Recognition and response to deterioration in complex client
Write an Essay in which you critically evaluate a case study of a patient who has died, related to your clinical specialty.
Patient deterioration has become a common or casual phenomenon due to increasing complexity in hospitalized patients as well as lacking professional expertise in health services. Around 17% of hospitalised patients experience adverse event in their complete duration of hospital stay (Pocock, 2013). According to Lambe, Currey & Considine (2016) studies patient deterioration is one of the main reasons for increased mortality and morbidity as per Australian Commission on Safety and Quality in Health Care statistics.
This study aims to demonstrate, evaluate and understand one such patient deterioration care that ended into the death of the patient named Jenny Whyte. The complete case is critically analysed followed by providing recommendations that can help to avoid or manage such deterioration event in healthcare practices.
Recognition and response are two strategic concepts that directly aim to ensure patient safety avoiding the risk of deterioration (Potter et al. 2016). According to Odell (2015) studies recognising in healthcare services involves determining the patient data, assessment of patient health information (primary, secondary health data), patient education and critical patient observations. Further, recognising process is completed with measurement and documentation of patient data.
Secondly, responding involves situation awareness, effective communication, and knowledge transmission, providing support care services, processing patient information with teamwork and avoiding any kind of risk to the patient (Fayers & Machin, 2013). According to Barker, Rushton & Smith (2015) studies an effectively recognised and responded patient case will involve the minimum chance of emergency admission, long-term hospitalization or patient deterioration. Osborne et al. (2015) studied about the National Safety and Quality Health Services (NSQHS) standard 9 that is “Recognising and Responding to clinical deterioration in acute healthcare”. This standard aims to ensure proper recognition and response to patient deterioration. The four criteria that hospitals need to follow as per this standard are installing recognition and response systems, diagnosing clinical deterioration, escalating care, acting to clinical deterioration and proper communication with patients and carers.
The early recognising and responding to patient deterioration using effective action implants improved patient outcomes, minimises the level of deterioration, stabilises patient condition, lessen required intervention effort as well as avoid the condition of death. The process of recognition and responding surely addresses all of these factors across every area of a healthcare facility (Potter et al. 2016). The present study helps to understand the importance of early recognition and responding to avoid the condition of deterioration that occurred in case of the patient, Jenny Whyte.
Case study evaluation
Understanding patient condition and management recommendations
In the provided patient deterioration case Jenny Renne Whyte was a 15-year-old girl admitted to the emergency department complaining headache, dizziness, aches in legs and arms. Jenny confronted deterioration condition due to negligence, malfunction and situational factors in healthcare service. As per condition analysis, Jenny was suffering from meningococcal septicaemia, which is a serious, and life-threatening condition caused by infection of Neisseria meningococcal bacteria in bloodstream. The initial vital signs and symptoms of Jenny clearly indicated about meningococcal disease. As per Considine & Currey (2015) studies fever, headache, rapid breathing, severe aches, vomiting and rashes on the body are most simple signs of meningococcal infection. Jenny was complaining about the similar condition when admitted to hospital. Further, bacterial infection was already rife in Jenny’s town indicating a requirement of serious action. The vital signs of Jenny involved a high pulse rate, increased respiratory rate and low blood pressure. In case of Jenny, these vital signs and symptoms got worse with time creating patient deterioration. Lastly, Jenny faced breathing difficulties with no blood pressure readings confronting cardiac arrest leading to death.
As per the patient condition analysis, the most essential management recommendation involves assessment of primary and secondary vital signs which is missed in case. The Jenny’s health condition requires blood culture analysis (blood or cerebrospinal fluid test) followed by meningococcal PCR analysis (PCR testing) (Mochizuki et al. 2017). After PCR reports a CSF test should be performed to determine gram stain (gram negative diplococcic). But, antibiotic treatment should not be avoided to obtain CSF results because Trinkle & Flabouris (2011) indicated that meningococcal bacteria start to disappear within 24 hours if proper antibiotic treatment is implemented on time. In case of Jenny, the vital signs and symptoms highlighting bacterial infection were avoided completely leading to deterioration. The antibiotic treatment (flucloxacillin or ceftriaxone 50mg/kg, max 2g or benzylpensillin 60mg/kg, max 2.4g) and fluid resuscitation would have avoided the severity of bacterial infection in Jenny’s case. The antibiotic treatment should last minimum 5-7 days (Pocock, 2013).
According to Campbell et al. (2016) studies Meningococcal disease spreads from person to person through respiratory droplets, therefore, hospital staff needs to take necessary personal precautions as well as keep patient under isolated conditions. In case of Jenny, proper isolation and droplet precaution is another mandatory management condition to avoid deterioration. Further, management requires implementing respiratory support because Jenny was confronting breathing difficulties and norepinephrine warm shock to correct hypotension (lower blood pressure) avoiding cardiac arrest criticalness (Hart et al. 2014). Jenny should be shifted to ICU followed by a proper blood test to avoid deterioration.
Understanding patient condition and management recommendations
Identifying situational factors and point time where care was incorrect
The arrival of Jenny to the emergency department involved highlighted vital signs that were not properly monitored and no proper comprehensive assessment was performed related to these vital signs. Further, ED nurse didn’t even call emergency and neither added scoring to ADDS chart in the emergency department. Even the assessment session by the doctor in ED department missed orders or test related to vital signs clearly identified in the initial admission of Jenny to ED. Hence, Jenny’s vital signs got worsen with time till evening in the emergency department.
Further, ED nurses provided no clear plans or handover after Jenny’s transfer in the hospital ward at evening 6 o’clock. There was a missed bedside rounding after admission to ward at 1800 hr and staff performed no frequent observations. Further, staff failed to call for help or emergency even after continuous worsening of vital signs involving low blood pressure, increased respiratory rate a vomiting by Jenny in the night at 2320hr. The next day at 0242hr, Jenny faced breathing difficulties but no ventilator was provided to control this emergency condition.
The deterioration in Jenny’s case occurred due to situational factors where the emergency department of the hospital was full due to dehydration and electrolyte imbalance. Further, there was a shortage of staff in the hospital because the town was facing Gastroenteritis rife creating maximised sick leaves by hospital staff. Most of the implemented staff was having less than 3 years experience. Therefore, high workload, mismanagement, staff shortage and exhaustion created deterioration. There was failing in proper communication, teamwork and proper leadership approach. The nursing staff fails to perform proper recognition unable to use ADDS score chart, inadequate nursing skills and lacking experience.
Identifying Patient-complexities contributed to the outcome
Some of the patient complexities that contributed to the deterioration in Jenny’s case involved inadequate assessment performed by nursing staff followed by the improper handover of patient information from emergency department to the ward staff that highlights poor communication and documentation in hospital. Further, there was no family member of Jenny present all over the hospital admission process to report or identify the mismanagement in the handling of Jenny’s case. Even at the time of death, no family member of Jenny was present, the doctor called her mother after Jenny passed away on 4th August afternoon in the hospital.
Outlining Legal and ethical issues missed in case
Identifying situational factors and point time where care was incorrect
The ethical missed In Jenny’s case involved non-maleficence and beneficence. The ethics of beneficence instruct healthcare professional to benefit the patient in all possible manner and situation (McKenna et al. 2014). In Jenny’s case, healthcare professionals in their assessment, diagnosis, management and communication process missed ethic of beneficence. The professionals avoided various vital disease signs and symptoms that clearly highlighted the occurrence of the emergency condition. No oxygen support, ventilator and medications were administrated from Jenny’s complex conditions like breathing difficulties, low blood pressure, rashes etc.
Further, the ethical principle of non-maleficence is also missed in this case, which indicates that it is a primary duty of healthcare professional to ensure “no harm” to the patient. In this case, nursing staff mishandled Jenny (Jenny was allowed to use mobile), avoided emergency situations to call doctor, careless attitude in the ward observations etc. clearly highlight a miss in non-maleficence ethics.
Further, legal obligations, in this case, involve miss to Safe Patient Care Act 2015, National standard: 9 by NSQHS “Recognising and Responding to Clinical Deterioration in Acute Health Care” and NMBA standard 4 “Comprehensive conducts assessments” (Pocock, 2013). The hospital and professionals in Jenny’s case have missed all these legal practices implemented as a duty of conduct in their profession. They missed providing proper professional care to Jenny, followed by improper recognition and responding in the care process. Lastly, the patient assessments were either missed or improperly performed by the nurse in hospital confirming these legal obligations in Jenny’s case.
Recommendations for improvement in trigger points to reduce future errors in patient deterioration
As per conditions in the provided case study of Jenny, there is a requirement of proper management strategies and techniques to overcome issues triggering patient deterioration. According to Newman, Patterson & Clark (2015) studies, acute care hospitals in Australia are now confronting complex patient problems that require the special approach to handling with care. As per one survey, 4.5% patient in hospital meets clinical deterioration at some point or other. The present case of Jenny is also a clear case of patient deterioration leading to death. The trigger points leading to this situation of Jenny are lacking team-work, improper leadership, unskilled staff, negligence, improper communication and management in the hospital.
The most suitable form leadership strategy for the provided case study is implementing helicopter view phenomenon in the hospital (Barr & Dowding, 2015). According to Tume, Sefton & Arrowsmith (2014) studies the helicopter view in leadership is the most contemporary and advanced form of leadership strategy that works effectively in companies or structures having a huge human resource like hospitals, corporates, airlines etc. Newman, Patterson & Clark (2015) opine that with helicopter view leadership, one can get a view from different angles, aspects, structures and perspective to implement successful working of the organisation. In the present case of patient deterioration, there was a missing hold to the condition variable factors. No person or professional was answerable for the death of Jenny due to missing helicopter view in leadership. To overcome patient deterioration because of small issues it is required by the hospital to implement helicopter view leadership where one professional is responsible for delegating the task to staff members, implementing team plans, collecting information from staff, cross-checking and detecting emergency (Lavoie, Pepin & Alderson, 2016). This recommended leadership strategy works to address “Governance for safety and Quality in Health Service Organisations” standard by NSQHS. As per this standard, every organisation requires a specific management framework to ensure quality of the health service organisations ensuring safety.
Another recommendation suitable to manage patient deterioration case like Jenny is implementing “Track and trigger system”. This system is basically an early warning system constructed to support early clinical deterioration identification involving periodic vital signs measurement (tracking) and calling response or emergency help (triggering) when a marked threshold is identified in particular case (Romero-Brufau et al. 2014). There are four types of track and trigger system recommended by NICE in 2007 that are single parameter, multiple parameters, aggregate scoring and combination system. The implementation of the system depends on the clinical condition of the patient. In the present case, Jenny was having more than one disturbed vital sign, therefore, the track and trigger system suitable for this case is “Multiple parameter systems” because this system provides a response for more than one criterion to be met. The medical emergency team (MET) dealing with more than one parameter is called for help through this system (Simpson, 2016).
According to Romero-Brufau et al. (2014) studies, the single parameter system is generally used in the Australian hospitals and an aggregate scoring system is used in hospitals of the United Kingdom. But, Australian healthcare is working to upgrade its system to multiple and combination track and trigger system. Through the multiple and combination system, a core set of parameters like respiratory rate, pulse, blood pressure, temperature, oxygen saturation and urine output are easy to be measured at the same time allowing better control over patient deterioration. In the present case Jenny was facing an issue in more than one vital sign with low blood pressure, high respiratory rate and no urine output that required emergency call but due to the missing system the staff was not able to call for emergency help or are unaware about emergency calling system. Therefore, multiple track and trigger system can be considered a best recommendation to control patient deterioration. According to Bunkenborg et al. (2014) studies, this multiple track and trigger system is a part of NSQHS standard “Recognising and Responding to Clinical Deterioration” working to establish recognition and response system missing in the acute care process of Jenny.
Further, Tobiano et al. (2017) studied the use of communication tools in health care practices that work to escalate information between team members. One of the most successful communication tools controlling patient deterioration condition is RSVP (Reason, Story, Vital signs and Plan). This communication tool is designed for emergency and involves easy techniques to remember information allowing the appropriate call for an emergency at the appropriate time. RSVP communication tool is suitable for acute life-threatening event recognition and treatment (ALERT). The condition of Jenny can be considered as an ALERT condition because her blood pressure went very low with 24 hours of duration followed by difficulty breathing and cardiac arrest. Therefore, RSVP is a vital sign based communication tool that can help nursing staff to initiate proper communication getting emergency help in Jenny’s deterioration case.
Lastly, the situation factor of lacking experienced nursing staff that lead to deterioration of Jenny’s condition in the provided case can be overruled by providing a stand-alone course to nursing staff that is developed to enhance recognition, responding, communication and management of adult patients facing critical conditions (Hargestam et al. 2013). This course was first practised in Portsmouth Hospital, United Kingdom as a part of short and quick nursing education to staff handling emergency cases (Potter et al. 2016). In the provided case, the situational factor of work overload and lacking skilled staff can be overruled by providing this quick and short education to less experienced nursing staff. This staff education will help to overcome patient deterioration in case of medical emergency situations like Jenny’s case. These can be considered as some of the best recommendations to overcome reasons that developed deterioration situation for Jenny. These recommendations helicopter view leadership, track and trigger system, RSVP communication tool and staff education can help to avoid further patient deterioration in medical premises facing any such case as Jenny’s death.
Conclusion
A proper system of recognition and response is a mandatory requirement to control the patient deterioration condition allowing a proper system to handle critical illness, patient observations, and team communication and asking for help. The provided case about Jenny Renne Whyte is clearly a deterioration case occurred due to negligence by staff, improper communication, lacking skilled staff, missing leadership, recognition and response system within hospital along with various other situational factors that resulted in patient’s death. These issues in the patient handling also missed ethical and legal obligations of non-maleficence, beneficence ethics as well as National standard 9 & 4 provided by NSQHS.
The study involves identification of certain recommendations to get a control over such deterioration cases. The provided recommendations are as per issues identified in case of Jenny but these recommendations can be implemented in any case scenario avoiding the situation of patient deterioration. The recommendations involve helicopter view leadership, track and trigger system, RSVP communication tool and staff education to get a control over severe patient deterioration
References
Books
Barr, J., & Dowding, L. (2015). Leadership in health care. Sage.
Fayers, P. M., & Machin, D. (2013). Quality of life: the assessment, analysis and interpretation of patient-reported outcomes. John Wiley & Sons.
Pocock, S. J. (2013). Clinical trials: a practical approach. John Wiley & Sons.
Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing-E-Book. Elsevier Health Sciences.
Journals
Barker, M., Rushton, M., & Smith, J. (2015). How to assess deteriorating patients. Nursing Standard, 30(11), 34
Bunkenborg, G., Samuelson, K., Poulsen, I., Ladelund, S., & Åkeson, J. (2014). Lower incidence of unexpected in-hospital death after interprofessional implementation of a bedside track-and-trigger system. Resuscitation, 85(3), 424-430.
Campbell, H., Parikh, S. R., Borrow, R., Kaczmarski, E., Ramsay, M. E., & Ladhani, S. N. (2016). Presentation with gastrointestinal symptoms and high case fatality associated with group W meningococcal disease (MenW) in teenagers, England, July 2015 to January 2016. Eurosurveillance, 21(12).
Considine, J., & Currey, J. (2015). Ensuring a proactive, evidence?based, patient safety approach to patient assessment. Journal of Clinical Nursing, 24(1-2), 300-307.
Hargestam, M., Lindkvist, M., Brulin, C., Jacobsson, M., & Hultin, M. (2013). Communication in interdisciplinary teams: exploring closed-loop communication during in situ trauma team training. BMJ Open, 3(10), 1-8.
Hart, P. L., Brannan, J. D., Long, J. M., Maguire, M. B. R., Brooks, B. K., & Robley, L. R. (2014). Effectiveness of a structured curriculum focused on recognition and response to acute patient deterioration in an undergraduate BSN program. Nurse education in practice, 14(1), 30-36.
Lambe, K., Currey, J., & Considine, J. (2016). Frequency of vital sign assessment and clinical deterioration in an Australian emergency department. Australasian Emergency Nursing Journal, 19(4), 217-222.
Lavoie, P., Pepin, J., & Alderson, M. (2016). Defining patient deterioration through acute care and intensive care nurses’ perspectives. Nursing in critical care, 21(2), 68-77.
McKenna, L., Missen, K., Cooper, S., Bogossian, F., Bucknall, T., & Cant, R. (2014). Situation awareness in undergraduate nursing students managing simulated patient deterioration. Nurse Education Today, 34(6), e27-e31.
Mochizuki, K., Shintani, R., Mori, K., Sato, T., Sakaguchi, O., Takeshige, K.,Nitta, K., & Imamura, H. (2017). Importance of respiratory rate for the prediction of clinical deterioration after emergency department discharge: a single?center, case–control study. Acute Medicine & Surgery, 4(2), 172-178
Newman, C., Patterson, K., & Clark, G. (2015). Evaluation of a support and challenge framework for nursing managers in correctional and forensic health. Journal of nursing management, 23(1), 118-127.
Odell, M. (2015). Detection and management of the deteriorating ward patient: an evaluation of nursing practice. Journal of Clinical Nursing, 24(1-2), 173-182.
Osborne, S., Douglas, C., Reid, C., Jones, L., Gardner, G., & RBWH Patient Assessment Research Council. (2015). The primacy of vital signs – Acute care nurses’ and midwives’ use of physical assessment skills: A cross sectional study. International Journal of Nursing Studies, 52(5), 951-962.
Romero-Brufau, S., Huddleston, J. M., Naessens, J. M., Johnson, M. G., Hickman, J., Morlan, B. W., … & Morgenthaler, T. I. (2014). Widely used track and trigger scores: are they ready for automation in practice?. Resuscitation, 85(4), 549-552.
Simpson, E. (2016). In-hospital resuscitation: recognising and responding to adults in cardiac arrest. Nursing Standard (2014+), 30(51), 50.
Tobiano, G., Whitty, J.A., Bucknall, T., & Chaboyer, W. (2017). Nurses’ perceived barriers to bedside handover and their implication for clinical practice. Worldviews on Evidence-Based Nursing, 14(5), 343-349.
Trinkle, R. M., & Flabouris, A. (2011). Documenting Rapid Response System afferent limb failure and associated patient outcomes. Resuscitation, 82(7), 810-814.
Tume, L. N., Sefton, G., & Arrowsmith, P. (2014). Teaching paediatric ward teams to recognise and manage the deteriorating child. Nursing in critical care, 19(4), 196-203.
Order an Essay Now & Get These Features For Free:
Turnitin Report
Formatting
Title Page
Citation
Outline
