Background: Early Warning Scores were introduced into acute hospitals in 2000. 99% of acute hospitals employ a EWS to monitor deteriorating patients with 97.9% of these linked to a referral protocol. Despite this high level of adoption, there has been little improvement in the recognition and response to deteriorating patients over the last decade.Objective: To explore the patterns of compliance with Early Warning Track and Trigger Tools Design: A narrative review Data sources: Electronic databases (Medline, CIHAHL, EmBase, the Cochrane library, the Centre for Reviews and Dissemination (CRD) and PROSPERO) were searched from 1 January 2000 to 5 July 2018. Titles, abstracts and full text papers were screened (two independent reviewers) against inclusion criteria and seven papers were included in the review. Data were extracted by one reviewer and checked by a second reviewer using a bespoke data collection sheet.Review methods: All papers were quantitative in design but demonstrated clinical and methodological heterogeneity therefore a meta-analysis was not possible. A qualitative approach was undertaken to synthesise findings using a framework analysis and narrative synthesis. Themes were identified, named, defined and reported according to outcome measure.Results: 7/27 papers representing over 3000 patients and 963,000 data points were included in the analysis. Reported studies were conducted in the United Kingdom (n=4), Denmark (n=2) and Amsterdam (n=1). Three key themes were identified, early warning score calculation accuracy, monitoring frequency and clinical response. This review identifies poor compliance with the Early Warning Score (EWS) protocol in all three themes.There is significant scoring inaccuracy with omitted EWS, missing elements of the EWS and incorrectly calculated EWS. Adherence to monitoring frequency is poor with a higher EWS being associated with reduced compliance with the escalation protocol. There is inadequate compliance with the escalation element of the EWS protocol with concerning extended

Aim: To determine the effect of Early Warning Track and Trigger Tools on patient outcomes. Design: A systematic review: synthesis without meta-analysis. Data sources: Electronic databases were searched from 1 January 2013-1 August 2018 and 221 papers identified. Review methods: A systematic review and narrative synthesis supported the identification of synthesized findings named and reported according to outcome measure. RESULTS: Five international papers representing over 74,000 patients were included in the analysis. Seven key findings were identified, the impact of NEWS on: (a) cardiopulmonary arrest; (b) mortality; (c) serious adverse events; (d) length of hospital stay; (e) hospital admissions; (f) observation frequency; and (g) Intensive/High dependency Unit admission. Papers identified statistically significant improvements in mortality, serious adverse events, hospital admissions, observation frequency, and intensive care unit/high dependency unit admission when an Early Warning Track and Trigger protocol is in use. There were conflicting results regarding length of stay and cardiopulmonary arrest data. Conclusion: Early Warning Track and Trigger Tools can aid recognition of deteriorating patients. Further research is required in relation to hospital length of stay and cardiopulmonary arrests. Impact: Early warning track and trigger tools have been implemented nationally and to a lesser degree internationally. There is evidence to suggest improved clinical outcomes following their use. Further research needs to combine the use of the National Early Warning Score with an agreed set of measured outcomes, and then subsequent study data could be combined to provide much stronger levels of evidence.

Aims To explore registered nurses' experiences of patient safety in intensive care during COVID‐19. Design A qualitative interview study informed by constructivism. Method Semi‐structured interviews were conducted and audio‐recorded with 19 registered nurses who worked in intensive care during COVID‐19 between May and July 2021. Interviews were transcribed verbatim and thematically analysed utilizing framework. Results Two key themes were identified. ‘On a war footing’—an unprecedented situation which describes the situation nurses faced, and the actions are taken to prepare for the safe delivery of care. ‘Doing the best we can’—Safe Delivery of Care which describes the ramifications of the actions taken on short‐ and long‐term patient safety including organization of care, missed and suboptimal care and communication. Both themes were embedded in the landscape of Staff Well‐being and Peer Support. Conclusion Nurses reported an increase in patient safety risks which they attributed to the dilution of skill mix and fragmentation of care. Nurses demonstrated an understanding of the holistic and long‐term impacts on patient safety and recovery from critical illness. Impact This study explored the perceived impact of COVID‐19 on patient safety in intensive care from a nursing perspective. Dilution of skill mix, where specialist critical care registered nurses were diluted with registered nurses with no critical care experience, and the fragmentation of care was perceived to lead to reduced quality of care and increased adverse events and risk of harm which were not consistently formally reported. Furthermore, nurses demonstrated a holistic and long‐term appreciation of patient safety. These findings should be considered as part of future nursing workforce modelling and patient safety strategies by intensive care leaders and managers. No public or patient contribution to this study. The study aims and objectives were developed in collaboration with health care professionals.

Background: Since the start of the global COVID-19 pandemic in 2019, critical care nurses across the world have been working under extreme levels of pressure. Aim: To understand critical care nurses' experiences of and satisfaction with their role in the pandemic response across the United Kingdom (UK). Study Design: A cross-sectional electronic survey of critical care nurses (n = 339) registered as members of the British Association of Critical Care Nurses. Anonymous quantitative and open-ended question data were collected in March and April 2021 during the height of the second surge of COVID-19 in the UK via an online questionnaire. Quantitative data were analysed using descriptive statistics and free text responses were collated and analysed thematically.Results: There was a response rate of 17.5%. Critical care nurses derived great satisfaction from making a difference during this global crisis and greatly valued teamwork and support from senior nurses. However, nurses consistently expressed concern over the quality of safe patient care, which they perceived to be suboptimal due to staff shortages and a dilution of the specialist skill mix. Together with the high volume of patient deaths, critical care nurses reported that these stressors influenced their personalwell-being. Conclusions:This study provides insights into the key lessons health care leaders must consider when managing the response to the demands and challenges of the ongoing COVID-19 pandemic. COVID-19 is unpredictable in its course, and what future variants might mean in terms of transmissibility, severity and resultant pressures to critical care remains unknown.

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BackgroundThe importance of good oral hygiene for patients in Intensive Care Units (ICUs) is well recognized, however, the most effective way to achieve good oral care in the ICU is unclear.AimThis study aimed to provide a national picture of oral care practices in adult ICUs in the United Kingdom (UK) to identify areas for improvement.Study DesignA national one‐day point prevalence study was undertaken in adult ICUs in the UK in the period from 30th September to 14th October 2021. Data were collected on all patients in the ICU on the date of data collection. Using a validated electronic data collection form, anonymised data were collected on methods and frequency of oral care provided, and the use of oral care protocols within the ICU. Data were analysed using descriptive analysis.ResultsData from 195 patients in 15 ICUs in England, Wales and Northern Ireland were collected. Written oral care protocols were available for use in the care of 65% (n = 127) of patients. 73% (n = 142) of patients received oral care within the 24‐h period. Oral care methods included toothbrushing 41% (n = 79), foam sticks 3% (n = 5), moisturizing the oral cavity 10% (n = 19) and mouth rinse with chlorhexidine 3% (n = 5) and other oral care methods not specified 12% (n = 23). 44% (n = 85) of patients had an oral assessment within the 24‐h period and variable assessment methods were used.ConclusionThere is large variability in oral care provision and methods for intubated ICU patients and a lack of consensus was revealed in the study. Oral assessment is conducted less frequently using multiple tools. Optimal oral care standards and further research into oral care provision is pivotal to address this important patient‐relevant practice.Relevance to Clinical PracticeOral care is a fundamental part of care for ICU patients, however, there is a large degree of variability, and oral care is often not based upon oral assessment. The use of an oral care protocol and oral assessments would help to improve patient care, ease of use for staff and provide a tailored oral care plan for patients, improving efficiency and preventing wasted resources.

Background:The role of the paramedic has changed significantly over the last 10 years. In order for paramedic students to gain the necessary skills and knowledge to effectively manage the increasing complexity of patient presentations a wide range of placement opportunities are required to support learning.Objective: To explore first year student paramedic experiences of non-ambulance placements. Design: A qualitative studyMethods: Semi-structured interviews and thematic analysis was used to explore first year student paramedic's experiences of non-ambulance placements. The study took place in one higher education institution in England, UK.Results: Thirty-three first year BSc (hons) Paramedic Science students agreed to be interviewed. All the students had undertaken at least one non-ambulance placement within a hospital setting. Four key themes that emerged from the transcripts, Expectations, The Patient Journey, Communication and Mentorship. Conclusion:In order to prepare students for the future, to deliver quality care and to improve patient outcomes a variety of educational opportunities is crucial. There remains work to be done supporting clinical mentors, tearing down barriers between professional groups and exploring our similarities and strengths.

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