Australasian Emergency Nursing Journal (2015) 18, 33—41
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/aenj
RESEARCH PAPER
Unreported clinical deterioration in emergency department patients: A point prevalence study Belinda Mitchell Scott, RN, BN, CertEmergNurs, GradDipMngt, MNursPrac a,∗
Julie Considine, RN, PhD, FACN b Mari Botti, PhD, GDCAP, BA, RN c a
Northern Health, 185 Cooper St, Epping, Victoria 3076, Australia Eastern Health — Deakin University Nursing & Midwifery Research Centre, School of Nursing and Midwifery, Deakin University, Centre for Quality and Patient Safety Research, Australia c Epworth Deakin Centre for Clinical Nursing Research, School of Nursing and Midwifery, Deakin University, Centre for Quality and Patient Safety Research, Australia b
Received 5 August 2014; received in revised form 14 September 2014; accepted 15 September 2014
KEYWORDS Emergency medicine; Emergency nursing; Patient safety; Risk management; Deteriorating patient; Rapid response system
Summary Background: Formal processes for recognising and responding to deteriorating emergency department (ED) patients are variable despite features of the ED context that may increase the risk of unrecognised or unreported clinical deterioration. The aim of this study was to determine the frequency and nature of unreported clinical deterioration in emergency care. Methods: A prospective, exploratory descriptive design was used. Data were collected during nine point prevalence surveys (PPS) from 1 May to 30 June 2009 at an urban district hospital in Melbourne Australia. Patients present in ED cubicles during the PPS (n = 186) were included in the study. Results: Unreported clinical deterioration occurred in 12.9% of patients (n = 24/186). Unreported clinical deterioration was more common when: (i) patients aged ≥65 years comprised >50% of patients within the ED; (ii) occupancy of the resuscitation, monitored or general adult cubicles was >50%; and (iii) the proportion of patients requiring treatment within 30 min (Australasian Triage Category 1, 2 or 3) was ≤50% of the total ED population.
∗ Corresponding author at: c/- Emergency Department, Northern Health, 185 Cooper St, Epping, Victoria, 3076, Australia. Tel.: +61 421122268; fax: +61 392446159. E-mail addresses: [email protected] (B.M. Scott), [email protected] (J. Considine), [email protected] (M. Botti).
http://dx.doi.org/10.1016/j.aenj.2014.09.002 1574-6267/© 2014 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
34
B.M. Scott et al. Conclusions: Unreported clinical deterioration is an important quality indicator of emergency care. The effect of the collective ED patient group on the frequency and nature of adverse events for individual ED patients is poorly understood and warrants further investigation. © 2014 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
What is known • Physiological abnormalities are known antecedents to in-hospital adverse events such as unplanned intensive care admission and cardiac arrest. • Formal processes for recognising and responding to deteriorating patients are well established in the ward areas of most major Australian hospitals. • Formal systems for systems for recognising and responding to deteriorating patients in Australian emergency departments are less well developed.
What this paper adds? • This study adds to the body of knowledge related to the frequency and nature of deterioration in emergency department patients. • This is the first Australian study to explore relationships between patient characteristics (age, clinical urgency) and emergency department characteristics (occupancy, staffing), and the frequency and nature of unreported clinical deterioration in emergency department patients. • Unreported clinical deterioration was more common when there were high proportions of older patients in the emergency department, when emergency department occupancy was high, and when the proportion of high acuity patients was reduced.
Introduction The majority of patients who suffer in-hospital adverse events with high risk of death (e.g. cardiac arrest or unplanned intensive care unit admission) have clearly abnormal physiological signs in the hours before these events, and there is a well-documented relationship between abnormal vital signs and mortality.1—8 Timely recognition of, and response to, deteriorating patients improves patient outcomes and decreases the incidence of high mortality adverse events such as cardiac arrest and unplanned intensive care unit admission.9—11 Although the majority of studies to date have been situated in inpatient ward areas, it logical to extrapolate that emergency department (ED) patients with abnormal vital signs are also at high risk of adverse events. Formal processes for recognising and responding to deteriorating patients are well established in the ward areas of most major Australian hospitals and, the Medical Emergency Team (MET) is the predominant model of rapid response that brings critical care equipment and expertise to the bedside of deteriorating patients.12 However, formal systems
for recognising and responding to deteriorating patients in emergency departments are less well developed13,14 despite more than 6.7 million emergency department attendances per year.15 One example of a formal ED specific rapid response system for recognising and responding to deteriorating patients is that published by Considine et al.14 This system comprises clinical instability criteria aimed at increasing the recognition of deteriorating patients and an escalation protocol aimed at enabling a consistent and timely response to deteriorating patients by senior ED clinicians.14 Evaluation of the uptake of this ED rapid response system in an urban district hospital in Melbourne, Australia showed that the system was activated in 1.5% of ED patients, and the most common reasons for system activation were hypotension (27.7%) and tachycardia (23.7%).14 The majority of system activations were by emergency nurses (93.1%) and the median time between documenting physiological abnormalities and system activation was 5 min.14 A limitation of this study was that only patients in whom the ED rapid response system was activated were included in the study; the number of patients who met the clinical instability criteria and in whom the system was not activated remains unknown.14 Emergency nurses are also primarily responsible for physiological assessment and ongoing surveillance for the patient’s entire ED episode of care. Further, it is a core emergency nursing responsibility to engage in advanced health assessment and initiate investigations and inventions within their scope of practice, before the patient has been assessed by medical staff. Emergency nurses are therefore well placed to recognise and respond to deteriorating patients. However, there are several features unique to the ED context, that may increase the risk of unrecognised, unreported and/or under-treated clinical deterioration. Emergency nurses provide care for undiagnosed and undifferentiated patients of all age groups, many of whom have nonspecific complaints and the majority of whom are unknown to clinicians.13,16 The ED environment is time pressured with frequent interruptions and, at times, an unpredictable workload that when combined, result in high levels of decision density, high cognitive load, and decision making under conditions of uncertainty.13,16
Aim The aim of this study was to determine the frequency and nature of unreported clinical deterioration in emergency care. For the purpose of this study, an unreported clinical deterioration was defined as documentation of one or more physiological parameters within the ED clinical instability criteria and no documentation of escalation to the nurse in charge or emergency physician. A secondary aim of the study was to explore whether there were relationships between ED patient characteristics (age, clinical urgency) and ED
Unreported deterioration in ED patients characteristics (ED occupancy, ED staffing), and the frequency and nature of unreported clinical deterioration in the ED.
Methods A prospective, exploratory descriptive design was used to establish the frequency of unreported clinical deterioration in the ED. Approval for the study was granted from the Human Research & Ethics Committees at the study site and Deakin University.
Setting The study was conducted in a government funded health service located in the northern suburbs of Melbourne, Australia. The ED in which the study was conducted is located in the only acute care campus of the health service. When the study was conducted, the ED was managing approximately 61,700 attendances per year and 20% of attendances were children aged 16 years or less.17 There were 30 treatment areas including two resuscitation cubicles, eleven monitored cubicles, eleven general adult non-monitored cubicles and six paediatric cubicles, and the admission rate was 25%.17 At the time of the study, the ED had Clinical Instability Criteria (CIC) which was a single trigger system using evidence based physiological parameters for the recognition of clinical deterioration.14 If a patient met any one of the CIC, an escalation of care protocol was triggered whereby the clinician detecting the instability was required to report the clinical deterioration to the emergency physician who reviewed the patient within 5 min and initiated treatment if required.14 The adult parameters that triggered the escalation protocol were: stridor, upper airway obstruction, or threatened airway; oxygen saturation less than 90% (on oxygen 10 L/min via mask); respiratory rate less than 10 or greater than 30 breaths/min; heart rate less than 50 min or greater 120 beats/min; systolic blood pressure less than 90 or greater than 200 mmHg; sudden decrease in consciousness (fall in Glasgow Coma Scale score greater than 2 points); repeated or prolonged seizures; and clinician concern.
Sample All ED patients (n = 186) receiving care in an ED cubicle during the times of the PPS were included in the study: patients in the waiting room were excluded from the study.
Data collection Data were collected using point prevalence surveys (PPS). Point prevalence survey methods derive from the discipline of epidemiology and rely on the researcher collecting ‘snapshots’ (cross sectional data) of the affected population in order to establish the frequency in which an event or phenomenon occurs.18 PPS were used to collect data related to unreported clinical deterioration. In addition, data related to contextual factors such as ED patient characteristics, staffing and workload were also collected during the point
35 prevalence surveys to enable the analysis of relationships between unreported clinical deterioration and patient and ED characteristics at the time of data collection. A total of nine PPS were conducted between 1 May and 30 June 2009 and occurred over various days of the week and times of the day and night. All ED cubicles were included in each PPS and the following data were collected for each patient present in an ED cubicle during data collection:
i) Patient characteristics: presenting problem, arrival time, entry time to the ED cubicle, time of last emergency nursing assessment, ED length of stay (calculated from arrival in the ED until the time of point prevalence survey) and time intervals between nursing assessments ii) Specific elements of ED CIC: stridor or upper airway obstruction, bradypnoea, tachypnoea, bradycardia, tachycardia, hypotension, hypertension, decreased conscious state, acidosis, seizures and clinician concern.
In addition, the following data were collected at the conclusion of each point prevalence survey:
i) ED patient characteristics: age of all patients in ED cubicles, Australasian Triage Scale (ATS) category of all patients present in the ED (cubicles and waiting room) ii) ED characteristics: occupancy of resuscitation, monitored, general adult and paediatric cubicles, unfilled nursing and medical deficits, seniority of nursing and medical staff. Patients aged five years or less19,20 or 65 years and over21—24 are known to be at increased risk of adverse events during hospital treatment. Therefore consideration was given to whether the proportion of high risk patients was less than or equal to 50% or greater than 50% of patients located in ED cubicles. Clinical urgency was defined by the proportion of patients present in the ED (cubicle and waiting room) who were requiring emergency care within 30 min (ATS 1, 2 and 3 patients). Again an arbitrary division was made when the proportion of patients requiring emergency care within 30 min was less than or equal to 50% or greater than 50% of the total ED population (cubicle and waiting room patients). The occupancy of resuscitation, monitored, general adult and paediatric cubicles was subcategorised into less than or equal to 50% or greater than 50%. Unfilled nursing and medical deficits were subcategorised as yes or no. The seniority of nursing staff was based on the organisational requirement to have at least five Registered Nurses with postgraduate qualifications in emergency nursing per shift to safely staff the in-charge, triage and resuscitation positions and was therefore subcategorised as yes or no.
Data analysis Data analysis was performed using IBM SPSS Statistics Version 18. Descriptive statistics were used to summarise the study data.
100 0.53 1 0.53 1 1.6 3 4.3 8 2.7 5 1.6 3 3 Total
186
1.6
0.0 0.0 0.0 0.0 0.0 4.3 0.0 0.0 0.0 0 0 0 0 0 1 0 0 0 4.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1 0 0 0 0 0 0 0 0 0.0 0.0 4.3 0.0 7.1 4.3 0.0 0.0 0.0 0 0 1 0 1 1 0 0 0 4.5 0 8.7 10.5 0 4.3 4.3 4.0 0 1 0 2 2 0 1 1 1 0 0.0 5.0 0.0 0.0 0.0 4.3 8.7 4.0 0.0 0 1 0 0 0 1 2 1 0 0.0 5.0 0.0 0.0 7.1 0.0 0.0 0.0 5.9 0 1 0 0 1 0 0 0 1 0.0 0.0 0.0 5.3 0.0 4.3 4.3 0.0 0.0 0 0 0 1 0 1 1 0 0
n n
22 20 23 19 14 23 23 25 17
% % n % n % n % n % n %
Unreported decreased conscious state Unreported hypertension Unreported hypotension Unreported tachycardia Unreported bradycardia Unreported tachypnoea Number of patients in ED cubicles
The profile of all patients present in the ED (cubicles and waiting room) was used to examine whether patient characteristics (age and clinical urgency) had an effect on the frequency of unreported clinical deterioration. Threequarters of the episodes of unreported clinical deterioration (n = 18) occurred when the proportion of patients in high risk age groups was greater than 50% of the total number of patients in ED cubicles. The proportion of patients aged 5 years or less was never greater than 50% of patients in
Point prevalence survey
Effect of patient characteristics on unreported clinical deterioration
Frequency of unreported clinical deterioration per point prevalence survey.
Unreported clinical deterioration occurred in 12.9% of patients who were located in an ED cubicle (n = 24/186). There were no episodes of unreported stridor or upper airway obstruction, bradypnoea, acidosis or seizures. Hypotension was the most common abnormality; 33.3% of patients (n = 8) with unreported clinical deterioration had a systolic blood pressure less than 90 mmHg. Tachycardia was present in 20.8% of patients (n = 5) with unreported clinical deterioration. Less common sources of unreported clinical deterioration were hypertension (n = 3), bradycardia (n = 3) and tachypnoea (n = 3). The other two instances of unreported clinical deterioration were the result of decreased conscious state (n = 1) and ‘clinician concern’ (n = 1). The number of patients who experienced unreported clinical deterioration and type of deterioration are shown in Table 1.
Table 1
Unreported clinical deterioration
Clinician concern
There were 396 patients in the ED during the nine PPS; 186 of these patients (46.9%) were being cared for in an ED cubicle, the remainder were in the ED waiting room. During the PPS, the number of patients in an ED cubicle ranged from 14 to 25 and the total number of patients present in the ED (in cubicles and the waiting room) ranged from 20 to 53. Of the patients present in ED cubicles during PPS, abdominal pain was the most common presenting problem (n = 28; 15.5%) followed by shortness of breath (n = 25; 13.8%) and chest pain (n = 19; 10.5%). When patient age groups were examined, 73.1% of patients (n = 136/186) were from high risk age groups. Specifically, there were four patients aged less than 28 days, 22 patients aged 5 years or less, 59 patients aged 65—79 years and 51 patients aged over 80 years. At the time of the point prevalence surveys, 18.8% of patients (n = 72/396) were still waiting to be seen by a doctor and 78.2% of patients (n = 310/396) had been seen by a doctor. Of the 72 patients waiting to be seen by a doctor, 59.7% of patients (n = 43) were still within their ATS treatment time recommendations.25 However, 40.3% of patients (n = 29) waiting to be seen by a doctor had waited longer than the recommended ATS treatment time.25 Of the patients seen by a doctor (n = 310), 42.2% of patients (n = 131) had treatment commenced within the ATS time recommendations and 67.8% patients did not (n = 179).
%
Patient characteristics
n
Total
Results
9.1 10.0 13.0 21.0 14.3 21.7 17.4 8.0 5.8
B.M. Scott et al.
1 2 3 4 5 6 7 8 9
36
Unreported deterioration in ED patients Table 2
Frequency of unreported clinical deterioration and patient age groups and clinical urgency.
Unreported clinical deterioration
Tachypnoea Bradycardia Tachycardia Hypotension Hypertension Decreased conscious state Other CIC Total a
37
Proportion of patients aged 5 years or lessa
Proportion of patients aged 65 years and overa
Proportion of patients whose clinical urgency required treatment within 30 mina
≤50%
>50%
≤50%
≤50%
3 3 5 8 3 1
0 0 0 0 0 0
0 0 1 3 1 0
3 3 4 5 2 1
3 0 4 6 1 1
0 3 1 2 2 0
1
0
0
1
1
0
24
0
5
19
16
8
>50%
>50%
% of patients within ED cubicles (waiting room patients excluded).
ED cubicles during any of the PPS. Therefore all episodes of unreported clinical deterioration occurred when the proportion of children aged 5 years or less was less than 50% of ED patients in cubicles. The proportion of patients aged 65 years and over was greater than 50% of patients in ED cubicles in five of the nine PPS (PPS numbers 4, 5, 6, 8 and 9) and 79.2% (n = 19) of episodes of unreported clinical deterioration occurred when the proportion of older people aged 65 years and over was greater than 50% of ED patients in cubicles (Table 2). The proportion of patients requiring treatment within 30 min (ATS 1, 2 and 3 patients) was greater than 50% of the total ED population (waiting room and ED cubicles) in all but three PPS (PPS 1, 6 and 8). Patients were twice as likely to experience unreported clinical deterioration when the proportion of patients requiring treatment within 30 min was less than 50% of the total ED population (Table 2). When the proportion of patients requiring treatment within 30 min was greater than 50% of the total ED population the frequency of unreported bradycardia increased by 37.5% but unreported tachypnoea, tachycardia and hypotension were less common (Table 2).
over 50% and when the paediatric cubicle occupancy was 50% or less (Table 3).
Effect of ED nurse staffing on unreported clinical deterioration During PPS 1 and 5, there were four registered nurses on shift with postgraduate qualifications in emergency nursing: there were two episodes of unreported clinical deterioration during each of these PPSs (n = 4; 16.7%). The same PPS had unfilled nursing deficits: three unfilled deficits during PPS 1 and one unfilled nursing deficit during PPS 5 (Table 4). Finally, the relationship between unreported clinical deterioration and day of week and time of day was examined. Overall, twice as many episodes of unreported clinical deterioration occurred during the week compared with weekend days (n = 16; 66.7% versus n = 8; 33.3%). The greatest proportion of unreported clinical deterioration occurred during the evening shift (n = 15; 62.5%), followed by day shift (n = 7; 29.2%) and then night shift (n = 2; 8.3%).
Discussion Effect of ED characteristics on unreported clinical deterioration Resuscitation cubicle and general cubicle occupancy was greater than 50% during seven PPS (resuscitation = PPS 3, 4, 5, 6, 7, 8 and 9/general cubicles = PPS 1, 2, 3, 6, 7, 8 and 9), the monitored cubicles had greater than 50% during all nine PPS, and the paediatric cubicles had greater than 50% occupancy during four PPS (PPS 1, 2, 7 and 8). When the 24 episodes of unreported clinical deterioration were examined against occupancy of various ED care areas, two thirds of episodes of unreported clinical deterioration were shown to have occurred when the resuscitation cubicle occupancy was greater than 50%. All unreported clinical deterioration occurred when the occupancy of the monitored cubicles was over 50% (Table 3) as they were at this level of occupancy for all PPS. Twenty-two episodes of unreported clinical deterioration occurred when the general cubicle occupancy was
This study had six major findings. First, one in seven patients (12.9%) had unreported clinical deterioration. Other Australian studies of deterioration in ED patients show the prevalence of deterioration ranges from 2% to 14.8% depending on the patient cohort examined and the definition of deterioration.14,26—28 This study had similar findings to that of Richmond et al.28 who reported that 10% of the clinical issues identified during bedside reviews of care of ED patients were related to clinically unstable patients. Similarly, Considine et al.26 showed that 11.6% of ED patients with presenting complaints of shortness of breath, chest pain or abdominal pain, experienced one or more episodes of unreported clinical deterioration (defined using the same CIC as the study reported in this paper). Studies reporting lower rates of deterioration,14,27 were focused on reported deterioration so did not capture patients who may have suffered unreported deterioration.
38 Table 3
B.M. Scott et al. Frequency of unreported clinical deterioration and ED occupancy of ED care areas.
Unreported clinical deterioration
Resuscitation cubicle occupancy
Monitored cubicle occupancy
General cubicle occupancy
Paediatric cubicle occupancy
≤50% n
≤50% n
≤50% n
≤50% n
>50% n
>50% n
>50% n
>50% n
Tachypnoea Bradycardia Tachycardia Hypotension Hypertension Decreased conscious state Other CIC
0 2 1 3 2 1
3 1 4 5 1 0
0 0 0 0 0 0
3 3 5 8 3 1
0 1 0 0 1 0
3 2 5 8 2 1
2 3 5 7 3 0
1 0 0 1 0 1
0
1
0
1
0
1
1
0
Total
9
15
0
24
2
22
21
3
Second, the most common types of unreported clinical deterioration were hypotension and tachycardia. This finding bears some similarity to other studies. Considine et al.26 found that 73.1% of episodes of tachycardia and 50% of episodes of hypotension went unreported in ED patients with presenting complaints of shortness of breath, chest pain or abdominal pain. However in this study, tachypnoea was the most common cause of unreported clinical deterioration with 74.5% of episodes of tachypnoea documented but not reported.26 Again, the criteria for defining deterioration were the same as those used in this current study. A study conducted at the same ED and focusing on reported deterioration found that the most common causes of deterioration resulting in escalation of care were hypotension (27.7%) and tachycardia (23.7%).14 Third, patient factors (age and clinical urgency) appeared to influence the prevalence of unreported clinical deterioration. When greater than 50% of patients were from high risk age groups, the prevalence of unreported clinical deterioration was six times greater. However the numbers of children aged 5 years or less were small so the greatest
Table 4
influence on this finding was the proportion of older patients aged 65 years or over. When the proportion of ED patients aged 65 years or over was greater than 50% of the total ED population, the frequency of unreported clinical deterioration increased fourfold. It is important to recognise that this study was not about unreported clinical deterioration in older people per se, but rather about the impact of high numbers of older people on unreported clinical deterioration across the whole ED. There are no published studies related to clinical deterioration in older ED patients, however a number of studies have shown that older people are at increased risk of adverse events and reported incidents during their ED care. Patients aged over 65 years were more likely to suffer incidents related to breach of skin integrity, patient management, diagnosis and patient identification than younger ED patients.21 Although not focused specifically on older ED patients, studies of deterioration in ED patients have shown the median age of ED patients who required activation of an ED rapid response system was 65.1 years.14 In a comparison of two systems for recognising clinical deterioration
Unreported clinical deterioration and ED nurse staffing.
Unreported clinical deterioration
Postgraduate qualified RNs
Unfilled nursing deficits
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/aenj
RESEARCH PAPER
Unreported clinical deterioration in emergency department patients: A point prevalence study Belinda Mitchell Scott, RN, BN, CertEmergNurs, GradDipMngt, MNursPrac a,∗
Julie Considine, RN, PhD, FACN b Mari Botti, PhD, GDCAP, BA, RN c a
Northern Health, 185 Cooper St, Epping, Victoria 3076, Australia Eastern Health — Deakin University Nursing & Midwifery Research Centre, School of Nursing and Midwifery, Deakin University, Centre for Quality and Patient Safety Research, Australia c Epworth Deakin Centre for Clinical Nursing Research, School of Nursing and Midwifery, Deakin University, Centre for Quality and Patient Safety Research, Australia b
Received 5 August 2014; received in revised form 14 September 2014; accepted 15 September 2014
KEYWORDS Emergency medicine; Emergency nursing; Patient safety; Risk management; Deteriorating patient; Rapid response system
Summary Background: Formal processes for recognising and responding to deteriorating emergency department (ED) patients are variable despite features of the ED context that may increase the risk of unrecognised or unreported clinical deterioration. The aim of this study was to determine the frequency and nature of unreported clinical deterioration in emergency care. Methods: A prospective, exploratory descriptive design was used. Data were collected during nine point prevalence surveys (PPS) from 1 May to 30 June 2009 at an urban district hospital in Melbourne Australia. Patients present in ED cubicles during the PPS (n = 186) were included in the study. Results: Unreported clinical deterioration occurred in 12.9% of patients (n = 24/186). Unreported clinical deterioration was more common when: (i) patients aged ≥65 years comprised >50% of patients within the ED; (ii) occupancy of the resuscitation, monitored or general adult cubicles was >50%; and (iii) the proportion of patients requiring treatment within 30 min (Australasian Triage Category 1, 2 or 3) was ≤50% of the total ED population.
∗ Corresponding author at: c/- Emergency Department, Northern Health, 185 Cooper St, Epping, Victoria, 3076, Australia. Tel.: +61 421122268; fax: +61 392446159. E-mail addresses: [email protected] (B.M. Scott), [email protected] (J. Considine), [email protected] (M. Botti).
http://dx.doi.org/10.1016/j.aenj.2014.09.002 1574-6267/© 2014 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
34
B.M. Scott et al. Conclusions: Unreported clinical deterioration is an important quality indicator of emergency care. The effect of the collective ED patient group on the frequency and nature of adverse events for individual ED patients is poorly understood and warrants further investigation. © 2014 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
What is known • Physiological abnormalities are known antecedents to in-hospital adverse events such as unplanned intensive care admission and cardiac arrest. • Formal processes for recognising and responding to deteriorating patients are well established in the ward areas of most major Australian hospitals. • Formal systems for systems for recognising and responding to deteriorating patients in Australian emergency departments are less well developed.
What this paper adds? • This study adds to the body of knowledge related to the frequency and nature of deterioration in emergency department patients. • This is the first Australian study to explore relationships between patient characteristics (age, clinical urgency) and emergency department characteristics (occupancy, staffing), and the frequency and nature of unreported clinical deterioration in emergency department patients. • Unreported clinical deterioration was more common when there were high proportions of older patients in the emergency department, when emergency department occupancy was high, and when the proportion of high acuity patients was reduced.
Introduction The majority of patients who suffer in-hospital adverse events with high risk of death (e.g. cardiac arrest or unplanned intensive care unit admission) have clearly abnormal physiological signs in the hours before these events, and there is a well-documented relationship between abnormal vital signs and mortality.1—8 Timely recognition of, and response to, deteriorating patients improves patient outcomes and decreases the incidence of high mortality adverse events such as cardiac arrest and unplanned intensive care unit admission.9—11 Although the majority of studies to date have been situated in inpatient ward areas, it logical to extrapolate that emergency department (ED) patients with abnormal vital signs are also at high risk of adverse events. Formal processes for recognising and responding to deteriorating patients are well established in the ward areas of most major Australian hospitals and, the Medical Emergency Team (MET) is the predominant model of rapid response that brings critical care equipment and expertise to the bedside of deteriorating patients.12 However, formal systems
for recognising and responding to deteriorating patients in emergency departments are less well developed13,14 despite more than 6.7 million emergency department attendances per year.15 One example of a formal ED specific rapid response system for recognising and responding to deteriorating patients is that published by Considine et al.14 This system comprises clinical instability criteria aimed at increasing the recognition of deteriorating patients and an escalation protocol aimed at enabling a consistent and timely response to deteriorating patients by senior ED clinicians.14 Evaluation of the uptake of this ED rapid response system in an urban district hospital in Melbourne, Australia showed that the system was activated in 1.5% of ED patients, and the most common reasons for system activation were hypotension (27.7%) and tachycardia (23.7%).14 The majority of system activations were by emergency nurses (93.1%) and the median time between documenting physiological abnormalities and system activation was 5 min.14 A limitation of this study was that only patients in whom the ED rapid response system was activated were included in the study; the number of patients who met the clinical instability criteria and in whom the system was not activated remains unknown.14 Emergency nurses are also primarily responsible for physiological assessment and ongoing surveillance for the patient’s entire ED episode of care. Further, it is a core emergency nursing responsibility to engage in advanced health assessment and initiate investigations and inventions within their scope of practice, before the patient has been assessed by medical staff. Emergency nurses are therefore well placed to recognise and respond to deteriorating patients. However, there are several features unique to the ED context, that may increase the risk of unrecognised, unreported and/or under-treated clinical deterioration. Emergency nurses provide care for undiagnosed and undifferentiated patients of all age groups, many of whom have nonspecific complaints and the majority of whom are unknown to clinicians.13,16 The ED environment is time pressured with frequent interruptions and, at times, an unpredictable workload that when combined, result in high levels of decision density, high cognitive load, and decision making under conditions of uncertainty.13,16
Aim The aim of this study was to determine the frequency and nature of unreported clinical deterioration in emergency care. For the purpose of this study, an unreported clinical deterioration was defined as documentation of one or more physiological parameters within the ED clinical instability criteria and no documentation of escalation to the nurse in charge or emergency physician. A secondary aim of the study was to explore whether there were relationships between ED patient characteristics (age, clinical urgency) and ED
Unreported deterioration in ED patients characteristics (ED occupancy, ED staffing), and the frequency and nature of unreported clinical deterioration in the ED.
Methods A prospective, exploratory descriptive design was used to establish the frequency of unreported clinical deterioration in the ED. Approval for the study was granted from the Human Research & Ethics Committees at the study site and Deakin University.
Setting The study was conducted in a government funded health service located in the northern suburbs of Melbourne, Australia. The ED in which the study was conducted is located in the only acute care campus of the health service. When the study was conducted, the ED was managing approximately 61,700 attendances per year and 20% of attendances were children aged 16 years or less.17 There were 30 treatment areas including two resuscitation cubicles, eleven monitored cubicles, eleven general adult non-monitored cubicles and six paediatric cubicles, and the admission rate was 25%.17 At the time of the study, the ED had Clinical Instability Criteria (CIC) which was a single trigger system using evidence based physiological parameters for the recognition of clinical deterioration.14 If a patient met any one of the CIC, an escalation of care protocol was triggered whereby the clinician detecting the instability was required to report the clinical deterioration to the emergency physician who reviewed the patient within 5 min and initiated treatment if required.14 The adult parameters that triggered the escalation protocol were: stridor, upper airway obstruction, or threatened airway; oxygen saturation less than 90% (on oxygen 10 L/min via mask); respiratory rate less than 10 or greater than 30 breaths/min; heart rate less than 50 min or greater 120 beats/min; systolic blood pressure less than 90 or greater than 200 mmHg; sudden decrease in consciousness (fall in Glasgow Coma Scale score greater than 2 points); repeated or prolonged seizures; and clinician concern.
Sample All ED patients (n = 186) receiving care in an ED cubicle during the times of the PPS were included in the study: patients in the waiting room were excluded from the study.
Data collection Data were collected using point prevalence surveys (PPS). Point prevalence survey methods derive from the discipline of epidemiology and rely on the researcher collecting ‘snapshots’ (cross sectional data) of the affected population in order to establish the frequency in which an event or phenomenon occurs.18 PPS were used to collect data related to unreported clinical deterioration. In addition, data related to contextual factors such as ED patient characteristics, staffing and workload were also collected during the point
35 prevalence surveys to enable the analysis of relationships between unreported clinical deterioration and patient and ED characteristics at the time of data collection. A total of nine PPS were conducted between 1 May and 30 June 2009 and occurred over various days of the week and times of the day and night. All ED cubicles were included in each PPS and the following data were collected for each patient present in an ED cubicle during data collection:
i) Patient characteristics: presenting problem, arrival time, entry time to the ED cubicle, time of last emergency nursing assessment, ED length of stay (calculated from arrival in the ED until the time of point prevalence survey) and time intervals between nursing assessments ii) Specific elements of ED CIC: stridor or upper airway obstruction, bradypnoea, tachypnoea, bradycardia, tachycardia, hypotension, hypertension, decreased conscious state, acidosis, seizures and clinician concern.
In addition, the following data were collected at the conclusion of each point prevalence survey:
i) ED patient characteristics: age of all patients in ED cubicles, Australasian Triage Scale (ATS) category of all patients present in the ED (cubicles and waiting room) ii) ED characteristics: occupancy of resuscitation, monitored, general adult and paediatric cubicles, unfilled nursing and medical deficits, seniority of nursing and medical staff. Patients aged five years or less19,20 or 65 years and over21—24 are known to be at increased risk of adverse events during hospital treatment. Therefore consideration was given to whether the proportion of high risk patients was less than or equal to 50% or greater than 50% of patients located in ED cubicles. Clinical urgency was defined by the proportion of patients present in the ED (cubicle and waiting room) who were requiring emergency care within 30 min (ATS 1, 2 and 3 patients). Again an arbitrary division was made when the proportion of patients requiring emergency care within 30 min was less than or equal to 50% or greater than 50% of the total ED population (cubicle and waiting room patients). The occupancy of resuscitation, monitored, general adult and paediatric cubicles was subcategorised into less than or equal to 50% or greater than 50%. Unfilled nursing and medical deficits were subcategorised as yes or no. The seniority of nursing staff was based on the organisational requirement to have at least five Registered Nurses with postgraduate qualifications in emergency nursing per shift to safely staff the in-charge, triage and resuscitation positions and was therefore subcategorised as yes or no.
Data analysis Data analysis was performed using IBM SPSS Statistics Version 18. Descriptive statistics were used to summarise the study data.
100 0.53 1 0.53 1 1.6 3 4.3 8 2.7 5 1.6 3 3 Total
186
1.6
0.0 0.0 0.0 0.0 0.0 4.3 0.0 0.0 0.0 0 0 0 0 0 1 0 0 0 4.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1 0 0 0 0 0 0 0 0 0.0 0.0 4.3 0.0 7.1 4.3 0.0 0.0 0.0 0 0 1 0 1 1 0 0 0 4.5 0 8.7 10.5 0 4.3 4.3 4.0 0 1 0 2 2 0 1 1 1 0 0.0 5.0 0.0 0.0 0.0 4.3 8.7 4.0 0.0 0 1 0 0 0 1 2 1 0 0.0 5.0 0.0 0.0 7.1 0.0 0.0 0.0 5.9 0 1 0 0 1 0 0 0 1 0.0 0.0 0.0 5.3 0.0 4.3 4.3 0.0 0.0 0 0 0 1 0 1 1 0 0
n n
22 20 23 19 14 23 23 25 17
% % n % n % n % n % n %
Unreported decreased conscious state Unreported hypertension Unreported hypotension Unreported tachycardia Unreported bradycardia Unreported tachypnoea Number of patients in ED cubicles
The profile of all patients present in the ED (cubicles and waiting room) was used to examine whether patient characteristics (age and clinical urgency) had an effect on the frequency of unreported clinical deterioration. Threequarters of the episodes of unreported clinical deterioration (n = 18) occurred when the proportion of patients in high risk age groups was greater than 50% of the total number of patients in ED cubicles. The proportion of patients aged 5 years or less was never greater than 50% of patients in
Point prevalence survey
Effect of patient characteristics on unreported clinical deterioration
Frequency of unreported clinical deterioration per point prevalence survey.
Unreported clinical deterioration occurred in 12.9% of patients who were located in an ED cubicle (n = 24/186). There were no episodes of unreported stridor or upper airway obstruction, bradypnoea, acidosis or seizures. Hypotension was the most common abnormality; 33.3% of patients (n = 8) with unreported clinical deterioration had a systolic blood pressure less than 90 mmHg. Tachycardia was present in 20.8% of patients (n = 5) with unreported clinical deterioration. Less common sources of unreported clinical deterioration were hypertension (n = 3), bradycardia (n = 3) and tachypnoea (n = 3). The other two instances of unreported clinical deterioration were the result of decreased conscious state (n = 1) and ‘clinician concern’ (n = 1). The number of patients who experienced unreported clinical deterioration and type of deterioration are shown in Table 1.
Table 1
Unreported clinical deterioration
Clinician concern
There were 396 patients in the ED during the nine PPS; 186 of these patients (46.9%) were being cared for in an ED cubicle, the remainder were in the ED waiting room. During the PPS, the number of patients in an ED cubicle ranged from 14 to 25 and the total number of patients present in the ED (in cubicles and the waiting room) ranged from 20 to 53. Of the patients present in ED cubicles during PPS, abdominal pain was the most common presenting problem (n = 28; 15.5%) followed by shortness of breath (n = 25; 13.8%) and chest pain (n = 19; 10.5%). When patient age groups were examined, 73.1% of patients (n = 136/186) were from high risk age groups. Specifically, there were four patients aged less than 28 days, 22 patients aged 5 years or less, 59 patients aged 65—79 years and 51 patients aged over 80 years. At the time of the point prevalence surveys, 18.8% of patients (n = 72/396) were still waiting to be seen by a doctor and 78.2% of patients (n = 310/396) had been seen by a doctor. Of the 72 patients waiting to be seen by a doctor, 59.7% of patients (n = 43) were still within their ATS treatment time recommendations.25 However, 40.3% of patients (n = 29) waiting to be seen by a doctor had waited longer than the recommended ATS treatment time.25 Of the patients seen by a doctor (n = 310), 42.2% of patients (n = 131) had treatment commenced within the ATS time recommendations and 67.8% patients did not (n = 179).
%
Patient characteristics
n
Total
Results
9.1 10.0 13.0 21.0 14.3 21.7 17.4 8.0 5.8
B.M. Scott et al.
1 2 3 4 5 6 7 8 9
36
Unreported deterioration in ED patients Table 2
Frequency of unreported clinical deterioration and patient age groups and clinical urgency.
Unreported clinical deterioration
Tachypnoea Bradycardia Tachycardia Hypotension Hypertension Decreased conscious state Other CIC Total a
37
Proportion of patients aged 5 years or lessa
Proportion of patients aged 65 years and overa
Proportion of patients whose clinical urgency required treatment within 30 mina
≤50%
>50%
≤50%
≤50%
3 3 5 8 3 1
0 0 0 0 0 0
0 0 1 3 1 0
3 3 4 5 2 1
3 0 4 6 1 1
0 3 1 2 2 0
1
0
0
1
1
0
24
0
5
19
16
8
>50%
>50%
% of patients within ED cubicles (waiting room patients excluded).
ED cubicles during any of the PPS. Therefore all episodes of unreported clinical deterioration occurred when the proportion of children aged 5 years or less was less than 50% of ED patients in cubicles. The proportion of patients aged 65 years and over was greater than 50% of patients in ED cubicles in five of the nine PPS (PPS numbers 4, 5, 6, 8 and 9) and 79.2% (n = 19) of episodes of unreported clinical deterioration occurred when the proportion of older people aged 65 years and over was greater than 50% of ED patients in cubicles (Table 2). The proportion of patients requiring treatment within 30 min (ATS 1, 2 and 3 patients) was greater than 50% of the total ED population (waiting room and ED cubicles) in all but three PPS (PPS 1, 6 and 8). Patients were twice as likely to experience unreported clinical deterioration when the proportion of patients requiring treatment within 30 min was less than 50% of the total ED population (Table 2). When the proportion of patients requiring treatment within 30 min was greater than 50% of the total ED population the frequency of unreported bradycardia increased by 37.5% but unreported tachypnoea, tachycardia and hypotension were less common (Table 2).
over 50% and when the paediatric cubicle occupancy was 50% or less (Table 3).
Effect of ED nurse staffing on unreported clinical deterioration During PPS 1 and 5, there were four registered nurses on shift with postgraduate qualifications in emergency nursing: there were two episodes of unreported clinical deterioration during each of these PPSs (n = 4; 16.7%). The same PPS had unfilled nursing deficits: three unfilled deficits during PPS 1 and one unfilled nursing deficit during PPS 5 (Table 4). Finally, the relationship between unreported clinical deterioration and day of week and time of day was examined. Overall, twice as many episodes of unreported clinical deterioration occurred during the week compared with weekend days (n = 16; 66.7% versus n = 8; 33.3%). The greatest proportion of unreported clinical deterioration occurred during the evening shift (n = 15; 62.5%), followed by day shift (n = 7; 29.2%) and then night shift (n = 2; 8.3%).
Discussion Effect of ED characteristics on unreported clinical deterioration Resuscitation cubicle and general cubicle occupancy was greater than 50% during seven PPS (resuscitation = PPS 3, 4, 5, 6, 7, 8 and 9/general cubicles = PPS 1, 2, 3, 6, 7, 8 and 9), the monitored cubicles had greater than 50% during all nine PPS, and the paediatric cubicles had greater than 50% occupancy during four PPS (PPS 1, 2, 7 and 8). When the 24 episodes of unreported clinical deterioration were examined against occupancy of various ED care areas, two thirds of episodes of unreported clinical deterioration were shown to have occurred when the resuscitation cubicle occupancy was greater than 50%. All unreported clinical deterioration occurred when the occupancy of the monitored cubicles was over 50% (Table 3) as they were at this level of occupancy for all PPS. Twenty-two episodes of unreported clinical deterioration occurred when the general cubicle occupancy was
This study had six major findings. First, one in seven patients (12.9%) had unreported clinical deterioration. Other Australian studies of deterioration in ED patients show the prevalence of deterioration ranges from 2% to 14.8% depending on the patient cohort examined and the definition of deterioration.14,26—28 This study had similar findings to that of Richmond et al.28 who reported that 10% of the clinical issues identified during bedside reviews of care of ED patients were related to clinically unstable patients. Similarly, Considine et al.26 showed that 11.6% of ED patients with presenting complaints of shortness of breath, chest pain or abdominal pain, experienced one or more episodes of unreported clinical deterioration (defined using the same CIC as the study reported in this paper). Studies reporting lower rates of deterioration,14,27 were focused on reported deterioration so did not capture patients who may have suffered unreported deterioration.
38 Table 3
B.M. Scott et al. Frequency of unreported clinical deterioration and ED occupancy of ED care areas.
Unreported clinical deterioration
Resuscitation cubicle occupancy
Monitored cubicle occupancy
General cubicle occupancy
Paediatric cubicle occupancy
≤50% n
≤50% n
≤50% n
≤50% n
>50% n
>50% n
>50% n
>50% n
Tachypnoea Bradycardia Tachycardia Hypotension Hypertension Decreased conscious state Other CIC
0 2 1 3 2 1
3 1 4 5 1 0
0 0 0 0 0 0
3 3 5 8 3 1
0 1 0 0 1 0
3 2 5 8 2 1
2 3 5 7 3 0
1 0 0 1 0 1
0
1
0
1
0
1
1
0
Total
9
15
0
24
2
22
21
3
Second, the most common types of unreported clinical deterioration were hypotension and tachycardia. This finding bears some similarity to other studies. Considine et al.26 found that 73.1% of episodes of tachycardia and 50% of episodes of hypotension went unreported in ED patients with presenting complaints of shortness of breath, chest pain or abdominal pain. However in this study, tachypnoea was the most common cause of unreported clinical deterioration with 74.5% of episodes of tachypnoea documented but not reported.26 Again, the criteria for defining deterioration were the same as those used in this current study. A study conducted at the same ED and focusing on reported deterioration found that the most common causes of deterioration resulting in escalation of care were hypotension (27.7%) and tachycardia (23.7%).14 Third, patient factors (age and clinical urgency) appeared to influence the prevalence of unreported clinical deterioration. When greater than 50% of patients were from high risk age groups, the prevalence of unreported clinical deterioration was six times greater. However the numbers of children aged 5 years or less were small so the greatest
Table 4
influence on this finding was the proportion of older patients aged 65 years or over. When the proportion of ED patients aged 65 years or over was greater than 50% of the total ED population, the frequency of unreported clinical deterioration increased fourfold. It is important to recognise that this study was not about unreported clinical deterioration in older people per se, but rather about the impact of high numbers of older people on unreported clinical deterioration across the whole ED. There are no published studies related to clinical deterioration in older ED patients, however a number of studies have shown that older people are at increased risk of adverse events and reported incidents during their ED care. Patients aged over 65 years were more likely to suffer incidents related to breach of skin integrity, patient management, diagnosis and patient identification than younger ED patients.21 Although not focused specifically on older ED patients, studies of deterioration in ED patients have shown the median age of ED patients who required activation of an ED rapid response system was 65.1 years.14 In a comparison of two systems for recognising clinical deterioration
Unreported clinical deterioration and ED nurse staffing.
Unreported clinical deterioration
Postgraduate qualified RNs
Unfilled nursing deficits
