Diagnóstico y Determinación de necesidades

This section describes how the literature search was carried out, including search terms, databases, inclusion and exclusion criteria used. The search strategy was designed to identify focussed, relevant literature and provide a transparent audit-trail to facilitate reproducibility (Bettany-Saltukov, 2010).

a) Aim of the search

The aim of the search was to identify the national and international body of literature that describes or evaluates the way in which acutely ill,

deteriorating patients are identified, managed and cared for in the ward environment by the healthcare team.

b) Databases and search engines used

Publications listed on websites from national organisations (Table 3 below), familiar to the researcher, provided an initial starting point for the search in conjunction with personal knowledge of existing literature. The Cochrane Library4 _{provided an initial source for systematic reviews. Two core}

databases (Embase and Ovid MEDLINE) were accessed via OvidSP/Wolters Kluwer Health5_{. After initial searches, the Allied and Complementary}

Medicine [AMED] database was found to be inappropriate for use in this topic area and discarded. The Cumulative Index to Nursing and Allied Health Literature (CINAHL) database was accessed via EBSCO Host provider at local university and NHS Trust portals. Google and Google Scholar were

4_{www.cochranelibrary.com} 5_{http://ovidsp.uk.ovid.com}

used as supplementary reference points throughout the search, but not as primary access points because of their high sensitivity and poor specificity.

Table 3. National organisations and associated websites.

Organisation Found at (website)

Department of Health (DH) https://www.gov.uk/government/org

anisations/department-of-health

Intensive Care Society (ICS) www.ics.ac.uk

Royal College of Nursing (RCN) www.rcn.org.uk

British Association of Critical Care Nurses

(BACCN) www.baccn.org.uk

National Outreach Forum (NORF) www.norf.org.uk National Institute for Health and Clinical

Excellence (NICE) www.nice.org.uk

National Patient Safety Agency (NPSA) www.npsa.nhs.uk/ NHS Institute for Innovation and

Improvement www.institute.nhs.uk/

National Confidential Enquiry into Patient

Outcome and Death (NCEPOD) www.ncepod.org.uk

c) Search terms

In addition to the Medical Subject Headings (MeSH) terms used, search terms were generated, in part, from experiential knowledge, but also from bibliographical searches using reference lists as the work progressed and key words used in the vernacular were identified. Three key areas of practice literature were searched:

 Care of the acutely ill patient prior to unexpected ICU admission, cardiac arrest, death and failure to rescue

 Factors used in the identification of the deteriorating patient, including routine observations and physiological measurements  Rapid response systems (RRS) including physiological track and

Search terms used are listed in Table 4 below. To increase the power of the search, Boolean (logical) operators were also used, including AND to combine searches and increase specificity, OR to allow more than one term to be used to broaden the search and increase sensitivity, and “….” for key terms and phrases. NOT was used to exclude terms (e.g. paediatrics). The truncation asterisk (*) was used to source information on similar wards, so for example, critical* would also search for critically.

Table 4. Search terms used.

Search Terms

 Rapid response systems

 Rapid response teams

 Critical care outreach teams

 Patient at risk teams

 Medical Emergency Teams

 deteriorat*

 critical* acute*

 ‘at risk’

 wards or ward-based

 Early warning scores

 Modified early warning score

 Patient at risk score

 Physiological track and trigger scores

 National early warning score

 failure to rescue

 antecedents

 vital signs

 nurse concern

c) Key author search

Table 5. Key authors used

Key Authors Bellomo R Buist M Cioffi J Cretikos M DeVita M Endacott R Hillman K Jones D Odell M Prytherch D Smith G B Subbe C

Key authors, familiar to the researcher from previous experience and identified from the bibliographical ancestral search, listed in the summary Table 5 above, were used to focus the review and to capture additional material.

d) Inclusion and exclusion criteria

Inclusion and exclusion criteria were designed to focus the search but avoid limiting the scope too narrowly. Studies were reviewed that described, explored, explained or evaluated any intervention or outcome related to the specified population (acutely ill, deteriorating adult patients in ward

settings). Primary research (all designs), literature reviews and conference papers were included; multi- or single-centre qualitative and quantitative studies were admissible if an abstract was provided to allow initial

screening. Letters, editorials and commentary papers were not included. International studies were restricted to those published in the English language. The focus of this study was adult patients on general wards therefore research in obstetrics or with children under 18 years was excluded, as were studies carried out in ICU (Level 3 care), HDU (Level 2 care), palliative care, mental health, the pre-admission environment,

emergency departments and other highly specialist areas. Studies involving end of life care decisions were not included in this review.

e) Date limits

The initial literature review examined the available body of work from 1990 to 2009. An early report regarding the duration of physiological

abnormalities in patients prior to a cardiac arrest published in 1990 (Schein et al., 1990) provided a provisional starting point for the initial review. This review would identify gaps in the evidence and justify the current research for ethical board review in 2009/10. The review was later updated to cover the literature from 2010 to 2014. A final search was run in November 2014.

2.2.2 Selection and assessment of studies

This section describes how the data from the search was managed and how studies were selected for inclusion in the review.

a) Data management

As an iterative process over a seven-year period of study, managing the data was a complex and difficult process. This was complicated further with incidental findings and changes in database search protocols (Finfgeld- Connett and Johnson, 2012). On reflection, bibliographical management software, such as Endnote for example, would have simplified the process, but in this case Microsoft Word files were used to store results of the searches from each database under each search term. The search strategy elicited a high number of repetitive citations. Duplications were eliminated by manually cross-referencing Word files using the ‘find’ function and a final citation count was elicited. A separate file with an alphabetical list of all references used was manually updated regularly and can be found in the Reference section at the end of this thesis.

b) Selection of studies

Studies were selected for inclusion in the review based both on their relevance to the defined area of study and their quality. Initially, the citations were screened by title alone. The subsequent subset was then reviewed by abstract. Those studies that fitted the inclusion criteria were then subject to full-text review. Where full-text versions were available online in portable document format (pdf), studies were downloaded into

computer files with subject headings derived from the search terms (early warning scores, critical care outreach teams, antecedents, suboptimal care and failure to rescue, for example). Papers not available in full text online were obtained through a local university library and hard copies were stored similarly in box files.

Table 6. Factors reviewed in full text. Factors reviewed in full text

 Abstract and title  Introduction and aims  Method and data

extraction

 Sampling technique  Data analysis  Ethics

 Findings and results

 Transferability or generalisability  Implications for practice and

usefulness

Analysis and critique of individual studies was supported by the use of the Critical Appraisal Skills Programme CASP tools6_{. CASP provides structured}

guidance for evaluating studies from a range of research methodologies including systematic reviews, randomised controlled trials, case control studies, cohort studies and qualitative studies. These were used free of charge in this case for non-commercial reasons under the Creative

Commons license. Essentially, the full-text papers accessed were reviewed in respect of the key points listed in Table 6 above, as suggested by

Flemming (2009). Appraisal notes were recorded manually, in hard copy notebooks for each paper under different subject headings.

The results of the search strategy are summarised in Table 7 below, following application of the inclusion and exclusion criteria and CASP assessment checklists for study quality. More details of the findings can be found in Appendix 2.

Table 7. Results of the search strategy.

Search Results (filters applied

and duplicates removed)

Key author 84

Acute/ deterioration/ ward 38

Track and trigger scores 48

Rapid response teams 217

Miscellaneous e.g. ‘failure to rescue’ 85

Total 472

2.2.3 Summary

This section has articulated the literature review methodology including the search strategy used to identify evidence that explored the multi-

professional care of the acutely ill patient, how the data was extracted, stored, managed and analysed, and how the quality of the studies was evaluated. The following section will present the findings of the literature review.