We conducted 58 interviews from February through June 2017. Table 1 describes the number of interview subjects by care area and role. Direct care nursing refers to General Care, Post Anesthesia Care Unit (PACU), and Surgical Intensive Care Unit (SICU) nurses. These nurses hold primary responsibility for their assigned patient’s care and are considered the first line at the bedside. Consultation services include Life Safety nurses and Respiratory Therapists (RT). Life Safety nurses are ACLS and PALS certified critical care RNs, who are the first tier of the hospital’s Rapid Response Team (RRT). A Life Safety Consult may be initiated by a frontline nurse whereby a Life Safety nurse comes to the bedside for assessment and provides necessary critical care and referral to a higher level of care. At the physician level, house officers are comprised of interns and residents, designated by their post-graduate year (PGY).
Table 2 provides representative examples of facilitators and barriers to recognition of patient deterioration or complication by clinician type. The primary concepts identified within the recognition domain include 1) use of existing technology to aid in recognition of decline, 2) importance of staff experience level, and 3) acting on clinical intuition alone without supporting physiologic data.
The use of technology that aids in detection of patient deterioration was a common point of emphasis across clinicians. There was uniform agreement that these tools are helpful, but that they do not replace the importance of visual and physical assessment of patients. For example, PACU nurses commented on this socio-technical relationship, reflecting on both alarms being sensitive to alert when vital signs change and having nurses available with their eyes on the patients 24/7 to detect decline.
Respondents cited the importance of staff experience level is for identifying important problems and knowing when to call for help. General care nurses specifically noted that the majority of staff on the floor are inexperienced”both nurses and house officers. An Attending Surgeon stated the barrier is that both the direct care nurse and the junior house officer are the team members with the least amount of experience, yet they are the keystone to early recognition. Some noted the importance of allowing new staff to have teachable moments, however, when issues of patient safety arise, experienced level staff have to intervene and escalate care accordingly.
Clinical intuition is developed over years of experience and may not have traditional physiologic data that accompanies it. Clinicians cited difficulty in appropriately communicating development of a hunch or gut feeling of potential patient deterioration. For example, general care nurses reflected on hesitating to call when an issue first started to develop. They still felt the need to allow the issue to develop further before calling the surgeon or life safety team. Also, while junior house officers described having suspicions that their patient was not doing well, they deferred to the opinions of their senior resident, which may be delayed.
Table 3 provides representative examples of communication processes, such as handoffs and communication hierarchies that influence the rescue process. The primary concepts identified include 1) the availability of the primary and consulting services, 2) how well information was relayed and received in report, and 3) the involvement of staff during rounding.
The ability of primary and consulting services to connect with the direct care nurse was consistently described as a key barrier to early detection of deterioration. For example, general care nurses reported the unavailability of consultation and specialty services to meet face to face to discuss individual patients would often leave the nurse to communicate crucial information in an unstructured, ad-hoc manner. Nuances of patient concerns across providers could be lost in these circumstances.
The quality of information exchange during routine patient handoffs or discussions relied on three factors: 1) the clinician relaying the information, 2) the clarity of expectations or orders, and 3) the platform used to communicate. For example, nurses and RTs cited the need for physician to physician communication regarding escalation of care. Recommendations for escalation from nurses and RTs were taken into consideration, but not necessarily acted upon immediately. Also, more precise and clear instructions from physicians on postoperative care pathways proved invaluable to managing patients and detecting early deviation from the expected course. Finally, physicians and others cited verbal communication via telephone or in-person as key to effective communication of concerns or plans.
Many respondents also noted the importance of shared rounding and the presence of frontline staff to effective communication. For example, house officers and SICU nurses described rounds as a time for discussion and interdisciplinary contributions to the care plan. In particular, they noted the tension between both the immense value and logistic difficulty in interdisciplinary rounds for complex patients. Specifically nurses felt this poorly coordinated communication process may result in potential missed opportunities for early detection.
Table 4 provides representative examples of the timely accessibility of appropriate clinicians involved in a patient’s care. The primary concepts identified include 1) ability to contact the patient’s primary decision-making clinician, 2) day of week and shift related staff availability, and 3) response times based on the position of who calls.
Clinicians reported barriers in the ability to contact the appropriate clinician responsible for decision making in a timely and efficient manner. General care and PACU nurses expressed that while access to urgent or emergent services like Life Safety or rapid response teams were excellent, the accessibility of the surgical provider or team often delayed care. Determination of the primary team by frontline clinicians was not always clear and resulted in frustration and delay. For example, if all interns were in the operating room, the general care nurses could not determine who the covering provider was. This seemingly routine step in communication was also highlighted by attending surgeons who found similar barriers in contacting consulting services.
A distinct and important factor in accessibility of providers was the day of week and shift. Uniformly, clinicians reported barriers to accessing staff and resources on weekends and during the night shift. Even in high acuity setting such as the SICU, nurses reported ease in getting a hold of a staff member on a week day or during the day shift, but significant difficulty on nights and weekends. House officers reported needing to alter their practices and adapt to having fewer people and resources during these off hours and days.
When contacting clinicians, response times varied according to the perceived positional status of the caller. Some staff reported that all concerns were not weighted equally when expressed by general care nurses versus PACU or Life Safety nurses. For example, PACU and Life Safety nurses reported receiving more respect from other staff solely based on their title. Interns and residents responded to Life Safety nurses with urgency, ensuring they were readily available by pager and responsive at the bedside.
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