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The Medical Emergency Team (MET) has enhanced the recognition and response to clinical deterioration in acute healthcare. However, patients reviewed by the MET are at increased risk of in-hospital death. Identifying patients at risk of deterioration may improve patient outcomes. To identify patient demographic, medical characteristics and healthcare systems and processes at the time of admission (baseline), associated with Medical Emergency Team (MET) review within 48 h (MET-48 h) of admission. Single-site, year-long, retrospective cohort comprising patients admitted for at least 24 h, using routinely collected hospital data. A three-stage modelling approach was used to identify baseline factors associated with MET-48 h The study included 15,695 patients with mean age 62.1 years (SD 19.6), male (53.5%), born in Australia or New Zealand (60.9%) and 51.6% held a low-income concession card. A total of 4.3% of patients received a MET review within 48 h of admission. Variables independently associated with MET-48 h in a fully adjusted logistic model included age of 80 years or more (OR = 1.37); ≥3 previous emergency admissions (OR = 1.59); Charlson Comorbidity Index 1 or 2 (OR = 1.47), or ≥ 3 (OR = 1.99); history of alcohol-related behaviour concerns (OR = 2.04), chronic heart failure (OR = 1.48); chronic obstructive pulmonary disease (OR = 1.35); admission for colorectal (OR = 2.66) or upper gastro-intestinal (OR = 1.94) surgery, respiratory or tracheostomy (OR = 2.24); immunology and infections (OR = 1.90); emergency admission (OR = 1.36); admission at night (OR = 1.74), or summer (OR = 1.41) This is the first study to demonstrate the potential to predict clinical deterioration using data that is readily accessible at the time of admission to hospital. • At admission, patient diagnosis, comorbidities are associated with later MET review. • Charlson Score 1–2 or ≥ 3; 3+ prior emergency admissions; are important risk factors. • MET risk double in admissions for colorectal, respiratory, upper GI or infection. • Health system factors including time or season of admission associated with MET. • Associations similar for MET within 48 or 72 h of admission. [ABSTRACT FROM AUTHOR]

Background: Prescribing of recommended medications for heart failure (HF) is suboptimal, leaving patients at a high risk of death or rehospitalization post discharge. Nurse-led titration (NLT) clinics are one strategy that could potentially improve the prescription of these medications., Objective: The aim of this article was to determine the effect of NLT clinics on all-cause mortality, all-cause or HF rehospitalizations, and adverse effects in patients with HF., Methods: We searched MEDLINE, EMBASE, Cochrane CENTRAL, International Clinical Trials Registry Platform, and ClinicalTrials.gov to identify randomized controlled trials comparing NLT of β-blocking agents, angiotensin receptor-neprilysin inhibitors, angiotensin-converting enzyme inhibitors, and/or angiotensin receptor blockers to optimization by another health professional in patients with HF. We used the fixed-effects Mantel-Haenszel method or meta-analyses. We assessed heterogeneity between studies using χ 2 and I2 ., Results: Eight studies with 2025 participants were included. Participants in the NLT group experienced a lower rate of all-cause rehospitalizations (relative risk, 0.76, 95% confidence interval, 0.68-0.85; moderate quality of evidence) and less HF-related rehospitalizations (relative risk, 0.47; 95% confidence interval, 0.33-0.66; high quality of evidence) compared with the usual care group. All-cause mortality was lower in the NLT group (relative risk, 0.67; 95% confidence interval, 0.48-0.92; moderate quality of evidence) compared with the usual care group. Authors of one study reported no adverse events, and another study found one adverse event., Conclusion: This meta-analysis indicates that NLT clinics may improve optimization of guideline-recommended medications with the potential to reduce rehospitalization and improve survival in a cohort of patients known for their poor outcomes., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

There is mounting evidence that the pre-medical emergency team (pre-MET) of rapid response systems is underutilised in clinical practice due to suboptimal structures and processes and resource constraints. In this perspective article, we argue for examining the pre-MET through a 'Behaviour Change Wheel' lens to improve the pre-MET and maximise the associated patient safety benefits. Using pre-MET communication practices as an example, we illustrate the value of the COM-B model, where clinicians' 'capability', 'opportunity', and 'motivation' drive 'behaviour'. Optimising clinicians' behaviours and establishing failsafe rapid response systems is a complex undertaking; however, examining clinicians' behaviours through the COM-B model enables reframing barriers and facilitators to develop multifaceted and coordinated solutions that are behaviourally and theoretically based. The COM-B model is recommended to clinical governance leaders and health services researchers to explore the underlying causes of behaviour and successfully enact change in the design, implementation, and use of the pre-MET to improve patient safety.

Aim(s): To explore the published research related to nurses' documentation and use of vital signs in recognising and responding to deteriorating patients., Design: Scoping review of international, peer-reviewed research studies., Data Sources: Cumulative Index to Nursing and Allied Health Literature Complete, Medline Complete, American Psychological Association PsycInfo and Excerpta Medica were searched on 25 July 2023., Reporting Method: Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews., Results: Of 3880 potentially eligible publications, 32 were included. There were 26 studies of nurses' vital sign documentation: 21 adults and five paediatric. The most and least frequently documented vital signs were blood pressure and respiratory rate respectively. Seven studies focused on vital signs and rapid response activation or afferent limb failure. Five studies of vital signs used to trigger the rapid response system showed heart rate was the most frequent and respiratory rate and conscious state were the least frequent. Heart rate was least likely and oxygen saturation was most likely to be associated with afferent limb failure (n = 4 studies)., Conclusion: Despite high reliance on using vital signs to recognise clinical deterioration and activate a response to deteriorating patients in hospital settings, nurses' documentation of vital signs and use of vital signs to activate rapid response systems is poorly understood. There were 21studies of nurses' vital sign documentation in adult patients and five studies related to children., Implications for the Profession And/or Patient Care: A deeper understanding of nurses' decisions to assess (or not assess) specific vital signs, analysis of the value or importance nurses place (or not) on specific vital sign parameters is warranted. The influence of patient characteristics (such as age) or the clinical practice setting, and the impact of nurses' workflows of vital sign assessment warrants further investigation., Patient or Public Contribution: No Patient or Public Contribution., (© 2024 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

Aim: To explore nurses' perceptions of using point-of-care ultrasound for assessment and guided cannulation in the haemodialysis setting., Background: Cannulation of arteriovenous fistulae is necessary to perform haemodialysis. Damage to the arteriovenous fistula is a frequent complication, resulting in poor patient outcomes and increased healthcare costs. Point-of-care ultrasound-guided cannulation can reduce the risk of such damage and mitigate further vessel deterioration. Understanding nurses' perceptions of using this adjunct tool will inform its future implementation into haemodialysis practice., Design: Descriptive qualitative study., Methods: Registered nurses were recruited from one 16-chair regional Australian haemodialysis clinic. Eligible nurses were drawn from a larger study investigating the feasibility of implementing point-of-care ultrasound in haemodialysis. Participants attended a semistructured one-on-one interview where they were asked about their experiences with, and perceptions of, point-of-care ultrasound use in haemodialysis cannulation. Audio-recorded data were transcribed and inductively analysed., Findings: Seven of nine nurses who completed the larger study participated in a semistructured interview. All participants were female with a median age of 54 years (and had postgraduate renal qualifications. Themes identified were as follows: (1) barriers to use of ultrasound; (2) deficit and benefit recognition; (3) cognitive and psychomotor development; and (4) practice makes perfect. Information identified within these themes were that nurses perceived that their experience with point-of-care ultrasound was beneficial but recommended against its use for every cannulation. The more practice nurses had with point-of-care ultrasound, the more their confidence, dexterity and time management improved., Conclusions: Nurses perceived that using point-of-care ultrasound was a positive adjunct to their cannulation practice and provided beneficial outcomes for patients., Implications for the Profession And/or Patient Care: Haemodialysis clinics seeking to implement point-of-care ultrasound to help improve cannulation outcomes may draw on these findings when embarking on this practice change., Reporting Method: This study is reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ)., Patient or Public Contribution: Patients were not directly involved in this part of the study; however, they were involved in the implementation study., Trial and Protocol Registration: The larger study was registered with Australian New Zealand Clinical Trials Registry: ACTRN12617001569392 (21/11/2017) https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373963&isReview=true., (© 2023 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

Background: The pre-medical emergency team (pre-MET) tier of rapid response systems facilitates early recognition and treatment of deteriorating ward patients using ward-based clinicians before a MET review is needed. However, there is growing concern that the pre-MET tier is inconsistently used., Objective: This study aimed to explore clinicians' use of the pre-MET tier., Methods: A sequential mixed-methods design was used. Participants were clinicians (nurses, allied health, doctors) caring for patients on two wards of one Australian hospital. Observations and medical record audits were conducted to identify pre-MET events and examine clinicians' use of the pre-MET tier as per hospital policy. Clinician interviews expanded on understandings gained from observation data. Descriptive and thematic analyses were performed., Results: Observations identified 27 pre-MET events for 24 patients that involved 37 clinicians (nurses = 24, speech pathologist = 1, doctors = 12). Nurses initiated assessments or interventions for 92.6% (n = 25/27) of pre-MET events; however, only 51.9% (n = 14/27) of pre-MET events were escalated to doctors. Doctors attended pre-MET reviews for 64.3% (n = 9/14) of escalated pre-MET events. Median time between escalation of care and in-person pre-MET review was 30 min (interquartile range: 8-36). Policy-specified clinical documentation was partially completed for 35.7% (n = 5/14) of escalated pre-MET events. Thirty-two interviews with 29 clinicians (nurses = 18, physiotherapists = 4, doctors = 7) culminated in three themes: Early Deterioration on a Spectrum, A Safety Net, and Demands Versus Resources., Conclusions: There were multiple gaps between pre-MET policy and clinicians' use of the pre-MET tier. To optimise use of the pre-MET tier, pre-MET policy must be critically reviewed and system-based barriers to recognising and responding to pre-MET deterioration addressed., (Copyright © 2023 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Standard cannulation practice for hemodialysis consists of inserting needles "blindly" through skin into an arteriovenous fistula (AVF), which is more likely to cause damage. Point-of-care ultrasound (POCUS) guided cannulation has potential for less damage; however, efficacy of this technique has not been explored. Our purpose was to test the feasibility and effectiveness of POCUS guidance for cannulation of AVFs in hemodialysis patients., Methods: A random-order crossover research design was used; patients and nurses acted as their own control. Sample included 13 patients with functioning AVFs and 9 nurses, recruited from a single hemodialysis center. All nurses cannulated all patients using standard and POCUS-guided cannulation. Data were collected at each cannulation (time taken, nurse position, probe direction, pressures, patient satisfaction, pain scores). Ultrasound images of needle position were collected from which needle tip locations inside vessels were measured. Nurses were surveyed at three timepoints and were interviewed at conclusion of data collection. Analysis involved linear mixed-models for clinical data, descriptive statistics for binary and feasibility data, and content analysis for interview data., Results: Eleven patients and seven nurses completed. Protocol adherence was 94.4%. Two miscannulations occurred, both during standard cannulation. Cannulation time using POCUS guidance was significantly higher than standard cannulation ( p  = 0.008, 95% CI 39-166). All other variables showed no statistically significant difference. Content analysis of interview data showed cultural shift toward use of POCUS; nurses gained confidence and become more proficient in their POCUS technique., Conclusions: Random-order crossover is a feasible design to measure differences in POCUS-guided and standard cannulation. It is also feasible to implement POCUS into hemodialysis centers and whilst POCUS guidance takes longer, nurses become more proficient, and confident with persistent use., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective To explore clinicians' use and perceptions of interdisciplinary communication pathways for escalating care within the pre-medical emergency team (pre-MET) tier of rapid response systems. Method A sequential mixed-methods study was conducted using observations and interviews. Participants were clinicians (nurses, allied health, doctors) caring for orthopaedic and general medicine patients at one hospital. Descriptive and thematic analyses were conducted. Results Escalation practices were observed for 13 of 27 pre-MET events. Leading communication methods for escalating pre-MET events were alphanumeric pagers (61.5%) and in-person discussions (30.8%). Seven escalated pre-MET events led to bedside pre-MET reviews by doctors. Clinician interviews (n  = 29) culminated in two themes: challenges in escalation of care, and navigating information gaps. Clinicians reported deficiencies in communication methods for escalating care that hindered interdisciplinary communication and clinical decision-making pertaining to pre-MET deterioration. Conclusion Policy-defined escalation pathways were inconsistently utilised for pre-MET deterioration. Available communication methods for escalating pre-MET events inadequately fulfilled clinicians' needs. Variable perceptions of escalation pathways illuminated a lack of of a shared mental model about clinicians' roles and responsibilities. To optimise timely and appropriate management of patient deterioration, communication infrastructure and interdisciplinary collaboration must be enhanced.

Objective: Evaluate the feasibility and acceptability of an online guided self-determination (GSD) program to improve diabetes self-management skills among young adults with type 1 diabetes (YAD)., Methods: An online program comprising seven structured interactive conversations was designed. A pre- and post- interventional study used a sequential, two-phase multiple method design. Phase one comprised a training program for diabetes educators (DEs). In Phase two YAD participated in program and completed pre- and post-surveys assessing motivation to self-manage, perceived competence in diabetes and communication with DEs. Both YAD and DEs provided a program evaluation., Results: The online GSD program was acceptable, feasible and effective in improving autonomous motivation in self-management and communication with DEs. Easy access and program flexibility were highly appreciated by both participant groups and perceived to assist YAD to stay motivated., Conclusion: The program had a significant impact on the diabetes self-management of YAD and was a feasible and acceptable way to engage and communicate with DEs. The GSD platform contributes to age appropriate and person-centred diabetes self-management. It can potentially reach geographically distanced populations, or with social circumstances or other barriers impeding in-person service provision., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Background: For over a decade, patients experiencing clinical deterioration have been attended to by specialised nurses, the most senior of which are intensive care unit liaison nurses (ICU LNs) or critical care outreach nurses. These roles have evolved without consistent and formal recognised educational preparation. To continue to advance patient safety, an understanding of the educational requirements for these vital roles is required., Aim: The aim of this study was to ascertain nurses' perceptions of the curriculum required to perform the roles of ICU LNs or critical care outreach nurses within an acute care sector rapid response system., Methods: An exploratory descriptive study was conducted at an international rapid response system conference in 2016 following ethics approval. Using convenience sampling, extended response surveys were completed by nurses with rapid response system leadership experience and roles. Data were analysed using content analysis according to a priori themes of theoretical knowledge, skills, and attributes., Results: Seventy-seven registered nurses volunteered to take part in the study, forming 14 groups, each with four to seven members. Participants identified key concepts for desired theoretical knowledge, practical skills, and personal attributes. Professional behaviours were more frequently emphasised than theoretical knowledge or practical skills, suggesting personal attributes were highly valued in these leadership roles., Conclusions: A curriculum designed to prepare patient safety leadership roles of the ICU LN or critical care outreach nurse has been identified. These findings can inform the development of postgraduate courses and training requirements, along with position descriptions and expectations of employers regarding the skill set expected in these leadership roles., (Copyright © 2021 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Coronavirus disease 2019 (COVID-19) has again highlighted the crucial role of healthcare workers in case management, disease surveillance, policy development, and healthcare education and training. The ongoing pandemic demonstrates the importance of having an emergency response plan that accounts for the safety of frontline healthcare workers, including those working in critical care settings., Objectives: The aim of the study was to explore Australian critical care nurses' knowledge, preparedness, and experiences of managing patients diagnosed with severe acute respiratory syndrome coronavirus 2 infection (SARS-CoV-2) and COVID-19., Methods: An exploratory cross-sectional study of Australian critical care nurses was conducted between June and September 2020. An anonymised online survey was sent to Australian College of Critical Care Nurses' members to collect information about their knowledge, preparedness, and experiences during the COVID-19 pandemic. Descriptive statistics were used to summarise and report data., Results: A total of 157 critical care nurses participated, with 138 fully complete surveys analysed. Most respondents reported 'good' to 'very good' level of knowledge about COVID-19 and obtained up-to-date COVID-19 information from international and local sources. Regarding managing patients with COVID-19, 82.3% felt sufficiently prepared at the time of data collection, and 93.4% had received specific education, training, or instruction. Most participants were involved in assessing (89.3%) and treating (92.4%) patients with COVID-19. Varying levels of concerns about SARS-CoV-2 infection were expressed by respondents, and 55.7% thought the pandemic had increased their workload. The most frequent concerns expressed by participants were a lack of appropriate personal protective equipment (PPE) and fear of PPE shortage., Conclusions: While most nurses expressed sufficient preparedness for managing COVID-19 patients, specific education had been undertaken and experiential learning was evident. Fears of insufficient or lack of appropriate PPE made the response more difficult for nurses and the community. Preparedness and responsiveness are critical to successful management of the COVID-19 pandemic and future outbreaks of emerging infectious diseases., Competing Interests: Conflict of interest The authors have no conflict of interest to declare., (Copyright © 2021 Australian College of Critical Care Nurses Ltd. All rights reserved.)

Background: Medical emergency team (MET) activation criteria are sometimes modified to minimise unnecessary MET calls in patients who have chronic physiological derangements, have limitation of medical treatment orders in place, or have recently received treatment for clinical deterioration. However, the safety implications of modifying MET activation criteria are poorly understood., Objectives: The aim of the study was to examine the safety of modifying MET activation criteria. Specifically, we aimed to examine the frequency and nature of modifications to MET activation criteria and compare characteristics and outcomes of patients with and without modifications to MET activation criteria., Methods: This was a point prevalence study using a retrospective medical record audit. Patients admitted to 14 wards on November 7, 2018, at two acute-care hospitals of one health service in Melbourne, Australia, were included (N = 430). Data were analysed using descriptive and inferential statistics. The main outcome measures included frequency and nature of modifications to MET activation criteria on a specified date, MET calls, intensive care unit admission, in-hospital cardiac arrest, and in-hospital death., Results: Amongst 430 inpatients, there were 30 modifications to MET activation criteria in 26 (6.0%) patients. All modifications were intended to trigger METs at more extreme levels of physiological derangement. Most modifications pertained to tachypnoea (26.7%; n = 8/30) and bradycardia (23.3%; n = 7/30). Patients with modifications were more likely to have documented physiological deterioration that fulfilled MET (47.8%, n = 11; p < 0.001) or pre-MET (87.0%, n = 20; p < 0.001) criteria in the preceding 24-h period than patients without modifications. Of patients with modifications, none were admitted to an intensive care unit, had a cardiac arrest, or died in the hospital. There were no differences in hospital length of stay or discharge destination between patients with and without modifications., Conclusions: In this point prevalence study, modifications to MET activation criteria were infrequent and not associated with negative patient safety outcomes., Competing Interests: Conflict of Interest None., (Copyright © 2021 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: The pre-medical emergency team (pre-MET) tier of rapid response systems (RRSs) includes extended activation criteria to identify earlier clinical deterioration and a ward-based patient review that is undertaken by the affected patient's admitting team or covering doctors. There is limited understanding of the structure and processes of the pre-MET RRS tier that are expected to guide clinicians' actions and subsequent patient safety outcomes., Objective: The aim of the study was to describe the structure and processes of the pre-MET RRS tier in one acute care setting., Methods: An exploratory descriptive design involving document analysis was used. Guidance documents (policies, procedures, guidelines, charts, educational materials) were obtained from one health service with a mature, multitiered RRS in Melbourne, Australia. Documents were analysed using content analysis. Concept- and data-driven approaches were used to construct a coding frame., Results: Nineteen guidance documents supporting the pre-MET RRS tier on general wards were analysed. The coding frame consisted of seven main categories: Defining the Pre-MET RRS Tier, Essential Resources for Operationalisation, Recognising Pre-MET Events, Pathways for Activation, Exceptions to the Rule, Clinician Responses to Pre-MET Events, and Recording Pre-MET Events. The structures and processes of the pre-MET RRS tier were largely consistent with national guidelines, but there were internal inconsistencies in pre-MET activation criteria and unclear recommendations for modifying criteria. Pathways for activating the pre-MET RRS tier were complex and involved many steps, including validation processes before escalation of care to doctors. Responses to pre-MET events were seldom aligned to specific clinician types or groups, with nurses and allied health clinicians being under-represented., Conclusions: We identified opportunities to improve guidance documents supporting the pre-MET RRS tier that may assist other health services engaged in planning or evaluating pre-MET strategies. Further research is needed to understand clinicians' use of the pre-MET RRS tier to inform targeted strategies to optimise its design and implementation., (Copyright © 2020 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Team-based learning (TBL) is an evidence-based, highly structured teaching strategy., Purpose: The purpose of this review was to explore the specific TBL structure and process design elements reported in nursing education studies., Methods: A scoping review was undertaken according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. Databases were searched on February 15, 2021, using search terms related to nursing, education, and TBL., Results: Of 226 potentially relevant citations, 45 studies were included. The specific TBL design elements reported were team size (n = 41), team formation (n = 24), readiness assurance process (n = 45), immediate feedback (n = 42), activity sequencing (n = 42), 4S application design (n = 13), incentive structure(s) (n = 22), and peer evaluation (n = 13)., Conclusions: There was variability in the reporting of TBL design elements. Preclass preparation and individual and team Readiness Assurance Tests were well reported. Application exercise design and approach to peer evaluation were gaps in the included studies., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The aim of this review was to explore use of the pre-Medical Emergency Team (pre-MET) tier of Rapid Response Systems to recognise and respond to adult ward patients experiencing early clinical deterioration., Methods: A scoping review of studies published in English reporting on use of a pre-MET tier in adult ward patients was conducted. Three databases were searched (Medline, CINAHL, EMBASE) for studies published between January 1995 and September 2020. Two researchers independently performed screening and quality assessments. Findings were synthesised thematically. Reporting of the review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews., Results: Six of 1669 studies were included in this review. All were single-site studies of single-parameter Rapid Response Systems in Australian hospitals. Five were quantitative studies; one had a qualitative design. Studies fulfilled 50-100% of quality criteria. Two themes were constructed: Afferent processes - Recognising and escalating pre-MET events; and Efferent processes - Pre-MET reviews and associated interventions. There was disparity between clinical practice and pre-MET escalation protocols, and reports of nurse-initiated management of early deterioration. Prospective methods and exploration of multidisciplinary perspectives were notable research gaps., Conclusion: Use of the pre-MET tier of Rapid Response Systems is under-researched. Further research is needed to understand barriers and facilitators influencing use of pre-MET strategies to address patient deterioration., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Clinical leadership is fundamental to patient safety. The Emergency Department (ED) nurse-in-charge is a key leadership role; however, few studies have explored the management of clinical deterioration from the ED nurse-in-charge perspective. The aim of this study was to explore ED nurses-in-charge' perceptions of their role in responding to episodes of escalation of care for clinical deterioration of ED patients., Methods: A prospective exploratory descriptive design was used to address the study aims. The study was conducted in an urban ED in Melbourne, Australia. Senior emergency nurses who fulfilled the role of being in charge of the ED were invited to participate. In-depth semi-structured interviews were conducted between December 2015 and March 2016. Interview transcripts were analysed using thematic analysis., Results: Two major themes, each with two subthemes were identified. The first major theme of Clinical Risk Management comprised sub-themes of Clinical Skills and Confidence. The second major theme of Resource Management comprised sub-themes of Human Resource Management and Logistical Resource Management., Conclusions: Strong collaboration, logistical and clinical risk management roles were perceived as fundamental to the nurse-in-charge's capacity to respond to escalations of care for clinical deterioration within in a complex team environment such as the ED., (Copyright © 2020 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.)

Background: In-hospital adverse events such as cardiac arrest are preceded by abnormalities in physiological data and are associated with high mortality. Healthcare institutions have implemented rapid response systems such as the medical emergency team for early recognition and response to clinical deterioration. Yet, most cardiac catheterisation laboratories, have yet to formally implement a rapid response system, so the nature and frequency of clinical deterioration is unclear and no published data exist., Objectives: To explore the nature and frequency of clinical deterioration in ST- elevation myocardial infarction patients in a cardiac catheterisation laboratory without a Medical emergency team, and 24 hours after percutaneous coronary intervention and the immediate nursing responses to clinical deterioration., Method: An exploratory descriptive study using retrospective medical audit was conducted in a public tertiary teaching hospital in Melbourne, Australia. In 2014, there were 327 ST- elevation myocardial infarction presentations of which 75 were randomly selected. Descriptive statistics were used to analyse the data., Results: In the cardiac catheterisation laboratory, 82.6% of patients fulfilled medical emergency team activation criteria and deterioration was predominantly cardiovascular. Respiratory rate was not documented for all patients in cardiac catheterisation laboratory. Post percutaneous coronary intervention, 31% of patients fulfilled medical emergency team activation criteria and this deterioration occurred secondary to hypoxia. There were no documented abnormalities in respiratory rate., Conclusion: The ST- elevation myocardial infarction patients admitted to the cardiac catheterisation laboratory are critically ill patients. Failure to monitor for signs of respiratory dysfunction such as respiratory rate in cardiac catheterisation laboratory may delay recognition of clinical deterioration and timely escalation of care. Further research is required to inform changes in the system to improve patient safety., Competing Interests: Declaration of competing interests The authors declare that there is no conflict of interest., (Copyright © 2020 Australian College of Critical Care Nurses Ltd. All rights reserved.)

Background: Patients presenting to the cardiac catheter laboratory for treatment of unstable acute coronary syndromes (ACS) experience a mismatch in myocardial oxygen supply and demand, causing vital sign abnormalities prior to neurological, cardiac and respiratory deterioration. Delays in detecting clinical deterioration and escalating care increases risk of adverse events, unplanned intensive care (ICU) admission, cardiac arrest, and in-hospital mortality., Objectives: The objective of the study was to explore how nurses in the cardiac catheter laboratory (CCL) recognise and respond to clinical deterioration in patients with unstable ACS undergoing primary percutaneous coronary intervention (PCI)., Methods: A prospective exploratory descriptive design was used with 30 participants completing 10 written clinical scenarios. Participants scored their level of concern for each physiological cue and then then ranked their preferred immediate response based on the deterioration identified., Results: Hypotension and the presence of pain were the physiological cues of highest concern. The most common responses to clinical deterioration were to increase vital sign assessment to 5-minutely intervals, administer pain relief or provide reassurance. Despite the presence of clinical deterioration fulfilling organisational escalation of care criteria, calling cardiac arrest or rapid response team (RRT) were not commonly selected responses., Conclusion: Nurses most commonly use hypotension and the presence of pain to recognise clinical deterioration in patients presenting to the CCL with an unstable ACS. Once clinical deterioration is identified, interventional cardiac nurses delay the escalation of care to the RRT or cardiac arrest team, preferring to implement local nurse initiated interventions., (Copyright © 2018 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Improving the timely recognition and response to clinical deterioration is a critical challenge for clinicians, educators, administrators and researchers. Clinical deterioration leading to Rapid Response Team review is associated with poor patient outcomes. A range of factors associated with clinical deterioration and its outcomes have been identified, and may help with early identification of deteriorating patients. However, the relative importance of each factor on the development of clinical deterioration is unknown., Objective: To identify the relative importance of factors contributing to the development of clinical deterioration in ward patients, as perceived by health professionals who have experience in recognising or responding to clinical deterioration, or in the management, administration or governance of RRSs., Methods: A written questionnaire containing 12 pre-determined factors was provided to participants. Participants were asked to rank the items from most to least important contributors to ward patient deterioration. The study took place during a session of the Australia and New Zealand Intensive Care Society Rapid Response Team conference., Results: A final sample of 233 (83% response rate), returned the questionnaire. The sample comprised specialist ICU registered nurses with direct patient contact (64%), ICU consultant doctors (17%), ICU nurse managers (7%), hospital administrators (2%), ICU registrars (2%), quality coordinators (2%) and non-hospital staff (4%). The patient's presenting illness/main diagnosis was the highest ranked factor, followed by pre-existing co-morbidities, seniority of nursing ward staff, medical documentation, senior medical staff, and interdisciplinary communication. Almost two-thirds of participants ranked patient characteristics as the most important contributor to clinical deterioration., Conclusion: Health professionals who have experience in recognising or responding to clinical deterioration, or in the management, administration or governance of RRSs perceive that patient characteristics such as the patient's primary diagnosis and comorbidities to be the most important contributors to clinical deterioration., (Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.)

Introduction: Critical care nurses have been involved in Rapid Response Teams since their inception, particularly in medically led RRTs, known as Medical Emergency Teams. It is assumed that critical care skills are required to escalate care for the deteriorating ward patient. However, evidence to support critical care nurses' involvement in METs is anecdotal. Currently, little is known about the educational requirements for nurses involved in RRT or METs., Objectives: We aimed to identify and describe what nurses involved in a MET consider the most vital areas of knowledge and skill when delivering care to the deteriorating ward patient., Methods: An exploratory descriptive design was used and data was collected at a session of the Australian and New Zealand Intensive Care Society Rapid Response Team (ANZICS-RRT) Conference held at The Gold Coast, Australia in July 2015. All conference delegates were eligible to take part. Conference delegates totalled 293; 194 nurses, 89 doctors and 10 allied health professionals. Data collection took place in three phases, over a 90-minute period. First, demographic data were collected from all participants at the start of data collection. These data were collected using paper-based surveys. Second, extended response surveys; that is, paper-based surveys that asked open-ended questions to elicit free text responses, were used to collect participants' individual responses to the question: "What are the specific theoretical knowledge, skills and behavioural attributes required in a curricula to prepare nurses to be high functioning members of a MET?" Demographic, educational and work characteristics were descriptively analysed using SPSS (version 22). Participants perceptions of what knowledge, skills and attributes are required for nurses to recognise and respond to clinical deterioration were thematically analysed., Results: Participants were predominantly female (88.3%, n = 91) with 54.4% (n = 56) holding a Bachelor of Nursing. Participants had a median of 20 years (IQR 16) experience as RNs, and a median of 14 years (IQR 13) experience in critical care. Participants formed part of METs frequently, with nearly half the cohort seeing clinically deteriorating patients more than once per day (37.9%, n = 33) or daily (10%, n = 9). Thematic analysis of survey responses revealed four main themes desired in Rapid Response Team Curricula: Clinical Deterioration Theory, Clinical Deterioration Skills, Rapid Response System Governance, and Professionalism and Teamwork., Conclusions: We suggest that a curriculum that educates nurses on the specific requirements of assessing, managing and evaluating all aspects of clinical deterioration is now required., (Crown Copyright © 2018. Published by Elsevier Ltd. All rights reserved.)

Background: Recognising and responding to clinical deterioration is a safety priority. The aim of this study was to determine the frequency, nature, and response of emergency department Nursing Shift Leaders to episodes of escalation of care for patient clinical deterioration., Methods: A prospective exploratory descriptive design was used. Participants were recruited from the senior nurses at the study site that fulfilled the role of being in charge of the ED. Study data were collected between 29 October and 17 December 2015 across various shifts using an observation tool developed specifically for this study., Results: This study had three major findings. First, escalation of care for clinically deteriorating patients to the Nursing Shift Leader occurs frequently. There were 37 observed escalations of care, equating to 1.02 episodes per hour. Second, Nursing Shift Leaders rely on clinical emergency nursing skills to recognise, prioritise and respond to escalation of care for clinically deteriorating patients. Finally, the Nursing Shift Leaders' role in responding to escalation of care for clinical deterioration is multifaceted., Conclusions: The Nursing Shift Leaders' role in responding to escalation of care for clinical deterioration is complex and includes navigation of a multifaceted team environment and logistical challenges unique to the time pressured, unpredictable ED milieu., (Copyright © 2018 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.)

Objective: To reduce radial arterial catheter failure in patients admitted to an adult intensive care unit (ICU)., Design: A randomised controlled trial., Setting: A single site, large metropolitan tertiary referral public hospital., Participants: Three hundred participants admitted to an adult ICU were enrolled between 25 May and 13 September 2015., Interventions: Participants were randomly assigned to one of two treatment groups (a polyurethane adhesive keyhole dressing or a polyurethane adhesive keyhole dressing together with a polyurethane semipermeable transparent dressing)., Main Outcome Measure: Arterial catheter failure., Results: Data were complete for 289 of the 300 adult participants, who were randomised to one of the two groups. There were 179 men (62%) with a median age of 61 years (IQR, 48-74). Overall, there were 109 arterial catheter failures (38%). There was a significantly higher catheter failure rate in the usual care group (65, 60%) compared with the intervention group (44, 40%; P = 0.05). Accidental catheter removal occurred in 87% of cases (n = 27) in the usual care group and in 13% of cases (n = 4) in the intervention group (P = 0.05). There was no significant difference between the two groups for time to catheter failure (P = 0.06). However, if patients were sedated, they were 54% less likely to experience arterial catheter failure (OR, 0.46; 95% CI, 0.31-0.67; P < 0.0001)., Conclusion: This study showed a statistically significant reduction in arterial catheter failure using a radial arterial catheter dressing of a polyurethane adhesive keyhole dressing together with a polyurethane semipermeable transparent dressing. The nursing care technique of applying this dressing may improve dressing efficacy and patient safety and reduced costs.

Background: The introduction of rapid response systems has reduced the incidence of in-hospital cardiac arrest; however, many instances of clinical deterioration are unrecognised. Afferent limb failure is common and may be associated with unplanned intensive care admissions, heightened mortality and prolonged length of stay. Patients reviewed by a Medical Emergency Team are inherently vulnerable with a high in-hospital mortality., Objective: To explore perceptions of intensive care unit (ICU) staff who attend deteriorating acute care ward patients regarding current problems, barriers and potential solutions to recognising and responding to clinical deterioration that culminates in a Medical Emergency Team review., Methods: A descriptive exploratory design was used. Registered intensive care nurses and medical staff (N=207) were recruited during a professional conference using purposive sampling for experience in attending deteriorating patients. Written response surveys were used to address the study aim. Data were analysed using content analysis., Results: Four major themes were identified: Governance, Teamwork, Clinical Care Delivery and End of Life Care. Participants perceived there was a lack of sufficient and senior staff with the required theoretical knowledge; and inadequate assessment and critical thinking skills for anticipating, recognising and responding to clinical deterioration. Senior doctors were perceived to inappropriately manage End of Life Care issues and displayed Teamwork behaviours rendering ward clinicians feeling fearful and intimidated. A lack of System and Clinical Governance hindered identification of clinical deterioration., Conclusions: To improve patient safety related to recognising and responding to clinical deterioration, suboptimal care due to professionals' knowledge, skills and behaviours need addressing, along with End of Life Care and Governance., (Copyright © 2017 Australian College of Critical Care Nurses Ltd. All rights reserved.)

Background: The study aim was to explore the systems for recognising and responding to clinical deterioration in adult and paediatric Victorian emergency department (ED) patients after their initial triage assessment., Methods: A survey of Victorian EDs was conducted. Senior ED nursing staff was asked about ED characteristics, vital sign documentation, systems for recognising and responding to deteriorating ED patients, quality assurance and governance of ED rapid response systems (RRSs)., Results: Sixteen EDs participated (17 metropolitan and 13 regional or rural) giving a response rate of 53.3% (16/30). The organisational definition of a deteriorating patient applied to the ED at 50% of sites (n=8). Vital sign documentation was paper-based (43.6%), electronic (37.6%) or a combination (18.8%) of both. The majority of EDs (87.5%, n=14) had an ED RRS; 50% had one tier, single trigger RRS and 31.3% of EDs had a two tier, single trigger RRS. At 68.8% of sites the ED RRS activation criteria were the same as ward MET (medical emergency team) activation criteria. The most common method of escalation of care for deteriorating ED patients were face-to-face communication (87.5%) and overhead announcements within the ED (68.8%). The ED rapid response team (RRT) was composed of ED specific staff in 50.5% of sites, and staff external to the ED at 12.5% of sites. Two thirds of sites (68.7%) collected data about clinical deterioration in ED patients., Conclusions: Most EDs had an RRS but there was variability in activation criteria and members of the responding team both between EDs, and between ED and the ward RRSs., (Copyright © 2018 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.)

Team-Based Learning (TBL) is a teaching strategy designed to promote problem solving, critical thinking and effective teamwork and communication skills; attributes essential for safe healthcare. The aim was to explore postgraduate student perceptions of the role of TBL in shaping learning style, team skills, and professional and clinical behaviours. An exploratory descriptive approach was selected. Critical care students were invited to provide consent for the use for research purposes of written reflections submitted for course work requirements. Reflections of whether and how TBL influenced their learning style, teamwork skills and professional behaviours during classroom learning and clinical practice were analysed for content and themes. Of 174 students, 159 participated. Analysis revealed three themes: Deep Learning, the adaptations students made to their learning that resulted in mastery of specialist knowledge; Confidence, in knowledge, problem solving and rationales for practice decisions; and Professional and Clinical Behaviours, including positive changes in their interactions with colleagues and patients described as patient advocacy, multidisciplinary communication skills and peer mentorship. TBL facilitated a virtuous cycle of feedback encouraging deep learning that increased confidence. Increased confidence improved deep learning that, in turn, led to the development of professional and clinical behaviours characteristic of high quality practice., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objectives: To investigate the frequency, characteristics and timing of objectively measured clinical instability in adult ward patients in the 24 hours preceding activation of the medical emergency team (MET). We also examined ward clinician responses to documented clinical instability., Design, Setting and Participants: A descriptive, exploratory design with a retrospective medical record audit. We descriptively analysed data from 200 ward patients reviewed by the MET at a tertiary teaching hospital in Melbourne, Australia, during 2014., Main Outcome Measures: Frequency and characteristics of urgent clinical review (UCR) criteria breaches in the 24 hours preceding MET activation, and in-hospital mortality., Results: Overall, 78.5% of patients breached UCR criteria at least once in the 24 hours preceding MET activation, with 80.9% having multiple breaches. The most common causes of UCR criteria breaches were hypoxaemia without supplemental oxygen (27.4%, n = 43) and hypoxaemia with supplemental oxygen (21.7%, n = 34) for first UCR criteria breaches, and tachycardia (33.1%, n = 42) for last UCR criteria breaches during the 24 hours we examined. The median time before MET activation for first and last breaches was 17.1 hours and 1.2 hours, respectively. Examination of the clinician documentation suggested a high incidence of pre-MET activation afferent limb failure. In-hospital mortality was 12%., Conclusions: Patients commonly and repeatedly breached objectively measured UCR criteria in the 24 hours preceding MET activation, providing numerous opportunities for clinicians to recognise and respond to early clinical deterioration. The high incidence of pre- MET afferent limb failure requires further exploration.

Background: Understanding of clinical deterioration of emergency department patients is rapidly evolving. The aim of this study was to investigate the frequency and nature of vital sign collection and clinical deterioration in emergency care., Methods: A descriptive exploratory approach was used. Data were collected from the records of 200 randomly selected adults with presenting complaints of abdominal pain, shortness of breath, chest pain and febrile illness from 1 January to 31 December 2014 at a 22 bed emergency department in Melbourne, Australia., Results: When controlled for length of stay, heart rate was the most frequently assessed vital sign per hour (median=0.9) whilst Glasgow Coma Score was the least frequently assessed vital sign per hour (median=0.5). Clinical deterioration (one or more vital signs fulfilling hospital medical emergency team activation criteria during emergency department care) occurred in 14.5% of patients. Of the 5466 vital sign measures, 19.6% were abnormal, 1.9% indicated clinical deterioration., Conclusions: Clinical deterioration occurred in one in seven patients, and one in five vital signs documented were outside of accepted normal ranges. Thus, emergency department physiological status has implications for patient safety and nursing practice, in particular clinical handover for patients requiring hospital admission., (Copyright © 2016 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.)

Background: The nature of acute clinical deterioration has changed over the last three decades with a decrease in in-hospital cardiac arrests and an increase in acute clinical deterioration. Despite this change, research related to family presence continues to focus on care during resuscitation rather than during acute deterioration., Aim: To explore healthcare clinician attitudes, beliefs and perceptions of current practices surrounding family presence during episodes of acute deterioration in adult Emergency Department patients., Methods: Clinicians (n=156) from a single study site in Melbourne, Australia completed a 17-item survey., Results: Participants disagreed that family members would interrupt (59.0%) or interfere (61.5%) with patient care if present during episodes of patient deterioration. Most (77.6%) participants stated that they included family during episodes of patient deterioration. Females, nurses and Australians/New Zealanders had a more positive attitude towards including family during episodes of patient deterioration when compared to males, doctors and clinicians of other ethnicities. Nurses with post-graduate qualifications and those with more years of experience had a more positive attitude towards including family during episodes of patient deterioration than nurses without post-graduation qualification and with less years of experience., Conclusions: Clinicians had predominantly positive attitudes towards including family during episodes of patient deterioration and perceived it to be a common day-to-day practice. Gender, profession, country of birth, education level and years of experience all impacted on clinician attitudes, beliefs and perceptions of family presence during acute deterioration., (Crown Copyright © 2016. Published by Elsevier Ltd. All rights reserved.)

Objective: To examine the relationship between patient physiological status in the emergency department (ED) and inhospital mortality after rapid response team (RRT) or cardiac arrest team (CAT) activations within 72 hours of emergency admission to medical or surgical wards., Design, Setting and Participants: A multisite, retrospective, cohort study of 660 randomly selected (220 patients per site) adult medical or surgical patients who were admitted from the ED during 2012 and who had had an RRT or CAT activation within 72 hours of admission, at three hospitals in Melbourne, Australia., Main Outcome Measure: Inhospital mortality., Results: There were 825 RRT activations (for 634 patients) and 42 CAT activations (for 35 patients). The median time to the first RRT or CAT activation was 18.8 hours and was significantly shorter in patients who died in hospital (14.6 v 20.6 hours, P=0.036). Compared with survivors, patients who died were more likely to have at least one observation meeting RRT criteria during their ED stay (45.9% v 34.8%; P=0.029): tachypnoea (21.1% v 13.4%, P=0.039), hypotension (20.2% v 11.8%, P=0.018), hypoxaemia (8.3% v 3.1%, P=0.001) and altered conscious state (6.2% v 1.3%, P=0.001) were more common in patients who died. The risk-adjusted odds ratio (OR) for inhospital death was highest for patients with an altered conscious state during their ED stay (OR, 4.633; 95% CI, 1.365-15.728; P=0.014)., Conclusions: In patients who needed an RRT or CAT activation within the first 72 hours of emergency admission to medical or surgical wards, there was a strong association between physiological derangement during ED care and inhospital death.

Background: Despite emerging evidence regarding clinical deterioration in emergency department (ED) patients, the widespread uptake of rapid response systems (RRS) in EDs has been limited., Aims: To evaluate the effect of an ED RRS on reporting of clinical deterioration and determine if there were differences between patients who did, and did not, deteriorate during ED care., Methods: A retrospective cross sectional design was used to conduct this single site study in Melbourne, Australia. Stratified random sampling identified 50 patients with shortness of breath, chest pain or abdominal pain per each year studied (2009-2012) giving a total of 600 patients. The intervention was an ED RRS implemented in stages., Results: The frequency of clinical deterioration was 14.8% (318 episodes/89 patients). Unreported deterioration decreased each year (86.7%; 68.8%; 55.3%; 54.0%, p=0.141). Patients who deteriorated during ED care had a longer median ED length of stay (2.8h; p<0.001), were 31.9% more likely to need hospital admission (p<0.001) and 4.9% more likely to die in hospital (p=0.044)., Conclusions: A staged ED specific RRS decreased the frequency of unreported clinical deterioration. Controlled multi-site studies of ED specific RRSs are needed to examine the effect of formal ED RRSs on patient outcomes., (Copyright © 2015 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.)

Objectives: To establish the prevalence of emergency responses for clinical deterioration (cardiac arrest team or medical emergency team [MET] activation) within 24 hours of emergency admission, and determine if there were differences in characteristics and outcomes of ward patients whose emergency response was within, or beyond, 24 hours of emergency admission., Design, Setting and Participants: A retrospective, descriptive, exploratory study using MET, cardiac arrest, emergency department and inpatient databases, set in a 365-bed urban district hospital in Melbourne, Australia. Participants were adult hospital inpatients admitted to a medical or surgical ward via the emergency department (ED) who needed an emergency response for clinical deterioration during 2012., Main Outcome Measures: Inhospital mortality, unplanned intensive care unit admission and hospital length of stay (LOS)., Results: A total of 819 patients needed an emergency response for clinical deterioration: 587 patients were admitted via the ED and 28.4% of emergency responses occurred within 24 hours of emergency admission. Patients whose first emergency response was within 24 hours of emergency admission (compared with beyond 24 hours) were more likely to be triaged to Australasian triage scale category 1 (5.4% v 1.2%, P=0.005), less likely to require ICU admission after the emergency response (7.6% v 13.9%, P=0.039), less likely to have recurrent emergency responses during their hospital stay (9.7% v 34%, P < 0.001) and had a shorter median hospital LOS (7 days v 11 days, P < 0.001)., Conclusions: One-quarter of emergency responses after admission via the ED occurred within 24 hours. Further research is needed to understand the predictors of deterioration in patients needing emergency admission.

Purpose: The purpose of this study was to explore the extent and sources of variability of critical care nurses' hemodynamic decision making as a function of contextual factors in the immediate 2-hour period after cardiac surgery., Methods: A qualitative exploratory design with observation and interview was used. Eight critical care nurses were observed on different occasions in clinical practice for a 2-hour period. A brief interview immediately followed each observation to clarify observation data., Findings: Analysis of the data revealed that patient management decisions were made both by individual nurses and by a team of nurses and health professionals. Team decision making (TDM) is described in this study as integrated or non-integrated and refers to an intra-professional nursing team. During displays of integrated TDM, the primary nurse, who was assigned to care for the patient, made most hemodynamic decisions and nurses who assisted the primary nurse deferred decisions. During displays of non-integrated TDM, nurses assisting the primary nurse assumed responsibilities for most patient-related decisions. Non-integrated TDM occurred more frequently when inexperienced cardiac surgical intensive care nurses were in the role of primary nurse, whereas integrated TDM was more common among experienced cardiac surgical intensive care nurses., Conclusions: This observed variability can occur in multiple ways and in hemodynamic decision making has implications for patient outcomes as behaviors of non-integrated TDM led to nurses sensing a loss of control of patient management.