Judith Currey

Clinician and manager perceptions of factors leading to ward patient clinical deterioration

BACKGROUND Improving the timely recognition and response to clinical deterioration is a critical challenge for clinicians, educators, administrators and researchers. Clinical deterioration leading to Rapid Response Team review is associated with poor patient outcomes. A range of factors associated with clinical deterioration and its outcomes have been identified, and may help with early identification of deteriorating patients. However, the relative importance of each factor on the development of clinical deterioration is unknown. OBJECTIVE To identify the relative importance of factors contributing to the development of clinical deterioration in ward patients, as perceived by health professionals who have experience in recognising or responding to clinical deterioration, or in the management, administration or governance of RRSs. METHODS A written questionnaire containing 12 pre-determined factors was provided to participants. Participants were asked to rank the items from most to least important contributors to ward patient deterioration. The study took place during a session of the Australia and New Zealand Intensive Care Society Rapid Response Team conference. RESULTS A final sample of 233 (83% response rate), returned the questionnaire. The sample comprised specialist ICU registered nurses with direct patient contact (64%), ICU consultant doctors (17%), ICU nurse managers (7%), hospital administrators (2%), ICU registrars (2%), quality coordinators (2%) and non-hospital staff (4%). The patients presenting illness/main diagnosis was the highest ranked factor, followed by pre-existing co-morbidities, seniority of nursing ward staff, medical documentation, senior medical staff, and interdisciplinary communication. Almost two-thirds of participants ranked patient characteristics as the most important contributor to clinical deterioration. CONCLUSION Health professionals who have experience in recognising or responding to clinical deterioration, or in the management, administration or governance of RRSs perceive that patient characteristics such as the patients primary diagnosis and comorbidities to be the most important contributors to clinical deterioration.

Combining critical care nurses decision making with human and technological resources for patient safety: Do we fulfil our obligations?

As critical care nurses, we deeply appreciate our role as the uardians of patient safety. Patients and their families and friends ho encounter, observe and interact with nurses also understand, nd highly value our commitment to patient safety. In this issue, atters related to the nurses’ decision making, use of charting and echnologies; and the ways nurses can realise other team member ontributions to augment patient safety are presented. Indeed, the ractice Standards for Specialist Critical Care Nurses1 emphasise all f these roles for specialist nurses.2 In recent years, we’ve gained a wealth of understanding through xtensive Australian and international research regarding nurses’ ecisions to identify patient clinical deterioration. Initially hypohesised as something that could be identified through patient ata, the role of nurses in anticipating, recognising and responding o clinical deterioration is now indisputable. Through nurse deciion making, accurate assessment, recording and documentation of ital signs or other concerns, and timely escalation to medical staff, atient safety can be enhanced.3–5 Although nurses’ decision making is a complex and an essential lement to patient safety, decision biases, timeliness and decision omplexity all impact patient safety. A key paper by Jones and ohnstone6 in this issue highlight the role of inattentional blindess to our understanding of cognitive processes impacting patient afety. This phenomenon are often recalled in the invisible gorilla ideo,7 although a more comprehensive explanation can be found n the book by Chabris and Simons.8 The argument forwarded by ones and Johnstone offers an insightful perspective to our potenial limitations in applying our knowledge and skills in practice. his perspective is useful in our own clinical reflections along with ur teaching and management practices. As humans, nurses as with other clinicians are fallible. Human actors theory and research can, and has been used to inform ways f augmenting patient safety decisions.9 One aspect of human facors that has been explored is communication through various orms of charting vital signs. Le Lagadec and Dwyer10 note that harting to capture clinical deterioration can take one of three orms: single or multiple parameter systems; aggregated weighted coring systems; or combinations of single or multiple parameter nd aggregated weighted scoring systems. Results of their scoping eview illustrate that such charting can inform decision making o improve patient safety with strong clinician engagement. All orms of early warning systems do not replace clinician thinking