Research paper
Systems for recognition and response to clinical deterioration in Victorian emergency departments

https://doi.org/10.1016/j.auec.2017.12.003Get rights and content

Abstract

Background

The study aim was to explore the systems for recognising and responding to clinical deterioration in adult and paediatric Victorian emergency department (ED) patients after their initial triage assessment.

Methods

A survey of Victorian EDs was conducted. Senior ED nursing staff was asked about ED characteristics, vital sign documentation, systems for recognising and responding to deteriorating ED patients, quality assurance and governance of ED rapid response systems (RRSs).

Results

Sixteen EDs participated (17 metropolitan and 13 regional or rural) giving a response rate of 53.3% (16/30). The organisational definition of a deteriorating patient applied to the ED at 50% of sites (n = 8). Vital sign documentation was paper-based (43.6%), electronic (37.6%) or a combination (18.8%) of both. The majority of EDs (87.5%, n = 14) had an ED RRS; 50% had one tier, single trigger RRS and 31.3% of EDs had a two tier, single trigger RRS. At 68.8% of sites the ED RRS activation criteria were the same as ward MET (medical emergency team) activation criteria. The most common method of escalation of care for deteriorating ED patients were face-to-face communication (87.5%) and overhead announcements within the ED (68.8%). The ED rapid response team (RRT) was composed of ED specific staff in 50.5% of sites, and staff external to the ED at 12.5% of sites. Two thirds of sites (68.7%) collected data about clinical deterioration in ED patients.

Conclusions

Most EDs had an RRS but there was variability in activation criteria and members of the responding team both between EDs, and between ED and the ward RRSs.

Introduction

Emergency departments (EDs) are a major component of the Australian health care system and in 2015–16, ED clinicians managed almost 7.5 million attendances [1]. Managing the risk of clinical deterioration is fundamental to emergency nursing practice and commences at the point of triage [2]. Over the last three decades, EDs have developed systematic approaches to the assessment, risk management and clinical care of specific patient groups such as trauma, stroke and acute coronary syndrome [2]. rapid response systems (RRSs) are well established for patients who deteriorate on hospital wards. In Australia, national standards mandate that all acute care facilities have a RRS for the recognition and response to deteriorating ward patients [3]. However, broader systems for the recognition and response to deteriorating ED patients following their initial triage have only emerged in recent years [2], [4], [5].

The major components of RRS are the afferent limb to detect clinical deterioration, a response or efferent limb, and audit and governance limbs. Recent research reports that up to 40% of Australian ED patients fulfil hospital Medical Emergency Team (MET) criteria at one or more times during their ED care [4], [6], [7], [8], [9] and approximately 13% of clinical deterioration episodes in ED patients are unreported [4], [9]. Although there are systematic approaches established to respond to patients with sepsis, acute coronary syndrome, stroke, major trauma and cardiac arrest within the ED [2], less is known about systems in EDs to respond to clinical deterioration for the broader, more heterogeneous ED population. These systems are important given there is emerging evidence that clinical deterioration in the ED is associated with subsequent adverse events on the wards in admitted patients [6], [10]. Although the governance and team composition of ward based RRS has been studied [11], less is known about these variables within ED-based RRSs.

The aim of this study was to explore the current systems for recognising and responding to clinical deterioration in Victorian ED patients after their initial triage assessment. The specific research questions addressed by this study were as follows:

  • How are deteriorating ED patients recognised?

  • What strategies are utilised to escalate care for deteriorating ED patients?

  • What response is elicited by escalation of care and specifically, who becomes involved in the care of ED patients recognised as deteriorating?

For the purpose of this study, an ED is defined as having on-site access to both nursing and medical staff 24 h/7 days per week [12].

Section snippets

Design

A descriptive, exploratory research design was used and study data were collected using survey methods. The study was approved by the Human Research and Ethics Committee at Deakin University (HEAG-H 106_2016).

Setting and sample

The setting for this study was publicly funded Victorian EDs. There are a total of 39 public EDs in Victoria including one specialist children's hospital, two specialist women's hospitals, two specialist adult hospitals and one hospital specialising in eye and ear conditions [1]. One

Results

A total of 30 EDs agreed to participate (17 metropolitan and 13 regional or rural). The response rate was 53.3% with surveys returned from 11 metropolitan and 5 regional or rural EDs. Of the respondents, 56.3% (n = 9) were CNEs, 31.3% (n = 5) were NUMs and the other respondents were a clinical nurse specialist (n = 1) and a clinical nurse consultant (n = 1). Most EDs in this study were reported as Level 3 (Table 1) according to the Australasian College for Emergency Medicine (ACEM) criteria [12]. There

Discussion

Although the majority of respondents from publicly funded Victorian EDs surveyed had a system for recognising and responding to deteriorating ED patients, there was substantial variability in ED RRS activation criteria, team composition and expected response across the State. Most EDs had a one tier, single trigger RRS that was largely aligned with ward MET criteria. Two tier, single trigger systems were in place at one third of the EDs surveyed; this finding is not surprising given that two

Conclusions

RRSs were implemented in most EDs surveyed. There was variability in ED RRS activation criteria and response to escalation of care between EDs, and between ED and ward RRSs, raising issues of unwarranted practice variation for deteriorating ED patients. Systems and processes for recognising and responding to deteriorating patients in the ED need to be systematic to ensure safety for all patients located in the ED including boarding inpatients.

Conflict of interest

Professor Julie Considine is a senior editor of Australasian Emergency Nursing Journal but had no role or part in the peer review or editorial decision-making of this paper, and was blinded to the manuscript in the Elsevier Editorial System.

Funding

This is an unfunded, investigator driven study.

Authors’ contribution

JCo conceived and designed the study. JCo, KR and JCu developed the study protocol and designed and tested the study instruments. KR collected the study data, JCo and JCu supervised data collection. JCo analysed the data. JCo, KR, DJ and JCu prepared and approved the manuscript.

References (21)

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