Critical analysis on recognising and responding to clinical deterioration: A case study
This assignment will illustrate a case study and focus to explore current nursing practice relating to the assessment and interventions required for recognising the patient who is at risk of deterioration in the clinical environment. The insight into the value of clinical reasoning and critical thinking for the nursing professional will be addressed. Critical reflection surrounding the identification and management of early warning signs, effective communication skills, clinical judgments and professional role of nurses providing timely and appropriate managed care will be discussed.
A review of current literature has been undertaken from 2004 to 2014 to find the best available data on the subject. The literature search is outline in appendix 1 were critically analysed to provide an objective and balanced consideration of the issues arising, and limitations of current practice in regards to the nursing role of recognition and management of patient deterioration. The search of the literature has been carried out using the electronic databases such as EBSCO host, Medline, CINAHL, Science Direct and library search through the ……. University search engines. The key words used were: deterioration, critically ill, nurse, recognising, management, evaluation, early warning systems, policies, recommendations, clinical judgments and nurse responsibilities. A total of ……articles were come up to be of use, few of this were published outside the UK. However, through critical evaluation of the data presented it was decided that evidence was relevant and they were considered appropriate to use. Subsequently, 125 article were identify using inclusion and exclusion criteria, year from 2004 and 2014, peer review journals. The search shown the topic had been fairly well researched. However, a further search was undertaken using the terms communication, SBAR and RSCP to bring more concurrent articles. In addition, Department of Health, the National Institute of Clinical Excellence, Patient Safety First, National Patient Safety Agency were useful references.
A case study centred on events witnessed by an author while providing a direct postoperative care to the patient in post anaesthetic care unit (PACU) – Observation Area (OA). This reflective piece of work aim to provide a clear description of the situation with a critical analysis, where other options are considered as well as reflection upon experience to examine what the health care practitioner would do should the situation arise again. In order to maintain confidentiality of the patients, the patient will be referred to as Mrs. Jones (HCPC, 2008; NMC, 2008).
Mrs. Jones, a 32 years old mother, 42+ weeks pregnant was admitted to delivery suite for induction of labour. Due to prolonged labour and fetal bradycardia, Mrs Jones underwent an emergency lower segment caesarean section (LSCS) under combined spinal/epidural anaesthesia (CSE). During surgical procedure patient shown signs of tachycardia (121b/min), being hypertensive (158/75) and with a temperature of 37.6. C.
On admission to the OA, Mrs. Jones was enjoying her healthy baby boy. However, she has remained being hypertensive (155/84) and with elevated temperature of 37.8 C. In order to provide an optimal pain relief the CSE stayed insitu. A junior midwife took over care for Mrs Jones following by handover from anaesthetic and scrub nurse. Later on (1hr), phone call came from OA regarding Mrs Jones heath status and was referred to anaesthetic to review the patient as Mrs Jones became confused, with low oxygen level (92% on RA) and still hypertensive. Due to the emergency case in the theatre, anaesthetist made a request to his colleague from general theatre (10mins away) to review the patient, but meantime send a second anaesthetic nurse to carry out an assessment. Upon arrival of anaesthetic nurse, a systematic approach based on airway, breathing, circulation, disability and exposure (ABCDE) was performed immediately by anaesthetic practitioner to determine and treat (if required) Mrs. Jones.
Upon assessment, it has been noted that Mrs Jones has also developed haematoma around insertion of epidural catheter and continue to bleed (approximately 250ml of blood loss) from insertion point, while junior midwife was unaware of this problem. By following the assessment, the cold compress and pressure was applied to stop the bleeding and concerns were relayed to the second anaesthetist who arrived shortly after. Mrs Jones being promptly examined and medical intervention were given where appropriate and she continuously stayed under a close observation for the next 48hrs.
According to the Health Social Care Information Centre (HSCIC) on the 5th of November 2013, NHS hospitals across England are dealing with 15.1 million admissions a year and rising up to 13% in five years. On average 1.500 patients admitted every day. Patients placed their trust in the healthcare professionals caring for them, believing that appropriate care and prompt actions will be undertaken by medical team if any deterioration in their condition arise.
Unfortunately, this is not always the case. National Institute for Health and Clinical Excellence (NICE) (2007) emphasized that many patients, who are became or acutely ill in the hospital setting may be given suboptimal care due to number of reasons, such as: inability of the medical staff to recognized the signs of deteriorations, late respond, poor communication and documentation, lack and provision of critical care expertise as well as heavy workload. Therefore, NICE and National Safety Patient Agency endeavour of introducing systems to be able assist healthcare professionals to recognise deteriorating patient early and act upon appropriately (NICE, 2007; NPSA, 2007a; 2007b).
An Early Warning Systems (EWS) is known to be critical tool to assist healthcare professionals in recognising patients at risk of deterioration and deliver appropriate managed care. The Department of Health has also emphasized on using EWS system throughout the UK supporting the rationale behind it (DH, 2000). However, Cuthbertson and Smith (2007) argues the effectiveness of EWS, highlighting that further assessments of the use of EWS must be undertaken, ensuring a structured and evidence based approach to their development and evaluation.
The identification and management of early warning signs are critical and perhaps a junior midwife was well aware of that. However, reflecting on the case study it is also important to highlight the importance of a full clinical assessment, and of tailoring the written monitoring and management plans to the individual patient’s clinical circumstances, as well as clear communication strategies, which in this case were unexploited. The ABCDE approach was not been embark on by midwife correctly and concerns were not communicated accurately. Therefore, the clinical management of the patient could be delayed and clinical intervention focused in different clinical area.
Recommendation for Practice
In this paper the reflective analysis on a case study was given to enhanced knowledge and skills of nurses on assessment and evaluation in the care of patients at risk of deterioration.
Nowadays a lot of attention still on emphasising the importance of nursing actions, interventions and ability to timely manage and respond to the early warning signs, use of clinical judgments and communication skills while caring for patient who are at risk of deteriorating. Careful observation and appropriate action must be utilised by nurses and be a fundamental practice rather than a basic task.
Cuthbertson, B and Smith, G (2007) A warning on early-warning scores! British Journal of Anaesthesia. 98 (6), 704-706.
Health Social Care Information Centre (2013) Hospital Episode Statistics, Admitted Patient Care, England – 2012-2013 (NS). Available at: http://www.hscic.gov.uk/article/3674/41500-patients-admitted-to-hospital-every-day-in-England—up-nearly-13-per-cent-in-five-years (assessed on 07/11/14)
National Patient Safety Agency (2007) Recognising and responding appropriately to early signs of deterioration in hospitalised patient. Available at: http://www.npsa.nhs.uk/corporate/news/deterioration-in-hospitalised-patients/?locale=en (assessed on 07/10/14).
National Patient Safety Agency (2007) Safer care for the acutely ill patient: learning from serious incidents. Available at: http://www.npsa.nhs.uk/corporate/news/deterioration-in-hospitalised-patients/?locale=en (assessed on 07/10/14).
National Institute for Health and Care Excellence (2007) Acutely ill patients in hospital: Recognition of and response to acute illness in adults in hospital. Available at: http://www.nice.org.uk/guidance/CG50 (assessed on 07/10/14).
Patient Safety First (2008) The ‘How to Guide’ for reducing harm from deterioration. Available at: http://www.patientsafetyfirst.nhs.uk/ashx/Asset.ashx?path=/How-to-guides-2008-09-19/Deterioration%201.1_17Sept08.pdf (assessed on 07/10/14)