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