The Health Information and Quality Authority (HIQA), City Gate, Mahon, Cork, T12 Y2XT, Ireland.
HRB Centre for Primary Care Research and Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland.
BMC Emerg Med. 2021 Jan 28;21(1):15. doi: 10.1186/s12873-021-00403-9.
Early warning systems (EWSs) are used to assist clinical judgment in the detection of acute deterioration to avoid or reduce adverse events including unanticipated cardiopulmonary arrest, admission to the intensive care unit and death. Sometimes healthcare professionals (HCPs) do not trigger the alarm and escalate for help according to the EWS protocol and it is unclear why this is the case. The aim of this qualitative evidence synthesis was to answer the question 'why do HCPs fail to escalate care according to EWS protocols?' The findings will inform the update of the National Clinical Effectiveness Committee (NCEC) National Clinical Guideline No. 1 Irish National Early Warning System (INEWS).
A systematic search of the published and grey literature was conducted (until February 2018). Data extraction and quality appraisal were conducted by two reviewers independently using standardised data extraction forms and quality appraisal tools. A thematic synthesis was conducted by two reviewers of the qualitative studies included and categorised into the barriers and facilitators of escalation. GRADE CERQual was used to assess the certainty of the evidence.
Eighteen studies incorporating a variety of HCPs across seven countries were included. The barriers and facilitators to the escalation of care according to EWS protocols were developed into five overarching themes: Governance, Rapid Response Team (RRT) Response, Professional Boundaries, Clinical Experience, and EWS parameters. Barriers to escalation included: Lack of Standardisation, Resources, Lack of accountability, RRT behaviours, Fear, Hierarchy, Increased Conflict, Over confidence, Lack of confidence, and Patient variability. Facilitators included: Accountability, Standardisation, Resources, RRT behaviours, Expertise, Additional support, License to escalate, Bridge across boundaries, Clinical confidence, empowerment, Clinical judgment, and a tool for detecting deterioration. These are all individual yet inter-related barriers and facilitators to escalation.
The findings of this qualitative evidence synthesis provide insight into the real world experience of HCPs when using EWSs. This in turn has the potential to inform policy-makers and HCPs as well as hospital management about emergency response system-related issues in practice and the changes needed to address barriers and facilitators and improve patient safety and quality of care.
预警系统 (EWS) 用于协助临床判断，以检测急性恶化，避免或减少不良事件，包括意外心肺骤停、入住重症监护病房和死亡。有时医护人员 (HCP) 未按照 EWS 协议触发警报并升级以寻求帮助，不清楚为什么会出现这种情况。本定性证据综合的目的是回答“为什么 HCP 未按照 EWS 协议升级护理？”调查结果将为更新国家临床效果委员会 (NCEC) 爱尔兰国家早期预警系统 (INEWS) 国家临床指南 No.1 提供信息。
对已发表和灰色文献进行了系统搜索（截至 2018 年 2 月）。两名审查员使用标准化数据提取表和质量评估工具独立进行数据提取和质量评估。对纳入的定性研究进行主题综合，并分类为升级的障碍和促进因素。使用 GRADE CERQual 评估证据的确定性。
纳入了来自七个国家的各种 HCP 参与的 18 项研究。根据 EWS 协议升级护理的障碍和促进因素被分为五个总体主题：治理、快速反应小组 (RRT) 反应、专业界限、临床经验和 EWS 参数。升级障碍包括：缺乏标准化、资源、缺乏问责制、RRT 行为、恐惧、等级制度、增加冲突、过度自信、缺乏信心和患者变异性。促进因素包括：问责制、标准化、资源、RRT 行为、专业知识、额外支持、升级许可、跨越界限的桥梁、临床信心、授权、临床判断和检测恶化的工具。这些都是升级的相互关联的障碍和促进因素。
本定性证据综合研究结果深入了解了医护人员使用 EWS 时的真实世界体验。这反过来又有可能为决策者和医护人员以及医院管理人员提供有关实践中紧急响应系统相关问题的信息，以及为解决障碍和促进因素以及提高患者安全和护理质量所需的变革。
