Identifying barriers and facilitators to recognition and response to patient clinical deterioration by clinicians using a behaviour change approach: A qualitative study.

BACKGROUND: Failure of clinicians to recognise and respond to patient clinical deterioration is associated with increased hospital mortality. Emergency response teams are implemented throughout hospitals to support direct-care clinicians in managing patient deterioration, but patient clinical deterioration is often not identified or acted upon by clinicians in ward settings. To date, no studies have used an integrative theoretical framework in multiple sites to examine why clinicians' delay identification and action on patients' clinical deterioration. AIM: To identify barriers and facilitators that influence clinicians' absent or delayed response to patient clinical deterioration using the Theoretical Domains Framework. METHODS: The Theoretical Domains Framework guided: (a) semi-structured interviews with clinicians, health consumers and family members undertaken at two sites; (b) deductive analyses of inductive themes to identify barriers and facilitators to optimal care. This study complied with the COREQ research guidelines. FINDINGS: Seven themes identified: (a) information transfer; (b) ownership of patient care; (c) confidence to respond; (d) knowledge and skills; (e) culture; (f) emotion; and (g) environmental context and resources. DISCUSSION: The Theoretical Domains Framework identified traditional social and professional hierarchies and limitations due to environmental contexts and resources as contributors to diminished interprofessional recognition and impediments to the development of effective relationships between professional groups. Communication processes were impacted by these restraints and further confounded by inadequate policy development and limited access to regular effective team-based training. As a result, patient safety was compromised, and clinicians frustrated. CONCLUSIONS: These results inform the development, implementation and evaluation of a behaviour change intervention and increase knowledge about barriers and facilitators to timely response to patient clinical deterioration. RELEVANCE TO CLINICAL PRACTICE: Results contribute to understanding of why clinicians delay responding to patient clinical deterioration and suggest key recommendations to identify and challenge traditional hierarchies and practices that prevent interdisciplinary collaboration and decision-making.

Are Postoperative Clinical Outcomes Influenced by Length of Stay in the Postanesthesia Care Unit?

PURPOSE: To compare clinical outcomes of patients who required a prolonged length of stay in the postanesthesia care unit (PACU) with a control group. DESIGN: A single-center purposive-sampled retrospective medical record and database audit. METHODS: Patients with prolonged PACU stays were compared to a group of patients whose stay was less than median for outcome measures: rapid response team (RRT) activation, cardiac arrest, unanticipated intensive care unit admissions, and survival to discharge. FINDINGS: A total of 1,867 patients were included in the analysis (n = 931 prolonged stay and n = 933 control group). Prolonged stay in PACU was higher among patients who were older, had higher American Society of Anesthesiologist score, and were discharged to wards during the afternoon or late nursing shift. RRT activation after discharge from PACU occurred in more patients in the study group compared with the control group (7% vs 1%, respectively). There were no cardiac arrests recorded in either group within the 24 hours after PACU discharge period. CONCLUSIONS: Prolonged stay in the PACU for 2 or more hours because of clinical reasons appears to be associated with a higher incidence of clinical deterioration in the ward setting requiring RRT intervention within 24 hours after discharge from PACU.

Effect of a 2-tier rapid response system on patient outcome and staff satisfaction.

BACKGROUND: Rapid response systems (RRS) have been recommended as a strategy to prevent and treat deterioration in acute care patients. Questions regarding the most effective characteristics of RRS and strategies for implementing these systems remain. AIMS: The aims of this study were to (i) describe the structures and processes used to implement a 2-tier RRS, (ii) determine the comparative prevalence of deteriorating patients and incidence of unplanned intensive care unit (ICU) admission and cardiac arrest prior to and after implementation of the RRS, and (iii) determine clinician satisfaction with the RRS. METHOD: A quasi-experimental pre-test, post-test design was used to assess patient related outcomes and clinician satisfaction prior to and after implementation of a 2-tier RRS in a tertiary metropolitan hospital. Primary components of the RRS included an ICU Outreach Nurse and a Rapid Response Team. Prevalence of deteriorating patients was assessed through a point prevalence assessment and chart audit. Incidence of unplanned admission to ICU and cardiac arrests were accessed from routine hospital databases. Clinician satisfaction was measured through surveys. RESULTS: Prevalence of patients who met medical emergency call criteria without current treatment reduced from 3% prior to RRS implementation to 1% after implementation; a similar reduction from 9% to 3% was identified on chart review. The number of unplanned admissions to ICU increased slightly from 17.4/month prior to RRS implementation to 18.1/month after implementation (p=0.45) while cardiac arrests reduced slightly from 7.5/month to 5.6/month (p=0.22) but neither of these changes were statistically significant. Staff satisfaction with the RRS was generally high. CONCLUSION: The 2-tier RRS was accessed by staff to assist with care of deteriorating patients in a large, tertiary hospital. High levels of satisfaction have been reported by clinical staff.

Right person, right skills, right job: the contribution of objective structured clinical examinations in advancing staff nurse experts.

Recruitment processes need to discriminate among candidates to ensure that the right person with the right skills is selected for advancement opportunities. An innovative recruitment process using an objective structured clinical examination grounded in best practice guidelines resulted in improved recruitment practices for senior nursing clinical expert roles. Candidates' skills, knowledge, and attitudes in the areas of patient focus, clinical expertise, teamwork, and leadership were assessed using a clinical simulation. Candidates achieving advancement were assessed at 6 months to validate the efficacy of the process.