Recognition of patients who require emergency assistance: A descriptive study

doi:10.1067/mhl.2000.108327

Heart & Lung

Volume 29, Issue 4, July–August 2000, Pages 262-268

https://doi.org/10.1067/mhl.2000.108327 Get rights and content

Abstract

Objective: The purpose of this study was to explore and describe the patient characteristics and the process of recognition nurses use to recognize patients about whom they are seriously worried. Design: The study design was qualitative, exploratory, and descriptive, and it used in-depth interviews and a purposive sample. Setting: The study setting included a teaching hospital and a peripheral hospital in a Sydney area health service. Participants: Participants included registered nurses (N = 32) with 5 or more years of experience and a history of calling the medical emergency team (MET). Mean years of experience as a registered nurse was 14 years, and the mean calls to the MET since employed in current hospital was 16 calls. Findings: Primary findings showed that nurses relied on 4 patient characteristics to apply the MET criterion, “seriously worried about a patient.” These 4 characteristics were (1) feeling “not right,” (2) color, (3) agitation, and (4) observations marginally changed or not changed at all. The process used to gather and interpret information to recognize these patients who were deteriorating involved touching, observing, listening, feeling or sensing, and “knowing.” In this process of recognition, nurses relied heavily on past experiences and knowledge to detect differences in patient condition. Conclusions: The 4 characteristics need to be included as an explanation for the MET criterion, “seriously worried about a patient.” Additional validation and refinement of the 4 characteristics of the nonspecific MET criterion, “seriously worried about a patient,” should be carried out. Continuing education programs in health care facilities need to support the use of subjective information in complex situations that result in decisions to call emergency assistance so patients whose conditions are deteriorating can be identified early and responded to rapidly. (Heart Lung^® 2000;29:262-8.)

Section snippets

Recognition of patients who need emergency assistance

In nursing practice, decision making is often a complex process.⁴ Nurses have been shown to recognize patients “at risk” and have claimed they make decisions on the bases of intuition and experience. For example, a nurse, who called the emergency code for a patient who had been assessed as “going sour” just before he had a respiratory arrest, stated that she would have “bet her last paycheck he was going to arrest.”⁵ Another nurse recalled having “bad feelings” about a patient whose vital signs

Method

This exploratory descriptive study used interviews to investigate the experiences of nurses who had been involved in calling the MET for their patients. The study sites included 4 units in a teaching hospital and 3 units in a peripheral hospital in an area health service. The clinical specialties of these units were medical, surgical, renal, gynecological, coronary care, and orthopedics. These areas all had high numbers of MET calls. Institutional ethics committees of the area health service

Overview

Analysis of the transcripts showed that nurses relied on 4 patient characteristics to apply the MET criterion, “seriously worried about a patient.” These 4 characteristics were not necessarily used independently but were usually combined. Most frequently, nurses detected a difference in the state of the patients compared with what their condition had been previously. The 4 characteristics were feeling “not right”, color, agitation, and observations. These characteristics appeared to alert the

Discussion

Nurses who used the criterion, “seriously worried about a patient,” to call the MET were found to make their decisions on the basis of the recognition of “just not right” or “unwell” as declared by the patient or as recognized by the nurse from the patient’s color, clamminess, and coldness; agitation or observations that were marginally changed; or as a result of nothing unusual. Usually when nurses called the MET on the basis of this criterion, objective physiologic data were not evident. One

Implications and Recommendations

The MET criterion, “seriously worried about a patient,” usually involves 1 or more of the 4 patient characteristics:

•
“Not right” or “unwell” declared by the patient or recognized by the nurse as a difference in the patient
•
Color, clamminess, and coldness with color (quite pale, porcelain pale, pale dusky, and sort of gray) or draining color
•
Agitation
•
Observations that were slightly abnormal or not unusual at all

These identified characteristics provide more specificity to the MET criterion,

Acknowledgements

I thank Ms S. Eagar; Mr C. Thebridge; Mr M. Masso; all the nurses who participated in this study; and all the health professionals who developed and implemented the MET calling system in 1989.

References (17)

K Daffurn et al.
Do nurses know when to summon emergency assistance?
Intensive Crit Care Nurs
(1994)
P Ellis
Processes used by nurses to make decisions in the clinical practice setting
Nurse Educ Today
(1997)
J Cioffi
Decision making by emergency nurses in triage assessment
Accid Emerg Nurs
(1998)
A Lee et al.
The medical emergency team
Anaesth Intensive Care
(1995)
Liverpool Health Service
Medical emergency team booklet
(1998)
P Benner et al.
Clinical judgement: how expert nurses use intuition
Am J Nurs
(1987)
P Benner et al.
Skilled clinical knowledge: the value of perceptual awareness
Nurse Educ
(1982)
A Tierney
A view on clinical judgement and decision making from the perspective of the nursing process

There are more references available in the full text version of this article.

Cited by (71)

Surgical nurses’ responses to worry: A qualitative focus-group study in the Netherlands
2022, Intensive and Critical Care Nursing
Hospital nurses observe and respond to deterioration using the ‘National Early Warning Score 2’. Surgical nurses are highly engaged in the early recognition of and response to deterioration. Responses to deterioration are based on deviating vital signs, while nurses also act on subjective indicators like worry. Scientific literature and (inter)national guidelines do not mention any information about acting upon worry.
To gain an in-depth understanding of the actions nurses on surgical wards undertake to generate an appropriate response to nurses’ worry when the ‘National Early Warning Score 2’ does not indicate deterioration.
A qualitative focus-group study with surgical nurses working at a hospital in the Netherlands. Data was collected by focus-group interviews supported by vignettes and analysed thematically.
Four focus-group interviews with a total of 20 participants were conducted between February and April 2020. Two sequential themes emerged: ‘Searching for explanation and confirmation’ and ‘Responding by actively applying nursing interventions’. Nurses gathered additional information about the patient and searched for a reference point to place this information in perspective. Nurses also approached others for co-assessment and verification. However, nurses faced barriers in calling for medical assistance. They felt physicians did not take them seriously. After gathering additional information, nurses responded by applying nursing interventions to comfort the patient.
Nurses mainly try to formalise an in-depth understanding of their feeling of worry to convince a physician to accurately treat the patient. Spending much time on a search to this understanding leads to delays in escalating care.
Distinguishing between common cause variation and special cause variation in a manufacturing system: A simulation of decision making for different types of variation
2020, International Journal of Production Economics
Citation Excerpt :
When human teams are supported by an RPD-enabled decision support tool, the performance of team decision making can be improved in high pressure situations (Fan et al., 2005; Kaempf et al., 1996; Fan and Su, 2010; Barnes and Hammell, 2008). In addition to supporting human-agent collaboration, the RPD model has been applied to emergency decision making, such as clinical judgment and responding to natural disasters (Cioffi, 2000; Elstein, 2001; Norita, 2004). This article uses an RPD model to represent how an experienced individual makes decisions within a manufacturing setting.
Controlling variation is an important aspect of quality improvement. Deming distinguishes between common cause variation and special cause variation and argues that both types of variation frequently result from people participating in the process. Confusing common cause and special cause variation can lead to incorrect decisions. This article analyzes the impact of an individual's ability to distinguish between common cause and special cause variation by simulating a manufacturing system with several human operators and a production manager. We use a recognition primed decision (RPD) model to simulate how human operators and the production manager would interpret the variation and make decisions to reduce the variation. A shared mental model with the RPD framework describes the interactions between different operators and the production manager. Results from this simulation demonstrate the importance of distinguishing between common cause and special cause variation, especially when problems occur at bottleneck points in the manufacturing system.
Identifying nurses’ concern concepts about patient deterioration using a standard nursing terminology
2020, International Journal of Medical Informatics
Nurse concerns documented in nursing notes are important predictors of patient risk of deterioration. Using a standard nursing terminology and inputs from subject-matter experts (SMEs), we aimed to identify and define nurse concern concepts and terms about patient deterioration, which can be used to support subsequent automated tasks, such as natural language processing and risk predication.
Group consensus meetings with nurse SMEs were held to identify nursing concerns by grading Clinical Care Classification (CCC) system concepts based on clinical knowledge. Next, a fundamental lexicon was built placing selected CCC concepts into a framework of entities and seed terms to extend CCC granularity.
A total of 29 CCC concepts were selected as reflecting nurse concerns. From these, 111 entities and 586 seed terms were generated into a fundamental lexicon. Nursing concern concepts differed across settings (intensive care units versus non-intensive care units) and unit types (medicine versus surgery units).
The CCC concepts were useful for representing nursing concern as they encompass a nursing-centric conceptual framework and are practical in lexicon construction. It enabled the codification of nursing concerns for deteriorating patients at a standardized conceptual level. The boundary of selected CCC concepts and lexicons were determined by the SMEs. The fundamental lexicon offers more granular terms that can be identified and processed in an automated fashion.
The clinical surveillance process as carried out by expert nurses in a critical care context: A theoretical explanation
2018, Intensive and Critical Care Nursing
Citation Excerpt :
Exploratory and descriptive studies related to data collection, clinical reasoning and decision-making generally provide the best insight into the behavioural and cognitive process underpinning clinical surveillance. While authors such as Hedberg and Sätterlund Larsson (2003), McKnight (2006), and Edwards and Donner (2007) describe the sources and means of information used by the nurse during data collection, others have addressed the characteristics of patients presenting a problem (Cioffi, 2000; Cioffi et al., 2009). Some researchers have also focused their reflection on the nurses’ reasoning strategies when they detect a problem or make decisions (Aitken, 2003; Ramezani‐Badr et al., 2009).
Nursing Science presents surveillance as an indispensable component of patient safety. Although the literature defines surveillance fully, its implementation is not well understood.
This research aims to formulate a theoretical explanation of the surveillance process that expert nurses employ in critical care.
To develop the theoretical explanation for the surveillance process of critical care nurses, Strauss and Corbin’s (1998) grounded theory approach and Think Aloud Method (Fonteyn et al., 1993) were used with fifteen expert critical care nurses (n = 15).
Surveillance in critical care is a continual process of collaborative vigilance that starts with the thought process and behaviour related to data collection, analysis and interpretation. The surveillance process comprises five key elements: 1) Managing the risk of complications; 2) Collecting data; 3) Detecting a problem; 4) Making a decision and 5) Working in synergy.
In developing a theoretical explanation, this research leads to an understanding of the surveillance process performed by expert nurses in a critical care context.
Effectiveness of a patient education intervention in enhancing the self-efficacy of hospitalized patients to recognize and report acute deteriorating conditions
2014, Patient Education and Counseling
To develop and pilot test the effectiveness of a patient education intervention in enhancing the self-efficacy of hospitalized patients to recognize and report symptoms of acute deteriorating conditions.
Using cluster randomization, acute care general wards were randomized to the experimental and control groups. 34 patients in the experimental group received a 30-minute patient education intervention on Alert Worsening conditions And Report Early (AWARE) while 33 patients in the control group received the routine care only. Levels of self-efficacy to recognize and report symptoms were measured before and after the intervention.
The level of self-efficacy reported by the experimental group was significantly higher than the control group (p < 0.0001).
The AWARE intervention was effective in enhancing the self-efficacy of hospitalized patients to recognize and report acute deteriorating conditions.
Patient engagement through patient education could be included in the rapid response system which aims to reduce hospital mortality and cardiac arrest rates in the general wards.
Nursing surveillance for deterioration in pediatric patients: An integrative review
2020, Journal of Pediatric Nursing
Adverse events occur in up to 19% of pediatric hospitalized patients, often associated with delays in recognition or treatment. While early detection is recognized as a primary determinant of recovery from deterioration, most research has focused on profiling patient risk and testing interventions, and less on factors that impact surveillance efficacy. This integrative review explored actions and factors that influence the quality of pediatric nursing surveillance.
Original research on nursing surveillance, escalation of care, or cardiopulmonary deterioration in hospitalized pediatric patients in non-critical environments, published in English in peer reviewed journals.
Twenty-four studies from a literature search within the databases of CINAHL, PubMed, and Web of Science were evaluated and synthesized using a socio-technical systems theory framework. Study quality was assessed using The Mixed Methods Appraisal Tool.
Assessment, documentation, decision-making, intervening and communicating were identified as activities associated with surveillance of deterioration. Factors that influenced nurses' detection of deterioration were patient acuity, nurse education, experience, expertise and confidence, staffing, standardized assessment and communication tools, availability of emergency services, team composition and opportunities for multidisciplinary care planning.
Research provides insight into some aspects of nursing surveillance but does not adequately explore factors that affect clinical data interpretation and synthesis, and role integration between nurse and parents, and nurse and other clinicians on surveillance of clinical stability.
Research is needed to enhance understanding of the contextual factors that impact nursing surveillance to inform intervention design to support nurses' timely recognition and mitigation of clinical deterioration.

View all citing articles on Scopus

^*: Supported by a University of Western Sydney Hawkesbury Internal Research Grant.

^**: Reprint requests: Dr Jane Cioffi, Faculty of Health University of Western Sydney Hawkesbury, Locked Bag 1, PO Richmond 2753, New South Wales, Australia.

View full text

Issues in Critical CareRecognition of patients who require emergency assistance: A descriptive study*,**

Abstract

Section snippets

Recognition of patients who need emergency assistance

Method

Overview

Discussion

Implications and Recommendations

Acknowledgements

Intensive Crit Care Nurs

Nurse Educ Today

Accid Emerg Nurs

The medical emergency team

Anaesth Intensive Care

Medical emergency team booklet

Clinical judgement: how expert nurses use intuition

Am J Nurs

Skilled clinical knowledge: the value of perceptual awareness

Nurse Educ

A view on clinical judgement and decision making from the perspective of the nursing process

Issues in Critical Care
Recognition of patients who require emergency assistance: A descriptive study*,**