Patient deterioration : the effect of humans and systems in one health care system

Abstract

The failure to recognise and to respond to adult deteriorating patients in general hospital wards leads to unexpected and potentially preventable deaths. Aims. 1. To improve the understanding of the clinical processes and influences involved in managing patient deterioration. 2. To examine the effect of a deteriorating patient intervention on clinical processes and patient outcome. 3. To determine if the effects of a deteriorating patient intervention are sustainable. Methods. Quantitative Studies. i. Observational Study: Clinical processes in 34 patients undergoing 45 Medical Emergency Team reviews were examined retrospectively. ii. lnterventional Study: A prospective controlled trial, before and after a multifaceted intervention for managing patient deterioration was undertaken in two wards in two hospitals for two{u00AD} four month periods. Changes in deteriorating patient clinical processes and outcome were measured. iii. Sustainability Study: Adult patients admitted to two wards in one hospital during three four{u00AD} month periods, one before, one immediately after the patient deterioration intervention and one two years later. Changes in deteriorating patient clinical processes and outcome were measured. Qualitative Studies. i. Behavioural Study: Interviews of 12 healthcare workers involved in the patient deterioration intervention were undertaken to generate a model of why behaviour changed with the installation of the multifaceted intervention for managing patient deterioration. Grounded theory methodology described on page 80 was used. ii. Human Element Study: Focus groups of healthcare workers were held to generate discussion and used to generate a model of the influences on healthcare professionals in managing patient deterioration. Grounded theory methodology was used. Results. Clinical processes for managing patient deterioration were found to be deficient. Deficiencies included infrequent documentation of vital signs, particularly respiratory rate and limited involvement of senior decision makers leaving junior clinicians to manage patient deterioration, which delayed appropriate treatment. The multifaceted intervention significantly improved patient outcome and improved behaviour such as documentation of vital signs, supported by a hospital policy, and timeliness of medical review, triggered by more confident nursing staff underpinned by objective evidence (the modified early warning score) of patient deterioration. Improvement in timeliness of medical review and documentation of vital signs were sustained two years later but patient hospital outcome and the nurses calling for further medical help were not. Further investigation of behaviours that were not sustained revealed that junior medical and nursing staff lacked adequate clinical experience to facilitate timely decision making necessitating input from their consultants. Timely and appropriate communication was hindered through fear, lack of confidence or lack of knowledge and poor consultant approachability. Conclusion. Identified shortcomings in the teamwork managing patient deterioration improved with the installation of a multifaceted intervention and, improved patient hospital outcome. Significant behavioural issues, especially communication with consultants, were identified as likely to hamper further improvement. In an age of shift work and reduced clinical experience, enhanced decision making will need a more intelligent system that can accurately detect patients at risk of patient deterioration and improved access to consultants to gain maximal benefit from the healthcare team. Show more