in-hospital mortality after serious adverse events on medical and surgical nursing units: a mixed...

ORIGINAL ARTICLE

In-hospital mortality after serious adverse events on medical and

surgical nursing units: a mixed methods study

Koen De Meester, Peter Van Bogaert, Sean P Clarke and Leo Bossaert

Aims and objectives. To investigate the circumstances of nursing care eight hours before serious adverse events (=SAE’s) on

medical and surgical nursing units with subsequent in-hospital mortality in order to identify the extent to which these SAE’s

were potentially preventable.

Background. The prevention of SAE ‘s in acute care is coming under increasing scrutiny, while the role nursing care plays in the

prevention of acute critical deterioration of patients is unclear.

Methods. Retrospective review of patient records of 63 SAE’s in a Belgian teaching hospital where death was the final outcome

following a cardiac arrest team call or unplanned ICU admission from an acute care unit. Data from chart reviews were

combined with data regarding working conditions on the nursing unit at the time of the events and experts’ opinions regarding

the preventability of the outcomes. Finally, a pilot survey of staff nurses about their experiences with deteriorating patients and

knowledge of vital signs and call criteria was conducted independently of the chart abstractions and case reviews.

Results. Experts were almost five times more likely to designate a case as potentially preventable when a cardiac arrest team call

was the terminal event and were 40% less likely to designate a case as potentially preventable when more observations were

documented in patient records. Survey results revealed that nurses were often unaware that their patients were deteriorating

before the crisis. Nurses also reported threshold levels for concern for abnormal vital signs that suggested they would call for

assistance relatively late in clinical crises.

Conclusion. Renewed attention to accurate recording, documentation and interpretation of vital signs in hospital nursing

practice appears needed.

Relevance to clinical practice. Timely detection of deteriorating patients to assist staff to improve their outcomes appears to be

jeopardised by a number of practices and factors and merits deeper study.

Key words: adverse events, early interventions, in-hospital mortality, mixed methods, patient deterioration, patient safety,

retrospective analyse, staff awareness, vital sign

Accepted for publication: 12 February 2012

Authors: Koen De Meester, MNSc, RN, PhD Candidate, Faculty of

Medicine and Health Sciences Division of Nursing and Midwifery

Sciences, University of Antwerp, Antwerp and Director of Nursing,

Antwerp University Hospital, Antwerp; Peter Van Bogaert, MA,

PhD, RN, Faculty of Medicine and Health Sciences Division of

Nursing and Midwifery Sciences, University of Antwerp, Antwerp

and Director of Nursing, Antwerp University Hospital, Antwerp,

Belgium; Sean P Clarke, CRNP, FAAN, PhD, RN, Associate

Professor, Lawrence S. Bloomberg Faculty of Nursing, University of

Toronto, Toronto and Peter Munk Cardiac Centre, University Health

Network, Toronto, Canada; Leo Bossaert, MD, PhD, Professor

Emeritus, Faculty of Medicine and Health Sciences Division of

Nursing and Midwifery Sciences, University of Antwerp, Antwerp

and Department of Intensive Care, Antwerp University Hospital,

Antwerp, Belgium

Correspondence: Koen De Meester, PhD Candidate, Faculty of

Medicine and Health Sciences Division of Nursing and Midwifery

Sciences, University of Antwerp, Belgium and Director of Nursing,

Antwerp University Hospital, Antwerp, Belgium. Telephone:

+32 3 265 25 04.

E-mail: [email protected]

� 2012 Blackwell Publishing Ltd

Journal of Clinical Nursing, doi: 10.1111/j.1365-2702.2012.04154.x 1

Introduction

Growing evidence suggests that a significant proportion of

hospital patient deaths occur after serious unforeseen adverse

events (Kohn et al. 1999, Zeger et al. 2009). Concerns have

been raised that too often patients’ acute deteriorations,

particularly on surgical and medical wards outside critical

care settings, are identified too late and corrective actions

taken too slowly (De Vita et al. 2010). Many initiatives have

been taken to prevent unexpected death by timely recogni-

tion, intervention and resuscitation efforts. Some reports have

suggested that rapid response teams (RRTs) may reduce

cardiac arrest rates outside the ICU by as much as 34%

(Chan et al. 2010).

Rescuing patients experiencing clinical deterioration hinges

on timely recognition of important clinical changes through

effective observations. Observing patients is a fundamental

element of nursing practice and of course, patient assessment

constitutes the first step in the nursing process (Nightingale

1860, Sellman & Snelling 2010). Yet a US study several years

ago found that because of factors including inefficient work

design and heavy documentation burden, only about 7Æ2% of

nurses’ time is spent on patient assessment and vital signs

monitoring (Hendrich et al. 2008).

Common sense, clinical experience and a growing body of

empirical evidence make it clear that nurses’ work environ-

ments, including staffing levels and working conditions, play

an important role in quality of practice around issues like

surveillance, as well as patient safety outcomes (Page et al.

2004). Therefore, in addition to examining the intensity of

surveillance and quality of decision-making, it is essential to

investigate environmental conditions that may have impacts

on the prevention of serious adverse events (Irvine et al.

1998).

Background

The literature suggests that vital signs are usually collected

based on tradition or routine with little evidence that

frequency of vital signs is tailored to patient risk for

complications (Zeitz & McCutcheon 2006). This is partic-

ularly distressing in the light of compelling evidence suggest-

ing that vital signs and call criteria have considerable utility

in predicting adverse events. Other researchers have found

incomplete documentation of vital signs and other clinical

assessments (McGain et al. 2008) and limited nurse aware-

ness of normal and abnormal vital signs (Fuhrmann et al.

2008). Still others have found that making and recording

observations critical to assessing stability (appearance, skin

condition, complaints and vital signs) are assigned a low

priority and are often delegated to junior nurses or support

workers (Higgins et al. 2008). Moreover, respiratory rate is

the most neglected documented vital sign but at the same time

has been the most specific predictor of major adverse events

(Buist et al. 2004, Cretikos et al. 2007, McGain et al. 2008,

Rose & Clarke 2010).

This study investigated the circumstances surrounding in-

hospital deaths after cardiac arrest team calls and unplanned

ICU admissions for patients treated on medical and surgical

nursing units in a major Belgian teaching hospital that had

not, at the time of the project, instituted a RRT. The goal was

to identify the extent to which clinical downturns resulting in

death were potentially preventable. The International Con-

ceptual Framework for the Classification for Patient Safety

defines an adverse event as ‘a negative consequence of care

that results in unintended injury or illness which may or may

not have been preventable’ (WHO 2009). Our intent was to

explore preventability and provide direction for practice

development efforts around vital signs monitoring. Guide-

lines for measuring, evaluating and reducing hospital mor-

tality rates Move Your Dot of the Institute for Healthcare

Improvement (Jarman et al. 2003) and The Recommended

Guidelines for Monitoring, Reporting, and Conducting

Research on Medical Emergency Team, Outreach, and Rapid

Response Systems (RRS): An Utstein-Style Scientific State-

ment (Peberdy et al. 2007) were used. The selection of

variables was partially based on components of the Nursing

Role Effectiveness Model (Irvine et al. 1998).

Methods

Design

This mixed methods study (Creswell & Plano Clark 2007)

had four components:

1 A retrospective review of the records of consecutive cases

of deaths following cardiac arrest team calls or unplanned

ICU admissions from medical and surgical units, particu-

larly with respect to recorded vital signs eight hours prior

to an event.

2 Merging of data in (1) with nursing unit variables at the

time of the events.

3 Review of the data in (1) by a panel of clinical experts and

assessments of the degree to which the events were

potentially preventable (as opposed to mainly attributable

to the underlying disease or injury).

4 A survey of 44 staff nurses from the hospital regarding

their experience with deteriorating patients and knowledge

of vital signs and thresholds for calling for assistance. The

survey was conducted separately from the chart reviews.

K De Meester et al.


2 Journal of Clinical Nursing

The study in its entirety was reviewed and approved by the

research ethics committee of the study hospital. The authors

declare that they have no conflict of interest.

Sample/participants

The study was conducted in a 600-bed tertiary hospital in

Belgium with a 39-bed intensive care unit and a cardiac arrest

team (composed of emergency department staff). The

8Æ5-month study period was between 1 March 2007–15

November 2007. During the study period, 14,106 patients

were admitted to all 15 30-bed medical and surgical nursing

units. There were 70 cases of cardiac arrest team calls and

129 unplanned ICU admissions of patients without docu-

mented do not resuscitate orders. In 63 cases, the patients

involved ultimately died and their cases were selected for closer

examination here.

Data collection

Study case variables

The following parameters were abstracted from patient

records: timing of the event (day vs. night, workweek

vs. weekend), patient characteristics (patient age, gender,

reason of admission in the hospital, prior medical history),

classification of the nature of deterioration by the cardiac

arrest team or ICU admission chart as for instance, septic

shock, arrhythmia, respiratory insufficiency, cardiac arrest,

sudden death, cardiogenic shock, haemorrhage, altered level

of unconsciousness, general deterioration, ICU admissions

prior to the crisis earlier in the hospital stay, the presence or

absence of observations eight hours before the event (an

observation was considered to have taken place when even a

single vital sign was documented in the record). Also

abstracted and analysed for each patient were length of stay

on the nursing unit and total length of hospital stay.

Nursing unit variables

A number of variables related to the conditions on the nursing

unit on the day of the arrest call or transfer to ICU were drawn

from several hospital administrative databases searching by

unit and date. First, on the study units, charge nurses rate of

staffing adequacy on a 4-point scale shortly after the beginning

of the day shift (at 8:00 AM). These ratings are used to assist

nursing directors to reallocate nurses on a daily basis; they are

recorded in a searchable database. The scale is (1) overstaffed

to the point of being able to provide support to another unit/

units, (2) ‘normal’ conditions, (3) high but sustainable work-

load in relation to staffing, and (4) understaffed and in need of

an extra staff member. Also, drawn from the databases were

the numbers of patients on the unit, admissions and discharges

that day. Finally, the staffing data were merged with a human

resources database that enabled analyses of a number of

characteristics of the nursing staff on duty, including the per-

centage who were permanent members of staff (i.e. not floating

or interim nurses) and the qualifications of the permanent staff

on duty (mean years in nursing and on the unit and percentage

who were baccalaureate prepared).

Expert review of cases

Three clinical experts (one emergency physician and two

nursing directors) independently reviewed the abstracted data

regarding the cases. Each experts classified cases as poten-

tially preventable (1), not potentially preventable (�1) or of

equivocal preventability (unclear = 0). Reviewers were pre-

sented with a definition of a preventable event as one that

‘could have been anticipated and prepared for, but that

occur[red] because of an error or other system failure’ (WHO

2009). The Kappa coefficients of ratings were 0.34 and 0.37,

respectively, between each director of nursing and the

physician and 0.43 between the two directors of nursing.

Because retrospective review was used, the term potentially

preventability was adopted to refer the final classification of

cases because of possibility of hindsight bias and the modest

interrater agreement between experts (Zeger et al. 2010). To

label cases as potentially preventable, not potentially pre-

ventable or equivocal, the reviewers’ scores were added

together. A total <0, >0 or of 0 were considered to

represent consensus of the group that the event was not

potentially preventable, potentially preventable or of unclear

preventability, respectively. Summary scores imply that when

at least two of the reviewers agreed about preventability or

when two reviewers classified cases as equivocal/clear and the

third thought the case was potentially preventable, the cases

were deemed potentially preventable. Similarly, when at least

two of the reviewers agreed about non-preventability or

when two reviewers classified cases equivocal/unclear and the

third as not preventable, the cases were considered not

potentially preventable. Cases deemed as being of equivocal/

unclear preventability by all reviewers or where the reviewers

were divided in their opinions but the balance of classifica-

tions was 0 were considered of unclear preventability.

Staff nurse surveys

A small voluntary survey was conducted with a convenience

sample of staff nurses exploring their most recent experiences

of caring for a patient with sudden deterioration. Nurses were

asked to fill in the survey if they had ever been involved in the

Original article In-hospital mortality after SAE


Journal of Clinical Nursing 3

care of a patient whose condition had deteriorated at some

point in their career in hospital nursing. There was no formal

connection between the cases reviewed in the other stages of

the study and the nurses surveyed or the events the nurses were

recalling in the questionnaires. Questionnaires were distrib-

uted and collected by a single contact person on all 15 nursing

units over a short period of two weeks (February 2008).

The survey tool began with questions asking about the

most recent case of a sudden clinical deterioration, the vital

signs gathered and recorded and which ones caused concern.

These were followed by a series of questions asking nurses for

their perspectives of high and low levels of vital signs that

would lead them to call for help, either from a physician or

from a crisis/cardiac arrest team. Nurse surveys were anal-

ysed descriptively. Guidelines for Medical Emergency Team

(MET) call and criteria for early and late signs as described in

previous studies and shown in Table 4 (Harrison et al. 2005,

Hillman et al. 2005, Dacey et al. 2007) were used to provide

a context for interpreting nurses’ responses to questions

about high and low thresholds of vital signs that would lead

them to call for help.

Data analysis

Statistical significance was set at p < 0.05. The Statistical

Package for the Social Sciences (SPSSSPSS, IBM SPSS Statistics,

Armonk, NY, USA) version 18.0 software was used for all

analyses. Descriptive, chi-square, t-test and correlational

analyses of variables from patient records were performed.

Bivariate and multivariate logistic regression analyses were

used to compare characteristics of cases classified by the

panel as potentially preventable vs. not potentially prevent-

able.

Results

During time period across which cases were drawn, there

were 14,106 admissions to 15 non-critical care nursing units.

Records indicate that 70 cardiac arrest team calls and 129

unplanned ICU transfers from these units occurred, and 63

study patients who died following an acute clinical crisis had

an average age of 65Æ1 years (range: 32–84).

Table 1 presents the characteristics and unit conditions at

the time of the cases. The major cause of the cases identified

in the patient records were respiratory failure (38Æ1%), septic

shock (17Æ5%) and cardiac arrest (14Æ3%). The mean length

of stay on the nursing unit was nine days (range: 0–47) and

the mean length of stay in the hospital more than 22 days

(range: 0–208). Moreover, in 29 cases (46%), patients had

spent time in the ICU during their hospital stays before the

final clinical crisis. A mean of 2Æ3 (range 0–12) chart entries

and/or lone vital signs/vital sign sets were documented in the

eight hours before the event.

At the time of the events, the mean patient-to-nurse ratio was

9Æ2 (range: 4Æ2–30), and charge nurses rated staffing conditions

on the nursing units at the time of the events as reflecting a high

but sustainable workload (three on a four-point scale). On the

day of the events, mean practice experience of the permanent

nursing staff on the units was approximately 9Æ7 years (range:

0–27), more than four of five nurses held a bachelor degree in

nursing, and more than 90% (range: 40–100) of the personnel

on duty were permanent nursing unit staff members.

The balance of opinion in 31 (49Æ2%) and 26 (41Æ2%)

cases was that the terminal events were potentially prevent-

able and not potentially preventable, respectively. Of these

cases, the experts were unanimous in designating 15 of the

cases as potentially preventable and seven cases as not likely

to have been prevented. The remaining six cases (9Æ5%) were

designated as unclassifiable or of unclear preventability.

Table 2 summarises descriptive and logistic regression

analyses examining various independent variables as predic-

tors of expert opinion of the cases as preventable (leaving

aside the equivocal cases). Bivariate logistic regression

analyses suggest that cases where a cardiac arrest call was

involved were five times more likely to be designated as

potentially preventable by experts, and every additional vital

signs recorded in the record prior to the event decreased the

likelihood that the case would be classified as preventable by

almost half (odds ratios 5Æ10, 0.57, respectively). None of the

63 patients had a respiratory rate recorded on the chart

within eight hours prior to their event. The presence of at

least one entry of any of the other vital signs (e.g. heart rate,

systolic blood pressure, oxygen saturation or temperature)

decreased the likelihood greatly that the case would be

deemed preventable. Heavier patient loads on the nursing

units at the time of the event, a factor that experts were not

provided with at the time of their reviews, did not reach

statistical significance as a predictor of greater likelihood of a

case being designated as preventable. Cardiac arrest team call

as the triggering event and the number of documented

observations eight hours before the event were the only

multivariate predictors of expert assessments of preventabil-

ity (odds ratios 5Æ94, 0Æ60, respectively).

Table 3 presents the results of the nurse surveys, completed

by 44 nurses and at least two respondents for each of the 15

units, regarding their most recent experiences with a deteri-

orating patient. In almost two of three cases, nurses reported

being unaware that their patient was deteriorating before the

actual clinical event. While nearly every respondent reported

taking vital signs before the event, only three of four reported

documenting vital signs in the patient record, two of three

K De Meester et al.



documented other observations, and just over half of the

respondents documented the actions they took in the patient

record. Nearly, all respondents believed that staffing levels

were sufficient and that staff on duty had the requisite

competence and skills to deal with the crisis.

Table 4 summarises respondents’ impressions regarding

the critical levels of vital signs indicating a need to call a

physician or the cardiac arrest team. Wide variations were

observed. Between 9–48% of the nurses felt that calling a

physician or the arrest team depended on the patient’s

situation. The respondents’ mean values for a cardiac arrest

team call were lower for the decreased and higher for the

increased values of critical vital signs compared with the

MET, early and late signs criteria.

Discussion

Nearly, half (49Æ2%) of the 63 cases of clinical deterioration

of a patient from a medical or surgical unit ending with death

were considered potentially preventable by expert reviewers

examining clinical details of the cases. Reviewers were almost

six times (multivariate analysis) more likely to designate cases

where the first major clinical action was a cardiac arrest call

rather than transfer to the ICU and those where few vital

signs were documented as being potentially preventable.

These results suggest that expert rates appear to feel that

delayed recognition of clinical deterioration may be a

significant factor in a considerable number of the poor

outcomes observed in patients cared for off critical care units.

Table 1 Descriptive analysis of study variables

Cases

Unanimous classification

(n = 22) Consensus classification (n = 63)

Total

Potentially

preventable

Unlikely to have

been prevented

Potentially

preventable

Unlikely to have

been prevented Unclear

Event-related variables (n/%)

Number of patients 63 15 7 31 26 6

Male 36/57Æ1 9 1 19 12 5

Events at night between 23 PM and 7 AM 12/19Æ0 4 2 8 4 0

Event at weekend day 17 27Æ0 3 2 7 9 1

Cardiac arrest team calls 25/39Æ7 9 1 17* 5 3

Initially admitted to ICU 29/46Æ0 7 3 16 10 3

Description of the deteriorations by respondents

Respiratory failure 24/38Æ1 5 1 10 12 2

Septic shock 11/17Æ5 1 2 5 3 3

Cardiac arrest 9/14Æ3 3 1 6 2 1

General deterioration 5/7Æ9 2 1 3 2 0

Loss of consciousness 4/6Æ3 1 1 2 2 0

Haemorrhage 3/4Æ8 2 1 2 1 0

Cardiac shock 5/7Æ9 0 0 1 4 0

Mean/range

Age (range) 65Æ1/32–84 65Æ3/44–84 63Æ6/32–80 66Æ1/44–84 63Æ8/32–83 65Æ7/59–77

Length of stay at the nursing unit (days) 9Æ0/0–47 7Æ5/0–31 15Æ7/2–30 7Æ0/0–37 11Æ5/1–47 8Æ67/1–25

Length of stay in the hospital (days) 22Æ1/0–208 23Æ8/0–105 28Æ0/10–63 17Æ4/0–105 27Æ9/1–208 21Æ3/2–44

Number of documented at least single

vital signs eight hours before an event

2Æ3/0–12 1Æ2/0–6* 3Æ4/2–9 1Æ6/0–6** 3Æ2/0–12 1Æ6/1–3

Nursing unit-related variables

Care intensity score (1 = lowest intensity,

4 = highest intensity)

3/2–4 2Æ9/2–4 2Æ9/2–3 2Æ9/2–4 3Æ1/2–4 3Æ2/3–4

Patient-to-nurse ratio per shift 9Æ0/4Æ2–30 11Æ0/4Æ8–23Æ0 8Æ9/4Æ5–21Æ0 10Æ1/4Æ2–23Æ0 8Æ5/4Æ4–30Æ0 6Æ4/4Æ3–8Æ7Years in nursing unit 9Æ7/0–27 9Æ0/0–24 14Æ5/3–26 8Æ0/0–24 11Æ49/1–27 9Æ91/2–17

Regular nursing unit staff (%) 91Æ2/40–100 96Æ1/67–100 95Æ2/67–100 92Æ1/50–100 89Æ9/40–100 91Æ7/67–100

Bachelor in nursing (%) 83Æ7/0–100 85Æ6/33–100 82Æ1/0–100 86Æ3/0–100 79Æ1/0–100 90Æ0/60–100

*p < 0Æ05; **p < 0Æ01.




There was a total absence of the documentation of

respiratory rate in the patient records of the cases. Clearly,

measuring the respiratory rate was not common practice in

the hospital during the research period. Almost two of three

nurses stated that they were unaware of their patients’

deterioration before the situation became critical the last time

they cared for a patient in crisis. Many nurses did not feel that

there were firm levels of vital signs that should lead to

automatic notification of clinicians. The levels offered by

respondents often encompassed but were considerably looser

than those suggested by consensus/policy statements/practice

guidelines, suggesting that many of the respondents would

wait to call for assistance until abnormalities were consider-

ably more severe than expert and consensus documents

suggest. In addition, there was a certain consistency between

the results of the review of patient records and the survey

findings. It is notable that at the time of the study, there was

no formal observation and ‘ramp up’/escalation protocol in

place in the facility. The only call criteria in effect were for

cardiac arrest. Nurses were trained annually in basic life

support. The first level of escalation clinical crises other than

cardiac arrest events was calls to junior doctors undergoing

training in internal medicine, surgery or anaesthesiology.

These junior doctors could call for assistance of a senior

doctor or a physician specialised in emergency or critical care

medicine. Doctors were summoned based on ward nurses’

assessment skills and clinical knowledge. Depending on

medical specialty of the ward, more advanced assessments

Table 2 Descriptive and logistic regression analyses of the selected study items as independent variables and not potentially preventable cases

(0) – potentially preventable cases (1) as dependent variable

Study variables Units

Potentially preventable cases Univariate analysis Multivariate analysis

No n = 26 (0) Yes n = 31 (1) OR (95% CI) OR (95% CI)

Events at night between

23 PM and 7 AM

n 4 8 1Æ913 (0Æ503–7Æ269)

Events at weekend days n 9 7 0Æ551 (0Æ172 – 1Æ770)

Length of stay at the nursing

unit in days

Mean (SD) 11Æ5 (12Æ3) 7Æ0 (9Æ5) 0Æ961 (0Æ913–1Æ012)

Length of stay in the hospital

in days

Mean (SD) 27Æ9 (40Æ5) 17Æ4 (24Æ2) 0Æ989 (0Æ969–1Æ009)

Initial admission at ICU n 10 16 1Æ707 (0Æ592–4Æ919)

Care intensity mean (SD) 3Æ1 (0Æ5) 2Æ9 (0Æ4) 0Æ329 (0Æ088–1Æ224)

Years in nursing unit mean (SD) 11Æ5 (8Æ1) 8Æ0 (6Æ2) 0Æ935 (0Æ866–1Æ009)

Percentage of regular staff nurses Mean (SD) 89Æ9 (16Æ0) 92Æ1 (14Æ3) 1Æ010 (0Æ975–1Æ046)

Percentage of bachelor in

nursing science

Mean (SD) 79Æ1 (30Æ7) 86Æ3 (24Æ1) 1Æ010 (0Æ990–1Æ030)

Patient-to-nurse ratio per shift ratio mean (SD) 8Æ5 (6Æ2) 10Æ0 (4Æ8) 1Æ058 (0Æ943–1Æ186)

Cardiac arrest team calls n 5 17 5Æ100 (1Æ529–17Æ014)** 5Æ939 (1Æ522–23Æ175)**

Number of documented at least

single vital signs eight hours

before an event

Mean (SD) 3Æ23 (2Æ5) 1Æ6 (1Æ5) 0Æ571 (0Æ370–0Æ882)* 0Æ603 (0Æ367–0Æ915)*

Documented in patient record:

Respiratory rate n 0 0

Heart rate n 23 19 0Æ225 (0Æ055–0Æ926)*

Systolic blood pressure n 25 20 0Æ080 (0Æ009–0Æ679)*

Oxygen saturation n 22 17 0Æ238 (0Æ066–0Æ861)*

Administration of oxygen n 18 12 0Æ296 (0Æ098–0Æ897)*

Glasgow coma scale n 2 1 0Æ414 (0Æ035 – 4Æ846)

Temperature n 24 17 0Æ109 (0Æ022–0Æ547)**

*p < 0Æ05; **p < 0Æ01; multivariate analysis explained variance Nagelkerke R2 = 0Æ360.

Table 3 Nurse self-reports of their most recent experiences with

patient in clinical crisis (n = 44)

Yes %

Were you aware that the patients’ condition was

worsening before he/she deteriorated?

13 30

Did you take vital signs before the patient deteriorated? 43 98

Did you note vital signs in the patient record? 33 75

Did you note other observations in the patient record? 29 66

Did you note actions taken in patient record? 25 57

Was staff during your and the previous shift enough

competent

to handle deteriorating patients?

41 93

K De Meester et al.



(for example, blood gas analysis or electrocardiogram trac-

ings) may have influenced nurses’ judgements regarding the

timing and rationales for calls.

Numerous studies link inconsistent vital sign monitoring

with poor outcomes, especially among patients who experi-

ence complications. In the SOCCOR study, 18% and 30% of

patient records showed abnormal vital signs eight and two

hours prior to a critical event (Harrison et al. 2006). An

earlier study of five wards in a 600–bed teaching hospital

showed that one of five patients displayed abnormal vital

signs, and the nursing staff were unaware of these abnormal

findings in slightly over half the cases (Fuhrmann et al. 2008).

Patients with abnormal vital signs had threefold increased 30-

day mortality risk compared with those who had normal vital

signs.

Most researchers and commentators are in agreement that

improved identification of patients at risk is a crucial first step

in preventing adverse events on the general wards. While many

agree that responses to patient deterioration in acute hospital

care are inadequate (Kellett 2009a), there is also growing

consensus on the impact of the afferent (input or activation)

limb of RRS that begins with front line clinical nursing

observations (Devita et al. 2010, Kellett 2009b). It is as yet

unclear whether interventions to increase the number or

frequency of observations being made or whether education

and implementation of observation and call protocols based on

early warning scores (Higgins et al. 2008) will best achieve the

overall goal of preventing irreversible declines or whether both

strategies should be implemented. The ideal frequency for

observation has not yet been determined (Devita et al. 2010).

NICE Guideline 50 advises standard physiological observation

at least every 12 hours unless a decision has been made at a

senior level to increase or decrease this frequency for an

individual patient and frequency of monitoring should increase

if abnormal physiology is detected (Centre for Clinical Practice

at NICE 2007). The need for more frequent observations can be

triggered by using observation and escalation protocols includ-

ing Early Warning Scores enabling graded response, but patient

safety continues to depend on nurses’ clinical judgment (Kyria-

cos et al. 2011). A retrospective study investigating staff

decisions to activate medical emergency teams in patients

meeting call criteria 15 minutes to 24 hours prior an in-hospital

event suggests that several factors can be involved such as an

error in judgement, lack of MET education, change of staff

documenting subsequentvital signs, the wayMET interacts with

ward staff and/or the extent of collaboration amongst doctors

and nurses (Trinkle & Flabouris 2011). Multiple organisational

changes at several levels are likely necessary to achieve timely

identification and intervention for at-risk patients.

Less favourable nursing staffing (in terms of higher patient-

to-nurse ratios) was not predictive of a case being considered

potentially preventable in bivariate analyses. A number of

studies show associations between nurse staffing and patient

mortality in medical and surgical populations (Estabrooks

et al. 2005, Tourangeau et al. 2007, Aiken et al. 2008, Friese

et al. 2008), including a recent Belgian study linking regis-

tered nurses nurse hours per patient day (NHPPD) with

postoperative in-hospital mortality at general nursing unit

level in cardiac surgery patients (Van den Heede et al. 2009).

Heavier patient loads presumably influence the quantity and

quality of nursing attention that patients receive and thereby

exert an influence on patient outcomes (Clarke & Donaldson

2008), and patient surveillance is a major clinical process

linking staffing levels with failure to rescue (death following

complications) (Clarke & Aiken 2003, Clarke 2004). Unex-

pectedly, in this study, nurses’ compliance with documenting

patients’ vital signs did not appear influenced by workload,

and therefore, further research is recommended.

Table 4 Nurses’ answers about their knowledge of vital signs and call criteria (n = 44)

Threshold for notification of the

physician

Threshold for calling emergency

team

vital signs and call criteria from the

literature

Dependent on

patient

situation (%)

Mean (range) for

nurses who

provided a range

Dependent on

patient

situation (%)

Mean (range) for

nurses who

provided a range Early signs* Late signs* MET**

High limit heart rate (beats/min)> 4 (9) 135 (110–180) 17 (38Æ6%) 172 (120–200) 120–140 >140 140

Low limit heart rate (beats/min)< 4 (9) 42 (30–60) 11 (25%) 29 (0–40) 40–49 <40 40

Respiratory rate (breaths/min)> 17 (38Æ6) 34 (18–80) 21 (48%) 38 (25–60) – – 36

Respiratory rate (breaths/min)< 17 (38Æ6) 8 (0–15) 15 (34%) 4 (0–12) – – 5

Oxygen saturation (%)< 5 (11Æ4) 86 (75–91) 9 (20Æ5%) 68 (30–85) 90–95 <90 90

Systolic blood pressure (mmHg)> 7 (16) 186 (150–220) 17 (38Æ6%) 225 (160–260) 180 –

Systolic blood pressure (mmHg)< 5 (11Æ4) 78 (40–100) 9 (20Æ5%) 59 (0–80) 80–100 <80 90

*Cut-off values of the SOCCOR study.

**Cut-off values of Medical Emergency Team Call of the MERIT study.




Study limitations

A number of limitations of the current study should be kept

in mind. This was a somewhat small project conducted in a

single institution that did not have a MET in place at the time

of data collection. Replication elsewhere would increase

confidence in the findings. The major dependent variable in

the study was the designation of the clinical circumstances

leading to a patient death as potentially preventable by a

panel of clinical experts, who displayed fair to moderate

agreement in their ratings relative to experts in other

retrospective adverse event studies (Zeger et al. 2010). The

use of expert reviews is common in the safety literature and

appears to be useful here; however, in future studies, further

refinement of the protocol, more extensive training of experts

and more explicit procedures for resolving differences and

achieving consensus are recommended (Zeger et al. 2007).

A short, newly developed survey was used to assess nurses’

experiences with cases of deteriorating patients and knowl-

edge of impending signs of early critical illness. A small

convenience sample was completed because of the low

number of nurses involved in the care of recent cases of

deteriorating patients. Selection biases in the sample as well

as self-reports and recall biases in the survey findings must

also be borne in mind. Using the survey with all categories of

nurses and junior doctors is recommended, as is review of the

same events by the various personnel involved.

Analyses of unit conditions on the day of the event were

limited to environmental variables that were easily accessible

using the institution’s internal administrative data. Nurse

perceptions of their work environments were not assessed

here and should be examined in future studies. In 2006, the

hospital had organised a survey to investigate the care

environment based on a translated and validated version of

the Revised Nursing Work Index (Van Bogaert et al. 2009a).

There were favourable nurses’ assessments of the collegial

nurse – physician relationship and nurse management at the

unit level (Van Bogaert et al. 2009b). However, there were

differences between nursing units with a wide variation about

the perceived care environment (Van Bogaert et al. 2010). It

is unclear to what extent elements of nurse work environment

can influence the surveillance capacity of nurses with or

without RRS (Chan et al. 2010) or how RRS influence nurse

satisfaction and prevent in-hospital complications. Also, the

unit staffing conditions examined in this preliminary study

were those on the day of the event, and it is possible that

working conditions and omitted observations on earlier days

or shifts are equally if not more important in accounting for

late identification of patients in clinical crisis and should be

examined in future studies.

However, given the seriousness of the findings and little

evidence that even with implementation of MET/RRTs that

delayed identification of patients in crisis has dramatically

improved, broader multicentre studies and larger samples are

recommended. It may be particularly valuable to examine

unit- and shift-level conditions and to design studies relative

to the implementation of early warning scores and rapid

response cascades.

Conclusion

This study, drawing upon independent expert review of cases

with poor outcomes and nurse self-reports of their practices and

opinions relative to patient surveillance, highlights a number of

concerning conditions and suggests that a considerable number

of cases of preventable in-hospital mortality may be linked to

poor practices. Even with current limitations and conflicting

findings in the RRT literature, the findings are consistent. The

set-up of a rapid response cascade based on a clear communi-

cation and intervention protocols, including a do not resuscitate

protocol for nurses and physicians, is recommended. Further

research is necessary to evaluate the nurse effectiveness and the

nurse work environment on deteriorating patients and the

prevention of serious adverse events.

Relevance to clinical practice

Nurses’ knowledge, performance and recording of observa-

tions and vital signs are crucial for an adequate surveillance

of patients. Hospital and nurse managers, physicians and

nurses should be aware of the importance of timely detection

of deteriorating patients in the process of nursing care in

handling clinical crises effectively.

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