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Detection and management of the deteriorating ward patient: an evaluation of nursing practice

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  • Mandy Odell

Abstract

Aims and objectives To audit ward nursing practice in the adherence to an early warning scoring protocol in the detection and initial management of the deteriorating ward patient and investigate factors that may impact on practice. Background Hospital inpatients can experience unexpected physiological deterioration leading to poor outcomes and death. Although deterioration can be signalled in the patients' physiological symptoms, evidence suggests that ward staff can miss, misinterpret or mismanage the signs. Rapid response systems have been implemented to address this problem. The rapid response systems consists of two phases: the afferent phase involves monitoring the patient, recognising deterioration and referring to more expert help and the efferent phase involves expert teams assessing and treating the patient. Research has tended to concentrate on the efferent phase of the process and has so far failed to show a significant impact on patient outcome. Methods Using cardiac arrest as a surrogate marker for deterioration, patient records were retrospectively reviewed during the 12 hours prior to the cardiac arrest event. Data relating to nursing practice and adherence to the early warning scoring protocol were extracted and analysed. Findings The findings suggest that ward nurses' monitoring of patients' observations has improved compared with earlier research, but errors in early warning scoring and nonadherence to referral protocols are still a problem. A number of potentially influential factors on nursing practice were tested, but only deterioration occurring outside normal weekdays was associated with a reduced quality of nursing adherence to protocol. Conclusions The implementation of rapid response systems may have been an oversimplified solution to the highly complex problem of undetected patient deterioration. There are a multitude of contributory factors to the problem of noncompliance to early warning scoring protocols, and possible solutions will need to reflect the breadth, depth and complexity of the problem if we are to improve patient experience and outcome. Relevance to clinical practice An audit of nursing practice against an early warning scoring protocol based on national recommendations and standards in the recording of and response to physiological deterioration in the ward patient has shown that vital signs recording has improved, but early warning scoring accuracy and referral to more expert help remain suboptimal. By identifying areas of suboptimal practice, strategies for education and training and service development can be better informed. More in‐depth evidence on factors that may impact the quality of nursing practice has been identified. Problems with rapid response systems assumptions have been highlighted, which may facilitate the implementation of more realistic solutions for managing the deteriorating ward patient.

Suggested Citation

  • Mandy Odell, 2015. "Detection and management of the deteriorating ward patient: an evaluation of nursing practice," Journal of Clinical Nursing, John Wiley & Sons, vol. 24(1-2), pages 173-182, January.
  • Handle: RePEc:wly:jocnur:v:24:y:2015:i:1-2:p:173-182
    DOI: 10.1111/jocn.12655
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    References listed on IDEAS

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    1. Debbie Massey & Leanne M Aitken & Wendy Chaboyer, 2010. "Literature review: do rapid response systems reduce the incidence of major adverse events in the deteriorating ward patient?," Journal of Clinical Nursing, John Wiley & Sons, vol. 19(23‐24), pages 3260-3273, December.
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    1. Sok Ying Liaw & Devon Yun Jia Chng & Lai Fun Wong & Jasmine Tze Yin Ho & Siti Zubaidah Mordiffi & Simon Cooper & Wei Ling Chua & Emily Neo Kim Ang, 2017. "The impact of a Web‐based educational program on the recognition and management of deteriorating patients," Journal of Clinical Nursing, John Wiley & Sons, vol. 26(23-24), pages 4848-4856, December.
    2. Clint Douglas & Catriona Booker & Robyn Fox & Carol Windsor & Sonya Osborne & Glenn Gardner, 2016. "Nursing physical assessment for patient safety in general wards: reaching consensus on core skills," Journal of Clinical Nursing, John Wiley & Sons, vol. 25(13-14), pages 1890-1900, July.
    3. Claire Foley & Maura Dowling, 2019. "How do nurses use the early warning score in their practice? A case study from an acute medical unit," Journal of Clinical Nursing, John Wiley & Sons, vol. 28(7-8), pages 1183-1192, April.
    4. Doug Elliott & Emily Allen & Sharon McKinley & Lin Perry & Christine Duffield & Margaret Fry & Robyn Gallagher & Rick Iedema & Michael Roche, 2016. "User acceptance of observation and response charts with a track and trigger system: a multisite staff survey," Journal of Clinical Nursing, John Wiley & Sons, vol. 25(15-16), pages 2211-2222, August.
    5. Chiara Dall’Ora & Peter Griffiths & Joanna Hope & Hannah Barker & Gary B Smith, 2020. "What is the nursing time and workload involved in taking and recording patients’ vital signs? A systematic review," Journal of Clinical Nursing, John Wiley & Sons, vol. 29(13-14), pages 2053-2068, July.
    6. Joanna Hope & Alejandra Recio‐Saucedo & Carole Fogg & Peter Griffiths & Gary B Smith & Greta Westwood & Paul E Schmidt, 2018. "A fundamental conflict of care: Nurses’ accounts of balancing patients' sleep with taking vital sign observations at night," Journal of Clinical Nursing, John Wiley & Sons, vol. 27(9-10), pages 1860-1871, May.
    7. Gitte Bunkenborg & Lars Smith‐Hansen & Ingrid Poulsen, 2019. "Implementing mandatory early warning scoring impacts nurses’ practice of documenting free text notes," Journal of Clinical Nursing, John Wiley & Sons, vol. 28(15-16), pages 2990-3000, August.

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