Email this article 
Defining and recognising clinical deterioration in the prehospital setting (PRECLuDE study): a systematic scoping review
DOI: http://dx.doi.org/10.32378/ijp.v5i1.245
Abstract
Introduction
Early identification of high-risk patients in the prehospital environment is crucial as it enables early intervention, transportation, and may determine the trajectory of future care. Although early warning systems (EWS) in-hospital are well established, it remains unclear whether adaptations of these systems can simply be extrapolated to prehospital care. This scoping review aims to explore how the current literature defines and recognises clinical deterioration in the prehospital setting.
Methods
In December 2019, a systematic search of five databases using a combination of terms describing ‘paramedic’, were integrated with terminology relating to ‘recognition’ of ‘clinical deterioration’. Additional reference chaining was also undertaken.
Results
A total of eight papers met the inclusion criteria. Seven out of eight studies included a definition, however these were primarily ad-hoc and fundamentally formed to support the creation of varying EWS. The prevalence of prehospital clinical deterioration is poorly explored in the literature, with only two studies discussing the frequency deterioration (5.1%). Furthermore, studies reported that paramedics were inadequate at identifying clinical deterioration due to medical aetiology by comparison to trauma. Additionally, a number of articles reported an association between clinician experience and recognition of clinical deterioration. As the topic of prehospital clinical deterioration has rapidly moved to focus on the potential implementation of EWS, with few studies providing fundamental description of the concept and its characteristics, there is no standardised operational definition available in the literature. The development of this definition is crucial to assessing clinical deterioration and improving the efficacy of EWS. Not only could this lead to improving early identification of risk factors, but it can lay the foundations for the development of an effective EWS.
Conclusion
This review has found that further quality research in this understated space is warranted to increase understanding and early identification of the deteriorating patient, prevent unnecessary harm, and ultimately, improve patient outcomes.
Keywords
Full Text:
PDFReferences
References
Australian Commission on Safety and Quality Healthcare. Safety and Quality Improvement Guide Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care 2012 [cited 2019 April 02]. Available from: https://www.safetyandquality.gov.au/publications/safety-and-quality-improvement-guide-standard-9-recognising-and-responding-to-clinical-deterioration-in-acute-health-care-october-2012/.
Patel R, Nugawela M, Edwards H, Richards A, Roux H, Pullyblank A, et al. Can early warning scores identify deteriorating patients in pre-hospital settings? A systematic review. Resuscitation. 2018;132:101-11. https://doi.org/10.1016/j.resuscitation.2018.08.028.
Fullerton J, Price C, Silvey N, Brace S, Perkins G. Is the Modified Early Warning Score (MEWS) superior to clinician judgement in detecting critical illness in the pre-hospital environment? Resuscitation. 2012;83:557-62. https://doi.org/10.1016/j.resuscitation.2012.01.004.
Kitahara O, Nishiyama K, Yamamoto B, Inoue S, Inokuchi S. The prehospital quick SOFA score is associated with in-hospital mortality in noninfected patients: A retrospective, cross-sectional study. PLoS ONE. 2018;13(8):1-11. https://doi.org/10.1371/journal.pone.0202111.
Brown E, Bleetman A. Ambulance alerting to hospital: the need for clearer guidance. Emergency Medicine Journal 2006;23:811-4.
Considine J, Rhodes K, Jones D, Currey J. Systems for recognition and response to clinical deterioration in Victorian emergency departments. Australasian Emergency Care. 2018;21(1):3-7. https://doi.org/10.1016/j.auec.2017.12.003.
Schein R, Hazday N, Pena M, Ruben B, Sprung C. Clinical Antecedents to In-Hospital Cardiopulmonary Arrest. Chest Journal. 1990;98(6):1388-92.
Jansen J, Cuthbertson B. Detecting critical illness outside the ICU: the role of track and trigger systems. Current Opinion in Critical Care. 2010;16(3):184-90. https://doi.org/10.1097/MCC.0b013e328338844e.
Quinten V, van-Meurs M, Olgers T, Vonk J, Ligtenberg J, ter-Maaten J. Repeated vital sign measurements in the emergency department predict patient deterioration within 72 hours: a prospective observational study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2018;26(1). http://doi.org/10.1186/s13049-018-0525-y.
Churpek M, Yuen T, Winslow C, Robicsek A, Meltzer D, Gibbons R, et al. Multicenter development and validation of a risk stratification tool for ward patients. Am J Respir Crit Care Med. 2014;190(6):649-55. https://doi.org/10.1164/rccm.201406-1022OC.
Osborne S, Douglas C, Reid C, Jones L, Gardiner G, RBWH Patient Assessment Research Council. The primacy of vital signs acute care nurses' and midwives' use of physical assessment skills: a cross sectional study. International Journal of Nursing Studies. 2015;52(5):951-62. https://doi.org/10.1016/j.ijnurstu.2015.01.014.
Vincent J, Einav S, Pearse R, Jaber S, Kranke P, Overdyk F, et al. Improving detection of patient deterioration in the general hospital ward environment. Eur J Anaesthesiol. 2018;35:325-33.
https://doi.org/10.1097/EJA.0000000000000798.
Felton M. Recognising signs and symptoms of patient deterioration. Emergency Nurse. 2013;20(8):23-7. https://doi.org/10.7748/en2012.12.20.8.23.c9480.
Padilla R, Mayo A. Clinical deterioration: A concept analysis. Journal of Clinical Nursing. 2018;27:1360-8. https://doi.org/10.1111/jocn.14238.
Australian Commission on Safety and Quality in Health Care. National consensus statement: essential elements for recognising and responding to clinical deterioration. Sydney: ACSQHC; 2010.
Cattermole G, Mak SP, Liow CE, Ho MF, Hung KYG, Keung KM, et al. Derivation of a prognostic score for identifying critically ill patients in an emergency department resuscitation room. Resuscitation. 2009;80:1000-5. https://doi.org/10.1016/j.resuscitation.2009.06.012.
Hagiwara MA, Magnusson C, Herlitz J, Seffel E, Axelsson C, Munters M, et al. Adverse events in prehospital emergency care: a trigger tool study. BMC Emergency Care. 2019;19(14):1-10. https://doi.org/10.1186/s12873-019-0228-3.
Evans R, McGovern R, Birch J, Newbury-Birch D. Which extended paramedic skills are making an impact in emergency care and can be related to the UK paramedic system? A systematic review of the literature. Emergency Medicine Journal. 2013;31:594-603. https://doi.org/10.1136/emermed-2012-202129.
Jensen JL, Croskerry P, Travers AH. Paramedic clinical decision making during high acuity emergency calls: design and methodology of a Delphi study. BMC Emergency Medicine [Internet]. 2009; 9(17). https://doi.org/10.1186/1471-227X-9-17.
Dyson K, Bray J, Smith K, Bernard S, Straney L, Finn J. Paramedic Exposure to Out-of-Hospital Cardiac Arrest Resuscitation Is Associated With Patient Survival. Circulation: Cardiovascular Quality and Outcomes. 2016;9(2):154-60. https://doi.org/10.1161/CIRCOUTCOMES.115.002317.
Department of Health. Taking healthcare to the patient, transforming NHS ambulance services. London, 2005.
Andrew E, Nehme Z, Cameron P, Smith K. Drivers of Increasing Emergency Ambulance Demand. Prehospital Emergency Care. 2019;12(1). https://doi.org/10.1080/10903127.2019.1635670.
Schierholtz T, Carter D, Kane A, Kemp O, Gallant C, Sheikh B, et al. Impact of Lift Assist Calls on Paramedic Services: A Descriptive Study. Prehospital Emergency Care. 2019;23(2):233-40. https://doi.org/10.1080/10903127.2018.1483454.
Leggatt L, VanAarsen K, Columbus M, Dukelow A, Lewell M, Davis M, et al. Morbidity and Mortality Associated with Prehospital “Lift-assist” Calls. Prehospital Emergency Care. 2017;21(5):556-62. https://doi.org/10.1080/10903127.2017.1308607.
Lawson P, Richmond C. Emergency problems in older people. Emergency Medicine Journal. 2005;22:370-4. https://doi.org/10.1136/emj.2005.023770.
Barker R, Stocker R, Russell S, Roberts A, Kingston A, Adamson J, et al. Using the National Early Warning Score (NEWS) outside acute hospital settings: a qualitative study of staff experiences in the West of England. Age and Ageing. 2019;49:141-5. https://doi.org/10.1136/bmjopen-2018-022528.
Arksey H, O’Malley L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology. 2005;8(1):19-32. https://doi.org/10.1080/1364557032000119616.
Peters M, Godfrey C, McInerney P, Parker D, Soares C. Methodology for JBI scoping reviews. The Joanna Briggs Institute Reviewers’ Manual. Adelaide: The Joanna Briggs Institute 2015.
Peters M, Godfrey C, McInerney P, Parker D, Soares C. Guidance for conducting systematic scoping reviews. International Journal of Evidence Based Healthcare. 2015;13:141-6. https://doi.org/10.1097/XEB.000000000000050.
Booth S, Bloch M. An evaluation of a new prehospital pre-alert guidance tool. Emergency Medicine Journal. 2012;30:820-3. https://doi.org/10.1136/emermed-2012-201545.
Seymour C, Kahn J, Cooke C, Watkins T, Heckbert S, Rea T. Prediction of critical illness during out-of-hospital emergency care. Journal of American Medical Association. 2010;304(7):747-54. https://doi.org/10.1001/jama.2010.1140.
Suffoletto B, Frisch A, Prabhu A, Kristan J, Guyette F, Callaway C. Prediction of serious infection during prehospital emergency care. Prehospital Emergency Care. 2011;15(3):325-30. https://doi.org/10.3109/10903127.2011.561411.
Boyle M, Smith E, Archer F. A review of patients who suddenly deteriorate in the presence of paramedics. BMC Emergency Medicine. 2008; 8(9). https://doi.org/10.1186/1471-227X-8-9.
Brown R, Warwick J. Blue calls - time for a change? Emergency Medicine Journal. 2001;18:289-92.
Singh J, MacDonald R, Bronskill S, Schull M. Incidence and predictors of critical events during urgent air-medical transport. CMAJ. 2009;181:579-84. https://doi.org/10.1503/cmaj.080886.
National Health and Medical Research Council. NHMRC additional levels of evidence and grades for recommendations for developers of guidelines: Australian Government; 2008 [cited 2019 September 15]. Available from: https://www.mja.com.au/sites/default/files/NHMRC.levels.of.evidence.2008-09.pdf.
Jones D, Mitchell I, Hillman K. Defining clinical deterioration. Resuscitation. 2013;84(8):1029-34. https://doi.org/10.1016/j.resuscitation.2013.01.013.
Olander A, Andersson H, Sundler A, Bremer A, Ljungström L, Hagiwara M. Prehospital characteristics among patients with sepsis: a comparison between patients with or without adverse outcome. BMC Emergency Medicine. 2019;19(43). https://doi.org/10.1186/s12873-019-0255-0.
Beaumont K, Luettel D, Thomson R. Deterioration in hospital patients: Early signs and appropriate actions. Nursing Standard. 2008;23(1):43-8. https://doi.org/10.7748/ns2008.09.23.1.43.c6653.
Tait D. Nursing recognition and response to signs of clinical deterioration. Nursing Management. 2010;17(6):31-5. https://doi.org/10.7748/nm2010.10.17.6.31.c8007.
Subbe CP, Welch JR. Failure to rescue: using rapid response systems to improve care of the deteriorating patient in hospital. Clinical Risk. 2013;19(1):6-11. https://doi.org/10.1177/1356262213486451.
Gerry S, Birks J, Bonnici T, Watkinson P, Kirtley S, Collins G. Early warning scores for detecting deterioration in adult hospital patients: a systematic review protocol. BMJ Open. 2017;7(12):e019268. https://doi.org/10.1136/bmjopen-2017-019268.
Doyle D. Clinical early warning scores: New clinical tools in evolution. The Open Anesthesia Journal. 2018;12:26-33. https://doi.org/10.2174/258945801812010026.
Martin-Rodriquez F, Castro-Villamor M, del Pozo Vegas C, Martin-Conty J, Mayo-Iscar A, Delgado Benito J, et al. Analysis of the early warning score to detect critical or high-risk patients in the prehospital setting. Internal and Emergency Medicine. 2019;14(4):581-9. https://doi.org/10.1007/s11739-019-02026-2.
Queensland Health. Queensland-designed patient safety tools go global Queensland Health; 2017 [cited 2018 30 May]. Available from: https://www.health.qld.gov.au/news-alerts/doh-media-releases/releases/queensland-designed-patient-safety-tools-go-global.
Scott L, Redmond N, Garrett J, Whiting P, Northstone K, Pullyblank A. Distributions of the National Early Warning Score (NEWS) across a healthcare system following a large-scale roll-out. Emergency Medicine Journal. 2019;36:287-92.
Brangan E, Banks J, Brant H, Pullyblank A, LeRoux H, Redwood S. Using the National Early Warning Score (NEWS) outside acute hospital settings: a qualitative study of staff experiences in the West of England. BMJ Open. 2018;8. https://doi.org/10.1136/bmjopen-2018-022528.
Scott L, Redmond N, Garrett J, Whiting P, Northstone K, Pullyblank A. Distributions of the National Early Warning Score (NEWS) across a healthcare system following a large-scale roll-out. Emerg Med J. 2019;36:287-92. https://doi.org/10.1136/emermed-2018-208140.
Silcock D, Corfield A, Gowens P, Rooney K. Validation of the National Early Warning Score in the prehospital setting. Resuscitation. 2015;89:31-5. https://doi.org/10.1016/j.resuscitation.2014.12.029.
Considine J, Rawet J, Currey J. The effect of a staged, emergency department specific, rapid response system on reporting of clinical deterioration. Australian Emergency Nursing Journal. 2015;18(4):218-26. https://doi.org/10.1016/j.aenj.2015.07.001.
Scott B, Considine J, Botti M. Unreported clinical deterioration in emergency department patients: a point prevalence study. Australian Emergency Nursing Journal. 2015;18(1):33-41. https://doi.org/10.1016/j.aenj.2014.09.002.
Dawson S, King L, Grantham H. Review article: Improving the hospital clinical handover between paramedics and emergency department staff in the deteriorating patient. Emergency Medicine Australasia. 2013;25:393-405. https://doi.org/10.1111/1742-6723.12120.
DOI: http://dx.doi.org/10.32378/ijp.v5i1.245
Refbacks
- There are currently no refbacks.
Copyright (c) 2020 Emma Bourke-Matas, Emma Bosley, Paul Gowens, Karen Smith, Kelly-Ann Bowles
This work is licensed under a Creative Commons Attribution 4.0 International License.
IJP is an Open Access journal and articles published are distributed under the terms of the Creative Commons Attribution 4.0 International (CC BY 4.0) licence. Article copyright remains with individual authors. Authors grant unrestricted copyright license to the IJP. Readers may copy, distribute, build upon, reproduce, and display the work with the proper citation of the original work in this publication.
DPLA Rights statement:http://rightsstatements.org/page/InC-NC/1.0/?language=en. The IJP supports the National Principles for Open Access Policy Statement.