Comparison of policies for recognising and responding to clinical deterioration across five Victorian health services

Abstract
Objectives The aim of the present study was to describe and compare organisational guidance documents related to recognising and responding to clinical deterioration across five health services in Victoria, Australia.

Methods Guidance documents were obtained from five health services, comprising 13 acute care hospitals, eight subacute care hospitals and approximately 5500 beds. Analysis was guided by a specific policy analysis framework and a priori themes.

Results In all, 22 guidance documents and five graphic observation and response charts were reviewed. Variation was observed in terminology, content and recommendations between the health services. Most health services’ definitions of physiological observations fulfilled national standards in terms of minimum parameters and frequency of assessment. All health services had three-tier rapid response systems (RRS) in place at both acute and subacute care sites, consisting of activation criteria and an expected response. RRS activation criteria varied between sites, with all sites requiring modifications to RRS activation criteria to be made by medical staff. All sites had processes for patient and family escalation of care.

Conclusions Current guidance documents related to the frequency of observations and escalation of care omit the vital role of nurses in these processes. Inconsistencies between health services may lead to confusion in a mobile workforce and may reduce system dependability.

What is known about the topic? Recognising and responding to clinical deterioration is a major patient safety priority. To comply with national standards, health services must have systems in place for recognising and responding to clinical deterioration.

What does this paper add? There is some variability in terminology, definitions and specifications of physiological observations and medical emergency team (MET) activation criteria between health services. Although nurses are largely responsible for physiological observations and escalation of care, they have little authority to direct frequency of observations and triggers for care escalation or tailor assessment to individual patient needs. Failure to identify nurses’ role in policy is concerning and contrary to the evidence regarding nurses and MET activations in practice.

What are the implications for practitioners? Inconsistencies in recommendations regarding physiological observations and escalation of care criteria may create patient safety issues when students and staff work across organisations or move from one organisation to another. The validity of other parameters, such as appearance, pain, skin colour and cognition, warrant further consideration as early indicators of deterioration that may be used by nurses to identify clinical deterioration earlier. A better understanding of the relationship between the sensitivity, specificity and frequency of monitoring of particular physiological observations and patient outcomes is needed to improve the predictive validity for identification of clinical deterioration.