Beane Abi, Wijesiriwardana Wageesha, Pell Christopher, Dullewe N P, Sujeewa J A, Rathnayake R M Dhanapala, Jayasinghe Saroj, Dondorp Arjen M, Schultsz Constance, Haniffa Rashan
Nat-Intensive Care Surveillance, MORU, Colombo, 08, Sri Lanka.
Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand.
Wellcome Open Res. 2022 Jun 13;7:137. doi: 10.12688/wellcomeopenres.17624.2. eCollection 2022.
Infrastructure, equipment and staff constraints are often cited as barriers to the recognition and rescue of deteriorating patients in resource-limited settings. The impact of health-system organisation, decision-making and organisational culture on recognition of deterioration is however poorly understood. This study explores how health care providers recognise deterioration of patients in acute care in Sri Lanka. In-depth interviews exploring decision making and care processes related to recognition of deterioration, were conducted with a purposive sample of 23 health care workers recruited from ten wards at a district hospital in Sri Lanka. Interviews were audio-recorded, transcribed and coded thematically, line-by-line, using a general inductive approach. A legacy of initial assessment on admission and inimical organisational culture undermined recognition of deteriorating patients in hospital. Informal triaging at the time of ward admission resulted in patients presenting with red-flag diagnoses and vital sign derangement requiring resuscitation being categorised as "bad". The legacy of this categorisation was a series of decision-making biases anchored in the initial assessment, which remained with the patient throughout their stay. Management for patients categorised as "bad" was prioritised by healthcare workers coupled with a sense of fatalism regarding adverse outcomes. Health care workers were reluctant to deviate from the original plan of care despite changes in patient condition (continuation bias). Organisational culture - vertical hierarchy, siloed working and a reluctance to accept responsibility- resulted in omissions which undermined recognition of deterioration. Fear of blame was a barrier to learning from adverse events. The legacy of admission assessment and hospital organisational culture undermined recognition of deterioration. Opportunities for improving recognition of deterioration in this setting may include establishing formal triage and medical emergency teams to facilitate timely recognition and escalation.
在资源有限的环境中，基础设施、设备和人员限制常常被视为识别和救治病情恶化患者的障碍。然而，卫生系统组织、决策和组织文化对病情恶化识别的影响却鲜为人知。本研究探讨了斯里兰卡急性护理中医疗服务提供者如何识别患者病情恶化。对从斯里兰卡一家区级医院的十个病房招募的23名医护人员进行了有目的抽样，进行了深入访谈，探讨与病情恶化识别相关的决策和护理过程。访谈进行了录音、转录，并采用一般归纳法逐行进行主题编码。入院时的初始评估遗留问题和有害的组织文化削弱了医院对病情恶化患者的识别。病房入院时的非正式分诊导致出现红旗诊断和需要复苏的生命体征紊乱的患者被归类为“病情严重”。这种分类的遗留问题是一系列基于初始评估的决策偏差，患者在整个住院期间都受其影响。医护人员将对被归类为“病情严重”患者的管理列为优先事项，同时对不良后果抱有宿命论。尽管患者病情发生变化，医护人员仍不愿偏离原护理计划（持续偏差）。组织文化——垂直等级制度、各自为政的工作方式以及不愿承担责任——导致了疏漏，从而削弱了对病情恶化的识别。害怕受到指责是从不良事件中吸取教训的障碍。入院评估和医院组织文化的遗留问题削弱了对病情恶化的识别。在这种情况下，改善病情恶化识别的机会可能包括建立正式分诊和医疗应急团队，以促进及时识别和病情升级。
