Research paper
The effect of a staged, emergency department specific rapid response system on reporting of clinical deterioration

https://doi.org/10.1016/j.aenj.2015.07.001Get rights and content

Summary

Background

Despite emerging evidence regarding clinical deterioration in emergency department (ED) patients, the widespread uptake of rapid response systems (RRS) in EDs has been limited.

Aims

To evaluate the effect of an ED RRS on reporting of clinical deterioration and determine if there were differences between patients who did, and did not, deteriorate during ED care.

Methods

A retrospective cross sectional design was used to conduct this single site study in Melbourne, Australia. Stratified random sampling identified 50 patients with shortness of breath, chest pain or abdominal pain per each year studied (2009–2012) giving a total of 600 patients. The intervention was an ED RRS implemented in stages.

Results

The frequency of clinical deterioration was 14.8% (318 episodes/89 patients). Unreported deterioration decreased each year (86.7%; 68.8%; 55.3%; 54.0%, p = 0.141). Patients who deteriorated during ED care had a longer median ED length of stay (2.8 h; p < 0.001), were 31.9% more likely to need hospital admission (p < 0.001) and 4.9% more likely to die in hospital (p = 0.044).

Conclusions

A staged ED specific RRS decreased the frequency of unreported clinical deterioration. Controlled multi-site studies of ED specific RRSs are needed to examine the effect of formal ED RRSs on patient outcomes.

Section snippets

What is known

  • There are few published studies detailing the effect of formal systems for recognising and responding to deteriorating emergency department (ED) patients.

  • In Australia, rapid response systems (RRSs) operate in most inpatient units in major health services; however, they do not typically operate in EDs despite clinical deterioration occurring in between 1.5% and 7.5% of ED patients.

  • The most common physiological derangements in ED patients that fulfil rapid response system activation criteria are

What this paper adds?

  • A multi-faceted approach increased staff reporting of clinical deterioration in ED patients.

  • One in six patients had documented evidence of clinical deterioration in the ED, supporting the argument for an ED specific RRS, particularly for patients with systemic presenting complaints.

  • The longitudinal nature of the study enables the impact of each separate element of the ED rapid response system as well as the cumulative effect of a multi-faceted intervention to be known.

Background

The majority of patients who suffer in-hospital adverse events with high risk of death (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 Rapid response systems (RRSs) are grounded in the premise that early intervention for deteriorating patients improves patient outcomes and decreases high mortality

Design

A retrospective cross sectional design was used to undertake this study. The primary outcome measure was unreported clinical deterioration. For the purposes of this paper, unreported clinical deterioration was defined as presence of documented physiological abnormalities that fulfilled the ED Clinical Instability Criteria (CIC)13 in ED nursing notes and no documentation that these abnormalities were reported to a medical officer. T0 (2009) was prior to any formal system for recognising and

Patient characteristics (n = 600)

Patient's median age was 55 years (IQR = 36–72) and 52.7% (n = 316) were female. Ambulance transport to the ED occurred in 40.3% (n = 242) and the remaining 59.7% (n = 358) arrived by private car. The Australasian Triage Scale (ATS) category distribution was: ATS 1 1% (n = 6), ATS 2 26.3% (n = 158), ATS 3 50.2% (n = 301), ATS 4 21.5% (n = 131) and ATS 5 0.2% (n = 1). The median time to nursing assessment was 11 min (IQR 3–28) and 69% (n = 414) of patients were seen by a nurse within their ATS category time. The

Discussion

It is difficult to understand the true frequency of clinical deterioration in ED patients. There are a number of studies that have used the same definition of deterioration (fulfilling ED CIC) however all have reported results from different patient populations. Considine et al.13 reported that ED RRS activation occurs in 1.5% of ED patients, however, the denominator in that study was all ED patients so patients with minor illnesses and injuries who are unlikely to suffer significant

Conclusion

A staged ED specific RRS decreased the frequency of unreported clinical deterioration. Each specific element of the RRS had an independent but cumulative effect in reducing unreported clinical deterioration. However, the effectiveness of the RRS plateaued when dissemination and implementation were complete and information regarding the RRS reverted to diffusion. Ongoing strategies to ensure clinician engagement with the aims, structure and function of RRSs are needed if ongoing improvements in

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.

Funding

This study was funded by the Australian Resuscitation Council (Victorian Branch).

Research ethics statement

This study was approved by the Human Research and Ethics Committees at Deakin University (2012-059) and Northern Health (LR 06/12).

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