Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
Plymouth University, Plymouth, UK.
BMJ Open Qual. 2021 Feb;10(1). doi: 10.1136/bmjoq-2020-001145.
Identifying how human factors affect clinical staff recognition and managment of the deteriorating ward patient may inform process improvements. We systematically reviewed the literature to identify (1) how human factors affect ward care escalation (2) gaps in the current literature and (3) critique literature methodologies.
We undertook a Qualitative Evidence Synthesis of care escalation studies. We searched MEDLINE, EMBASE and CINHAL from inception to September 2019. We used the Critical Appraisal Skills Programme and the Grading of Recommendations Assessment-Development and Evaluation and Confidence in Evidence from Reviews of Qualitative Research tool to assess study quality.
Our search identified 24 studies meeting the inclusion criteria. Confidence in findings was moderate (20 studies) to high (4 studies). In 16 studies, the ability to recognise changes in the patient's condition (soft signals), including skin colour/temperature, respiratory pattern, blood loss, personality change, patient complaint and fatigue, improved the ability to escalate patients. Soft signals were detected through patient assessment (looking/listening/feeling) and not Early Warning Scores (eight studies). In contrast, 13 studies found a high workload and low staffing levels reduced staff's ability to detect patient deterioration and escalate care. In eight studies quantifiable deterioration evidence (Early Warning Scores) facilitated escalation communication, particularly when referrer/referee were unfamiliar. Conversely, escalating concerning non-triggering patients was challenging but achieved by some clinical staff (three studies). Team decision making facilitated the clinical escalation (six studies).
Early Warning Scores have clinical benefits but can sometimes impede escalation in patients not meeting the threshold. Staff use other factors (soft signals) not captured in Early Warning Scores to escalate care. The literature supports strategies that improve the escalation process such as good patient assessment skills.
CRD42018104745.
识别人为因素如何影响临床工作人员对恶化病房患者的识别和管理，可能为改进流程提供信息。我们系统地回顾了文献，以确定（1）人为因素如何影响病房护理升级，（2）当前文献中的差距，以及（3）评价文献方法学。
我们对护理升级研究进行了定性证据综合。我们从创建到 2019 年 9 月在 MEDLINE、EMBASE 和 CINHAL 上进行了搜索。我们使用批判性评估技能计划和推荐评估、发展和评估分级以及从定性研究综述中评估证据信心工具来评估研究质量。
我们的搜索确定了 24 项符合纳入标准的研究。发现的信心为中度（20 项研究）到高度（4 项研究）。在 16 项研究中，识别患者病情变化的能力（软信号），包括皮肤颜色/温度、呼吸模式、失血、性格改变、患者投诉和疲劳，提高了升级患者的能力。软信号通过患者评估（观察/倾听/感觉）而不是早期预警评分（八项研究）来检测。相比之下，13 项研究发现工作量大、人员配备水平低会降低工作人员发现患者恶化和升级护理的能力。在八项研究中，可量化的恶化证据（早期预警评分）促进了升级沟通，特别是当推荐者/被推荐者不熟悉时。相反，升级不触发的患者具有挑战性，但一些临床工作人员（三项研究）做到了。团队决策促进了临床升级（六项研究）。
早期预警评分具有临床益处，但有时会阻碍不符合阈值的患者的升级。工作人员使用早期预警评分未捕获的其他因素（软信号）来升级护理。文献支持改善升级流程的策略，例如良好的患者评估技能。
PROSPERO 注册号：CRD42018104745。
