Research paperUnreported clinical deterioration in emergency department patients: A point prevalence study
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, 2, 3, 4, 5, 6, 7, 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, 10, 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
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 characteristics (ED occupancy, ED staffing), and the frequency and nature of unreported clinical deterioration in the ED.
Section snippets
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.
Patient characteristics
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
Discussion
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, 27, 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
Conclusion
Unreported clinical deterioration is an important quality indicator for emergency care. The results of this study show that the age and clinical urgency of the whole ED patient cohort influenced the prevalence of unreported clinical deterioration. 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. ED occupancy also influenced the prevalence of unreported clinical
Provenance and conflict of interest
Professor Julie Considine is a Deputy Editor of Australian Emergency Nursing Journal but has not been involved in the review process for this paper. This paper was not commissioned.
Acknowledgment
This research was generously funded by a Northern Health small research grant.
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