An Australian study identified problems in managing deteriorating patients and ways these could be resolved.
In this article…
- Research on patient deterioration
- The problems in managing deteriorating patients
- The benefits of simulations in developing staff skills
Simon Cooper is associate professor (acute care); Penny Buykx is research fellow; Tracy McConnell-Henry is lecturer (acute care); Leigh Kinsman is senior research fellow; Susan McDermott is assistant lecturer; all at Monash University, Victoria, Australia.
Cooper S et al (2011) Simulation: can it eliminate failure to rescue? Nursing Times; 107: 3, early on-line publication.
- This article has been double-blind peer reviewed
Evidence shows the management of deteriorating patients needs to be improved, particularly in midwifery care. In a series of three simulation-based studies in Australia we examined qualified nurses’, student nurses’ and midwives’ ability to manage patient deterioration. Nurses’ knowledge levels were acceptable but their skill performance was low and there was a gap between the theory and practice they had experienced. In these high-pressure situations, demographic factors (including educational level) had no impact on their performance, which suggests they need repetitive “high-stakes” simulation, improved feedback mechanisms and enhanced educational processes.
Managing deteriorating patients is a major patient safety issue. A recent series of studies highlighted the difficulties by examining evidence for simulation training in nursing and midwifery (Biro et al, 2010; Cooper et al, 2010a; Endacott et al, 2010). The research explored how nurses and midwives managed deteriorating patients using a variety of simulation approaches and techniques.
Training departments and higher education institutions worldwide dedicate a great amount of time to resuscitation training, yet we know that resuscitation events are infrequent (around one a day in a large district general hospital) (Cooper et al, 2006), practitioners’ skills decline rapidly and outcomes are poor. In hospital survival rates to discharge average at some 16% (Cooper et al, 2006) and range from 0-29% depending on the primary causes of arrest (Mutchner, 2007; Cooper et al, 2006). Up to 30% of patients are discharged with a degree of neurological and/or physical deficit (Ristagno et al, 2009).
Factors influencing survival included: time to initial resuscitation; length of resuscitation; primary arrhythmia; and age (Klocko, 2009; Mutchner, 2007; Cooper et al, 2006). The increased use of semi-automatic external defibrillators has had positive outcomes for patients in ventricular fibrillation (Leeper, 2009; Smith et al, 2008) but can delay chest compressions, which may influence survival (Klocko, 2009). Over the last five decades, numerous interventions have not significantly improved patient survival (Eisenberg et al, 2010) and death has become increasingly medicalised (Timmermans, 1999).
It would be more appropriate to focus training on managing deterioration so patients do not arrest in the first place. The evidence shows ward staff are poor at identifying and managing deterioration, with the “failure to rescue” literature highlighting the need for enhanced practice in general ward settings where the acuity of patients is increasing (Lewis, 2007; Endacott et al, 2006). Medical emergency teams (METs) have been introduced in response to these concerns, indicating how patient outcomes could be improved (Hillman et al, 2005), but there is unsubstantiated evidence that ward staff are becoming deskilled as METs take over. In smaller rural hospitals performance can be poor and support mechanisms are not available or delayed (Endacott et al, 2006).
With a scarcity of student placements worldwide, the need to supplement training with realistic approaches is essential. Researchers have therefore developed several training initiatives (Clinical Excellence Commission, 2010; Draycott et al, 2008), all of which include simulation. This enables the safe repetition of skills in a secure, supportive environment (McGaghie et al, 2006), encourages active learning (Endacott et al, 2003) and ensures performance can be measured.
Simulation does not have to involve high technology such as advanced life support manikins - standardised patients (patient actors) are often more believable and as plastic manikins were originally designed for resuscitation training, they do not replicate deteriorating - but alive - patients well. Simulation has significant benefits as an educational technique; evidence from a wide range of quantitative studies shows it is a valid teaching strategy in nursing and midwifery with the potential to improve knowledge, critical thinking, satisfaction and confidence (Cant et al, 2009; Siassakos et al, 2009).
Healthcare teams are starting to acknowledge the need to develop non-technical skills - such as leadership, teamwork and situation awareness - and a number of studies have examined teamwork performance in both simulated (Cooper et al, 2010b; Deering et al, 2009) and clinical settings (Cooper et al, 2010c; Borimnejad et al, 2008). However, such work rarely focuses on clinicians’ situation knowledge, namely how aware they are of their environment and how this influences their performance (Fletcher et al, 2003).
There are several key issues and gaps in our knowledge. As we do not understand the decision-making processes of those managing deteriorating patients, we do not know how to improve their performance. We understand that simulation is a good proxy to clinical practice but have yet to define best practice in simulation techniques. We know non-technical skills make a major contribution to patient safety but understand little about levels of awareness in emergency situations. This article addresses these key issues by summarising our findings from a range of studies.
Main findings on managing deterioration
In a series of three Australian simulation studies we examined the management of:
- Deteriorating patients by individual final-year students nurses (n=51) in two manikin based scenarios (hypovolemic and septic shock) (Cooper et al, 2010; Endacott et al, 2010);
- Deteriorating women by student midwives (n=35) in two standardised patient based scenarios for post-partum haemorrhage (PPH) and antepartum haemorrhage (APH). Patient actors wore a birthing suit to enhance the simulation fidelity (Biro et al, 2010);
- Deteriorating patients by qualified nursing staff (n=35) in a rural hospital based on scenarios of acute myocardial infarction and chronic obstructive pulmonary disease. Simulations were run in the hospital with patient actors using each hospital’s own equipment. We also examined patient records before and after the course to identify the impact on practice.
Apart from these scenario differences, we used the same methods throughout our research. We tested participants’ knowledge using a short multiple choice test focusing on patient deterioration management. This was followed by two eight-minute scenarios in which participants managed patients with the assistance of a researcher role-playing a medical role. Scenarios were video recorded and performance was rated on completion.
We asked participants situation awareness questions, either at a random point or at the end of the scenario, to elicit their perceptions of patient physiology and their understanding of current and future events. On completion, an experienced clinical researcher spent 30 minutes going through each videoed simulation to find out participants’ decision strategies - for example, “why did you do that?”, “what are you thinking there?” - a process known as “photo elicitation”. Each participant was given extensive feedback before the final programme evaluation.
Findings from student nurses
In the first study, students’ mean knowledge score was 74%, and the mean skill performance score across both scenarios was 60%. Skill performance improved significantly by the second scenario (p=<0.01), but declined significantly as the patient’s condition deteriorated (p=<0.012) . The skills being measured were basic, such as taking routine vital signs, and less likely to be performed in patients who were more poorly. The mean situation awareness score across both scenarios was 59%; participants tended to identify important physiological indicators of deterioration, such as knowing the heart rate, but did not understand why the patient was deteriorating.
Most participants tended to experience performance anxiety and clinical reasoning was often flawed (Endacott et al, 2010). They tended to focus too much on initial cues of information, such as patients’ abdominal pain, or failed to accumulate signs correctly - for example, starting cardiac massage based on an unrecordable blood pressure from an automated machine despite the fact that the patient had a pulse. Regarding help-seeking behaviour, we saw one of two phenomena: participants either sought help, such as calling the MET very early (perhaps to absolve themselves of decision-making responsibility) or never called for assistance (up to 30% of participants).
Using trained actors
After this study, participants and researchers were concerned about the dependability of the manikin based scenarios. It is hard for a patient who is relatively well and gradually declines to be simulated by a manikin as it cannot stimulate touch, sight, sound and smell. To solve this, in the second midwifery study we used female actors. In the first PPH scenario the actor wore a Model-med Obstetric Simulation Suit (modelmed.com.au) (Fig 1); this simulates a post-partum abdomen, including a boggy uterus and an anatomically correct vagina from which blood-like fluid can be haemorrhaged. In the APH scenario the actor wore a pregnancy suit with a firm uterus.
In this study of direct entry and postgraduate student midwives the knowledge score was again high (75%), scenario skill performance scores were low (54%) and decreased significantly (p=<0.023) as the women deteriorated. Situation awareness levels were low (54%), with awareness decreasing significantly (p=0.03) in the second and more difficult APH scenario. Participants’ recall of important physiological indicators was particularly low as they had often missed observations. Again performance anxiety was apparent, calls for help were delayed and there were notable delays in the administration of oxytocics. Participants tended to focus on “being with women”, rather than meeting the emergency nursing demands of the situation, such as taking observations and observing trends.
Findings from qualified nurses
The first two studies focused on student performance but it is also vital to understand the practice of nurses. The third study was set in a small rural hospital where specialist medical assistance was often delayed or unavailable (there was no MET), which resulted in increased demands on nursing performance. Again, to improve the sense of reality we used trained actors and the scenarios were set in the hospital’s training department, which matched the ward layout.
To understand the impact of our training we also examined patient records for six weeks before and after the study, aiming to identify deterioration management changes, such as differences in the frequency of observations. The results of this study are still being analysed, but provisional findings suggest outcomes are not dissimilar to those of the student cohorts.
The scarcity of clinical placements and the infrequency of emergencies demand alternative approaches to education; high- fidelity simulation fills this gap. This does not always mean high technology however - feedback showed that actors were believable and there was no need for technology.
Demographic factors, such as age, level of experience and qualifications did not affect performance but nurses’ performance was improved by repeating or maintaining simulations. Participant anxiety was apparent in most cases and increased as patients deteriorated; this suggests nurses and midwives need more support to develop and maintain emergency skills. Improving knowledge is not the answer - failing to apply knowledge is the real issue. This may be due to a lack of hands-on initial training and sufficient practice in realistic settings.
The solution is to develop educational models that give more support and enhance clinical practice, including repetitive high-stakes and high-fidelity simulation with video review. Curricula should focus on the links between pathophysiology and patient assessment, and identifying trends, rather than measuring observations in isolation. Such approaches will improve systematic patient assessment, comparative and inductive reasoning, situation awareness and teamwork, thereby enhancing the quality of patient care.
Although we have focused on Australian nurses, it is likely there is a performance parity worldwide. For example, in a comparative pilot study in the UK, early indications suggest performance there is similar. More work is needed to better understand decision-making and stress-induced performance problems, and to develop best practice education models.
Biro M et al (2010) Identifying maternal deterioration in a simulated environment: measuring and developing student midwives’ knowledge, clinical skills and situation awareness. Breathing New Life into Maternity Care. Alice Springs.
Borimnejad L et al (2008) Evaluation of a formal trained resuscitation team on outcome of CPR in a general teaching hospital. Heart, Lung and Circulation; 17: S7-S8.
Cant R et al (2009) Simulation based learning in nurse education: systematic review. Journal of Advanced Nursing; 66: 3-15.
Clinical Excellence Commission (2010) Between the Flags: Keeping Patients Safe. Sydney: Clinical Excellence Commission.
Cooper S et al (2010a) Managing the deteriorating patient in a simulated environment: nursing student’s knowledge, skill, and situation awareness. Journal of Clinical Nursing; 19: 15-16, 2309-2318.
Cooper S et al (2010b) Rating medical emergency teamwork performance: development of the team emergency assessment measure (TEAM). Resuscitation; 81: 446-452.
Cooper S et al (2010c) Measuring non-technical skills in medical emergency care: a review of assessment measures. Open Access Emergency Medicine; 2: 7-16.
Cooper S et al (2006) A decade of in-hospital resuscitation: outcomes and prediction of survival. Resuscitation; 68: 231-237.
Deering S et al (2009) Building team and technical competency for obstetric emergencies: the mobile obstetric emergencies simulator (MOES) system. Simulation in Healthcare: The Journal of the Society for Medical Simulation; 4: 166-173.
Draycott T et al (2008) Improving neonatal outcome through practical shoulder dystocia training. Obstetrics & Gynecology; 112: 14-20.
Eisenberg MS et al (2010) Cardiopulmonary resuscitation: celebration and challenges. The Journal of the American Medical Association; 304, 87-88.
Endacott R et al (2010) When do patient signs become cues? Detecting clinical cues of deterioration in a simulated environment. Journal of Advanced Nursing; 66: 12, 2722-2731.
Endacott R et al (2006) Managing patients at risk of deterioration in rural hospitals: a qualitative study. Australian Journal of Rural Health; 14: 275-279.
Endacott R et al (2003) The reality of clinical learning in critical care settings: a practitioner:student gap? Journal of Clinical Nursing; 12: 778-785.
Fletcher G et al (2003) Anaesthetists’ Non-Technical Skills (ANTS): evaluation of a behavioural marker system. British Journal of Anaesthesia; 90: 580-588.
Hillman K et al (2005) Introduction of the medical emergency team (MET) system: a cluster randomised controlled trial. Lancet; 365: 2091-2097.
Klocko DJ (2009) Have the latest CPR guidelines improved cardiac arrest outcomes? Journal of
the American Academy of Physician Assistants; 22: 30-34.
Leeper B (2009) In-hospital survival rates following cardiac arrest. AACN Advanced Critical Care; 20: 366-372.
Lewis G (2007) Saving Mothers’ Lives: Reviewing Maternal Deaths to Make Motherhood Safer - 2003-2005. The Seventh Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: The Confidential Enquiry into Maternal and Child Health.
McGaghie W et al (2006) Effect of practice on standardised learning outcomes in simulation-based medical education. Medical Education; 40: 792-797.
Mutchner L (2007) Emergency: The ABCs of CPR-Again: a review of the latest changes to the American Heart Association’s cardiopulmonary resuscitation and emergency cardiovascular care guidelines. American Journal of Nursing; 107: 60-69.
Ristagno G et al (2009) Cardiopulmonary resuscitation: from the beginning to the present day. Critical Care Clinics; 25: 1, 133-151.
Siassakos D et al (2009) Retrospective cohort study of diagnosis-delivery interval with umbilical cord prolapse: the effect of team training. BJOG: An International Journal of Obstetrics & Gynaecology; 116: 1089-1096.
Smith S et al (2008) An audit of nursing observations on ward patients. Nursing Times; 104: 30, 28-29.
Timmermans S (1999) Sudden Death and the Myth of CPR. Philadelphia: Temple University Press.
Simulation: can it eliminate failure to rescue?