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Attitudes of emergency department physicians and nurses toward implementation of an early warning score to identify critically ill patients: qualitative explanations for failed implementation

  • Blair L. Bigham (a1), Teresa Chan (a1), Steven Skitch (a1) and Alison Fox-Robichaud (a2)

Abstract

Background

Sepsis, a common, time-sensitive condition, is sometimes not identified at emergency department (ED) triage. The use of early warning scores has been shown to improve sepsis-related screening in other settings.

Objectives

Our objective was to elucidate nurse and physician perceptions with the Hamilton Early Warning Score (HEWS) in combination with the Canadian Triage Acuity Scale.

Method

Semi-structured interviews were conducted with nurses, resident physicians and attending physicians to explore perceived feasibility, utility, comfort, barriers, successes, opportunities and accuracy. A constructivist grounded theory approach was used. Transcripts were coded into thematic coding trees.

Results

The twelve participants did not value the HEWS in the ED because they felt it was not helpful in identifying critically ill patients. We identified five themes; knowledge of sepsis and HEWS, utility of HEWS in emergency triage, utility of HEWS at the bedside, utility in communicating acuity and deterioration, and feasibility and accuracy of data collection. We also found 9 barriers and 7 enablers to the use of early warning score in the ED.

Conclusions

In our emergency departments, we identified potential barriers to implementation of an early warning score. A pre-existing expertise and lexicon related to critically ill patients lessens the perceived utility of an EWS in the ED. Understanding these cultural barriers needs to be addressed through change theory and implementation science.

Contexte

Il arrive parfois que la sepsie, une affection fréquente, qui exige un traitement rapide, passe inaperçue au moment du triage au service des urgences (SU). L’application d’une échelle de détection de signes précoces a permis d’améliorer le dépistage de la sepsie dans d’autres milieux.

Objectif

L’étude visait donc à dégager les perceptions qu’avaient le personnel infirmier et le personnel médical de l’échelle Hamilton Early Warning Score (HEWS) en association avec l’Échelle canadienne de triage et de gravité.

Méthode

L’étude consistait en des entretiens semi-directifs avec des infirmières, des résidents et des médecins traitants afin de recueillir leurs perceptions de l’échelle à différents égards : la faisabilité, l’utilité, la facilité, les obstacles, les réussites, les possibilités et l’exactitude. Les chercheurs ont fait appel à une démarche théorique fondée sur le constructivisme, et la transcription des échanges a nécessité l’utilisation d’arbres de codage thématique.

Résultats

Les participants, au nombre de 12, estimaient que l’échelle HEWS n’était pas utile au SU parce qu’elle ne les aidait pas à reconnaître les patients gravement malades. Les auteurs ont dégagé 5 thèmes : la connaissance de la sepsie et de l’échelle HEWS, l’utilité de l’échelle durant le triage au SU, l’utilité de l’échelle au chevet du patient, l’utilité de l’échelle dans la communication du degré de gravité et de détérioration de l’état du malade ainsi que la faisabilité et l’exactitude de la collecte de données. Ont également été relevés 9 obstacles à l’application de l’échelle de détection de signes précoces au SU et 7 facteurs facilitants.

Conclusions

L’étude a permis de relever des obstacles possibles à l’application de l’échelle de détection de signes précoces dans les SU concernés. Une bonne connaissance préalable des signes de gravité et l’utilisation d’un lexique en la matière ont atténué la perception du degré d’utilité de ce type d’échelle au SU. Il faudrait recourir à la théorie des changements et à la science de la mise en œuvre pour mieux comprendre et traiter les obstacles de type culturel.

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Copyright

Corresponding author

Correspondence to: Dr. Blair L. Bigham, Department of Medicine, Division of Emergency Medicine, McMaster University, 1280 Main Street W, Hamilton, ON L8S 4L8; Email: blair.bigham@medportal.ca

References

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1.Smith, GB, Prytherch, DR, Meredith, P, Schmidt, PE, Featherstone, PI. The ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and death. Resuscitation 2013;84(4):465-470.10.1016/j.resuscitation.2012.12.016
2.Tam, B, Xu, M, Kwong, M, et al. The admission Hamilton Early Warning Score (HEWS) predicts the risk of critical event during hospitalization. Can J Gen Int Med 2016;11(4):24-27.
3.Martin, CM, Priestap, F, Fisher, H, et al. STAR Registry Investigators. A prospective, observational registry of patients with severe sepsis: the Canadian Sepsis Treatment and Response Registry. Crit Care Med 2009;37(1):81-88.10.1097/CCM.0b013e31819285f0
4.Gaieski, DF, Mikkelsen, ME, Band, RA, et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit Care Med 2010;38(4):1045-1053.10.1097/CCM.0b013e3181cc4824
5.Keep, JW, Messmer, AS, Sladden, R, et al. National early warning score at Emergency Department triage may allow earlier identification of patients with severe sepsis and septic shock: a retrospective observational study. Emerg Med J 2016;33(1):37-41.10.1136/emermed-2014-204465
6.Churpek, MM, Snyder, A, HanX, MD X, MD, et al. Quick Sepsis-related Organ Failure Assessment, Systemic Inflammatory Response Syndrome, and Early Warning Scores for Detecting Clinical Deterioration in Infected Patients outside the Intensive Care Unit. Am J Respir Crit Care Med 2017;195(7):906-911.10.1164/rccm.201604-0854OC
7.Skitch, S, Tam, B, Xu, M, et al. Examining the utility of the Hamilton early warning scores (HEWS) at triage: Retrospective pilot study in a Canadian emergency department. CJEM 2018;20(2):266-274.10.1017/cem.2017.21
8.Charmaz, K. Constructing grounded theory, 2nd ed. Thousand Oaks: Sage; 2014.
9.Kolb, SM. Grounded theory and the constant comparative method: valid research strategies for educators [JETERAPS]. J Emerg Trends Educ Res Policy Stud 2012;3(1):83-86.
10.Sibbald, M, Sherbino, J, Preyra, I, et al. Eyeballing: the use of visual appearance to diagnose ‘sick’. Med Educ 2017;51(11): 1138-1145.10.1111/medu.13396
11.Rohacek, M, Nickel, CH, Dietrich, M, Bingisser, R. Clinical intuition ratings are associated with morbidity and hospitalisation. Int J Clin Pract 2015;69(6):710-717.10.1111/ijcp.12606
12.Cabrera, D, Thomas, JF, Wiswell, JL, et al. Accuracy of ‘my gut feeling:’ comparing system 1 to system 2 decision-making for acuity prediction, disposition and diagnosis in an academic emergency department. West J Emerg Med 2015;16(5):653-657.10.5811/westjem.2015.5.25301
13.Goulet, H, Guerand, V, Bloom, B, et al. Unexpected death within 72 hours of emergency department visit: were those deaths preventable? Crit Care 2015;19:154.10.1186/s13054-015-0877-x
14.Bilben, B, Grandal, L, Søvik, S. National Early Warning Score (NEWS) as an emergency department predictor of disease severity and 90-day survival in the acutely dyspneic patient - a prospective observational study. Scand J Trauma Resusc Emerg Med 2016;24(1):80.10.1186/s13049-016-0273-9
15.Hiroc. Risk Reference Sheet 2016 [HIROC data]. Available at: https://www.hiroc.com/getmedia/0defd95d-0c43-4659-b4ff-12b23ae100be/6_Inadequate-Triage.pdf.aspx?ext=.pdf (accessed November 2017).
16.Callen, J, Braithwaite, J, Westbrook, JI. The importance of medical and nursing sub-cultures in the implementation of clinical information systems. Methods Inf Med 2009;48(2):196-202.

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Attitudes of emergency department physicians and nurses toward implementation of an early warning score to identify critically ill patients: qualitative explanations for failed implementation

  • Blair L. Bigham (a1), Teresa Chan (a1), Steven Skitch (a1) and Alison Fox-Robichaud (a2)

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