Esquema 2.1.4. Sistema Multiciclo (Castelló, 2001)
2.4. LAS LIMITACIONES INTELECTUALES.
Identifying abnormal vital signs is the key to detecting any deterioration in a patient’s condition (Hutson & Millar, 2009; National Institute for Clinical Excellence (NICE), 2007). A common system to aid clinical assessment is the airway, breathing, circulation (ABC) system. Airway obstruction requires immediate attention to ensure a patient can breath. It is generally agreed that breathing problems are indicated if the respiratory rate is greater than 30 per minute although some sources even suggest that a respiratory rate greater than
20 is significant (Duckitt et al., 2007; Morgan, Williams, & M, 1997; Prytherch, Smith, Schmidt, & Featherstone, 2010). A raised respiratory rate indicates an increased demand for oxygen and may be caused by pulmonary or cardiac problems, or any form of shock. Raised respiratory rate is the most significant sign of critical illness and monitoring of respiratory rate is therefore essential in improving detection and treatment of critical deterioration (Goldhill & Sumner, 1998; Schein, Hazday, Pena, Ruben, & Sprung, 1990; Subbe, Davies, Williams, Rutherford, & Gemmell, 2003). Circulation problems can be detected if the systolic blood pressure is lower than the heart rate (positive-shock index) and is another sign of critical deterioration. Cold and clammy skin and poor capillary refill time are also significant signs of circulatory problems. In addition to ABC assessment, the patient’s mental state should be observed in relation to deterioration, as confusion and altered conscious level are also early signs of clinical deterioration.
Routine checking of vital signs is an integral part of nursing, to monitor a patient's
physiological status. These checks have traditionally included observations of temperature, pulse rate, respiratory rate and systemic blood pressure. Urinary output has also been included in patient observation and more recently, peripheral oxygen saturation (SpO2)
percentage. If the patient’s vital signs are outside normal limits, clinical staff are expected to respond appropriately, for example, by increasing the frequency of recordings or calling for appropriate aid to initiate required treatment (Hutson & Millar, 2009). Nevertheless, these signs have often been missed by medical and nursing staff (Subbe, Slater, Menon, & Gemmell, 2006).
2.4.1 Sub-‐optimal care
In 1990, a study was carried out to identify possible clinical antecedents to cardiac arrest (Schein et al., 1990). The records of patients who had had a respiratory or cardiac arrest were reviewed. This study identified that there were documented signs of clinical
deterioration within eight hours of cardiac arrest. However, the results also indicated that patient deterioration, although documented, had not been acted upon. The most
prominent signs were related to deterioration in respiratory or mental functions; 53% showing altered respiratory function, 42% deterioration in mental function. Although this study implied that clinical criteria could be useful in triggering early intervention, it also highlighted the problem that there was lack of response to documented information. For example, an increase in respiratory rate did not always lead to appropriate respiratory therapy.
A subsequent study by Bedell et al (1991) also identified that failure to act on symptoms of breathlessness and increased respiratory rate could be directly related to events leading to a cardiac arrest. These findings prompted further studies which confirmed that patients with deteriorating physical conditions were receiving sub-optimal care; deterioration was not detected, not reported, not acted upon appropriately, or in time. These studies have
demonstrated that patients in hospital have pre-emptive physiological signs prior to cardiac arrest (Franklin & Mathew, 1994; Rich, 1999).
In patients admitted to intensive care units (ICU), similar findings have been demonstrated (Goldhill & Sumner, 1998; McGloin, Adam, & Singer, 1999; McQuillan et al., 1998). McQuillan et al (1998) investigated the prevalence of sub-optimal care before admission to an ICU. They studied the quality of care received by 50 consecutively admitted adult emergency patients who were subsequently admitted to intensive care units. A confidential inquiry was conducted by completing detailed questionnaires during structured interviews with a clinical admitting team and an intensive care team. They found that 54% of patients received sub-optimal care prior to admission to the ICU. They also found that 39% of patients were admitted to intensive care late in the clinical course of their illness. They suggested that there was a fundamental problem in recognizing the importance of airway, breathing and circulation as being important for life. “Failure of organization, lack of knowledge, failure to appreciate clinical urgency, lack of experience, lack of supervision, and failure to seek advice” were identified as the main causes of sub-optimal care.
Therefore, ‘sub-optimal care’ described the failure to identify, interpret and manage clinical signs of life (vital signs) (McQuillan et al., 1998).
2.4.2 Predisposing factors to sub-‐optimal care
There appear to be several factors that predispose to the prevalence of sub-optimal care. The first of these factors is related to the complexity of patients in hospital wards today. Current demographic trends demonstrate that, in western civilizations, people are living longer than ever before and hospitals now perform advanced procedures on much older patients. Furthermore, advanced technology, leading to the evolution of intensive care units and high dependency units, has made it possible to perform major surgery on patients with pre-existing conditions which previously would have been considered too high risk (Green & Williams, 2006). Thus, elderly patients with multiple diagnoses are now routinely treated in hospitals. Furthermore, many procedures are now performed as day cases, and shorter hospital stays greatly increase the turnover of patients, resulting in higher levels of acuity
among in-patient populations (Green & Williams, 2006; Johnstone, Rattray, & Myers, 2007). Therefore, acute hospitals tend to manage only seriously ill patients who require greater levels of monitoring and intervention (Hillman, Parr, Flabouris, Bishop, & Stewart, 2001).
A second predisposing factor is that an increasingly complex and elderly client group has led to an increase in workload. However, the increase in workload has not necessarily been matched by greater resourcing or an increase in qualified staff (NPSA, 2007). On the contrary, staffing on wards has suffered from a reduction in the number of qualified staff and inadequate nurse-patient ratios (Cutler, 2002). This puts increased pressure on staff in acute hospital wards and in turn may have led to an increased risk of poor detection of acute deterioration and patient co-morbidities (James et al., 2010).
A third predisposing factor is related to knowledge levels. There are studies that show that even qualified staff have overlooked important physiological findings (McGloin et al., 1999) These findings indicated the need for improved education (Bright, Walker, & Bion, 2004; Franklin & Mathew, 1994; McGloin et al., 1999; McQuillan et al., 1998). Lack of in- service study time has also been indicated as a reason for lack of knowledge and lack of appropriate action (McArthur-Rouse, 2001). The ALERT course was developed in response to the recognition of additional training needs for multiprofessional staff caring for acutely ill patients (Smith, Osgood, & Crane, 2002)
Finally, organisational problems may contribute to sub-optimal care. A global shortage of nurses has led to a lack of qualified staff, resulting in physiological parameters often being recorded by unqualified staff, such as Healthcare Assistants (HCA) who did not have the knowledge to interpret recordings and to notify a trained nurse (James et al., 2010; McArthur-Rouse, 2001). Furthermore, a lack of supervision of junior doctors and reluctance to call for help, could be another reason for sub-optimal care (NPSA, 2007). To summarise, there are four distinct categories of problems that can predispose to sub- optimal care: patient complexity; healthcare workforce; education; and organisation (Quirke, Coombs, & McEldowney, 2011). As a result of the identified problem of sub- optimal care, systems were developed that would facilitate the early recognition of deteriorating patients at the earliest possible stage. These are described in the following section (2.5).