Senior emergency nurses’ responses to escalations of care for clinical deterioration

Abstract

Background

Recognising and responding to clinical deterioration is a safety priority. The aim of this study was to determine the frequency, nature, and response of emergency department Nursing Shift Leaders to episodes of escalation of care for patient clinical deterioration.

Methods

A prospective exploratory descriptive design was used. Participants were recruited from the senior nurses at the study site that fulfilled the role of being in charge of the ED. Study data were collected between 29 October and 17 December 2015 across various shifts using an observation tool developed specifically for this study.

Results

This study had three major findings. First, escalation of care for clinically deteriorating patients to the Nursing Shift Leader occurs frequently. There were 37 observed escalations of care, equating to 1.02 episodes per hour. Second, Nursing Shift Leaders rely on clinical emergency nursing skills to recognise, prioritise and respond to escalation of care for clinically deteriorating patients. Finally, the Nursing Shift Leaders’ role in responding to escalation of care for clinical deterioration is multifaceted.

Conclusions

The Nursing Shift Leaders’ role in responding to escalation of care for clinical deterioration is complex and includes navigation of a multifaceted team environment and logistical challenges unique to the time pressured, unpredictable ED milieu.

Introduction

Adverse events as a result of unrecognised and unreported clinical deterioration can lead to increased morbidity and mortality, therefore it is crucial that clinicians respond to clinical deterioration in a timely manner [1]. Safety systems such as Medical Emergency Teams (METs) have been developed to ensure early and aggressive management of clinical deterioration and reduce the number of associated adverse events [2]. In Australia, recognising and responding to clinical deterioration was one of ten National Safety and Quality Health Service Standards introduced in 2011 with the aim of improving patient safety in acute care hospitals [3].

Not all adverse events are the result of a patient's underlying condition and many in-hospital adverse events worldwide are related to suboptimal patient management [4], patients being nursed in an area inappropriate for their condition [5] and communication errors [6]. In addition, there is a clear link between nursing leadership and patient safety [4], [5], [7], [8], [9], [10]. The Nursing Shift Leader role in the emergency department (ED) is the highest clinical nursing leadership position in the emergency nursing team and these senior nurses are responsible for the safety of ED patients, staff and visitors as well as ensuring a safe ED environment [11].

The Nursing Shift Leader role is complex and includes the oversight of admission, transfer and discharge of patients from the ED as well as patient assessment, staff supervision and delegation of care [12]. The ED safety systems such as METs require escalation of care to senior clinicians [13] including the Emergency Physician and the senior nurse in-charge of the shift (Nursing Shift Leader) [14]. The Nursing Shift Leader is pivotal in the management of the ED environment and the allocation and deployment of resources when a patient deteriorates and requires escalation of care, however to date there have been no studies exploring the management of clinical deterioration from the perspective of the ED Nursing Shift Leader. This study provides an opportunity to increase our understanding of this crucial role with a view to informing clinical practice, education and policy development and ultimately improving patient outcomes.