Recognising the deterioration of patients in acute care wards: a qualitative study

Abstract

Background: Infrastructure, equipment and staff constraints are often cited as barriers to the recognition and rescue of deteriorating patients in resource-limited settings. The impact of health-system organisation, decision-making and organisational culture on recognition of deterioration is however poorly understood. This study explores how health care providers recognise deterioration of patients in acute care in Sri Lanka. Methods: In-depth interviews exploring decision making and care processes related to recognition of deterioration, were conducted with a purposive sample of 23 health care workers recruited from ten wards at a district hospital in Sri Lanka. Interviews were audio-recorded, transcribed and coded thematically, line-by-line, using a general inductive approach. Results: A legacy of initial assessment on admission and inimical organisational culture undermined recognition of deteriorating patients in hospital. Informal triaging at the time of ward admission resulted in patients presenting with red-flag diagnoses and vital sign derangement requiring resuscitation being categorised as "bad". The legacy of this categorisation was a series of decision-making biases anchored in the initial assessment, which remained with the patient throughout their stay. Management for patients categorised as “bad” was prioritised by healthcare workers coupled with a sense of fatalism regarding adverse outcomes. Health care workers were reluctant to deviate from the original plan of care despite changes in patient condition (continuation bias). Organisational culture - vertical hierarchy, siloed working and a reluctance to accept responsibility- resulted in omissions which undermined recognition of deterioration. Fear of blame was a barrier to learning from adverse events. Conclusions: The legacy of admission assessment and hospital organisational culture undermined recognition of deterioration. Opportunities for improving recognition of deterioration in this setting may include establishing formal triage and medical emergency teams to facilitate timely recognition and escalation.

Same label, different patients: Health-workers’ understanding of the label ‘critical illness’

“…Additionally, patients in ICUs, in emergency departments or in other locations do not all have the same risks, prognosis or requirements for urgent care, so this understanding may direct care interventions inappropriately to patients who do not require them. This is a form of, “continuation bias”, which was identified as an important barrier to timely care of critically ill patients in Sri Lanka ( 24 ). Understanding ‘critical illness’ as referring to a situation where a certain level of advanced care such as mechanical ventilation is provided, will lead to the exclusion of patients who would benefit from such a label, but are either not in need of such advanced care, or who are cared for in settings where advanced care is not available ( 4 ).…”

Health Care Workers’ Experiences of Calling-for-help When Taking Care of Critically Ill Patients in Hospitals in Tanzania and Kenya

“…Adequate structures are required for managing patient deterioration (21,22), patient safety (23) and in facilitating communication in health care teams (24). Our study found that hospitals lack the structures for calling-for-help such as functional phones and alarm systems, which can be a large contributor to adverse clinical effects (24) and potentially leading to increased hospital mortality (25) as they prevent access to help.…”

Assessment and early warning signs of deterioration in hospitalized patients

“…Recognizing and acting upon warning signs of deterioration, in hospitalized patients is crucial for providing quality patient care. 13 By monitoring signs utilizing early warning scores relying on clinical judgment leveraging technological advancements and implementing rapid response protocols healthcare professionals can greatly enhance patient outcomes. It is important to conduct research promote education and refine these systems to ensure their effectiveness and minimize any limitations.…”