How can we better respond to deteriorating patients?

Dr Alison PirretDr Alison Pirret from the School of Nursing.

From the moment patients are admitted to hospital, they are monitored closely to identify whether their condition is improving or deteriorating. But are New Zealand hospitals and staff best equipped to manage this, and identify and respond to early warning signs of deterioration?

Dr Alison Pirret, from Massey University’s School of Nursing, specialises in research around managing deteriorating adult ward patients. She combines her work in the Critical Care Complex at Auckland’s Middlemore Hospital, with her research and teaching role at Massey.

“I’m interested in improving, recognising and responding to deteriorating patients once they enter hospital – how can we do it better, and also, how do we prepare medical and nursing staff to better recognise and manage these patients?

“In hospital populations, we have early warning scoring systems to assist doctors and nurses to recognise deterioration in patients’ vital signs. If these deteriorate, the early warning score increases, ensuring they are seen at the right time by the right person. A significant change in their vital signs will cause a significant increase in the early warning score, resulting in the ward nurse activating an emergency call,” she says.

“At Middlemore Hospital, as is the case in many hospitals, it will activate a Medical Emergency Team call. This team consists of doctors and nurses especially trained in managing and responding to deteriorating patients.”

Dr Pirret recently worked on a study utilising an oxygen device in the ward, which had previously only been used in an intensive care unit (ICU). “What we found was most patients’ condition improved significantly within 20 minutes of using the device. With the huge demand on ICU beds in New Zealand hospitals, it was really positive to be able to use this system in the wards, and see such significant impact almost immediately.”

This particular study was only done at Middlemore Hospital, but Dr Pirret hopes to roll out the study nationwide in the future.

She has also been working nationally with the Health Quality and Safety Commission Deteriorating Patient Programme on a five-year programme to improve care for deteriorating patients admitted to hospital. The group of people involved with this project include doctors representing ICU medicine, general medicine and emergency care, and nurses representing ICU in both the private and public sector. Middlemore hospital has implemented three of the four stages of the project.

“For the first two stages we’ve analysed a large amount of data to see what the results are. It involved more than 11,000 patients, with more than 300,000 sets of vital signs data. We’ve also analysed a years’ worth of high early warning scores that would trigger a Medical Emergency Team response. The results are currently  helping us establish if we have got the escalation response to early warning scores right, so this data will influence how we set up systems going forward, to enable us to better recognise and respond to deteriorating patients, without overloading the resources we have on hand.”

Dr Pirret says it is internationally recognised that patients and their families often notice deterioration, quicker than hospital staff. “Staff are not always looking after the same patient continuously, doctors pop in and out, so subtle changes in deterioration can be missed.”

She completed research with Middlemore colleagues to determine ward patients’ and families perspective of a need for a patient and family specific escalation system. Following that research, Middlemore Hospital has implemented a system where ward patients and/or their families can call the Patient at Risk Team directly if they think their deterioration has not been recognised by staff.

Planning ahead with patients

Dr Pirett says conversations around resuscitation and what matters to patients also need to change. “These are hard to have conversations, but are really important and is the final part of the five-year Health Quality and Safety Deteriorating Patient Programme. Resuscitation can come in a variety of forms, and often patients and their families tell me they don’t feel like they have been informed adequately, and when the time comes, it can be very distressing.

“For instance, it might be CPR after the patient suffers a cardiac arrest, or transfer to an intensive care unit for medication to help their blood pressure, or being assisted with a breathing machine. It could be as simple as providing an intravenous drip or blood transfusion to keep the blood pressure up,” she says.

“For some people, these treatments might not benefit them, or be what they want. So a lot of work needs to be done around advanced care planning conversations about what patients want if they get really sick, having meaningful conversations about what really matters to them, and what is actually in their best interests.”

Dr Pirret says trying to have these conversations with family members when their loved one is already deteriorating, is very stressful for all involved. “If we make these conversations part of the regular treatment plan, and encourage people to talk to family members at home before they get really sick, we can come up with an escalation plan with them, rather than around them. I’m really keen to improve the current work around that.”

Massey’s Master of Nursing prepares students for a range of clinical leadership roles in speciality areas, education, management or research. The Nurse Practitioner pathway is approved by the Nursing Council and meets the education requirements for registration as a NP. Students will develop advanced knowledge and skills in their field of study through a mix of theoretical and clinical courses.

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