C. R. Horwood1, M. Rayo1, M. Fitzgerald1, S. D. Moffatt-Bruce1 1Ohio State University,Columbus, OH, USA
Introduction: There are multiple early warning signals that can predict clinical decompensation. While these variables are assessed by all healthcare providers, there is little knowledge as to how different health care providers perceive and thereby appreciate clinical decompensation. It is also unclear how treatment is changed based on these perceptions. The aim of this study is to qualitatively assess how nurses, surgical residents, and attending surgeons perceive early warning signs that predict clinical decompensation, escalation of care, and clinical acuity in surgical patients.
Methods: Ethnographic interviews focused on patient decompensation and stability were performed on a surgical floor during three weeks in July and August of 2017. Thirteen nurses, 5 surgery residents and 2 surgical attending physicians who had direct involvement with patient care were interviewed, recorded and transcribed. Constant comparative analysis was used to analysis and draw conclusions from the interview data.
Results: Similarities between healthcare providers were seen in the data clinicians used to determine stability and decompensation. They primarily used vital signs, intake/output, physical exam, and lab values. Overall, healthcare providers determined decompensation and stability as trends, as opposed to thresholds, in the data analyzed. Continuity of care, as well as, an established intent of discharge resulted in less frequent monitoring, decreased patient’s perceived acuity and resulted in practitioners less likely to interpret patient clinical changes as warning signs of decompensation. Differences were seen primarily in how physicians versus nurses perceived stability. Physicians were more focused on stability during a work up for a diagnosis while nursing staff had a lower threshold to escalate care during this time. Furthermore, the amount of communication needed to relay decompensation was different between levels of providers. Interestingly, there was no correlation among physicians and nurses between years of experience and frequency of monitoring when a patient was determined unstable. There was, however, a difference in the method that nurses and doctors used to monitor patients, and more interventions were taken by residents than nursing prior to escalation of care.
Conclusion:
Our study revealed that all healthcare providers agree on similar data values for decompensation and the importance of trends. However, differences were found in determining acuity of a patient and the actual escalation of care. The perception of stability resulted in decreased monitoring overall, which likely increased overall efficiency but increased the risk of delayed recognition of more subtle trends of decompensation.