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Lisette Schoonhoven - One of the best experts on this subject based on the ideXlab platform.

  • Surgical Ward nurses responses to worry an observational descriptive study
    International Journal of Nursing Studies, 2018
    Co-Authors: Gooske Douw, Getty Huismande Waal, Arthur R H Van Zanten, Johannes G Van Der Hoeven, Lisette Schoonhoven
    Abstract:

    Abstract Background Rapid response systems aim to improve early recognition and treatment of deteriorating general Ward patients. Sole reliance on deviating vital signs to escalate care in rapid response systems disregards nurses' judgments about a patient's condition based on worry and other indicators of deterioration. To make worry explicit, the Dutch-Early-Nurse-Worry-Indicator-Score was developed, summarising non-quantifiable signs of deterioration in the nine indicators: breathing, circulation, temperature, mentation, agitation, pain, unexpected trajectory, patient indicates not feeling well and nurses' subjective observations. Nurses' worry can be present even when vital signs are largely unchanged, enabling treatment to commence at an early stage. On the other hand, reliance on nurses' worry might lead to unnecessary calls for medical assistance or an overuse of rapid response teams. Objectives Explore the occurrence of nurses' worry in real time, determine whether acting on worry leads to unnecessary action and determine the indicators present at different levels of deterioration. Design A prospective cohort study. Setting: Three Surgical Wards in a tertiary, university affiliated teaching hospital. Participants All nurses participated and adult, Surgical, native speaking patients were included in the study. Methods A descriptive analysis is performed on one year of data on Surgical Ward nurses' experience of worry and its underlying indicators in addition to routinely measured vital signs. Results Out of a total of 46,571 measurements, vital signs were normal 18,727 times, with worry expressed 605 times (3%), resulting in 62 calls (10.2%) to the attending physician. More than half of these calls resulted in necessary interventions. Calls for assistance and subsequent intervention after worry was expressed increase in parallel with early warning scores. The breathing indicator showed the highest increase in frequency with increasing deviation in vital signs. Conclusion This study suggests that worry has potential as an early indicator of deterioration, alerting nurses and encouraging them to start timely interventions. Overuse of medical assistance could not be determined, The Dutch-Early-Nurse-Worry-Indicator-Score objectifies worry when vital signs do not support its presence and systematic assessment of these indicators is recommended.

  • nurses worry as predictor of deteriorating Surgical Ward patients a prospective cohort study of the dutch early nurse worry indicator score
    International Journal of Nursing Studies, 2016
    Co-Authors: Gooske Douw, Getty Huismande Waal, Arthur R H Van Zanten, Johannes G Van Der Hoeven, Lisette Schoonhoven
    Abstract:

    Abstract Background Nurses' ‘worry' is used as a calling criterion in many Rapid Response Systems, however it is valued inconsistently. Furthermore, barriers to call the Rapid Response Team can cause delay in escalating care. The literature identifies nine indicators which trigger nurses to worry about a patient's condition. Objectives The objective of this study is to determine the significance of nurses' ‘worry' and/or indicators underlying ‘worry' to predict unplanned Intensive-Care/High-Dependency-Unit admission or unexpected mortality among Surgical Ward patients. Design A prospective cohort study. Settings A 500-bed tertiary University affiliated teaching hospital. Participants Adult, native speaking Surgical patients, admitted to three Surgical Wards (traumatology, vascular- and abdominal/oncological surgery). We excluded patients with a non-ICU policy or with no curative treatment. Mentally incapacitated patients were also excluded. Methods We developed a new clinical assessment tool, the Dutch-Early-Nurse-Worry-Indicator-Score (DENWIS) based on signs underlying ‘worry'. Nurses systematically scored their ‘worry' and the DENWIS once per shift or at any moment of ‘worry'. DENWIS measurements were linked to routinely measured vital signs. The composite endpoint was unplanned Intensive-Care/High-Dependency-Unit admission or unexpected mortality. The DENWIS-indicators were included in a univariate and multivariate logistic regression analysis, subsequently inserting ‘worry' and the Early Warning Score into the model. We calculated the area under the receiver-operating characteristics curve. Results In 3522 patients there were 102 (2.9%) patients with unplanned Intensive Care Unit/High Dependency Unit-admissions or unexpected mortality. ‘Worry' (0.81) and the DENWIS-model (0.85) had a lower area under the receiver-operating characteristics curve than the Early Warning Score (0.86). Adding ‘worry' and the Early Warning Score to the DENWIS-model resulted in higher areas under the receiver operating characteristics curves (0.87 and 0.91, respectively) compared with the Early Warning Score only based on vital signs. Conclusions In this single-center study we showed that adding the Early Warning Score based on vital signs to the DENWIS-indicators improves prediction of unplanned Intensive-Care/High-Dependency-Unit admission or unexpected mortality.

  • financial consequences of the implementation of a rapid response system on a Surgical Ward
    Journal of Evaluation in Clinical Practice, 2014
    Co-Authors: Friede Simmes, Lisette Schoonhoven, Joke Mintjes, Eddy M M Adang, Johannes G Van Der Hoeven
    Abstract:

    Rationale, aims and objectives: rapid response systems (RRSs) are recommended by the Institute for Healthcare Improvement and implemented worldwide. Our study on the effects of an RRS showed a non-significant decrease in cardiac arrest and/or unexpected death from 0.5% to 0.25%. Unplanned intensive care unit (ICU) admissions increased significantly from 2.5% to 4.2% without a decrease in APACHE II scores. In this study, we estimated the mean costs of an RRS per patient day and tested the hypothesis that admitting less severely ill patients to the ICU reduces costs. Methods: a cost analysis of an RRS on a Surgical Ward, including costs for implementation, a 1-day training programme for nurses, nursing time for extra vital signs observation, medical emergency team (MET) consults and differences in unplanned ICU days before and after RRS implementation. To test the hypothesis, we performed a scenario analysis with a mean APACHE II score of 14 points instead of the empirical 17.6 points for the unplanned ICU admissions, including 33% extra MET consults and 22% extra unplanned ICU admissions. Results: mean RRS costs were €26.87 per patient-day: implementation €0.33 (1%), training €0.90 (3%), nursing time spent on extended observation of vital signs €2.20 (8%), MET consults €0.57 (2%) and increased number of unplanned ICU days after RRS implementation €22.87 (85%). In the scenario analysis mean costs per patient-day were €10.18. Conclusions: the costs for extra unplanned ICU days were relatively high but the remaining RRS costs were relatively low. The ‘APACHE II 14’ scenario confirmed the hypothesis that costs for the number of unplanned ICU days can be reduced if less severely ill patients are referred to the ICU. Based upon these findings, our hospital stimulates earlier referral to the ICU, although further implementation strategies are needed to achieve these aims

Ara Darzi - One of the best experts on this subject based on the ideXlab platform.

  • identifying quality markers of a safe Surgical Ward an interview study of patients clinical staff and administrators
    Surgery, 2018
    Co-Authors: Yasmin Hassen, Philip H. Pucher, Pritam Singh, Maximilian J Johnston, Ara Darzi
    Abstract:

    Abstract Background Postoperative care quality is variable. Risk-adjusted mortality rates differ between institutions despite comparable complication rates. This indicates that there are underlying factors rooted in how care is delivered that determines patient safety. This study aims to evaluate systematically the Surgical Ward environment with respect to process-driven and structural factors to identify quality markers for safe care, from which new safety metrics may be derived. Methods Semistructured interviews of clinicians, nurses, patients and administrators were undertaken for the study. Results In the study, 97% of staff members recognized the existence of variation in patient safety between Surgical Wards. Four main error-prone processes were identified: Ward rounds (57%), medication prescribing and administration (49%), the presence of outliers (43%), and deficiencies in communication between clinical staff (43%). Structural factors were categorized as organizational or environmental; organizational included shortage in staffing (39%) and use of temporary staff (27%). Environmental factors considered layout and patient visibility to nurses (49%) as well as cleanliness (29%). Safety indicators identified included staff experience level (31%), overall layout of the Ward, cleanliness and leadership (all 27% each). The majority of patients (87%) identified staff attentiveness as a safety indicator. Conclusion This study demonstrates that there are a number of factors that may contribute to safety on the Surgical Ward spanning multiple processes, organizational, and environmental factors. Safety indicators identified across all these categories presents an opportunity to develop broader and more effectual safety improvement measures focusing on multiple areas simultaneously.

  • randomized clinical trial of the impact of Surgical Ward care checklists on postoperative care in a simulated environment
    British Journal of Surgery, 2014
    Co-Authors: Philip H. Pucher, Rajesh Aggarwal, Pritam Singh, M Qurashi, Ara Darzi
    Abstract:

    Background Complications are a common and accepted risk of surgery. Failure to optimize the management of patients who suffer postoperative morbidity may result in poorer Surgical outcomes. This study aimed to evaluate a checklist-based tool to improve and standardize care of postoperative complications. Methods Surgical trainees conducted baseline Ward rounds of three patients with common postoperative complications in a high-fidelity simulated Ward environment. Subjects were randomized to intervention or control groups, and final Ward rounds were conducted with or without the aid of checklists for management of postoperative complications. Adherence to critical care processes was assessed, in addition to technical (Surgical Ward-care Assessment Tool, SWAT) and non-technical (Ward NOn-TECHnical Skills (W-NOTECHS) scale) performance. Subjects completed a feedback questionnaire regarding their perception of the checklists. Results Twenty trainees completed 120 patient assessments. All intervention group subjects opted to use the checklists, resulting in significantly fewer critical errors compared with controls (median (i.q.r.) 0 (0–0) versus 60 (40–73) per cent; P < 0·001). The intervention group demonstrated improved patient management (SWAT-M) (P < 0·001) and non-technical skills (P = 0·043) between baseline and final Ward rounds, whereas controls did not (P = 0·571 and P = 0·809 respectively). A small learning effect was seen with improvement in patient assessment (SWAT-A) in both groups (P < 0·001). Intervention group subjects found checklists easy and effective to use, and would want them used for their own care if they were to experience postoperative complications. Conclusion Checklist use resulted in significantly improved standardization, evidence-based management of postoperative complications, and quality of Ward rounds. Simulation-based piloting aided appropriate use of checklists and staff engagement. Checklists represent a low-cost intervention to reduce rates of failure to rescue and to improve patient care.

  • Design and validation of the Surgical Ward round assessment tool: a quantitative observational study.
    American journal of surgery, 2014
    Co-Authors: Kamran Ahmed, Oliver Anderson, Muhammad Jawad, Tanya Tierney, Ara Darzi, Thanos Athanasiou, George B. Hanna
    Abstract:

    Abstract Background Ward round skills are essential for the best management of Surgical inpatients, but assessment of their quality has received inadequate attention. This study aims to design and validate the Surgical Ward round assessment tool (SWAT). Methods We used modified Healthcare Failure Mode and Effects Analysis to develop the SWAT by identifying Ward round steps. We assessed the validity of the SWAT using simulated and real Surgical Ward rounds. Results The Healthcare Failure Mode and Effects Analysis identified 30 Ward round steps that were developed into the SWAT. Nineteen surgeons completed simulated Surgical Ward rounds. Eight fully trained surgeons scored significantly higher than 11 trainee surgeons when assessed with the SWAT (P = .001). On average, the participants thought the realism of the simulation was good. Forty-four surgeons completed real Surgical Ward rounds. Fifteen experts scored significantly higher than 29 trainee surgeons when assessed with SWAT (P = .001). Inter-rater reliability was .85 to .89, respectively. Conclusions The SWAT can be used to assess the quality of task-based and nontechnical Surgical Ward round skills.

  • Ward simulation to improve Surgical Ward round performance a randomized controlled trial of a simulation based curriculum
    Annals of Surgery, 2014
    Co-Authors: Philip H. Pucher, Rajesh Aggarwal, Pritam Singh, Tharanny Srisatkunam, Ahmed Twaij, Ara Darzi
    Abstract:

    OBJECTIVE This study aimed to investigate the effects of a simulation-based curriculum for Ward-based care on Ward round (WR) performance. BACKGROUND Variability in Surgical outcomes does not relate to Surgical skill alone. Prevention, diagnosis, and treatment of peri- and postoperative morbidity are dependent on provision of high-quality Ward-based care. The focal point of this is the Surgical WR. Although WR conduct is learned primarily through experience, a simulated environment and validated assessment tools may enable measurement and enhancement of WR quality. METHODS Junior Surgical residents were randomized either to a half-day educational intervention with lectures, structured feedback, and debriefing, or to standard practice (control). All conducted a standardized, validated, simulated WR of 3 patients. Surgical Ward Care Assessment Tool and W-NOTECHS rating scales were used for technical and nontechnical skills assessment, respectively, and compared between groups. Subjects completed pre- and posttest confidence questionnaires and feedback forms. RESULTS Twenty-nine trainees were randomized to intervention (n = 14) or control (n = 15). Baseline confidence and demographics were equal between groups. Intervention group demonstrated better patient assessment: 63.5 ± 8.1% (control) versus 79.8 ± 11.9% (P = 0.002), management 56.0% ± 19.7% versus 72.2 ± 10.3% (P = 0.014), and nontechnical skills: W-NOTECHS 17.75 ± 2.06 versus 23.33 ± 1.21 (P < 0.001). Hundred percent of subjects felt that the curriculum improved their practice. CONCLUSIONS Conducting WRs is a crucial skill but not currently subject to formal training. Implementation of a comprehensive curriculum for Surgical WRs led to significant improvement in quality of patient assessment, management, and nontechnical skills. Improved WR performance may lead to earlier identification and amelioration of complications and improve patient outcomes.

  • Surgical Ward round quality and impact on variable patient outcomes.
    Annals of surgery, 2014
    Co-Authors: Philip H. Pucher, Rajesh Aggarwal, Ara Darzi
    Abstract:

    Objective:To investigate the relationship between variability in Surgical Ward round (WR) quality and clinical outcomes.Background:Evidence increasingly suggests that Ward-based care plays a key role in Surgical outcomes. The WR is the focal point of Surgical inpatient care. Assimilating various sou

Philip H. Pucher - One of the best experts on this subject based on the ideXlab platform.

  • identifying quality markers of a safe Surgical Ward an interview study of patients clinical staff and administrators
    Surgery, 2018
    Co-Authors: Yasmin Hassen, Philip H. Pucher, Pritam Singh, Maximilian J Johnston, Ara Darzi
    Abstract:

    Abstract Background Postoperative care quality is variable. Risk-adjusted mortality rates differ between institutions despite comparable complication rates. This indicates that there are underlying factors rooted in how care is delivered that determines patient safety. This study aims to evaluate systematically the Surgical Ward environment with respect to process-driven and structural factors to identify quality markers for safe care, from which new safety metrics may be derived. Methods Semistructured interviews of clinicians, nurses, patients and administrators were undertaken for the study. Results In the study, 97% of staff members recognized the existence of variation in patient safety between Surgical Wards. Four main error-prone processes were identified: Ward rounds (57%), medication prescribing and administration (49%), the presence of outliers (43%), and deficiencies in communication between clinical staff (43%). Structural factors were categorized as organizational or environmental; organizational included shortage in staffing (39%) and use of temporary staff (27%). Environmental factors considered layout and patient visibility to nurses (49%) as well as cleanliness (29%). Safety indicators identified included staff experience level (31%), overall layout of the Ward, cleanliness and leadership (all 27% each). The majority of patients (87%) identified staff attentiveness as a safety indicator. Conclusion This study demonstrates that there are a number of factors that may contribute to safety on the Surgical Ward spanning multiple processes, organizational, and environmental factors. Safety indicators identified across all these categories presents an opportunity to develop broader and more effectual safety improvement measures focusing on multiple areas simultaneously.

  • randomized clinical trial of the impact of Surgical Ward care checklists on postoperative care in a simulated environment
    British Journal of Surgery, 2014
    Co-Authors: Philip H. Pucher, Rajesh Aggarwal, Pritam Singh, M Qurashi, Ara Darzi
    Abstract:

    Background Complications are a common and accepted risk of surgery. Failure to optimize the management of patients who suffer postoperative morbidity may result in poorer Surgical outcomes. This study aimed to evaluate a checklist-based tool to improve and standardize care of postoperative complications. Methods Surgical trainees conducted baseline Ward rounds of three patients with common postoperative complications in a high-fidelity simulated Ward environment. Subjects were randomized to intervention or control groups, and final Ward rounds were conducted with or without the aid of checklists for management of postoperative complications. Adherence to critical care processes was assessed, in addition to technical (Surgical Ward-care Assessment Tool, SWAT) and non-technical (Ward NOn-TECHnical Skills (W-NOTECHS) scale) performance. Subjects completed a feedback questionnaire regarding their perception of the checklists. Results Twenty trainees completed 120 patient assessments. All intervention group subjects opted to use the checklists, resulting in significantly fewer critical errors compared with controls (median (i.q.r.) 0 (0–0) versus 60 (40–73) per cent; P < 0·001). The intervention group demonstrated improved patient management (SWAT-M) (P < 0·001) and non-technical skills (P = 0·043) between baseline and final Ward rounds, whereas controls did not (P = 0·571 and P = 0·809 respectively). A small learning effect was seen with improvement in patient assessment (SWAT-A) in both groups (P < 0·001). Intervention group subjects found checklists easy and effective to use, and would want them used for their own care if they were to experience postoperative complications. Conclusion Checklist use resulted in significantly improved standardization, evidence-based management of postoperative complications, and quality of Ward rounds. Simulation-based piloting aided appropriate use of checklists and staff engagement. Checklists represent a low-cost intervention to reduce rates of failure to rescue and to improve patient care.

  • Ward simulation to improve Surgical Ward round performance a randomized controlled trial of a simulation based curriculum
    Annals of Surgery, 2014
    Co-Authors: Philip H. Pucher, Rajesh Aggarwal, Pritam Singh, Tharanny Srisatkunam, Ahmed Twaij, Ara Darzi
    Abstract:

    OBJECTIVE This study aimed to investigate the effects of a simulation-based curriculum for Ward-based care on Ward round (WR) performance. BACKGROUND Variability in Surgical outcomes does not relate to Surgical skill alone. Prevention, diagnosis, and treatment of peri- and postoperative morbidity are dependent on provision of high-quality Ward-based care. The focal point of this is the Surgical WR. Although WR conduct is learned primarily through experience, a simulated environment and validated assessment tools may enable measurement and enhancement of WR quality. METHODS Junior Surgical residents were randomized either to a half-day educational intervention with lectures, structured feedback, and debriefing, or to standard practice (control). All conducted a standardized, validated, simulated WR of 3 patients. Surgical Ward Care Assessment Tool and W-NOTECHS rating scales were used for technical and nontechnical skills assessment, respectively, and compared between groups. Subjects completed pre- and posttest confidence questionnaires and feedback forms. RESULTS Twenty-nine trainees were randomized to intervention (n = 14) or control (n = 15). Baseline confidence and demographics were equal between groups. Intervention group demonstrated better patient assessment: 63.5 ± 8.1% (control) versus 79.8 ± 11.9% (P = 0.002), management 56.0% ± 19.7% versus 72.2 ± 10.3% (P = 0.014), and nontechnical skills: W-NOTECHS 17.75 ± 2.06 versus 23.33 ± 1.21 (P < 0.001). Hundred percent of subjects felt that the curriculum improved their practice. CONCLUSIONS Conducting WRs is a crucial skill but not currently subject to formal training. Implementation of a comprehensive curriculum for Surgical WRs led to significant improvement in quality of patient assessment, management, and nontechnical skills. Improved WR performance may lead to earlier identification and amelioration of complications and improve patient outcomes.

  • Surgical Ward round quality and impact on variable patient outcomes.
    Annals of surgery, 2014
    Co-Authors: Philip H. Pucher, Rajesh Aggarwal, Ara Darzi
    Abstract:

    Objective:To investigate the relationship between variability in Surgical Ward round (WR) quality and clinical outcomes.Background:Evidence increasingly suggests that Ward-based care plays a key role in Surgical outcomes. The WR is the focal point of Surgical inpatient care. Assimilating various sou

Johannes G Van Der Hoeven - One of the best experts on this subject based on the ideXlab platform.

  • Surgical Ward nurses responses to worry an observational descriptive study
    International Journal of Nursing Studies, 2018
    Co-Authors: Gooske Douw, Getty Huismande Waal, Arthur R H Van Zanten, Johannes G Van Der Hoeven, Lisette Schoonhoven
    Abstract:

    Abstract Background Rapid response systems aim to improve early recognition and treatment of deteriorating general Ward patients. Sole reliance on deviating vital signs to escalate care in rapid response systems disregards nurses' judgments about a patient's condition based on worry and other indicators of deterioration. To make worry explicit, the Dutch-Early-Nurse-Worry-Indicator-Score was developed, summarising non-quantifiable signs of deterioration in the nine indicators: breathing, circulation, temperature, mentation, agitation, pain, unexpected trajectory, patient indicates not feeling well and nurses' subjective observations. Nurses' worry can be present even when vital signs are largely unchanged, enabling treatment to commence at an early stage. On the other hand, reliance on nurses' worry might lead to unnecessary calls for medical assistance or an overuse of rapid response teams. Objectives Explore the occurrence of nurses' worry in real time, determine whether acting on worry leads to unnecessary action and determine the indicators present at different levels of deterioration. Design A prospective cohort study. Setting: Three Surgical Wards in a tertiary, university affiliated teaching hospital. Participants All nurses participated and adult, Surgical, native speaking patients were included in the study. Methods A descriptive analysis is performed on one year of data on Surgical Ward nurses' experience of worry and its underlying indicators in addition to routinely measured vital signs. Results Out of a total of 46,571 measurements, vital signs were normal 18,727 times, with worry expressed 605 times (3%), resulting in 62 calls (10.2%) to the attending physician. More than half of these calls resulted in necessary interventions. Calls for assistance and subsequent intervention after worry was expressed increase in parallel with early warning scores. The breathing indicator showed the highest increase in frequency with increasing deviation in vital signs. Conclusion This study suggests that worry has potential as an early indicator of deterioration, alerting nurses and encouraging them to start timely interventions. Overuse of medical assistance could not be determined, The Dutch-Early-Nurse-Worry-Indicator-Score objectifies worry when vital signs do not support its presence and systematic assessment of these indicators is recommended.

  • nurses worry as predictor of deteriorating Surgical Ward patients a prospective cohort study of the dutch early nurse worry indicator score
    International Journal of Nursing Studies, 2016
    Co-Authors: Gooske Douw, Getty Huismande Waal, Arthur R H Van Zanten, Johannes G Van Der Hoeven, Lisette Schoonhoven
    Abstract:

    Abstract Background Nurses' ‘worry' is used as a calling criterion in many Rapid Response Systems, however it is valued inconsistently. Furthermore, barriers to call the Rapid Response Team can cause delay in escalating care. The literature identifies nine indicators which trigger nurses to worry about a patient's condition. Objectives The objective of this study is to determine the significance of nurses' ‘worry' and/or indicators underlying ‘worry' to predict unplanned Intensive-Care/High-Dependency-Unit admission or unexpected mortality among Surgical Ward patients. Design A prospective cohort study. Settings A 500-bed tertiary University affiliated teaching hospital. Participants Adult, native speaking Surgical patients, admitted to three Surgical Wards (traumatology, vascular- and abdominal/oncological surgery). We excluded patients with a non-ICU policy or with no curative treatment. Mentally incapacitated patients were also excluded. Methods We developed a new clinical assessment tool, the Dutch-Early-Nurse-Worry-Indicator-Score (DENWIS) based on signs underlying ‘worry'. Nurses systematically scored their ‘worry' and the DENWIS once per shift or at any moment of ‘worry'. DENWIS measurements were linked to routinely measured vital signs. The composite endpoint was unplanned Intensive-Care/High-Dependency-Unit admission or unexpected mortality. The DENWIS-indicators were included in a univariate and multivariate logistic regression analysis, subsequently inserting ‘worry' and the Early Warning Score into the model. We calculated the area under the receiver-operating characteristics curve. Results In 3522 patients there were 102 (2.9%) patients with unplanned Intensive Care Unit/High Dependency Unit-admissions or unexpected mortality. ‘Worry' (0.81) and the DENWIS-model (0.85) had a lower area under the receiver-operating characteristics curve than the Early Warning Score (0.86). Adding ‘worry' and the Early Warning Score to the DENWIS-model resulted in higher areas under the receiver operating characteristics curves (0.87 and 0.91, respectively) compared with the Early Warning Score only based on vital signs. Conclusions In this single-center study we showed that adding the Early Warning Score based on vital signs to the DENWIS-indicators improves prediction of unplanned Intensive-Care/High-Dependency-Unit admission or unexpected mortality.

  • financial consequences of the implementation of a rapid response system on a Surgical Ward
    Journal of Evaluation in Clinical Practice, 2014
    Co-Authors: Friede Simmes, Lisette Schoonhoven, Joke Mintjes, Eddy M M Adang, Johannes G Van Der Hoeven
    Abstract:

    Rationale, aims and objectives: rapid response systems (RRSs) are recommended by the Institute for Healthcare Improvement and implemented worldwide. Our study on the effects of an RRS showed a non-significant decrease in cardiac arrest and/or unexpected death from 0.5% to 0.25%. Unplanned intensive care unit (ICU) admissions increased significantly from 2.5% to 4.2% without a decrease in APACHE II scores. In this study, we estimated the mean costs of an RRS per patient day and tested the hypothesis that admitting less severely ill patients to the ICU reduces costs. Methods: a cost analysis of an RRS on a Surgical Ward, including costs for implementation, a 1-day training programme for nurses, nursing time for extra vital signs observation, medical emergency team (MET) consults and differences in unplanned ICU days before and after RRS implementation. To test the hypothesis, we performed a scenario analysis with a mean APACHE II score of 14 points instead of the empirical 17.6 points for the unplanned ICU admissions, including 33% extra MET consults and 22% extra unplanned ICU admissions. Results: mean RRS costs were €26.87 per patient-day: implementation €0.33 (1%), training €0.90 (3%), nursing time spent on extended observation of vital signs €2.20 (8%), MET consults €0.57 (2%) and increased number of unplanned ICU days after RRS implementation €22.87 (85%). In the scenario analysis mean costs per patient-day were €10.18. Conclusions: the costs for extra unplanned ICU days were relatively high but the remaining RRS costs were relatively low. The ‘APACHE II 14’ scenario confirmed the hypothesis that costs for the number of unplanned ICU days can be reduced if less severely ill patients are referred to the ICU. Based upon these findings, our hospital stimulates earlier referral to the ICU, although further implementation strategies are needed to achieve these aims

Gooske Douw - One of the best experts on this subject based on the ideXlab platform.

  • Surgical Ward nurses responses to worry an observational descriptive study
    International Journal of Nursing Studies, 2018
    Co-Authors: Gooske Douw, Getty Huismande Waal, Arthur R H Van Zanten, Johannes G Van Der Hoeven, Lisette Schoonhoven
    Abstract:

    Abstract Background Rapid response systems aim to improve early recognition and treatment of deteriorating general Ward patients. Sole reliance on deviating vital signs to escalate care in rapid response systems disregards nurses' judgments about a patient's condition based on worry and other indicators of deterioration. To make worry explicit, the Dutch-Early-Nurse-Worry-Indicator-Score was developed, summarising non-quantifiable signs of deterioration in the nine indicators: breathing, circulation, temperature, mentation, agitation, pain, unexpected trajectory, patient indicates not feeling well and nurses' subjective observations. Nurses' worry can be present even when vital signs are largely unchanged, enabling treatment to commence at an early stage. On the other hand, reliance on nurses' worry might lead to unnecessary calls for medical assistance or an overuse of rapid response teams. Objectives Explore the occurrence of nurses' worry in real time, determine whether acting on worry leads to unnecessary action and determine the indicators present at different levels of deterioration. Design A prospective cohort study. Setting: Three Surgical Wards in a tertiary, university affiliated teaching hospital. Participants All nurses participated and adult, Surgical, native speaking patients were included in the study. Methods A descriptive analysis is performed on one year of data on Surgical Ward nurses' experience of worry and its underlying indicators in addition to routinely measured vital signs. Results Out of a total of 46,571 measurements, vital signs were normal 18,727 times, with worry expressed 605 times (3%), resulting in 62 calls (10.2%) to the attending physician. More than half of these calls resulted in necessary interventions. Calls for assistance and subsequent intervention after worry was expressed increase in parallel with early warning scores. The breathing indicator showed the highest increase in frequency with increasing deviation in vital signs. Conclusion This study suggests that worry has potential as an early indicator of deterioration, alerting nurses and encouraging them to start timely interventions. Overuse of medical assistance could not be determined, The Dutch-Early-Nurse-Worry-Indicator-Score objectifies worry when vital signs do not support its presence and systematic assessment of these indicators is recommended.

  • nurses worry as predictor of deteriorating Surgical Ward patients a prospective cohort study of the dutch early nurse worry indicator score
    International Journal of Nursing Studies, 2016
    Co-Authors: Gooske Douw, Getty Huismande Waal, Arthur R H Van Zanten, Johannes G Van Der Hoeven, Lisette Schoonhoven
    Abstract:

    Abstract Background Nurses' ‘worry' is used as a calling criterion in many Rapid Response Systems, however it is valued inconsistently. Furthermore, barriers to call the Rapid Response Team can cause delay in escalating care. The literature identifies nine indicators which trigger nurses to worry about a patient's condition. Objectives The objective of this study is to determine the significance of nurses' ‘worry' and/or indicators underlying ‘worry' to predict unplanned Intensive-Care/High-Dependency-Unit admission or unexpected mortality among Surgical Ward patients. Design A prospective cohort study. Settings A 500-bed tertiary University affiliated teaching hospital. Participants Adult, native speaking Surgical patients, admitted to three Surgical Wards (traumatology, vascular- and abdominal/oncological surgery). We excluded patients with a non-ICU policy or with no curative treatment. Mentally incapacitated patients were also excluded. Methods We developed a new clinical assessment tool, the Dutch-Early-Nurse-Worry-Indicator-Score (DENWIS) based on signs underlying ‘worry'. Nurses systematically scored their ‘worry' and the DENWIS once per shift or at any moment of ‘worry'. DENWIS measurements were linked to routinely measured vital signs. The composite endpoint was unplanned Intensive-Care/High-Dependency-Unit admission or unexpected mortality. The DENWIS-indicators were included in a univariate and multivariate logistic regression analysis, subsequently inserting ‘worry' and the Early Warning Score into the model. We calculated the area under the receiver-operating characteristics curve. Results In 3522 patients there were 102 (2.9%) patients with unplanned Intensive Care Unit/High Dependency Unit-admissions or unexpected mortality. ‘Worry' (0.81) and the DENWIS-model (0.85) had a lower area under the receiver-operating characteristics curve than the Early Warning Score (0.86). Adding ‘worry' and the Early Warning Score to the DENWIS-model resulted in higher areas under the receiver operating characteristics curves (0.87 and 0.91, respectively) compared with the Early Warning Score only based on vital signs. Conclusions In this single-center study we showed that adding the Early Warning Score based on vital signs to the DENWIS-indicators improves prediction of unplanned Intensive-Care/High-Dependency-Unit admission or unexpected mortality.