Abstract:
Recognition and response to the onset of patient clinical deterioration is critical to prevent
adverse events. Many hospitals use an early warning scoring (EWS) tool and emergency
teams to identify and manage patients at risk of clinical deterioration. An EWS tool yields a
score based on pre-defined ranges of a patient’s vital sign recordings, such as the
physiologically unstable patient (PUP) tool. Some tools include a concern criterion and there
is growing evidence that nurse concern often identifies patient deterioration prior to the
activation score on an EWS. Yet, little is known about what nurse concern means in the
context of patient deterioration. My study explores and identifies factors associated with
nurse concern when patient deterioration is recognised in the absence of an emergency
activation score. This was a multi-site study and a mixed methods approach was used. There
were two phases to the study. The first phase, a retrospective chart review of 19,326 referrals
for emergency assistance was conducted; and 3426 cases identified were nurse initiated
referrals. This comprised of PUP scores (n=3025) and nurse concern referrals (n=401). Data
analyses of nurse concern referrals and PUP 5 scores, indicating immediate emergency
assistance, yielded significant findings. Firstly, patient death occurred less frequently
following a nurse concern referral (0.7%, n=3) when compared to PUP 5 score referrals (5%,
n=74), (X2
(df1)=14.2, p<0.001). Secondly, patients were more likely to improve with ward
level care after a nurse concern referral (77%, n=295) than after a PUP 5 score referral (65%,
n=935), (X2
(df1)=20.22, p<0.001). Finally, patients were less likely to need higher level care
of an ICU/HDU following a nurse concern referral (12%, n=47) than a PUP 5 referral (17%,
n=247), (X2
(df1)=5.3, p=0.02). A cost estimate calculation of ICU/HDU admissions indicated
that hospital costs were saved with nurse concern referrals. In the second study, focus group
discussions were used to explore what nurses do when concerned about patient deterioration
in the absence of an EWS. Seven focus groups were conducted with a total of 29 nurse
participants. The study findings revealed that nurses were able to quickly intervene when
subtle cues of patient deterioration were identified because of their expertise, knowledge, and
proficiency of skills. The findings also identified barriers to nurses acting on their concern
and these were associated with communication issues, the hierarchical power relationships
between staff, and nurses’ expertise and experience being discounted. The findings have
significant implications for professional development and education, requiring better
recognition and value for nurse concern. This study identified that nurse concern and nurse’s
expertise saves lives and hospital costs through early identification of patient deterioration.