Clinical PaperLower incidence of unexpected in-hospital death after interprofessional implementation of a bedside track-and-trigger system☆
Introduction
A clinical adverse event is defined as an unintended injury caused by incorrect or suboptimal patient management, and resulting in clinical deterioration or even death.1 Serious in-hospital adverse events include cardiac arrest, sudden death (without cardiopulmonary resuscitation), and unplanned admission for intensive care.2
Readily assessable values of pathophysiological bedside parameters (including respiratory rate, heart rate, blood pressure, body temperature, level of consciousness, and haemoglobin saturation of oxygen) have been reported to deviate several hours ahead of clinical adverse events.3, 4, 5, 6 The clinical incidence of unexpected in-hospital death has been reported to be 1.63,7 and that of cardiac arrests to be 2.08,8 per 1000 patient admissions. Earlier recognition of deviating parameters might enable medical and nursing staff to reduce unexpected patient mortality in hospital wards, i.e. sudden death, death after cardiopulmonary resuscitation, or death within 24 h of admission for intensive care.
However, nursing staff have been reported to assess vital parameters infrequently or irregularly,9 and not to recognize, or react appropriately to, signs of early dysfunction in vital organ systems.10 Nurses are mostly alerted to deteriorating patients when their professional experience and clinical gaze make them worry,11 but early patient deterioration is often associated with detectable changes in the respiratory rate several hours before other clinical signs of deterioration can be observed.5, 6 To assist hospital staff in detecting deteriorated patients in due time, various hospital settings have designed, implemented and evaluated track-and-trigger systems, based on early warning scoring within rapid response systems.12, 13, 14, 15 Single-centre studies have reported clinical implementation of early warning score instruments, rapid response systems, and re-designed observation charts to be associated with lower numbers of cardiac arrest, unexpected death and unplanned admission for intensive care,7, 12, 16, 17, 18 but the reliability has been disputed because of inappropriate study designs.19 To our knowledge, previous studies on serious clinical adverse events have primarily focused on short-term interventional effects, and in-hospital teaching and training have been used. Interprofessional aspects within teaching and training as well as within communication or collaboration have not been addressed so far. All of which have been claimed to influence patient outcome.20
By particularly addressing interprofessional teaching, training, communication, and collaboration, this study was designed to evaluate short- and long-term effects of a clinical multi-component intervention, comprising a bedside track-and-trigger system, on unexpected in-hospital mortality in a general medical and surgical ward setting at a large Danish university hospital.
Section snippets
Study design
In this prospective non-randomized controlled clinical study, detailed information on all events of unexpected in-hospital death was obtained over three four-month study periods – a pre-interventional period in 2009 (1st March–30th June), and two postinterventional periods in 2010 (1st September–31st December) and 2011 (1st March–30th June). Information on all events of unexpected death (i.e. sudden death, death after cardiopulmonary resuscitation, and death within 24 h of admission for
Patient characteristics
During the pre-interventional study period (2009), a total number of 1870 adult patients were admitted for at least 24 h – corresponding to 9804 individual in-hospital days of care in the four-ward study setting (including the high-intensity monitoring area). Corresponding numbers during the two postinterventional study periods were 2079 patients and 12,584 patient days (2010), and 2234 patients and 13,356 patient days (2011). In 2009, the age of patients eligible for inclusion was 58 ± 19 years,
Discussion
In this study clinical implementation of a multi-component intervention aiming at reducing serious clinical adverse events by improving in-hospital patient monitoring was found to be associated with significantly lower unexpected in-hospital mortality, mainly due to considerably fewer patients with sudden death (no resuscitation attempt) in the study setting. This main finding of lower adjusted unexpected in-hospital patient MR is of importance to patients, relatives and care providers within
Conclusion
A clinical intervention comprising three interacting main components (systematic nursing monitoring practice with regular bedside use of a track-and-trigger system, a structured patient observation chart, and a clinical algorithm for immediate bedside action), implemented by teaching, simulation training, and optimization of interprofessional communication and collaboration, may significantly reduce unexpected in-hospital mortality.
Conflict of interest statement
We declare no conflicts of interest.
Role of the funding source
This study was supported by grants from Lund University Faculty of Medicine, Lund, and Skåne University Hospital, Malmö, Sweden, and from Copenhagen University Hospital, Hvidovre, and Trygfonden, Lyngby, Denmark. Financial sponsors of this study had no roles in the study design, in collection, analysis, interpretation, or compilation of the results, or in the writing of the manuscript or the decision on where to submit for publication.
Acknowledgements
We acknowledge Copenhagen University Hospital, Hvidovre, Denmark, for having made possible this project. We also thank the head of department and all nursing and medical staff at the study setting for generous participation.
References (30)
- et al.
What factors influence suboptimal ward care in the acutely ill ward patient?
Intens Crit Care Nurs
(2009) - et al.
Combinations of early signs of critical illness predict in-hospital death-the SOCCER study (signs of critical conditions and emergency responses)
Resuscitation
(2006) - et al.
Signs of critical conditions and emergency responses (SOCCER): a model for predicting adverse events in the inpatient setting
Resuscitation
(2006) - et al.
A prospective controlled trial of the effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients
Resuscitation
(2010) - et al.
Incidence, staff awareness and mortality of patients at risk on general wards
Resuscitation
(2008) - et al.
ViEWS—towards a national early warning score for detecting adult inpatient deterioration
Resuscitation
(2010) - et al.
A multi-professional full-scale simulation course in the recognition and management of deteriorating hospital patients
Resuscitation
(2009) - et al.
Rescuing A Patient In Deteriorating Situations (RAPIDS): a simulation-based educational program on recognizing, responding and reporting of physiological signs of deterioration
Resuscitation
(2011) - et al.
Rapid-response teams
N Engl J Med
(2011) - et al.
Antecedents to hospital deaths
Intern Med J
(2001)
Respiratory rate: the neglected vital sign
Med J Aust
Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial
Lancet
Suboptimal care of the acutely unwell ward patient: a concept analysis
J Adv Nurs
Nurses’ role in detecting deterioration in ward patients: systematic literature review
J Adv Nurs
Effectiveness of the Medical Emergency Team: the importance of dose
Crit Care
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A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2013.11.023.