A multi-facetted patient safety resource-A qualitative interview study on hospital managers' perception of the nurse-led Rapid Response Team.

AIM: To explore hospital managers' perceptions of the Rapid Response Team. DESIGN: An explorative qualitative study using semi-structured individual interviews. METHODS: In September 2019, a qualitative interview study including nineteen hospital managers at three managerial levels in acute care hospitals was conducted. Interview transcripts were analysed with an inductive content analysis approach, involving researcher triangulation in data collection and analysis processes. FINDINGS: One theme, 'A resource with untapped potential, enhancing patient safety, high-quality nursing, and organisational cohesion' was identified and underpinned by six categories and 30 sub-categories. CONCLUSION: The Rapid Response Team has an influence on the organization that goes beyond the team's original purpose. It strengthens the organization's dynamic cohesion by providing clinical support to nurses and facilitating learning, communication and collaboration across the hospital. Managers lack engagement in the team, including local key data to guide future quality improvement processes. IMPLICATIONS: For organizations, nursing, and patients to benefit from the team to its full potential, managerial engagement seems crucial. IMPACT: This study addressed possible challenges to using the Rapid Response Team optimally and found that hospital managers perceived this complex healthcare intervention as beneficial to patient safety and nursing quality, but lacked factual insight into the team's deliverances. The research impacts patient safety pointing at the need to re-organize managerial involvement in the function and development of the Rapid Response Team and System. REPORTING METHOD: We have adhered to the COREQ checklist when reporting this study. "No Patient or Public Contribution".

Transitional care model for older adults with multiple chronic conditions: An evaluation of benefits utilising an umbrella review.

AIMS: To synthesise and describe the combined evidence from systematic reviews of interventions using elements from the Transitional Care Model, on the content and timeframe of the interventions and the related improvement of outcomes for older patients with multiple chronic conditions. BACKGROUND: The population of older patients with multiple chronic conditions is increasing worldwide and trajectories are often complicated by risk factors. The Transitional Care Model may contain elements to support transitions between hospital and home. DESIGN: An umbrella review. REVIEW METHODS: A comprehensive search in five electronic databases was performed in April 2021 based on the search terms: 'Patients ≥60 years,' 'multi-morbidity,' 'Transitional care model,' 'Transitional care,' and 'Systematic review.' PRISMA guidelines was used. RESULTS: Five systematic reviews published from 2011 to 2020 comprising 62 intervention studies (59 randomised controlled trials and three quasi-experimental trials) were included in the review. The synthesis predominantly revealed significant improvements in decreasing re-admissions and financial costs and increasing patients' quality of life and satisfaction during discharge. CONCLUSION: The results of the review indicate that multiple elements from the Transitional Care Model have achieved significant improvements in older patients' transitions from hospital to home. Especially a combination of coordination, communication, collaboration and continuity of care in transitions, organised information and education for patients and pre-arranged structured post-discharge follow-ups. IMPACT: The transition from hospital to home is a complex process for older patients with multiple chronic conditions. A specific focus on coordination, continuity, and patient education should be implemented in the discharge process. Nurses with specialised knowledge in transitional care are needed to ensure safe transitions. PATIENT AND PUBLIC CONTRIBUTION: The umbrella review is part of a larger research program which involved a patient expert advisory board, which participated in discussing the relevance of the elements within the umbrella review.

How nurses use National Early Warning Score and Individual Early Warning Score to support their patient risk assessment practice: A fieldwork study.

AIM: To explore and describe how the National Early Warning Score (NEWS) and Individual Early Warning Score (I-EWS) are used and how they support nurses' patient risk assessment practice. DESIGN: A qualitative observational fieldwork study drawing on ethnographical principles was performed in six hospitals in two regions of Denmark in 2019. METHODS: Data were generated from participant observations and informal interviews with 32 nurses across 15 different wards in the hospitals. A total of 180 h of participant observation was performed. The observations lasted between 1.5 and 8 h and were conducted during day or evening shifts. RESULTS: NEWS and I-EWS supported nurses' observations of patients, providing useful knowledge for planning patient care, and prompting critical thinking. However, the risk assessment task was sometimes delegated to less experienced staff members, such as nursing students and healthcare assistants. The Early Warning Score (EWS) systems were often adapted by nurses according to contextual aspects, such as the culture of the speciality in which the nurses worked and their levels of competency. In some situations, I-EWS had the effect of enhancing nurse autonomy and responsibility for decision-making in relation to patient care. CONCLUSIONS: EWS systems support nurses' patient risk assessment practice, providing useful information. I-EWS makes it easier to factor the heterogeneity of patients and the clinical situation into the risk assessments. The delegation of risk assessment to other, less experienced staff members pose a risk to patient safety, which needs to be addressed in the ongoing debate regarding the shortage of nurses. IMPACT: The findings of this study can help ward nurses, hospital managers and policymakers to develop and improve strategies for improved person-centred nursing care.

Improving patient's intensive care admission through multidisciplinary simulation-based crisis resource management: A qualitative study.

AIM: To explore nurses' and physicians' experiences of simulation-based training in a crisis resource management quality improvement intervention on intensive care admission. BACKGROUND: Quantitative studies have documented that staffs' non-technical skills are improved after simulation-based training in crisis resource management interventions. Experienced-based consensus led to development of a quality improvement intervention based on principles of crisis resource management and tested in simulation-based training to enhance staffs' non-technical skills. However, the impact on staff is unexplored, leaving little understanding of the relationship between simulation-based training in crisis resource management interventions and changes in non-technical skills. DESIGN: A qualitative study with a hermeneutical approach. METHODS: Data consisted of semi-structured interviews with physicians (n = 5) and nurses (n = 15) with maximum variation in work experience. Data were collected 3 months after implementation and analysed using thematic analysis. The COREQ guideline was applied. RESULTS: The analysis revealed three themes: prioritising core clinical activities and patient centredness; transition into practice; and reflection on patient safety. These themes reflected staff's experiences of the intervention and implementation process, which evolved through prioritising core clinical activities that facilitated the transition into clinical practice and staff's reflection on patient safety. CONCLUSIONS: Prioritising core clinical activities were facilitated by clear communication, predefined roles and better teamwork. Transition into practice stimulated professional growth through feedback. Reflection on patient safety created a new understanding on how a new structure of intensive care admission could be implemented. Collectively, this indicated a joint understanding of admissions. IMPLICATIONS FOR PRACTICE: Findings enables health care professionals to understand how the intervention can contribute to improve quality of care in management of intensive care admission. Improving non-technical skills are vital in high-quality admissions, which supported a structured process and a collaborative professional standard of admissions. PATIENT AND PUBLIC CONTRIBUTION: None.

Interprofessional Collaboration Between Nurses and Physicians in the Perioperative Period.

PURPOSE: To explore nurses' and physicians' experiences of the six dimensions of interprofessional (IP) collaboration when using Goal-Directed Therapy (GDT), and to examine how existing protocols on GDT facilitate the six dimensions of IP collaboration. DESIGN: A qualitative design using individual semi-structured interviews and participant observations. METHODS: A secondary analysis of data from participant observation and semi-structured interviews with nurses (n= 23) and physicians (n=12) in three departments of anesthesiology. Observations and interviews were carried out from December 2016 to June 2017. A deductive, qualitative content analysis using the Inter-Professional Activity Classification as a categorization matrix was used to explore interprofessional collaboration as a barrier to implementation. This analysis was supplemented by a text analysis of two protocols. FINDINGS: Four dimensions were identified to influence IP collaboration: commitment, roles and responsibilities, interdependence, and integration of work practices. Negative factors included hierarchical boundaries, traditional nurse-physician relationship, unclear responsibility, and lack of shared knowledge. Positive factors included physician involvement of nurses in decisions and bedside education. The text-analysis showed a lack of clear directions of specific action and responsibility. CONCLUSIONS: Commitment and roles and responsibilities were dominant aspects of interprofessional collaboration in this context, causing problems for enhanced collaboration. Lack of clear guidance in the protocols might detract nurses' feelings of responsibility.

Rapid response teams-how and who? A protocol for a randomised clinical trial evaluating the composition of the efferent limb of the rapid response system.

BACKGROUND: Many patients experiencing deterioration have documented deviation of vital signs prior to the deterioration event. Increasing focus on these patients led to the rapid response systems and their configuration with afferent and efferent limbs. The two most prevalent team constellations in the efferent limb are the medical emergency team (MET), usually led by a doctor, and the critical care outreach team (CCOT), usually led by a nurse. The two constellations have not previously been examined in a comparative clinical trial. METHODS: This is a single centre non-inferiority randomised controlled trial of MET vs CCOT. All patients will be randomised at the time of the call. The intervention group will be the critical care outreach team. The primary outcome is mortality at 30 days and the occurrence of serious adverse events. All patients will be followed for 90 days. We aim to detect or reject a change of 7% in mortality whilst accepting a type I error of 5 and type II error of 20, using a sample size of maximum of 2000 individual patients. DISCUSSION: There is evidence supporting a benefit for the patient when using rapid response systems; however, earlier randomised studies are marked by cross-contamination and selection bias. Previous studies have primarily examined the effect of RRS on hospital cardiac arrests (IHCA) and mortality. Our study will be examining the effect on intensive care unit admissions as well as the ICHA and mortality. CONCLUSION: This study may highlight potential benefits of specific configurations of rapid response systems and their impact on safety outcomes.

Balancing responsibilities, rewards and challenges: A qualitative study illuminating the complexity of being a rapid response team nurse.

AIM AND OBJECTIVE: To explore Rapid Response Team nurses' perceptions of what it means being a Rapid Response Team nurse including their perceptions of the collaborative and organisational aspects of the rapid response team (RRT). BACKGROUND: For more than 20 years, RRT nurses have been on the frontline of critical situations in acute care hospitals. However, a few studies report nurses' perceptions of their role as RRT nurses, including collaboration with general ward nurses and physicians. This knowledge is important to guide development and adjustment of the RRT to benefit both patients' safety and team members' job satisfaction. DESIGN: Qualitative focus group interviews. METHODS: A qualitative approach was applied. Throughout 2018 and across three regions and three acute care settings in Denmark, eight focus group interviews were conducted in which 27 RRT nurses participated. Transcribed interviews were analysed using inductive content analysis. Reporting of this study followed the COREQ checklist. RESULTS: One overarching theme 'Balancing responsibilities, rewards, and challenges' was derived, comprising six categories: 'Becoming, developing and fulfilling the RRT nurse role', 'Helping patients as the core function of RRT', 'The RRT-call at its best', 'The obvious and the subtle RRT tasks', 'Carrying the burden of the RRT', and 'Organisational benefits and barriers for an optimal RRT'. CONCLUSION: Being a RRT nurse is a complex task. Nurses experience professional satisfaction and find it meaningful helping deteriorating patients. The inadequate resources available to train general ward staff how to manage basic clinical tasks are an added stress to nurses. RELEVANCE TO CLINICAL PRACTICE: Organisational managers need a better understanding of the necessary staffing requirements to attend patients' needs, train staff and handle the increasing acuity of ward patients. Failure to do so will be detrimental to patient outcomes and compromise RRT nurses' job satisfaction.

Nurse and Physician Perceptions of Working With Goal-Directed Therapy in the Perioperative Period.

PURPOSE: To explore nurse and physician perceptions of working with and collaborating about arterial wave analysis for goal-directed therapy to identify barriers and facilitators for use in anesthesia departments, postanesthesia care units, and intensive care units. DESIGN: A qualitative study drawing on ethnographic principles in a field study using the technique of nonparticipating observation and semistructured interviews. METHODS: Data collection occurred using semistructured interviews with nurses (n = 23) and physicians (n = 12) and field observations in three anesthetic departments. An inductive approach for content analysis was used. FINDINGS: The results showed one overarching theme Interprofessional collaboration encourage and impede based on three categories: (1) interprofessional and professional challenges; (2) obtaining competencies; and (3) understanding optimal fluid treatment. CONCLUSIONS: Several barriers identified related to interprofessional collaboration. Nurses and physicians were dependent on each other's skills and capabilities to use arterial wave analysis. Education of nurses and physicians is important to secure optimal use of goal-directed therapy.

"Struggling with practices" - a qualitative study of factors influencing the implementation of clinical quality registries for cardiac rehabilitation in England and Denmark.

BACKGROUND: The use of clinical quality registries as means for data driven improvement in healthcare seem promising. However, their use has been shown to be challenged by a number of aspects, and we suggest some may be related to poor implementation. There is a paucity of literature regarding barriers and facilitators for registry implementation, in particular aspects related to data collection and entry. We aimed to illuminate this by exploring how staff perceive the implementation process related to the registries within the field of cardiac rehabilitation in England and Denmark. METHODS: A qualitative, interview-based study with staff involved in collecting and/or entering data into the two case registries (England N = 12, Denmark N = 12). Interviews were analysed using content analysis. The Consolidated Framework for Implementation Research was used to guide interviews and the interpretation of results. RESULTS: The analysis identified both similarities and differences within and between the studied registries, and resulted in clarification of staffs´ experiences in an overarching theme: ´Struggling with practices´ and five categories; the data entry process, registry quality, resources and management support, quality improvement and the wider healthcare context. Overall, implementation received little focused attention. There was a lack of active support from management, and staff may experience a struggle of fitting use of a registry into a busy and complex everyday practice. CONCLUSION: The study highlights factors that may be important to consider when planning and implementing a new clinical quality registry within the field of cardiac rehabilitation, and is possibly transferrable to other fields. The results may thus be useful for policy makers, administrators and managers within the field and beyond. Targeting barriers and utilizing knowledge of facilitating factors is vital in order to improve the process of registry implementation, hence helping to achieve the intended improvement of care processes and outcomes.

Implementing mandatory early warning scoring impacts nurses' practice of documenting free text notes.

AIMS AND OBJECTIVES: To evaluate whether implementing the Modified Early Warning Scoring system impacts nurses' free text notes related to Airway, Breathing, Circulation and Pain in general ward medical and surgical patients. BACKGROUND: The quality of nursing documentation in patient health records is important to secure patient safety, but faces multiple challenges whether being paper-based or electronic. Nurses' ability to draw a complete picture of the patient situation is thereby compromised. Structured use of the Modified Early Warning Score, found to reduce unexpected death, might affect nurses' free text documentation of clinical observations. DESIGN: A prospective, pre- and postinterventional, nonrandomised study adhering to the EQUATOR guideline TREND. METHODS: Data on nurses' free text notes were obtained in 1,497 patient records during one preinterventional (March-June 2009) and two postinterventional study periods (September-December 2010 and March-June 2011) in a Danish university hospital. Data were organised by the Airway, Breathing and Circulation principles and by nurses' working shifts in the 56 hr surrounding the first recording of deviating vital parameters or a Modified Early Warning Score ≥ 2. Preinterventional free text notes were compared with notes from the two postinterventional periods, respectively. RESULTS: In the 8-hr working shift where deviations in vital parameters were recorded for the first time, nurses' free text notes related to patients' breathing (B) increased significantly, comparing 2009 with 2010 and 2011, respectively. In the 24 hr following initial deviations in vital parameters, a significant increase in free text notes was identified concerning Airway, Breathing and Circulation-related symptoms or problems. CONCLUSION: Mandatory use of the Modified Early Warning Score and related implementation activities significantly impacts nursing documentation of free text notes. RELEVANCE TO CLINICAL PRACTICE: Nurses' practice of communicating observed clinical symptoms by documenting free text notes should be supported through measures to enhance situation awareness.

The National Early Warning Score predicts mortality in hospital ward patients with deviating vital signs: A retrospective medical record review study.

AIMS AND OBJECTIVES: To evaluate whether the scale used for assessment of hospital ward patients could predict in-hospital and 30-day mortality amongst those with deviating vital signs; that is, that patients classified as medium or high risk would have increased risk of in-hospital and 30-day mortality compared to patients with low risk. BACKGROUND: The National Early Warning Score (NEWS) is a widely adopted scale for assessing deviating vital signs. A clinical risk scale that comes with the NEWS divides the risk for critical illness into three risk categories, low, medium and high. DESIGN: Retrospective analysis of vital sign data. METHODS: Logistic regression models for age-adjusted in-hospital and 30-day mortality were used for analyses of 1,107 patients with deviating vital signs. RESULTS: Patients classified as medium or high risk by NEWS experienced a 2.11 or 3.40 increase, respectively, in odds of in-hospital death (95% CI: 1.27-3.51, p = 0.004% and 95% CI: 1.90-6.01, p < 0.001) compared to low-risk patients. Moreover, those with NEWS medium or high risk were associated with a 1.98 or 3.19 increase, respectively, in odds of 30-day mortality (95% CI: 1.32-2.97, p = 0.001% and 95% CI: 1.97-5.18, p < 0.001). CONCLUSION: The NEWS risk classification seems to be a reliable predictor of mortality on patients in hospital wards. RELEVANCE TO CLINICAL PRACTICE: The NEWS risk classification offers a simple way to identify deteriorating patients and can aid the healthcare staff to prioritise amongst patients.

Bedside vital parameters that indicate early deterioration.

PURPOSE: The purpose of this paper is to determine associations between initially recorded deviations in individual bedside vital parameters that contribute to total Modified Early Warning Score (MEWS) levels 2 or 3 and further clinical deterioration (MEWS level=4). DESIGN/METHODOLOGY/APPROACH: This was a prospective study in which 27,504 vital parameter values, corresponding to a total MEWS level⩾2, belonging to 1,315 adult medical and surgical inpatient patients admitted to a 90-bed study setting at a university hospital, were subjected to binary logistic and COX regression analyses to determine associations between vital parameter values initially corresponding to total MEWS levels 2 or 3 and later deterioration to total MEWS level ⩾4, and to evaluate corresponding time intervals. FINDINGS: Respiratory rate, heart rate and patient age were significantly ( p=0.012, p<0.001 and p=0.028, respectively) associated with further deterioration from a total MEWS level 2, and the heart rate also ( p=0.009) from a total MEWS level 3. Within 24 h from the initially recorded total MEWS levels 2 or 3, 8 and 17 percent of patients, respectively, deteriorated to a total MEWS level=4. Patients initially scoring MEWS 2 had a 27 percent 30-day mortality rate if they later scored MEWS level=4, and 8.7 percent if they did not. PRACTICAL IMPLICATIONS: It is important to observe all patients closely, but especially elderly patients, if total MEWS levels 2 or 3 are tachypnoea and/or tachycardia related. ORIGINALITY/VALUE: Findings might contribute to patient safety by facilitating appropriate clinical and organizational decisions on adequate time spans for early warning scoring in general ward patients.

Nurses' Indications for Administration of Perioperative Intravenous Fluid Therapy-A Prospective, Descriptive, Single-Center Cohort Study.

PURPOSE: To examine whether nurse anesthetists and postanesthesia nurses' administration of intravenous (IV) fluid therapy during surgery and in the postanesthesia care unit is based on evidence. Secondarily to investigate if providing indications for IV fluid administration changed nursing practice. DESIGN: Prospective, descriptive, single-center study in Scandinavia comparing two cohorts. METHODS: Descriptive, fluid volume, and type data were obtained in both cohorts. Cohort 1 (n = 126) was used as baseline data. In cohort 2 (n = 130), nurses recorded indications for type and volume of fluid therapy using a validated list. Analysis compared median volumes of crystalloid or colloid fluids of surgical types by cohort. Analysis compared frequency of given indication reasons for each IV fluid by surgical type. FINDINGS: Basic static variables were chosen most frequently for indications of IV fluid needed for all surgeries except high-risk abdominal surgery where dynamic variables were more frequent. Signs and symptoms of inadequate tissue perfusion were only sparsely indicated. The volume of intraoperative crystalloid fluids was statistically different for patients with hip fracture surgery in cohort 2. Volumes of both colloid and crystalloid fluids were significantly higher for high-risk abdominal surgery in cohort 2. CONCLUSIONS: Nurse anesthetists and nurses in the postanesthesia care unit rely more on basic static parameters than signs of inadequate tissue perfusion when they make decisions about fluid administration. The indications cited for fluid administered to high-risk abdominal surgery and hip fracture patients did not always fit guidelines. This indicates the need of a stronger intervention to change practice to follow evidence-based clinical guidelines.

Handing over patients from the ICU to the general ward: A focused ethnographical study of nurses' communication practice.

AIM: To explore nursing practice and perception of engaging in communicative interaction when handing over multi-morbid patients from the ICU to general medical or surgical wards. BACKGROUND: Communication failures impose risks to patient safety. ICU and general ward nurses communicate in writing and verbally when handing over patients from one setting to another. A deeper understanding of nurses' communicative interaction and of nurses' perception of their interaction is crucial to facilitate clinical interventions focusing to improve patient safety. DESIGN: An explorative, qualitative design using focused ethnography was applied to the study. METHODS: Participant observation of 22 clinical situations of handing over patients from the ICU to general wards was conducted in November and December 2015, followed by five focus group interviews, three interviews with general ward nurses and two with ICU nurses in January-February 2016. Observation notes and interview transcripts were analysed using content analysis. FINDINGS: The theme "Communicative interaction as a process of sharing and adopting ownership" and the subtheme "Communicative interaction influenced by nurses individual expectations towards patient status and the handing over process" emerged from observation notes. From transcribed focus group interviews, the theme "Balancing and negotiating when passing on, consuming and adapting knowledge" was identified. CONCLUSION: A lack of shared goals regarding handing over patients from a high monitoring unit to general wards causes communicative and collaborative difficulties, loss of information and potential risks to patients. Organizational attention in relation to ICU discharge is crucial to improve collaboration, communication and patient safety.

Mandatory early warning scoring--implementation evaluated with a mixed-methods approach.

AIM: The aim of this study was to evaluate adherence to an intervention optimizing in-hospital monitoring practice, by introducing early warning scoring (EWS) of vital parameters. BACKGROUND: Interventions comprising EWS systems reduce in-hospital mortality, but evaluation of adherence to such interventions is required to correctly interpret interventional outcome. METHOD: Adherence was evaluated with a mixed-methods approach. Quantitative data, obtained pre-interventionally (2009) and postinterventionally (2010 and 2011), were used to calculate and compare time intervals between scorings of vital parameters. Semi-structured interviews were used to evaluate the implementation process. RESULTS: We found significant reductions in time intervals between measurements of vital parameters in 2011 compared to 2009. Scorings of vital parameters were repeated within 8 hours in 71-77% of patients scoring total modified EWS levels of 0, 2 or 4. The theme Motivation by clinical relevance and meaningfulness was identified as crucial to the implementation process. CONCLUSION: High adherence to an intervention may be strongly related to nurses' perceived clinical relevance of the intervention.

Impact of professionalism in nursing on in-hospital bedside monitoring practice.

AIM: This article reports a study exploring nursing practice of monitoring in-hospital patients including intra- and interprofessional communication and collaboration. BACKGROUND: Sub-optimal care in general in-hospital wards may lead to admission for intensive care, cardiac arrest, or sudden death. Reasons may include infrequent measurements of vital parameters, insufficient knowledge of their predictive values, and/or sub-optimal use of Medical Emergency Teams. This study was designed to improve understanding of nursing practice and to identify changes required to support nursing staff in improving standards of clinical monitoring practice and patient safety in general in-hospital wards. DESIGN: The study was designed as a qualitative descriptive clinical study, based on method triangulation including structured individual observations and semi-structured individual interviews. METHODS: In the spring of 2009, structured observations and semi-structured interviews of 13 nurses were carried out at a university hospital in Copenhagen, Denmark. The observational notes and interview transcriptions were analysed using content analysis. RESULTS: One theme (Professionalism influences nursing monitoring practice) and two sub-themes (Knowledge and skills and Involvement in clinical practice through reflections) were identified. Three categories (Decision-making, Sharing of knowledge, and Intra- and interprofessional interaction) were found to be associated with the theme, the sub-themes, and with each other. CONCLUSION: Clinical monitoring practice varies considerably between nurses with different individual levels of professionalism. Future initiatives to improve patient safety by further developing professionalism among nurses need to embrace individual and organizational attributes to strengthen their practice of in-hospital patient monitoring and management.

Clinical assessment as a part of an early warning score-a Danish cluster-randomised, multicentre study of an individual early warning score.

BACKGROUND: The clinical benefit of Early Warning Scores (EWSs) is undocumented. Nursing staff's clinical assessment might improve the prediction of outcome and allow more efficient use of resources. We aimed to investigate whether the combination of clinical assessment and EWS would reduce the number of routine measurements without increasing mortality. METHODS: We did a cluster-randomised, crossover, non-inferiority study at eight hospitals in Denmark. Patients aged 18 years or older, admitted for more than 24 h were included. Admissions to paediatric or obstetric wards were excluded. The participating hospitals were randomly assigned 1:1 to start as either intervention or control with subsequent crossover. Primary outcomes were 30-day all-cause mortality (non-inferiority margin=0·5%) and average number of EWS per day per patient. The intervention was implementation of the Individual EWS (I-EWS), in which nursing staff can adjust the calculated score on the basis of their clinical assessment of the patient. I-EWS was compared with the National Early Warning Score (NEWS). The study is registered at ClinicalTrials.gov, NCT03690128 and is complete. FINDINGS: Unique admissions longer than 24 h were included from Oct 15, 2018 to Sept 30, 2019. Of 90 964 patients assessed, n=46 470 were assigned to the I-EWS group and n=44 494 to the NEWS group. Mortality within 30 days was 4·6% for the I-EWS group, and 4·3% for the NEWS group (adjusted odds ratio 1·05 [95% CI 0·99-1·12], p=0·12). In subgroup analyses I-EWS showed increased 30-day mortality for hospitals that did I-EWS in fall-winter, which was probably due to seasonality, and within patients admitted in a surgical specialty. Overall risk difference was 0·22% (95% CI -0·04 to 0·48) meaning that the non-inferiority criteria were met. The average number of scorings per patient per day was reduced from 3·14 to 3·10 (ie, a relative reduction of 0·64% [95% CI -0·16 to -1·11], p=0·0084) in the I-EWS group. INTERPRETATION: Including clinical assessment in I-EWS was feasible and overall non-inferior to the widely implemented NEWS in terms of all-cause mortality at 30 days, and the number of routine measurements was minimally reduced. However I-EWS should be used with caution in surgical patients. FUNDING: Capital Region Research Foundation, Gangsted Foundation, Candys Foundation, Herlev-Gentofte Hospital Research Foundation, Laerdal Foundation, and The Foundation of Director Boennelycke and wife.

Nurses' Experiences and Perceptions of two Early Warning Score systems to Identify Patient Deterioration-A Focus Group Study.

AIMS: To explore Registered Nurses' experiences and perceptions with National Early Warning Score and Individual Early Warning Score to identify patient deterioration. DESIGN: A qualitative exploratory design. METHODS: Six focus groups were conducted at six Danish hospitals from February to June 2019. Registered Nurses from both medical, surgical and emergency departments participated. The focus groups were analysed using content analysis. RESULTS: One theme and four categories were identified. Theme: Meaningful in identifying patient deterioration but causing frustration due to lack of flexibility. Categories: (a) Inter-professional collaboration strengthened through the use of Early Warning Score systems, (b) Enhanced professional development and communication among nurses when using Early Warning Score systems, (c) Detecting patient deterioration by integrating nurses' clinical gaze with Early Warning Score systems and (d) Modification and fear of making mistakes when using Early Warning Score systems.

Adjusting Early Warning Score by clinical assessment: a study protocol for a Danish cluster-randomised, multicentre study of an Individual Early Warning Score (I-EWS).

INTRODUCTION: Track and trigger systems (TTSs) based on vital signs are implemented in hospitals worldwide to identify patients with clinical deterioration. TTSs may provide prognostic information but do not actively include clinical assessment, and their impact on severe adverse events remain uncertain. The demand for prospective, multicentre studies to demonstrate the effectiveness of TTSs has grown the last decade. Individual Early Warning Score (I-EWS) is a newly developed TTS with an aggregated score based on vital signs that can be adjusted according to the clinical assessment of the patient. The objective is to compare I-EWS with the existing National Early Warning Score (NEWS) algorithm regarding clinical outcomes and use of resources. METHOD AND ANALYSIS: In a prospective, multicentre, cluster-randomised, crossover, non-inferiority study. Eight hospitals are randomised to use either NEWS in combination with the Capital Region of Denmark NEWS Override System (CROS) or implement I-EWS for 6.5 months, followed by a crossover. Based on their clinical assessment, the nursing staff can adjust the aggregated score with a maximum of -4 or +6 points. We expect to include 150 000 unique patients. The primary endpoint is all-cause mortality at 30 days. Coprimary endpoint is the average number of times per day a patient is NEWS/I-EWS-scored, and secondary outcomes are all-cause mortality at 48 hours and at 7 days as well as length of stay. ETHICS AND DISSEMINATION: The study was presented for the Regional Ethics committee who decided that no formal approval was needed according to Danish law (J.no. 1701733). The I-EWS study is a large prospective, randomised multicentre study that investigates the effect of integrating a clinical assessment performed by the nursing staff in a TTS, in a head-to-head comparison with the internationally used NEWS with the opportunity to use CROS. TRIAL REGISTRATION NUMBER: NCT03690128.

A mixed methods exploration of intensive care unit nurses' perception of handling oxygen therapy to critically ill patients.

OBJECTIVES: Nurses handle supplementary oxygen to intensive care unit patients as part of their daily practise. To secure patients of optimal and safe care, knowledge of nurses' perception of this practise, including influencing factors for adjusting oxygenation levels is essential. This study aimed to explore intensive care nurses' perception of handling oxygenation and of factors that govern and influence this practise. RESEARCH METHODOLOGY/DESIGN: A mixed methods approach was applied comprising six focus group interviews, conducted in February/March 2017, leading to construction of a questionnaire distributed to 535 ICU nurses in September 2017. Following a process of content analysis, the findings were discussed against Gittell's framework for relational coordination. SETTING: Intensive care units in rural, urban and university hospital settings. MAIN OUTCOME: A deeper understanding of nurses' perception of handling oxygenation to patients in the intensive care unit. FINDINGS AND RESULTS: Findings are presented through the categories Treatment Guidance, Nursing Practise, Knowledge and Competences and Inter-professional Collaboration. CONCLUSION: Nurses' practise of handling supplementary oxygen therapy to the intensive care patient is influenced by day-by-day physician prescribed upper and lower limits for pO2 and pCO2, by nurses' understanding of the individual clinical patient situation and by knowledge of pros and cons in relation to oxygen therapy including observational and clinical assessment expertise. Establishing working environments in the intensive care unit setting based on mutual inter- and intra-professional respect may contribute to enhance safe and high quality patient care.