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In-hospital patient safety - prevention of deterioration and unexpected death by systematic and interprofessional use of early warning scoring

Bunkenborg, Gitte LU (2014) In Lund University, Faculty of Medicine, Doctoral Dissertation Series 2014:52.
Abstract (Swedish)
Popular Abstract in Danish

Summary in Danish

Patientsikkerhed på hospital – forebyggelse af uventede dødsfald via systematisk anvendelse af et Early Warning Score system

På hospitaler i den vestlige del af verden sker det, på trods af store indsatser for at øge patientsikkerheden, at indlagte patienters tilstand forværres alvorligt, og at nogle af disse patienter i værste tilfælde dør, som konsekvens af utilstrækkelig overvågning og uoptimal håndtering af situationen fra hospitalspersonalets side. I de sidste tyve år har man haft kendskab til, at patienter, der dør uventet på hospital, frembyder afvigende vitale parametre (puls, vejrtrækningsfrekvens, blodtryk og temperatur) i op til 48 timer inden det... (More)
Popular Abstract in Danish

Summary in Danish

Patientsikkerhed på hospital – forebyggelse af uventede dødsfald via systematisk anvendelse af et Early Warning Score system

På hospitaler i den vestlige del af verden sker det, på trods af store indsatser for at øge patientsikkerheden, at indlagte patienters tilstand forværres alvorligt, og at nogle af disse patienter i værste tilfælde dør, som konsekvens af utilstrækkelig overvågning og uoptimal håndtering af situationen fra hospitalspersonalets side. I de sidste tyve år har man haft kendskab til, at patienter, der dør uventet på hospital, frembyder afvigende vitale parametre (puls, vejrtrækningsfrekvens, blodtryk og temperatur) i op til 48 timer inden det uventede dødsfald.

Studier fra andre europæiske lande har dog vist, at noget af problemet med uventede dødsfald på hospital skyldes, at en stor del af det kliniske personale ikke er fortrolig med viden om betydningen af afvigende vitale parametre, og at de er usikre på, hvordan de skal tolke og agere overfor afvigende vitale parametre. Derudover har der, indtil for nylig, fra hospitalsorganisationers side, ikke været fokuseret på at introducere en øget observationspraksis inklusiv øget kendskab til håndtering af ustabile patienter.

Formålet med dette studie var at undersøge patientsikkerheden på almen medicinsk og kirurgisk afdeling på et dansk hospital, set i relation til sygeplejerskers observationspraksis af vitale parametre og det tværfaglige samarbejde vedrørende ustabile patienter. Undersøgelsen blev påbegyndt i 2009, hvor fire måneder i foråret udgjorde før-interventions perioden, og fire måneder i efteråret 2010 og i foråret 2011 udgjorde de to efter-interventionsperioder.

Indledningsvist undersøgte vi via observationer og interview den aktuelle observationspraksis. Det videre studie blev designet som et interventionsstudie med henblik på at undersøge, om en obligatorisk, systematisk og tværfaglig anvendelse af et observations- og vurderingsredskab, et såkaldt Early Warning Score system, kan opspore patienter i risiko for at blive akut kritisk syge, og om dette i kombination med et nyt dokumentationsredskab og en handlingsalgoritme kan bidrage til hurtigere iværksættelse af korrekt pleje og behandling.

Det overordnede formål var at undersøge interventionens effekt på antallet af uventede dødsfald, hjertestop eller uventet indlæggelse på intensiv afdeling hos patienter indlagte på almen kirurgisk og medicinsk afdeling. Desuden var formålet at undersøge i hvor høj grad interventionen var blevet fulgt, og hvordan implementeringsprocessen blev oplevet af personalet tæt på klinisk praksis.

Sluttelig ønskede vi at bestemme forbindelsen mellem tidligt opståede, lettere afvigende vitale parametre, og senere alvorlig forværring.

Resultaterne af den indledende observations- og interview undersøgelse viste, at der hos sygeplejersker fandtes et meget varierende niveau af professionalisme; et begreb, der indeholder karakteristika som: viden, evnen til at reflektere, autonomi men også arbejdsmiljøet og det tværfaglige samarbejde er indeholdt i begrebet professionalisme. Den enkelte sygeplejerskes grad ad professionalisme har indflydelse på hendes observationspraksis, og dette kan få betydning for patientsikkerheden.

Vejledt af litteraturen og resultaterne fra observations- og interviewstudiet blev der foretaget en række forskellige implementeringstiltag. Klinikere fra projekt afdelingen evaluerede, at det meningsgivende i interventionen og det store faglige fokus i projektet havde været meget motiverende for deres deltagelse og havde styrket en vellykket implementering af den kliniske intervention. Både ledelse og medarbejdere var aktivt inddraget i implementeringsfasen.

I de afdelinger der deltog i studiet, ændrede den daglige observationspraksis sig således, at tiden mellem individuelle målinger af puls, blodtryk og temperatur blev mindsket betydeligt. Derudover opnåede 75% af alle patienter af få repeteret måling af deres vitale parametre inden for den tidsramme på 8 og 4 timer som handlingsalgoritmen foreskrev. Alt i alt blev der målt tre gange så mange sæt vitale parametre i hver af de to efter-perioder som i før perioden. Hospitalets Mobile Akut team blev tilkaldt 3 gange oftere i perioden efter i forhold til i perioden før interventionen.

Forekomsten af uventede dødsfald faldt markant, hvis man sammenligner før-perioden med den sidste efter-periode. Men allerede i den første efter-periode var der et tydeligt, men ikke statistisk signifikant fald.

I den sidste undersøgelse fandt vi, at små ændringer i puls og vejrtrækningsfrekvens er forbundet med senere alvorlig forværring, Stigende alder er ligeledes forbundet med senere alvorlig forværring. Desuden forværredes 25%, af de, der havde fået målt tidlige og små afvigelser, senere alvorligt, med øget risiko for død til følge. Ca. halvdelen forværredes allerede inden for de første 48 timer.

Konklusionen på projektet er, at det er muligt at bidrage til nedbringelse af antallet af uventede dødsfald på hospital via en daglig, tværfaglig og struktureret anvendelse af et early warning score system og et understøttende handlings og dokumentationsredskab. (Less)
Abstract
Abstract

In-hospital patient safety is at times hampered, leaving general ward patients at considerable risk of gradual, even life-threatening, deterioration. In many European clinical settings, inappropriate nursing practice of bedside monitoring and management has recently been addressed as impending to in-hospital patient safety. Vital parameters have for two decades been known to deviate in individual patients hours ahead of serious adverse events, but this knowledge has not yet been generally rooted among nursing and medical in-hospital staff, contributing to misinterpretation of individual vital signs and inadequate bedside action being taken. Accordingly, this knowledge of the predictable value of deviations in bedside... (More)
Abstract

In-hospital patient safety is at times hampered, leaving general ward patients at considerable risk of gradual, even life-threatening, deterioration. In many European clinical settings, inappropriate nursing practice of bedside monitoring and management has recently been addressed as impending to in-hospital patient safety. Vital parameters have for two decades been known to deviate in individual patients hours ahead of serious adverse events, but this knowledge has not yet been generally rooted among nursing and medical in-hospital staff, contributing to misinterpretation of individual vital signs and inadequate bedside action being taken. Accordingly, this knowledge of the predictable value of deviations in bedside vital parameters has not until recently been reflected in general ward patient monitoring practice.

A clinical multi-component intervention comprising mandatory nursing bedside monitoring, based on structured regular in-hospital use and recording of modified early warning scores in in-hospital patients, was implemented by structured interprofessional teaching, training and promotion in a large medical and surgical study setting at an urban Scandinavian university hospital. This thesis has been based on four non-randomized pre- and postinterventional studies on bedside practice in this context (I-IV). Outcome measures of particular interest were associations between early deviation in various vital parameters and later severe deterioration (IV), and potential effects of the study intervention on unexpected death (III).

Before implementation of the study intervention, nursing monitoring practice was found to be influenced mainly by individual levels of professionalism, characterized by knowledge, reflection, and interprofessional collaboration (I).

After this implementation, the three most common bedside vital parameters were found to be recorded more frequently (II), and the unexpected in-hospital patient mortality in the study setting to be significantly lower (III), than before. Moreover, the medical emergency team was called in three times more often (III). Three quarters of the patients were rescored within the time limits of eight and four hours stated in the algorithm of bedside management (II). Sudden tachycardia or tachypnea in slightly deteriorated, particularly older, in-hospital patients was found to be significantly associated with later severe clinical deterioration (IV). (Less)
Please use this url to cite or link to this publication:
author
supervisor
opponent
  • professor Eintrei, Christina, Linköpings universitet
organization
publishing date
type
Thesis
publication status
published
subject
keywords
Patient safety, Adverse event, Vital parameters, Deterioration, Early warning score, Mortality rate, Unexpected death, Clinical intervention, Adherence, Implementation, association
in
Lund University, Faculty of Medicine, Doctoral Dissertation Series
volume
2014:52
pages
156 pages
publisher
Anaesthesiology and Intensive Care
defense location
Lilla aulan, Jan Waldenströms gata 5, Skånes Universitetssjukhus i Malmö.
defense date
2014-04-25 09:15
ISSN
1652-8220
ISBN
978-91-87651-78-6
language
English
LU publication?
yes
id
8f85afb5-0ef6-4693-a25a-6fec7537f2a2 (old id 4391307)
date added to LUP
2014-04-09 08:20:49
date last changed
2016-09-19 08:44:46
@phdthesis{8f85afb5-0ef6-4693-a25a-6fec7537f2a2,
  abstract     = {Abstract<br/><br>
In-hospital patient safety is at times hampered, leaving general ward patients at considerable risk of gradual, even life-threatening, deterioration. In many European clinical settings, inappropriate nursing practice of bedside monitoring and management has recently been addressed as impending to in-hospital patient safety. Vital parameters have for two decades been known to deviate in individual patients hours ahead of serious adverse events, but this knowledge has not yet been generally rooted among nursing and medical in-hospital staff, contributing to misinterpretation of individual vital signs and inadequate bedside action being taken. Accordingly, this knowledge of the predictable value of deviations in bedside vital parameters has not until recently been reflected in general ward patient monitoring practice. <br/><br>
A clinical multi-component intervention comprising mandatory nursing bedside monitoring, based on structured regular in-hospital use and recording of modified early warning scores in in-hospital patients, was implemented by structured interprofessional teaching, training and promotion in a large medical and surgical study setting at an urban Scandinavian university hospital. This thesis has been based on four non-randomized pre- and postinterventional studies on bedside practice in this context (I-IV). Outcome measures of particular interest were associations between early deviation in various vital parameters and later severe deterioration (IV), and potential effects of the study intervention on unexpected death (III). <br/><br>
Before implementation of the study intervention, nursing monitoring practice was found to be influenced mainly by individual levels of professionalism, characterized by knowledge, reflection, and interprofessional collaboration (I).<br/><br>
After this implementation, the three most common bedside vital parameters were found to be recorded more frequently (II), and the unexpected in-hospital patient mortality in the study setting to be significantly lower (III), than before. Moreover, the medical emergency team was called in three times more often (III). Three quarters of the patients were rescored within the time limits of eight and four hours stated in the algorithm of bedside management (II). Sudden tachycardia or tachypnea in slightly deteriorated, particularly older, in-hospital patients was found to be significantly associated with later severe clinical deterioration (IV).},
  author       = {Bunkenborg, Gitte},
  isbn         = {978-91-87651-78-6},
  issn         = {1652-8220},
  keyword      = {Patient safety,Adverse event,Vital parameters,Deterioration,Early warning score,Mortality rate,Unexpected death,Clinical intervention,Adherence,Implementation,association},
  language     = {eng},
  pages        = {156},
  publisher    = {Anaesthesiology and Intensive Care},
  school       = {Lund University},
  series       = {Lund University, Faculty of Medicine, Doctoral Dissertation Series},
  title        = {In-hospital patient safety - prevention of deterioration and unexpected death by systematic and interprofessional use of early warning scoring},
  volume       = {2014:52},
  year         = {2014},
}