Improving the care of acutely ill patients outside ICU settings
Garside, J., Prescott, S. (2008) Improving the care of acutely ill patients outside ICU settings. This is an extended version of the article published in Nursing Times; 104: 22, 25-26.
This article describes the development of a post-registration course to improve nurses’ skills in caring for acutely ill or acutely deteriorating adult patients. The article outlines background issues related to the recognition of and the response to acute deterioration, and discusses recent guidance and policy documents in this area. It outlines the implementation of the new course, teaching and assessment methods for students, and the evaluation of the programme. Plans are also detailed.
Joanne Garside, MSc, BSc, DPSN, RGN, is senior lecturer; Stephen Prescott, MSc, PG Cert, BSc, DPSN, RGN, is senior lecturer; both at University of Huddersfield.
This article describes the implementation of an innovative post-registration course for healthcare practitioners, which started in September 2006. The course was specifically designed for professionals involved in the assessment, care and management of acutely ill or acutely deteriorating patients in non-critical care areas in acute care.
Acute care on general wards
McQuillan et al (1998) suggested that the care and management of a high percentage of acutely and critically ill patients on general wards was suboptimal (in this case, 54 of the 100 patients studied). Suboptimal care was described as a lack of knowledge regarding the significance of findings on airway dysfunction, breathing and circulation that resulted in aspects of care being missed, misinterpreted and mismanaged. This suboptimal care had severe consequences for patients in relation to increased morbidity, mortality and requirements for ICU. Key recommendations followed the study but these were medically led, and included increasing the seniority of doctors assessing such patients. Garrard and Young (1998) advised that changes in practice should not be limited to medical staff and that experienced nurses and other healthcare professionals should be involved.
McGloin and Singer (1999) identified patients unexpectedly dying on general wards or requiring admission to ICU. They found that 317 of 477 hospital deaths in their study occurred on general wards. The authors concluded that patients with obvious clinical indicators of acute deterioration are frequently overlooked or poorly managed on wards. Many patients have clearly recorded evidence of marked physiological deterioration before the event, without appropriate action being taken (National Patient Safety Agency, 2007a).
Kause et al (2004) said that many patients show signs of physiological deterioration before admission to ICU, cardiac arrest and death. If timely and appropriate detection by medical and nursing staff of physiological deterioration is undertaken it is likely to benefit patients. The most common signs were hypotension and a fall in Glasgow coma scale scoring, that is, consciousness levels.
In 1999, the Department of Health convened an expert group to develop a framework for the future organisation and delivery of critical care. This incorporated a hospital-wide approach, extending beyond the boundaries of ICUs and impacting on the delivery of acute care as a whole (DH, 2000). The DH and Modernisation Agency (2003) reiterated that patients at risk of deteriorating or recovering from critical illness were not always well managed. Once again, substandard care was seen in failures to optimise essential functions - airway, breathing and circulation, oxygen therapy, fluid balance and monitoring. Organisational problems, inadequate supervision, failure to seek advice and poor communication compounded the situation, and significant deficits in fundamental skills and knowledge were also major factors.
Furthermore, the National Confidential Enquiry into Patient Outcomes and Death (NCEPOD, 2005) identified the decreasing number of hospital beds and the increased number of acutely ill patients in hospital. The enquiry argued it was important to recognise that acute care in today’s NHS depended largely on hard work and dedication of all grades of staff. While 90% of patients received good care, 10% did not.
More recently, NICE (2007) published guidelines on the recognition of and the response to acutely ill adults in hospital. The guidance featured a number of key recommendations exploring which physiological observations should be recorded and acted on, by whom and how frequently. One recommendation outlined the competencies that staff should have in relation to caring for acutely ill patients, adding that education and training should be provided to ensure staff have these skills, followed by staff assessment.
This NICE (2007) guidance coincided with a report by the NPSA (2007a). The NPSA conducted a detailed analysis of 1,804 serious incidents reported to the national reporting and learning system that resulted in patient death. Following expert review and analysis, it was concluded that 576 ‘could be interpreted as potentially avoidable and related to patient safety issues’ (NPSA, 2007a). Some 425 of these incidents occurred in acute/general hospitals. The agency’s report focused on 107 of these: 64 were related to patient deterioration that was not recognised or not acted on, and 43 involved a problem with resuscitation (such as not recognising the cardiac arrest, not calling for the resuscitation team or not initiating resuscitation) after cardiac arrest.
Key recommendations from the NPSA (2007a) report included:
Better recognition of patients at risk of or who have experienced deterioration;
Appropriate monitoring of vital signs;
Accurate interpretation of clinical findings;
Calling for help early and ensuring that it arrives;
Training and skills development.
The NPSA (2007b) published a further report on the same 576 deaths, focusing on the 64 (11%) deaths that occurred as a result of deterioration that was not recognised or acted on. Issues identified as contributing factors included:
Completely or partially omitting formal or visual observations, including colour or consciousness, temperature, pulse, blood pressure and oxygen saturations, but most commonly respiratory rate;
Not calculating the early warning scores correctly;
Not recognising when observations gave cause for concern;
Lack of communication and not acting on concerns during handover or transfer.
The NPSA (2007b) recognised that the underlying causes for these factors can be very complex, from staffing and workload to education and training issues.
Allen (2004) discussed how the nurses’ role enables them to be in constant contact with patients, arguing that nurses are in a prime position to identify problems at an early stage by using systematic patient assessment. This means appropriate treatment can be identified quickly, potentially saving a patient’s life. Watson (2006) warned that recording baseline observations is no longer sufficient.
In the current healthcare climate, which demands clinical effectiveness and value for money, a greater level of skill is required from nurses. They require a sound knowledge of basic anatomy and physiology in order to interpret observations, as well as of the pathology and nursing management of common illnesses and injuries. However, the DH and Modernisation Agency (2003) stated that current education does not properly equip healthcare providers to care for critically ill patients, particularly those outside designated critical care departments.
As a higher education institution, the University of Huddersfield provides specialist courses for registered nurses in traditional acute and critical care areas. These comprise specialist preparation in A&E, coronary care units and ICUs. No such course was provided for nurses working in non-specialist acute care areas to support the key developments in patterns of care, especially in relation to assessment, care and management of acutely ill patients. A gap in the range of courses offered by the university was identified, which was confirmed following consultation with practitioners.
This is supported by McArthur-Rouse (2001), who suggested that work was needed to educate nursing staff to care adequately for highly dependent patients in conventional ward settings.
A joint venture involving academic staff and senior nursing staff from a variety of acute care settings from partnership trusts was established. The result was a course designed specifically to meet these needs. The course became known as the ‘acute illness’ course.
The course encompasses two honours-level (level 3 equivalent) modules:
The professional principles underpinning acute clinical practice (20 credits);
The assessment, care and management of acutely ill patients (40 credits).
The professional principles module gives students the opportunity to explore, analyse and debate current healthcare issues, applying them to their own clinical practice. This module encourages students to understand the effects of national policies and their impact on patient care and management.
The second module promotes a deeper understanding of the evidence base underpinning current practice in assessment, care and management of acutely ill patients. This is achieved by developing students’ existing knowledge and skills. Students are supported and assessed through a variety of methods that focus on their academic and practical competence to evaluate and implement care for such patients.
Teaching and learning strategies
The course is delivered using a combination of lectures, seminars, group work and simulation strategies.
The traditional lecture has been used as a means of transmitting information since ancient Greek times (Quinn, 2000), and remains the most common teaching strategy used in adult education. The relatively small student numbers on the course (15-20) allows the lectures to be interactive and be more of a two-way process, prompting discussion and exploration of topic areas. Many sessions adopt the problem-based approach, focusing on issues that encourage reflection and analysis of current practices within the students’ own clinical area and personal experiences.
To ensure baseline knowledge is achieved, directed study elements are given before some sessions; these include prior reading and workbooks for anatomy and physiology.
As the course progresses, students are encouraged to offer regular feedback, with an element of flexibility and negotiation allowed in the syllabus, encouraging ownership of the subjects taught and the learning taking place. Following evaluation of the first cohort, it was noted that students requested increased use of simulation.
This is a key teaching and learning strategy for the course. Simulation can take many forms, ranging from the use of simple task or procedure trainers designed to develop basic psychomotor skills through a variety of mannikins to using real-life actors (Perkins, 2007; Alinier et al, 2006; Bland and Sutton, 2006).
The range of mannikins includes low-, intermediate- and high-fidelity ones. The term ‘fidelity’ refers to the extent to which the mannikin reflects reality (McCallum, 2007) and, as technology has developed over recent years, so has the ‘life-like’ nature of some of the mannikins. Some of the high-fidelity ones have been programmed to mimic human physiology and will respond ‘appropriately’ to a given treatment. For example, administration of intravenous fluids will correct signs of hypovolaemia (Perkins, 2007).
The mannikin used for the acute illness course is SimMan (Laerdal Medical, www.laerdal.co.uk). This is an advanced instructor-driven, full-sized patient simulator (Perkins, 2007). SimMan generates realistic heart, breath, bowel and blood pressure sounds. Vital signs are displayed on an accompanying monitor, with a range of parameters displayed that can be adjusted depending on students’ requirements.
Much has been written over the past decade on using simulation as a teaching strategy (Lammers, 2007; McCallum, 2007; Alinier et al, 2006; Cioffi, 2001). Cioffi (2001) suggested that simulation provides practitioners with a safe environment for learning without fear of personal failure. The quality of the learning experience through simulation depends on creating both a scenario and an environment that resemble reality (Parr and Sweeney, 2006).
Scenarios used on the course are not embellished for additional effect, but reflect a likely clinical situation. The simulation environment resembles a typical clinical environment with appropriate, fully working equipment and consumables.
The goal of simulation is to promote understanding through doing. It allows relevant theory to be integrated into practice, and also offers opportunity for ‘time out’ to be called, either by the facilitators or by students themselves (Bland and Sutton, 2006). Examples from the course include how to use a particular piece of equipment and the rationale and applied physiology behind a particular treatment or disease. Most importantly, time-outs provide an opportunity to review progress to date and/or to refocus the team. Taking time out may not be appropriate in a clinical setting, especially in an emergency.
The course is part time and students continue to work in their own clinical area. However, time is allocated within the programme to give them the opportunity to work in other areas. These alternative placements are students’ own choice but must be negotiated with module leaders. Placements may be local or regional, and general or specialist. Examples include:
Coronary care units;
Critical care outreach teams. These alternative clinical placements offer students the opportunity to build on knowledge gained on the course in their relevant areas. For example, a student wishing to develop rhythm recognition skills further may choose to work on a coronary care unit. Similarly, a student wishing to practise blood gas interpretation may elect to work on an ICU.
A variety of assessment strategies are used to develop students’ communication, clinical, written, reflective and critical analysis skills. The course outcomes (identified in Boxes 1 and 2) are assessed using a 2,000-word essay, a short presentation, a clinical practical exam and a portfolio.
Box 1. Professional principles underpinning acute clinical practice
Box 2. Assessment, care and management of acutely ill patients
Critically analyse aspects of disordered physiology and principles of accurate physiological and homeostatic measurement in relation to the care and management of people suffering acute deterioration of their condition.
Critically examine the contribution that recent developments and current research in the care and management of acutely ill patients can make to the delivery of high-quality care.
Critically examine provision of holistic care by the multiprofessional team for acutely ill patients with due consideration to evidence-based practice.
The assessment strategy for the second module was the cause of much debate during the planning stage, particularly in relation to the appropriate method for evaluating students’ skills. The purpose was not only to provide a theoretical course but also to provide a platform to improve clinical competence and enable practical skills when dealing with acutely ill patients.
The debates centred on whether the assessment of students should take place in clinical practice, promoting discussion around the appropriateness of the person who would assess their level of competence. As the course was new, it was not possible to rely on previous students to act as mentors/assessors, and no existing standard was available to clearly define appropriate assessors. It was agreed to assess part of the module using an adapted objective structured clinical exam (OSCE).
The OSCE method of assessment was pioneered by the medical profession (Race et al, 2003). The traditional OSCE consists of multiple-station examination processes that require students to demonstrate a level of competency within a specified time at each station (Brosnan et al, 2005), although on this course a single station OSCE using SimMan is used. The OSCE offers an opportunity to introduce a theory-based clinical examination aiming to closely simulate clinical practice and for students to demonstrate competency when caring for acutely ill patients.
Discussions were also held on the relevance of grading the OSCE. The agreement between academic and clinical staff was that, in a healthcare environment when assessing and managing acutely ill patients, practitioners would be either safe or unsafe. Therefore a simple pass or refer is the mark given.
The development of a portfolio is also used as a method of assessment. A portfolio is a collection of evidence, products and processes of learning (McMullan et al, 2003). The portfolio requires students to demonstrate critical analysis of current evidence, polices and practices, and reflection of learning on their alternative placements. They are also required to undertake these activities in relation to their clinical background or interest.
Evaluation of the course was undertaken using the university’s standard course evaluation form. Several quantitative questions were asked requiring Likert-style answers (Fig 1). The form includes a section for general comments about the course. Thirteen students undertook the first acute illness course; 11 (85%) completed the evaluation. Approval from the school research ethics committee was given and all participating students provided written consent to the use of anonymous quotes.
During analysis of the general comments section, several themes emerged, as follows:
Teaching and learning methods
Throughout the course, a strong mix of theoretical elements and practical skills was covered. The evaluation comments included:
‘The subjects covered were very relevant to our clinical practice, they have enabled me to consolidate a lot of knowledge but also made me realise how much I didn’t know and had forgotten!’
‘A good range of subjects and skills covered, relevant to all.’
‘Taught sessions have been delivered excellently. I have found all subjects covered by the course very relevant and very helpful to my work.’
The 13 students came from a wide variety of acute care backgrounds and experiences, from fairly newly qualified staff to experienced ward managers, which strengthened discussions and debates held in the group.
’I also feel that having a mix of skills/experience among the group has helped as it seemed everyone helped each other and also meant we could learn from each other. I have really enjoyed it and learnt a lot.’
As module leaders, we consciously aimed to ensure the course would enable students to feel supported and challenged and also to enjoy and value their study time each week. This was reflected in the comments:
‘The majority of sessions were very good - aided learning and made you feel comfortable. Knowledgeable, approachable, friendly and supportive course leaders.’
‘Fun and interesting learning opportunities.’
‘The course was fun and enjoyable and this has helped me to participate, especially in the practical sessions.’
Ultimately, the course aimed to develop standards of clinical practice, although evaluations were purely subjective and from the students’ own perspective:
’I have learnt many new skills and have improved my practice as a result.’
‘This is a great course for anyone who works in the acute environment to go on - it gives you knowledge to take back and also more confidence in your clinical environment.’
Many students on the course have carried on their studies working towards their degree. One particular student commented:
‘The course has been quite hard for me at times and there were times I wondered why I’d started doing it, but I feel I have learnt a lot and feel more confident about my abilities and knowledge base as a result of doing the course. I would like to do more learning as a result of the course.’
Some other comments include:
‘The course has been relevant to my work area and I would recommend it to all nurses working in acute settings.’
‘This course has been excellent; it is more than I expected, the content of the course has been relevant. It is a fantastic course which is very beneficial to me at this stage in my career. It has helped me develop myself personally and professionally. I feel a lot more confident at work and colleagues have praised me which I am grateful for, thanks to this course.’
Healthcare providers must ensure that strategies are in place to manage patients who are at risk of deteriorating or who are recovering from critical illness. An effective strategy is to empower individual practitioners caring for acutely ill patients with the appropriate knowledge, skills and competencies to recognise and effectively manage them.
The acute illness course has provided healthcare practitioners with a variety of experiences, promoting opportunities for students to develop their knowledge and skills to care for these vulnerable patients.
Furthermore, the NPSA (2007b) recommended that every acute trust should establish a deterioration recognition group to improve the safety of patients vulnerable to unexpected deterioration.
These groups should have representation from relevant stakeholders including managers, educationalists and patients. The groups need to measure baselines and monitor improvements in care for acutely ill patients in hospital. If no action is taken, the consequences will be the continued exposure of acute and critically ill patients to the suboptimal care identified by McQuillan et al (1998).
Partnership working to develop standards outlined by NICE (2007) and the NPSA (2007b), for example competency initiatives and educational membership on the local NHS deterioration recognition group.
Evaluation of the acute illness course from managers’ and students’ perspectives.
Evaluation of simulation as an effective teaching and assessment method.
Alinier, G. et al (2006) Effectiveness of intermediate-fidelity simulation training technology in undergraduate nursing education. Journal of Advanced Nursing; 54: 3, 359-369.
Allen, K. (2004) Recognising and managing adult patients who are critically sick. Nursing Times; 100: 34, 34-37.
Bland, A., Sutton, A. (2006) Using simulation to prepare students for their qualified role. Nursing Times; 102; 30, 30-32.
Brosnan, M. et al (2005) Implementing objective structured clinical skills evaluation (OSCE) in nurse registration programmes in a centre in Ireland: A utilised focused evaluation. Nurse Education Today; 26: 2, 115-122.
Cioffi, J. (2001) Clinical simulations: development and validity. Nurse Education Today; 21: 477-486.
Department of Health (2000) Comprehensive Critical Care. A Review of Adult Critical Care Services. www.dh.gov.uk
Department of Health, Modernisation Agency(2003) Critical Care Outreach 2003: Progress in Developing Services. www.dh.gov.uk
Garrard, C., Young, D. (1998) Editorial - Suboptimal care of patients before admission to ICU. British Medical Journal; 316: 1841-1842.
Kause, J. et al (2004) A comparison of antecedents to cardiac arrest, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom - the ACADEMIA study. Resuscitation; 62: 275-282.
Lammers, R. L. (2007) Simulation: The new teaching tool. Annals of Emergency Medicine; 49: 4, 505-506.
McArthur-Rouse, F. (2001) Critical care outreach services and early warning scoring systems: a review of the literature. Journal of Advanced Nursing; 36: 5, 696-704.
McCallum, J. (2007) The debate in favour of using simulation education in pre-registration adult nursing. Nurse Education Today; 27: 8, 825-831.
McGloin, H., Singer, M. (1999) Unexpected deaths and referrals to intensive care of patients on general wards. Are some cases potentially avoidable? Journal of the Royal College Physicians; 33: 3, 255-259.
McMullan, M. et al (2002) Portfolio and assessment of competence: a review of the literature. Journal of Advanced Nursing; 41: 3, 283-294.
McQuillan, P. et al (1998) Confidential inquiry into quality of care before admission to intensive care. British Medical Journal; 316: 1853-1858.
National Confidential Enquiry into Patient Outcome and Death (2005) An Acute Problem? A Report of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD). London: NCEPOD.
NICE (2007) Acutely Ill Patients in Hospital: Recognition of and Response to Acute Illness in Adults in Hospital. www.nice.org.uk
National Patient Safety Agency (2007a) Safer Care for the Acutely Ill Patient: Learning from Serious Incidents. www.npsa.nhs.uk
National Patient Safety Agency (2007b) Recognising and Responding Appropriately to Early Signs of Deterioration in Hospitalised Patients. www.npsa.nhs.uk
Parr, M.B., Sweeney, N.M. (2006) Use of human patient simulation in an undergraduate critical care course. Critical Care Nursing Quarterly; 29: 3, 188-198.
Perkins, G.D. (2007) Simulation in resuscitation training. Resuscitation; 73, 202-211.
Quinn, F.M. (2000) Principles and Practice of Nurse Education. Cheltenham: Nelson Thornes.
Race, P. et al (2005) 500 Tips on Assessment. New York, NY: Routledge-Falmer.
Watson, D. (2006) The impact of accurate patient assessment on the quality of care. Nursing Times; 102: 6, 34-37.