Author Affiliation: Chief Nurse Executive, University of Kentucky Healthcare, Lexington.
The author declares no conflicts of interest.
Correspondence: Dr Swartz, University of Kentucky Healthcare, 800 Rose Street, N-105, Lexington, KY 40536 (email@example.com).
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jonajournal.com).
Recognition and avoidance of further clinical deterioration can be termed a critical success factor in every care delivery model. As care resources become more constrained and allocated to the most critical of patients, some patients are being shifted to less intense and costly care settings where continuous physiologic monitoring may not be an option. Nurse executives are facing these complex issues as they work with clinical experts to develop systems of safety in the patient care arena. A systematic review of the literature related to the recognition of clinical deterioration is needed to identify areas for further leadership, research, and practice advancements
More than 100 years ago, Sir William Osler noted, “If you listen carefully to the patient they will tell you the diagnosis.”1 Even in the earlier years of clinical practice, the need to assimilate key messages signaling the care provider to take action was a clear and basic tenet of quality patient care. Recognition and avoidance of further clinical deterioration are critical success factors in every care delivery model. As care resources become more constrained and allocated to the most critical patients, care is being shifted to less intense and costly settings where continuous physiologic monitoring or increased nursing staffing levels may not be an option. The application of clinical gestalt and intuition by the care providers may not overcome the inadequacies of insufficient monitoring and assessment. Nurse executives are facing these complex issues as they work with clinical experts to develop systems of safety in patient care. A systematic review of the literature related to the recognition of clinical deterioration is indicated to focus areas for further research and practice advancements
The CINAHL EBSCO and PubMed databases were searched for topics related to clinical deterioration published between 1985 and 2010. Key words and concepts used included deterioration, rapid response teams, medical emergency teams, resuscitation, and combinations of key concepts and words including response to deterioration, resuscitation of deterioration, and recognition of deterioration. Results were limited to those presented in English.
An evidence summary table was created mapping samples, methods, findings, and grades of evidence (see Table, Supplemental Digital Content 1, http://links.lww.com/JONA/A230). The grading or strength of evidence was ranked according to specific criteria developed by Stetler and colleagues.2
Recognition of Deterioration
Buist3 defined “clinical futile cycles” of care that occur when much clinical activity is directed at the patient, but little of this activity relieves the dire circumstances experienced by the patient. These protracted cycles of care are a result of clinical culture, under appreciation of patient physiologic signaling and, perhaps, the increasingly chaotic and frenetic pace experienced by frontline caregivers, usually registered nurses (RNs). In addition, in teaching hospitals, the changing complexion of medical resident training has resulted in a reduction in resident availability (especially senior level residents) to discuss and deploy the necessary interventions to avert clinical deterioration.4 In nonteaching hospitals, the availability of resources such as hospitalists, nocturnists, and especially intensivists has become increasingly challenging based on physician manpower availability and cost concerns.5,6
The literature is replete with data regarding delays in deterioration recognition. These findings are present in literature related to cardiopulmonary arrest antecedents,7,9-11 genesis, and deployment of rapid response teams (RRTs) or medical evaluation teams (METs)12-15,16 and in recent interest in technology supporting the interpretation of deterioration and alerting of clinicians.17-21 Key findings from each manuscript are noted in brief in the annotated bibliography as well as delineation whether they are descriptive or interventional studies (see Table, Supplemental Digital Content 2, which shows the annotated bibliography, http://links.lww.com/JONA/A231).22-26
The absence of relevant information has not been supported as the problem, but the response to the information remains an area of concern. Hillman and colleagues7 identified that half of hospital deaths in their sample had physiologic abnormalities documented within 8 hours of death, and the same percentage had abnormalities in the period between 8 and 48 hours. Almost one-third of patients had the same serious abnormalities for the whole 48-hour period before death. More than 60% of patients had identifiable deterioration of vital signs before death. A similar finding was noted by Franklin and Mathew8 in that 66% of patients had documented clinical deterioration within 6 hours of the cardiopulmonary arrest. Unplanned intensive care unit (ICU) admission has been studied regarding the preemptive period leading up to the admission.9 A significant worsening of respiratory rate was noted in the 24 hours leading to ICU admission. The authors also noted that medical and nursing staff were aware of the patient deterioration but did not provide the appropriate treatment. A seminal article by Schein et al10 demonstrated that 84% of the patients had documented observations of clinical deterioration or new complaints within 8 hours of arrest. Seventy percent of patients had either deterioration of respiratory or mental function during the study period. Consistent findings were presented by Smith and Wood11 in that 51% of patients with in-hospital cardiopulmonary arrest had premonitory signs. Similarly, another study analyzing pre–cardiac arrest diaries of events noted that 76% of critical event patients had instability documented for more than 1 hour before the event, with a median duration of 6.5 hours.27
The MET or RRT is a concept that has been implemented as a system solution to address deterioration for more than a decade. Only 2 intervention studies were found related to the impact of MET. The Medical Emergency Response and Intervention Trial study conducted in Australia randomized 23 hospitals with the intervention of introduction of MET. The results demonstrated that MET calls greatly increased, but there was no significant impact on incidence of cardiac arrest, unplanned ICU admission, or unexpected death. Relative to recognition of clinical deterioration, the authors noted that in the unplanned ICU admission group, 50% had documented identifying criteria more than 15 minutes before the event, but only 30% of the patients had called the emergency team.15 Chan et al16 demonstrated a statistically significant reduction in hospital mortality in wards where the MET service was operating and demonstrated equivocal findings regarding hospital length of stay. A more recent systematic review and meta-analysis regarding RRTs demonstrated that collective implementation of RRT for adults was associated with a 33.8% reduction in rates of non-ICU-treated arrest. The pooled estimate regarding mortality trended toward the null and was not associated with lower mortality rates.16 Several other systematic reviews suggested no consistent improvement in clinical outcomes, and some studies were noted to have poor methodological quality.28-30
Studies identify barriers in prompt reporting of clinical deterioration. These barriers should be of particular concern to nurse leaders and nurse executives. Consistent themes include a lack of perception that the crisis was severe enough to warrant response and concerns regarding potential reprimand if the nurse bypassed physician notification in calling an RRT.31,32 Multiple layers of medical residents can complicate the relationship and reporting between nurse and physician in teaching environments. One characteristic that could contribute to suboptimal care was the concept of physicians and/or nurses experiencing information overload and thereby eroding perceptions regarding appropriate priorities and actions.10,11,33 Even with firm MET guidelines in place, a timely call for assistance given clinical deterioration remains problematic. Although the MET or RRT intuitively makes sense in providing a systemic response to deterioration, the activation of the team remains problematic, even in a mature/sophisticated system with evolved MET guidelines for activation.
Automation of Responses
Automation has been suggested as a vehicle to overcome many of the barriers noted above. Several recent studies demonstrate real potential in a single-channel, integrated monitoring system that could analyze conduction patterns of physiologic disturbance and report potential deterioration episodes to the appropriate individuals or team.17,18,34 Track and trigger systems use cultivated information from patient vital signs, integrated with a set of decision rules to discriminate between survivors and nonsurvivors using area under receiver operating characteristic curve.19-21 The variables needed to ensure prediction of clinical deterioration and an accurate early warning system continue to evolve. The sensitivity and specificity of any model require critical appraisal and relevance to the patient population. Future research and maturation of track and trigger systems are areas where nurse leaders can import clinical leadership and relevance to the practicing RN, adding value to the critical thinking required to preempt a deterioration event.
Implications for Nurse Leaders
Countermeasures to Optimize Early Recognition
Strategic considerations should be implemented to prioritize and implement effective countermeasures in the prevention or early detection of clinical deterioration. Initially, the ideal state would be to define certain physiologic values or trends that are early predictors of deterioration and automate the response based on a track and trigger system. Providing automation in this area would serve to neutralize many of the obstacles, such as fear of reprimand and lack of recognition. Automation and implementation of a track and trigger system are predicated on timely retrieval and entry of physiologic data. Nursing practice and workflow become an essential focal point for nurse executives. Prompt and timely recording of physiologic data is critical to optimize an early-warning system. Device integration at the bedside, especially in those areas where continuous physiologic monitoring is not conducted, should be prioritized. The ease of workflow for the RN and the unlicensed assistive personnel is vital to the success of early-warning systems. Creating standard work around this process and ensuring accountability related to standard adherence are areas of concentration for the nurse executive and nursing leadership. Ongoing and continuous monitoring of patient condition is an area of clinical practice seated firmly in the nursing domain. Leveraging technology to assist in critical thinking of the RN is a potent countermeasure that can result in systemic improvement in clinical care.
Any change in the care delivery model should be undertaken with an eye toward unintended consequences. Early-warning systems certainly have appeal given the potential impact on the early detection of deterioration. However, generating yet another alarm for the clinician to triage and potentially act upon certainly adds to an already complex landscape of critical thinking. In April 2013, The Joint Commission released a sentinel event alert on medical device alarm safety in hospitals.35 The number of alarm signals for inpatients in the current care environment easily reaches hundreds per day. The frequent alarms can quickly overwhelm the clinician, especially given the fact that between 85% and 99% do not require intervention.36 The issue of alarm management has been reported by the ECRI Institute since 2007. The RN at the bedside is typically the professional receiving, integrating, and making key decisions based on alarm inputs. The area of alarm management, alarm fatigue, clinical information systems, and meaningful use of clinical information generated by alarms provides fertile ground for future research as technology evolves and provides opportunities for improved clinical care.
The complexity of clinical care and the need for strong and coordinated interprofessional teams has become essential to achieve optimal clinical outcomes. Clinical assessment in a complex environment with multiple competing priorities and information overload at times continues to be one of the most value-added processes that RNs provide. Communication and coordination of care is 1 of the primary functions of the professional nurse. The sophistication of the critical thinking needed for this surveillance is often primarily acquired through experience. Creating standard work to guide nurse-to-physician communication regarding deterioration is essential for successful surveillance and disruption of the futile cycle of deterioration. Creative educational activities and competency establishment are rich opportunities for nurse executives. Setting a tone for clinical proficiency in this domain of care will impact every patient across the care system. Another essential consideration is the awareness of the RN that a track and trigger system is running and alerting the nurse that the system has issued an early-warning alert to the identified rescue team. Alerting the nurse then allows the nurse to respond concomitantly with the rescue team to refine assessment skills and engage actively in any necessary rescue. Nurses with critical thinking skills maintaining a high index of suspicion for clinical deterioration can certainly add value to the quest for a high-quality, low-cost care model.
Historically, much of the skill acquisition around critical thinking in the deterioration cycle has come from cumulative clinical experience and often from situations where deterioration was allowed to cycle until patient harm resulted. Nurse leaders can set a learning environment where this skill is acquired and honed to an exacting and precise skill set that significantly contributes to improved clinical outcomes and prevention of harm.
Simulation is a potential opportunity to allow practice of the skill in a safe environment. Simulation allows the RN to apply critical thinking and decision making with resulting variation in expression of outcome given the decision path chosen. Instruction should also be considered around the competency acquisition of communication effectiveness when a deterioration event occurs. Early recognition of deterioration and then prompt and accurate reporting can certainly promote an active and responsive system of care.
Today’s inpatient care units are overflowing with complex, acutely ill patients with the potential, at any time, for physiological instability. When destabilization occurs and clinical deterioration becomes evident, the system responsiveness must be failsafe. To create a system of precise, nonsubjective triggering of rescue systems, attention must be given by nurse leaders to communication, education, and process development that automate the triggering. This review of the literature demonstrates that knowledge of the deterioration is not the primary issue. The actionable data are present. Nursing leaders have opportunities for development of systems to address these vulnerabilities and opportunities. The execution of response to clinical deterioration presents a potential barrier to quality care based on multiple variables. Nurse executives must develop structures to support nursing autonomy and clinical empowerment. Interprofessional education and collaboration on multiple levels including simulation sessions will enable nurses to access physicians and other providers in nonthreatening communication patterns to discuss the signs and symptoms of clinical demise. The quest for a high-reliability organization is one that requires standard work development, then mechanisms for exacting and refining the execution of the work. Today’s care environments are dynamic and highly volatile. Introducing mechanisms to reduce variation in care and creating reliable processes require equally dynamic and versatile clinical leadership by the nurse executive. The nurse executive should set in motion a surveillance system to maximize the patient’s opportunity for exemplary clinical outcomes. Equipping the RN with tools and competencies for early detection of deterioration and supporting the effective, timely, and compelling communication of the data will create a countermeasure for clinical deterioration with the highest likelihood of preventing patient harm.
1. Bean RB. Sir William Osler: Aphorisms. New York, NY: Henry Shuman; 1950.
2. Stetler CB, Morsi D, Rucki S, et al. Utilization-focused integrative reviews in a nursing service. Appl Nurs Res. 1998; 11 (4): 195–206.
3. Buist M. The rapid response team paradox: why doesn’t anyone call for help? Crit Care Med. Feb 2008; 36 (2): 634–636.
4. Nuckols TK, Bhattacharya J, Wolman DM, Ulmer C, Escarce JJ. Cost implications of reduced work hours and workloads for resident physicians. N Engl J Med. 2009; 360 (21): 2202–2215.
5. Prasad M, Iwashyna T, Christie JD, et al. Effect of work-hours regulations on intensive care unit mortality in United States teaching hospitals. Crit Care Med. 2009; 37 (9): 2564–2569.
6. Shetty KD, Bhattacharya J. Changes in hospital mortality associated with residency work-hour regulations. Ann Intern Med. 2007; 147 (2): 73–80.
7. Hillman KM, Bristow PJ, Chey T, et al. Antecedents to hospital deaths. Intern Med J. 2001; 31 (6): 343–348.
8. Franklin C, Mathew J. Developing strategies to prevent inhospital cardiac arrest: analyzing responses of physicians and nurses in the hours before the event. Crit Care Med. 1994; 22 (2): 244–247.
9. Goldhill DR, White SA, Sumner A. Physiological values and procedures in the 24 h before ICU admission from the ward. Anaesthesia. 1999; 54 (6): 529–534.
10. Schein RM, Hazday N, Pena M, Ruben BH, Sprung CL. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest. 1990; 98 (6): 1388–1392.
11. Smith AF, Wood J. Can some in-hospital cardio-respiratory arrests be prevented? A prospective survey. Resuscitation. 1998; 37 (3): 133–137.
12. Quach JL, Downey AW, Haase M, Haase-Fielitz A, Jones D, Bellomo R. Characteristics and outcomes of patients receiving a medical emergency team review for respiratory distress or hypotension. J Crit Care. 2008; 23 (3): 325–331.
13. DeVita MA, Smith GB, Adam SK, et al. “Identifying the hospitalised patient in crisis”—a consensus conference on the afferent limb of rapid response systems. Resuscitation. 2010; 81 (4): 375–382.
14. Mitchell IA, McKay H, Van Leuvan C, et al. A prospective controlled trial of the effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients. Resuscitation. 2010; 81 (6): 658–666.
15. Hillman K, Chen J, Cretikos M, et al. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet. 2005; 365 (9477): 2091–2097.
16. Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Rapid response teams: a systematic review and meta-analysis. Arch Intern Med. 2010; 170 (1): 18–26.
17. Kho A, Rotz D, Alrahi K, et al. Utility of commonly captured data from an EHR to identify hospitalized patients at risk for clinical deterioration. AMIA…Annual Symposium proceedings/AMIA Symposium. AMIA Symposium. 2007: 404–408.
18. Tarassenko L, Hann A, Young D. Integrated monitoring and analysis for early warning of patient deterioration. Br J Anaesth. 2006; 97 (1): 64–68.
19. Smith GB, Prytherch DR, Schmidt PE, Featherstone PI, Higgins B. A review, and performance evaluation, of single-parameter “track and trigger” systems. Resuscitation. 2008; 79 (1): 11–21.
20. Smith GB, Prytherch DR, Schmidt PE, et al. Should age be included as a component of track and trigger systems used to identify sick adult patients? Resuscitation. 2008; 78 (2): 109–115.
21. Smith GB, Prytherch DR, Schmidt P, et al. Hospital-wide physiological surveillance-a new approach to the early identification and management of the sick patient. Resuscitation. 2006; 71 (1): 19–28.
22. Sax FL, Charlson ME. Medical patients at high risk for catastrophic deterioration. Crit Care Med. 1987; 15 (5): 510–515.
23. Goldhill DR, Sumner A. Outcome of intensive care patients in a group of British intensive care units. Crit Care Med. 1998; 26 (8): 1337–1345.
24. Sandroni C, Nolan J, Cavallaro F, Antonelli M. In-hospital cardiac arrest: incidence, prognosis and possible measures to improve survival. Intens Care Med. 2007; 33 (2): 237–245.
25. Priestley G, Watson W, Rashidian A, et al. Introducing Critical Care Outreach: a ward-randomised trial of phased introduction in a general hospital. Intens Care Med. 2004; 30 (7): 1398–1404.
26. McQuillan P, Pilkington S, Allan A, et al. Confidential inquiry into quality of care before admission to intensive care. BMJ. 1998; 316 (7148): 1853–1858.
27. Buist MD, Jarmolowski E, Burton PR, Bernard SA, Waxman BP, Anderson J. Recognising clinical instability in hospital patients before cardiac arrest or unplanned admission to intensive care: a pilot study in a tertiary-care hospital. Med J Aust. 1999; 171 (1): 22–25.
28. McGaughey J, Alderdice F, Fowler R, Kapila A, Mayhew A, Moutray M. Outreach and Early Warning Systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards. Cochrane Database Syst Rev. 2007; (3): CD005529.
29. Ranji SR, Auerbach AD, Hurd CJ, O’Rourke K, Shojania KG. Effects of rapid response systems on clinical outcomes: systematic review and meta-analysis. J Hosp Med. 2007; 2 (6): 422–432.
30. Schmid A, Hoffman L, Happ MB, Wolf GA, DeVita M. Failure to rescue: a literature review. J Nurs Adm. 2007; 37 (4): 188–198.
31. Jones D, Baldwin I, McIntyre T, et al. Nurses’ attitudes to a medical emergency team service in a teaching hospital. Qual Safety Health Care. 2006; 15 (6): 427–432.
32. Daffurn K, Lee A, Hillman KM, Bishop GF, Bauman A. Do nurses know when to summon emergency assistance? Intens Crit Care Nurs. 1994; 10 (2): 115–120.
33. Bedell SE, Deitz DC, Leeman D, Delbanco TL. Incidence and characteristics of preventable iatrogenic cardiac arrests. JAMA. 1991; 265 (21): 2815–2820.
34. Hravnak M, Edwards L, Clontz A, Valenta C, Devita MA, Pinsky MR. Defining the incidence of cardiorespiratory instability in patients in step-down units using an electronic integrated monitoring system. Arch Intern Med. 2008; 168 (12): 1300–1308.
35. Joint Commission on Accreditation of Healthcare Organizations. Medical device alarm safety in hospitals. Sentinel Event Alert. 2013; 50:1-3.
36. Keller JP, Diefes R, Graham K, et al. Why clinical alarms are a `top ten’ hazard: how you can help reduce the risk. Biomed Instrum Technol. 2011;suppl:17-23.
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