Critical Care Research and Practice / 2019 / Article / Tab 2

Review Article

Performance of the Afferent Limb of Rapid Response Systems in Managing Deteriorating Patients: A Systematic Review

Table 2

Summary of relevant studies on recognizing deteriorating patients.

Outcome measures

Donohue and Endacott [44]
To examine ward nurses and critical care outreach staff perceptions in acute wards
Semistructured interviews with hospital clinicians
11 nurses and 3 members of the outreach team
Staff perceptions in management of deteriorating patients
(i) The MEWS was not a key component of the patient assessment and was used to quantify deterioration after recognition of the patient’s instability
(ii) Clinicians needed better understanding of the value of TTSs in identifying trends in the patient's condition

Ludikhuize et al. [45]
To evaluate whether nurses trained in the use of the MEWS and SBAR communication tool were more effective to recognize a deteriorating patient
Prospective, quasi–experimental simulation study in one teaching hospital
Simulated case study presented to 47 trained and 48 nontrained nurses
The case was a fictitious deteriorating patient with the nursing chart including vital parameters
Monitoring of vital signs (HR, RR, SBP, SpO2, and T°)
(i) The MEWS was correctly determined by 11% (4/47) of the trained nurses with better notification to the physician; the SBAR communication tool was used by only 1 nurse
(ii) 77% (36/47) of the trained nurses vs. 58% (28/48) of the nontrained group assessed the patient immediately ()
(iii) The RR was measured twice as frequently (53% trained vs. 25% nontrained nurses, ) with no differences in other vital parameters

Kolic et al. [46]
To assess scoring accuracy and adequacy of clinical responses to the NEWS, and the impact of time of day, the day of the week, and score severity on responses
Prospective observational study in one general hospital
370 adult patients in an acute medical ward
Two outcomes: (1) scoring errors and adequacy of clinical responses; (2) whether inadequate NEWS responses were associated with increased patient mortality
(i) The NEWS was calculated incorrectly in 18.9% (70/370) of patients with a substantial increase in scoring errors as the NEWS increased
(ii) 25.9% (96/370) of patients had an inadequate responses to the NEWS
(iii) Substantially worse clinical responses on weekends

van Galen et al. [47]
To perform a root-cause analysis of unplanned ICU admissions. To assess adherence to the MEWS system in identifying deteriorating patients transferred to the ICU
Retrospective observational study in one university hospital
Out of 49 adult patients, 477 vital parameter sets were found in the 48 hours before ICU admission from a general ward
Causes of unplanned ICU admissions and adherence to the MEWS
(i) The MEWS was calculated correctly in only 1% (6/477) of measurements, 48 h before ICU admission, although 43% (207/477) had a critical score (MEWS score ≥3)
(ii) In 41% of the patients, vital signs monitoring was done as discussed with the physicians
(iii) The root causes were work-related (45%), mainly failures in patient monitoring, disease-related (46%), patient-related (7.5%), and organizational-related (3%)

Petersen et al. [48]
To identify barriers and facilitating factors related to the use of the EWS escalation protocol among nurses
Focus group in one tertiary hospital
18 nurses
Content analysis for three aspects of the EWS protocol: (1) adherence to the monitoring frequency; (2) call for junior doctors to patients with an elevated EWS; (3) call for the MET
(i) Monitoring less frequently than prescribed occurred regularly during busy periods and at night
(ii) To inform doctors about patients with EWS ≥3 is not particularly important for the number of patients with an elevated score
(iii) There were barriers to MET calls since many nurses had negative feelings toward the MET

Wong et al. [49]
To evaluate (1) how many patients had critical messages before the ICU transfer and the quality of messages; (2) whether the quality of the message, the quality of the response or the timeliness of RRT activation were related to death
Retrospective observational study in one tertiary hospital
236 general ward patients
All CM communicating deterioration in the 48 h before the ICU transfer
CM: messages with information that met the calling criteria of the institution
(i) 39% (93/236) of patients had CM 48 h before the ICU transfer
(ii) Only 45% of messages contained 2 or more vital signs and 3% contained the SBAR tool
(iii) The message quality, mainly the use of the SBAR tool, was positively related to in-hospital survival

EWS: early warning score; TTS: track and trigger system; HR: heart rate; RR: respiratory rate; SBP: systolic blood pressure; T°: temperature; SpO2: peripheral oxygen saturation; MEWS: modified early warning score; SBAR: situation-background-assessment-recommendation; ICU: intensive care unit; NEWS: national early warning score; MET: medical emergency team; RRT: rapid response team; CM: critical messages; h: hours.