Clinical paperA prospective controlled trial of the effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients☆
Introduction
The failure to recognise clinical deterioration in patients in general hospital wards, a state often characterised by significant physiological disturbances for over 24 h 1, 2 and manifested clinically as derangements in vital signs,3 leads to delays in appropriate management.4 Such worsening physiology is associated with an increase in hospital mortality in the critically ill 5 and adult hospital inpatients.6 These failures and delays lead to adverse events including unexpected admissions to the intensive care unit (ICU) 7 and unexpected deaths.8
Earlier intervention, prevention of further deterioration and an improvement in patient outcome requires a series of steps including vital sign documentation and interpretation; subsequent meaningful communication and timely and appropriate medical management. However the cornerstone, vital signs, is often poorly documented, particularly respiratory rate.9, 10 Reasons cited include poor observation chart design 11 and a deficiency in the understanding of why vital signs are measured.12 There is also failure to communicate adequately,13 which delays appropriate medical management.3 Early warning scores 14 have been developed to facilitate detection and communication by categorising the patient's severity of illness and prompting nursing staff to request a medical review at specific trigger points.
We hypothesised that by applying a multi-faceted intervention, namely a newly designed ward observation chart, a track and trigger system and an associated education program, COMPASS©, we would increase the frequency of documentation of vital signs and frequency of a medical review of a deteriorating patient, reduce the number of unplanned admissions to ICU and unexpected deaths.
We tested this hypothesis by conducting a prospective before-and-after controlled trial comparing these outcome measures with the introduction of this multi-faceted intervention.
Section snippets
Methods
The Australian Capital Territory (ACT) and Calvary Health Care ACT Health and Research Ethics Committee waived the need for patient informed consent guided by the National Health and Medical Research Council guidelines for audit.
The Hospitals
The Canberra (Hospital A) and Calvary (Hospital B) Hospitals are teaching hospitals of the Australian National University. The Canberra Hospital serves as the tertiary referral hospital for a population of 600,000 whilst Calvary Hospital serves as a metropolitan hospital. Four study wards were identified (two from each hospital) and were chosen for their mixed medical and surgical case mix and their high acuity reflected by receiving the highest number of Medical Emergency Team (MET) reviews
The ward observation chart
Vital signs were documented graphically with up to three variables being superimposed on the y-axis with different scales for each variable and placed without reference to relationships to each other. There were no hospital policies relating to frequency of measurement and documentation of vital signs other than for patients with an in situ epidural (hourly), patients receiving patient controlled analgesia (hourly) and post-operative patients (hourly, 6-h post-intervention).
Medical review and management
There was an
The ward observation chart
All vital sign variables had a discrete area on the y-axis except heart rate and blood pressure, where the scale was the same for both vital signs, and charted both graphically and numerically (Fig. 1). The vital sign variables were also colour coded for the modified early warning score (MEWS) earned (Table 1) and adapted from Morgan et al.14 A vital sign measurement policy was developed to mandate the frequency of vital sign measurement, six hourly unless otherwise specified, to summate the
Study design
The study design was a prospective, controlled before-and-after intervention trial. All adult patients admitted to the four wards were considered for participation.
Study principle
The principle underlying the multi-faceted intervention was that physiological instability identifies patients who are at risk of adverse events. The provision of a framework for nurses and doctors for the rapid identification, assessment and treatment of patients with physiological instability should prevent further deterioration and reduce adverse events.
Study periods
The duration of the control period was 4 months (4th February until 4th June 2006) during which outcome measures were studied under normal operating conditions. This was followed by an 8-month preparation and education period (5th June 2006 until 31st January 2007) during which a new ward observation chart, new hospital policy for vital sign measurement and new education program, COMPASS©, were developed. Ward focus groups and information sessions to all hospital staff were held in various
Subjects
Analysis included all adult subjects who had been admitted to the four wards during the two study periods. Subjects excluded from the study were those who were specifically admitted to the four wards for palliation, aged less than 18 years of age and those being readmitted to the four wards during the study periods to minimise contamination between periods and allow accurate calculation of unexpected deaths. Approximately 25% of patients were randomly selected as a sub-group for an in depth
Data collection
Data collected upon admission to the ward included demographic data, admission diagnosis, whether they were medical or surgical patients or whether there was a documented a not for resuscitation order. All study patients were followed up to either death or hospital discharge, which ever came sooner. During follow up, length of hospital stay and predefined adverse events were obtained. In the randomly selected sub-group of patients data collection included all the vital sign measurements
Outcome measures
The primary outcome measure was the incidence of unplanned admissions to ICU. The secondary outcome measure for the whole patient cohort was the incidence of individual adverse events including deaths without documented limitation of treatment. In the sub-group of patients, the secondary outcome measures were the daily documented frequency of vital sign measurements, the incidence of documented communication and documented medical review following clinical instability.
Statistical analysis
STATA/IC 10 was used for all data analyses. Descriptive statistics are presented using means standard deviations, counts and percentages. Comparisons of binomial proportions between two nominal periods were performed using the Chi-squared statistic or Fisher's Exact Test. Logistic regression analysis was also used to model dichotomous outcomes such as ICU admission to adjust for possible confounding variables. Comparisons of frequencies or rates were performed using negative binomial regression
Study processes
The COMPASS© program was undertaken by 177 of the 195 (90.8%) ward nursing staff, 28 of the 34 (82.3%) ward junior medical officers and all five physiotherapists prior to the intervention period.
Patient demographics
During the control period, we studied 1157 patients compared to 985 patients during the intervention period (97 and 44 readmissions were excluded, respectively). The demographics were similar between the two periods (Table 2) but there was a significant increase in the proportion of patients from
Discussion
We conducted a two-centre before-and-after study of the introduction of a multi-faceted ward based intervention to improve the detection clinical deterioration in patients and timely and appropriate intervention to improve their acute care. We found a decrease in unexpected admissions to ICU and a decrease in unexpected deaths with an associated increase in medical review (patient parent team or MET), on a background of increased documentation of vital signs. These findings have potential
Conclusion
This simple, practical ward based intervention improves the process of recognising clinical deterioration in ward patients from a tertiary and metropolitan institution and potentially may improve patient outcome. Given the simplicity and adaptability of the intervention, studies of its application to patient care in other institutions and geographical settings seems opportune.
Conflict of interest
All authors declare that there are no financial and personal relationships with other people or organisations that could inappropriately influence their work.
Sources of funding for the study
H. McKay, C. McCutcheon and R. Berry were funded by ACT Health to specifically undertake the study. All the other authors undertook the study in their own time. The study sponsor and funder, Mr. Mark Cormack (Chief Executive, ACT Health) did not have any role in the in the study design, in the collection, analysis and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication.
I.A. Mitchell, H. McKay, B. Avard and N. Slater were all
Acknowledgements
We would like to thank all the staff of 9A and 10A of The Canberra Hospital and 5W and 4E of Calvary Hospital, without their support, the pilot study would not have been possible. The project was expertly guided by the members of the Early Recognition of the Deteriorating Patient Steering Committee: Dr Darryl Magill (Chair), Ms Bobby Antoniou, Ms Karen Simpson, Dr Wayne Ramsey, Ms Alice Jones, Ms Sue Hogan and the late Mr Phillip Gleeson. The authors are indebted to Professor Rinaldo Bellomo
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2010.03.001.