Advertisement

Clinicians’ attitudes towards escalation and management of deteriorating patients: A cross-sectional study

Published:April 27, 2022DOI:https://doi.org/10.1016/j.aucc.2022.03.004

      Abstract

      Background

      Internationally, rapid response systems have been implemented to recognise and categorise hospital patients at risk of deterioration. Whilst rapid response systems have been implemented with a varying amount of success, there remains ongoing concern about the lack of improvement in the escalation, and management of the deteriorating patient. It also remains unclear why some clinicians fail to escalate concerns for the deteriorating patient.

      Objective

      The objective of this study was to explore clinicians’ attitudes towards the escalation, and management of the deteriorating patient.

      Methods

      A cross-sectional online survey of conveniently sampled clinicians from the acute care sector in a regional health district in Australia was conducted. The Clinicians’ Attitudes towards Responding and Escalating care of Deteriorating patients scale, was used to explore attitudes towards the escalation and management of the deteriorating patient.

      Results

      Survey responses were received from medical officers (n = 43), nurses (n = 677), allied health clinicians (n = 60), and students (n = 57). Years of experience was significantly associated with more confidence responding to deteriorating patients (p < .001) and significantly less fears about escalating care (p < .001). Nurses (M = 4.16, SD = .57) and students (M = 4.11, SD = .55) in general had significantly greater positive beliefs that the rapid response system would support them to respond to the deteriorating patient than allied health (M = 3.67, SD = .64) and medical (M = 3.87, SD = .54) clinicians, whilst nurses and medical clinicians had significantly less fear about escalating care and greater confidence in responding to deteriorating patients than allied health clinicians and healthcare students (p < .001).

      Conclusion

      Nurses and medical officers have less fear to escalate care and greater confidence responding to the deteriorating patient than allied health clinicians and students. Whilst the majority of participants had positive perceptions towards the rapid response system, those with less experience lacked the confidence to escalate care and respond to the deteriorating patient.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Australian Critical Care
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Andersen L.W.
        • Kim W.Y.
        • Chase M.
        • Berg K.-M.
        • Mortensen S.J.
        • Moskowitz A.
        • et al.
        The prevalence and significance of abnormal vital signs prior to in-hospital cardiac arrest.
        Resuscitation. 2015; 98: 112-117https://doi.org/10.1016/j.resuscitation.2015.08.016
        • Maharaj R.
        • Raffaele I.
        • Wendon J.
        Rapid response systems: a systematic review and meta-analysis.
        Crit Care. 2015; 19: 254https://doi.org/10.1186/s13054-015-0973-y
        • Cardona-Morrell M.
        • Prgomet M.
        • Lake R.
        • Nicholson M.
        • Harrison R.
        • Long J.
        • et al.
        Vital signs monitoring and nurse–patient interaction: a qualitative observational study of hospital practice.
        Int J Nurs Stud. 2016; 56: 9-16https://doi.org/10.1016/j.ijnurstu.2015.12.007
        • Lennox A.
        • Wright B.
        • Bragge P.
        How can we improve escalation of patient deterioration in the hospital setting? Briefing document. BehaviourWorks.
        Monash University, Australia2018
        • Seymour C.W.
        • Kahn J.M.
        • Martin-Gill C.
        • Callaway C.W.
        • Yealy D.M.
        • Scales D.
        • et al.
        Delays from first medical contact to antibiotic administration for sepsis.
        Crit Care Med. 2017; 45: 759-765https://doi.org/10.1097/ccm.0000000000002264
        • Massey D.
        • Chaboyer W.
        • Anderson V.
        What factors influence ward nurses' recognition of and response to patient deterioration? An integrative review of the literature.
        Nurs Open. 2017; 4: 6-23https://doi.org/10.1002/nop2.53
        • Devita M.A.
        • Bellomo R.
        • Hillman K.
        • Kellum J.
        • Rotondi A.
        • Teres D.
        • et al.
        Findings of the first consensus conference on medical emergency teams.
        Crit Care Med. 2006; 34: 2463-2478https://doi.org/10.1097/01.Ccm.0000235743.38172.6e
        • Australian Commission on Safety and Quality in Health Care
        Recognising and responsing to acute deterioration standard.
        2019
        • Australian Commision on Safety and Quality in Health Care
        National consensus statement: essential elements for recognising and responding to acute physiological deterioration.
        3rd ed. ACSQHC, Sydney2021
        • Bhonagiri D.
        • Lander H.
        • Green M.
        • Straney L.
        • Jones D.
        • Pilcher D.
        Reduction of in-hospital cardiac arrest rates in intensive care-equipped New South Wales hospitals in association with implementation of between the flags rapid response system.
        Intern Med J. 2021; 51: 375-384https://doi.org/10.1111/imj.14812
        • Aitken L.M.
        • Chaboyer W.
        • Vaux A.
        • Crouch S.
        • Burmeister E.
        • Daly M.
        • et al.
        Effect of a 2-tier rapid response system on patient outcome and staff satisfaction.
        Aust Crit Care. 2015; 28: 107-114https://doi.org/10.1016/j.aucc.2014.10.044
        • Bingham G.
        • Fossum M.
        • Barratt M.
        • Bucknall T.
        Clinical review criteria and medical emergency teams: evaluating a two-tier rapid response system.
        Crit Care Resusc. 2015; 17: 167-173
        • Aneman A.
        • Frost S.A.
        • Parr M.J.
        • Hillman K.M.
        Characteristics and outcomes of patients admitted to ICU following activation of the medical emergency team: impact of introducing a two-tier response system.
        Crit Care Med. 2015; 43: 765-773https://doi.org/10.1097/ccm.0000000000000767
        • Clinical Excellence Commission
        Between the flags.
        2021
        • Jones D.
        • Mitchell I.
        • Hillman K.
        • Story D.
        Defining clinical deterioration.
        Resuscitation. 2013; 84: 1029-1034https://doi.org/10.1016/j.resuscitation.2013.01.013
        • Devita M.A.
        • Hillman K.
        • Bellomo R.
        • Odell M.
        • Jones D.A.
        • Winters B.D.
        • et al.
        Rapid response systems: history and terminology.
        in: Devita M.A. Hillman K. Bellomo R. Textbook of rapid response systems. Springer International Publishing, 2017: 17-24
        • Alam N.
        • Hobbelink E.L.
        • van Tienhoven A.J.
        • van de Ven P.M.
        • Jansma E.P.
        • Nanayakkara P.W.B.
        The impact of the use of the early warning score (EWS) on patient outcomes: a systematic review.
        Resuscitation. 2014; 85: 587-594https://doi.org/10.1016/j.resuscitation.2014.01.013
        • Gong X.-Y.
        • Wang Y.-G.
        • Shao H.-Y.
        • Lan P.
        • Yan R.-S.
        • Pan K.-H.
        • et al.
        A rapid response team is associated with reduced overall hospital mortality in a Chinese tertiary hospital: a 9-year cohort study.
        Ann Transl Med. 2020; 8: 317https://doi.org/10.21037/atm.2020.02.147
        • O'Connell A.
        • Flabouris A.
        • Thompson C.H.
        Optimising the response to acute clinical deterioration: the role of observation and response charts.
        Intern Med J. 2020; 50: 790-797https://doi.org/10.1111/imj.14444
        • Hughes C.
        • Pain C.
        • Braithwaite J.
        • Hillman K.
        ‘Between the flags’: implementing a rapid response system at scale.
        BMJ Qual Saf. 2014; 23: 714-717https://doi.org/10.1136/bmjqs-2014-002845
        • Currey J.
        • Allen J.
        • Jones D.
        Critical care clinician perceptions of factors leading to medical emergency team review.
        Aust Crit Care. 2018; 31: 87-92https://doi.org/10.1016/j.aucc.2017.03.003
        • O'Neill S.M.
        • Clyne B.
        • Bell M.
        • Casey A.
        • Leen B.
        • Smith S.M.
        • et al.
        Why do healthcare professionals fail to escalate as per the early warning system (EWS) protocol? A qualitative evidence synthesis of the barriers and facilitators of escalation.
        BMC Emerg Med. 2021; 21 (15): 15https://doi.org/10.1186/s12873-021-00403-9
        • Ede J.
        • Westgate V.
        • Petrinic T.
        • Darbyshire J.
        • Watkinson P.J.
        How human factors affect escalation of care: a protocol for a qualitative evidence synthesis of studies.
        BMJ Open. 2019; 9: e025969https://doi.org/10.1136/bmjopen-2018-025969
        • Petersen J.A.
        • Rasmussen L.S.
        • Rydahl-Hansen S.
        Barriers and facilitating factors related to use of early warning score among acute care nurses: a qualitative study.
        BMC Emerg Med. 2017; 17 (36): 36https://doi.org/10.1186/s12873-017-0147-0
        • Burke J.R.
        • Downey C.
        • Almoudaris A.M.
        Failure to rescue deteriorating patients: a systematic review of root causes and improvement strategies.
        J Patient Saf. 2020; https://doi.org/10.1097/pts.0000000000000720
        • Allen E.
        • Elliott D.
        • Jackson D.
        Recognising and responding to in-hospital clinical deterioration: an integrative review of interprofessional practice issues.
        J Clin Nurs. 2017; 26: 3990-4012https://doi.org/10.1111/jocn.13839
        • Chua W.L.
        • Rahim N.R.B.A.
        • McKenna L.
        • Ho J.T.Y.
        • Liaw S.Y.
        Intraprofessional collaboration between enrolled and registered nurses in the care of clinically deteriorating ward patients: a qualitative study.
        Aust Crit Care. 2021; https://doi.org/10.1016/j.aucc.2021.01.009
        • Thiele L.
        • Flabouris A.
        • Thompson C.
        Acute clinical deterioration and consumer escalation in the hospital setting: a literature review.
        Resuscitation. 2020; 156: 72-83https://doi.org/10.1016/j.resuscitation.2020.08.011
        • Dwyer T.A.
        • Flenady T.
        • Kahl J.
        • Quinney L.
        Evaluation of a patient and family activated escalation system: ryan's rule.
        Aust Crit Care. 2020; 33: 39-46https://doi.org/10.1016/j.aucc.2019.01.002
        • Australian Institute of Health and Welfare
        Rural & remote health Canberra.
        AIHW, 2019
        • Chua W.L.
        • Tee A.
        • Hassan N.B.
        • Jones D.
        • Tam W.W.S.
        • Liaw S.Y.
        The development and psychometric evaluation of the clinicians' attitudes towards responding and escalating care of deteriorating patients scale.
        Aust Crit Care. 2021; 34: 340-349https://doi.org/10.1016/j.aucc.2020.08.008
        • Rusticus S A.
        • Lovato C Y.
        Impact of sample size and variability on the power and type I error rates of equivalence tests: a simulation study.
        Practical Assess Res Eval. 2014; 19: 1-10
        • Bland J.M.
        • Altman D.G.
        Statistics notes: cronbach's alpha.
        BMJ. 1997; 314 (72): 572https://doi.org/10.1136/bmj.314.7080.572
        • Leonard-Roberts V.
        • Currey J.
        • Considine J.
        Emergency nurses' perceptions of their role in responding to escalations of care for clinical deterioration.
        Australas Emerg Care. 2020; 23: 233-239https://doi.org/10.1016/j.auec.2020.03.002
        • Makarem A.
        • Heshmati-Nabavi F.
        • Afshar L.
        • Yazdani S.
        • Pouresmail Z.
        • Hoseinpour Z.
        The comparison of professional confidence in nursing students and clinical nurses: a cross-sectional study.
        Iran J Nurs Midwifery Res. 2019; 24: 261-267https://doi.org/10.4103/ijnmr.IJNMR_102_17
        • Smith D.
        • Cartwright M.
        • Dyson J.
        • Hartin J.
        • Aitken L.M.
        Barriers and enablers of recognition and response to deteriorating patients in the acute hospital setting: a theory-driven interview study using the theoretical domains framework.
        J Adv Nurs. 2021; 77: 2831-2844https://doi.org/10.1111/jan.14830
        • Chua W.L.
        • See M.T.A.
        • Legio-Quigley H.
        • Jones D.
        • Tee A.
        • Liaw S.Y.
        Factors influencing the activation of the rapid response system for clinically deteriorating patients by frontline ward clinicians: a systematic review.
        Int J Qual Health Care. 2017; 29: 981-998https://doi.org/10.1093/intqhc/mzx149
        • Lee W.
        • Kim M.
        • Kang Y.
        • Lee Y.J.
        • Kim S.M.
        • Lee J.
        • et al.
        Nursing and medical students' perceptions of an interprofessional simulation-based education: a qualitative descriptive study.
        Korean J Med Educ. 2020; 32: 317-327https://doi.org/10.3946/kjme.2020.179
        • Sharp S.
        • McAllister M.
        • Broadbent M.
        The tension between person centred and task focused care in an acute surgical setting: a critical ethnography.
        Collegian. 2018; 25: 11-17https://doi.org/10.1016/j.colegn.2017.02.002
        • Braithwaite J.
        • Herkes J.
        • Ludlow K.
        • Testa L.
        • Lamprell G.
        Association between organisational and workplace cultures, and patient outcomes: systematic review.
        BMJ Open. 2017; 7 (e08): e017708https://doi.org/10.1136/bmjopen-2017-017708
        • Anderson V.L.
        • Johnston A.N.B.
        • Massey D.
        • Bamford-Wade A.
        Impact of MAGNET hospital designation on nursing culture: an integrative review.
        Contemp Nurse. 2018; 54: 483-510https://doi.org/10.1080/10376178.2018.1507677
        • Della Ratta C.
        Challenging graduate nurses' transition: care of the deteriorating patient.
        J Clin Nurs. 2016; 25: 3036-3048https://doi.org/10.1111/jocn.13358
        • Al-Moteri M.
        • Plummer V.
        • Cooper S.
        • Symmons M.
        Clinical deterioration of ward patients in the presence of antecedents: a systematic review and narrative synthesis.
        Aust Crit Care. 2019; 32: 411-420https://doi.org/10.1016/j.aucc.2018.06.004
        • Marufu T.C.
        • Collins A.
        • Vargas L.
        • Gillespie L.
        • Almghairbi D.
        Factors influencing retention among hospital nurses: systematic review.
        Br J Nurs. 2021; 30: 302-308https://doi.org/10.12968/bjon.2021.30.5.302
        • Jarvelainen M.
        • Cooper S.
        • Jones J.
        Nursing students' educational experience in regional Australia: reflections on acute events. A qualitative review of clinical incidents.
        Nurse Educ Pract. 2018; 31: 188-193https://doi.org/10.1016/j.nepr.2018.06.007
        • Bogossian F.
        • Cooper S.
        • Kelly M.
        • Levett-Jones T.
        • McKenna L.
        • Slark J.
        • et al.
        Best practice in clinical simulation education − are we there yet? A cross-sectional survey of simulation in Australian and New Zealand pre-registration nursing education.
        Collegian. 2018; 25: 327-334https://doi.org/10.1016/j.colegn.2017.09.003
        • Australian Commision on Safety and Quality in Health Care
        National safety and quality health service standards.
        2nd ed. 2021 (Sydney)
        • Kinsman L.
        • Cooper S.
        • Champion R.
        • Kim J.-A.
        • Boyle J.
        • Cameron A.
        • et al.
        The impact of web-based and face-to-face simulation education programs on nurses' response to patient deterioration: a multi-site interrupted time series study.
        Nurse Educ Today. 2021; 102 (39): 104939https://doi.org/10.1016/j.nedt.2021.104939
        • Foronda C.
        • MacWilliams B.
        • McArthur E.
        Interprofessional communication in healthcare: an integrative review.
        Nurse Educ Pract. 2016; 19: 36-40https://doi.org/10.1016/j.nepr.2016.04.005