Failure to Appreciate Deteriorating Clients

The positive impact of early identification and management of client deterioration on clinical outcomes is well documented. The vast majority of catastrophic events are preceded by periods of physiological deterioration that is evident in vital signs prior to the event, such as temperature, heart rate (pulse), respiratory rate, blood pressure, oxygen saturation, and level of consciousness. Skill, knowledge, and practical experience of the provider is needed to support the rapid collection and integration of multiple clinical findings. Often, family members identify changes in the client’s behaviour such as alertness, level of awareness, as well as restlessness and / or agitation. Closely monitoring physiologic and behavioural changes, maintaining adequate level of observation, conducting appropriate risk assessments, and engaging family in consultations and communications are key to managing this risk. 

Expected Outcomes

Implement standardized evidence-based protocols and strategies to enhance early identification and management of client deterioration in all care settings. 

Cultivate a work environment that supports assertive and respectful:
o        Questioning and challenging of care decisions;
o        Facilitates appropriate workload;
o        Addresses critical alarm and alert fatigue.

Implement formal strategies to provide ongoing and targeted education and training to support and enhance the interdisciplinary team’s clinical knowledge, skills (technical and non-technical), and practical experience surrounding the prevention, recognition, and response to clinical deterioration.

Definitions and Acronyms

• Client – includes all persons who receive healthcare and related services including patients, residents and persons in-care
• Cross monitoring – safety feature that expects each team member to monitor each other’s task execution or behaviours and provide immediate and collegial feedback
• ED – emergency department
• Medical directive – an indirect order that gives authorization to a care provider or group of care providers (e.g., ED nurses) to implement the order (e.g., ED chest pain for adults) with a predefined client population (e.g., ED clients presenting with symptoms suggestive of cardiac ischemia or cardiovascular symptoms such as discomfort jaw to umbilicus, upper limb discomfort without known injury, chest trauma…)
• MRP – most responsible practitioner, often a nurse practitioner, midwife or physician
• Situational awareness – deliberate and active scanning and assessing of the situation to maintain a holistic understanding of the environment in which the team is functioning
• Virtual care - any interaction between clients and / or members of their circle of care that occurs remotely, using any forms of communication or information technology, with the aim of facilitating or maximizing the quality and effectiveness of client care (Canadian Institute for Health Information, 2022)

Common Claims Themes and Contributing Factors

Organization

• Rigid hierarchical structure impacting effective and timely communications and collaboration.
• Human healthcare resources impacting early identification, response, and resolution of a deteriorating client.
• Perceived and actual tolerance of unprofessional, unsafe, and / or disruptive behaviour as well as ongoing intra- and inter-disciplinary conflicts impacting team communication and safe delivery of care.
• Uncoordinated or disorganized codes (cardiac arrest) and resuscitation efforts.
• Distrust or misunderstanding of the:
  • Escalation protocol; 
  • Situational awareness and cross-monitoring activities;
  • Medical directives.
• Suboptimal facility and space designs i.e., design and space are not conducive to monitoring, observing, and treating clients at increased risk of physical or mental health deterioration.

Knowledge and Judgement

• Failure to or delay in identifying, assessing, and responding to early signs of deterioration, in particular related to sepsis and neurological deterioration. 
• Non-compliance with ED triage guidelines and inadequate history taking (e.g., circumstances of the accident and mechanism of injury) resulting in underestimation of the client's acuity level.
• Ignored or bypassed physiological alarms and alerts due to alarm fatigue and practitioner annoyance, including those monitored centrally.
• Normalizing and decreased vigilance over time towards:
  • Signs and symptoms of clinical deterioration; 
  • Clients’ response to interventions.
• Frequency of assessments and vitals is not adjusted as clinically indicated.
• Failure to implement orders (direct orders, care directives, and medical directives), particularly during the immediate post-operative period for clients in neuro-critical units (e.g., Q15 neuro assessments), intensive care units, and post-operative anesthetic units.

Communication 

• Hesitancy to relay information about deteriorating clients and / or escalate concerns about unsafe orders, practices and practitioners (including practitioners in leadership role) due to fear of criticism amongst the intra- and inter-disciplinary team members and leadership.
• Disagreement among the healthcare team as to when and whether:
  • Orders and changes to orders were provided;  
  • A report and / or consultation took place.
• Informal consultations, discussions, and orders surrounding a deteriorating client later disputed by one of the team members.
• Delays communicating status changes to the MRP, particularly overnight and early morning (e.g., wait until change of shift or morning rounds).
• Dismissal of or failure to act upon client and family concerns (e.g., agitation, pain, odd behaviour).
• Delays in calling code blue or resuscitation team.

Documentation

• Suspicious and self-serving late entries created following adverse events, in particular to clarify or defend why an order or care was not provided as per local guidelines.
• Inconsistent documentation of:
  • Scheduled and periodic checks, vital signs, and assessments, particularly overnight; 
  • Reports to and consults with the MRP and / or on-call practitioners;
  • Verbal orders;
  • Actions taken in response to unremediated or ongoing care concerns;
  • Resuscitation efforts.

Mitigation Strategies

Care Processes

• Implement standardized evidence-based protocols that address the frequency, components, and documentation of client assessments, vital signs monitoring, and trending of values including client -specific criteria for adjustments to the frequency of monitoring.
• Implement evidence-based practices to facilitate the appropriate practitioner skills mix and scope of practice in client assignments to complement client volumes and acuity; consider workload in addition to practitioner-to-client ratio during client assignments (Acar & Butt, 2016) (Allen, 2015) (Ball, et al., 2018) (Chen, et al., 2021) (Registered Nurses’ Association of Ontario, 2017) (Simpson, Whitt, & Berger, 2021).
• Adopt a standardized and formalized on-call and second on-call / contingency protocol for the rapid response for when the MRP, physician consultant, resuscitation team, or surgical team does not respond or is unable to respond in a clinically appropriate timeframe; ensure the protocol is updated based on human health resource changes and challenges (Canadian Medical Protective Association, 2022) (College of Physicians and Surgeons of BC, 2021) (Canadian Medical Protective Association, 2023).
• Implement formal evidence-based strategies to enhance the early detection of clinical deterioration across all sites and programs, such as (Burke, Downey, & Almoudaris, 2022):
  • Client and family-initiated escalations of care systems;
  • Practitioner activated early warning scoring systems;
  • Automated early warning score systems. 
• Implement formal strategies to increase the ready access to clinical protocols and policies (e.g., easy to access algorithms or decision trees to accompany the more comprehensive protocol; key word searches to facilitate searches for policies regardless of the sponsoring domain).

Health Equity

• Where utilized, implement formal strategies to review clinical policies / procedures / guidelines / algorithms and practices that use race as a ‘correction factor’ (Vyas, Eisenstein, & Jones, 2020) (Kane, Bervell, Zhang, & Tsai, 2022) (Becker, 2021) (Cerdena, Plaisime, & Tsai, 2020) (Neal & Morse, 2021) (Ibrahim & Pronovost, 2021).
• Implement strategies to enable access to interpreter services during (but not limited to) client and family engagement in care planning, shared decision making (informed choice-informed consent), education / training, and discharge.
• Where in place, adopt best practices for providing virtual care; ensure the framework, protocols, and practices align with applicable national, provincial / territorial and discipline-specific guidelines and standards (Hall, et al., 2022) (Health Canada, 2021) (Canadian Institute for Health Information, 2022) (Health Canada, 2021) (Task Team on Equitable Access, 2021) (Shuldiner, Srinivasan, Hall, May, & Desveaux, 2022).

Safety Culture

• Implement formal strategies to develop and maintain a work environment which supports and expects:
  • Early response to suspected and actual clinical deterioration, including seeking assistance from peers and other resources (e.g., rapid response teams);
  • Assertive and respectful questioning and challenging of care decisions (in order to obtain clarity and / or to advance client safety concerns);
  • Zero tolerance of intra- and inter-disciplinary bullying and intimidation (Burke, Downey, & Almoudaris, 2022) (Canadian Medical Protective Association, 2021a) (Canadian Patient Safety Institute, 2020a) (Smith, Wells, Friese, Krein, & Ghaferi, 2018).
• Adopt a standardized, formalized, and program-specific chain of command (escalation) protocol for the rapid escalation of unresolved care concerns or disagreements related to concerns about questionable client conditions, orders or care delivery (Canadian Medical Protective Association, 2021a) (Canadian Patient Safety Institute, 2020a) (Royal College of Nursing, 2020) (Canadian Patient Safety Institute, 2020b).

Strategies for Emergency Departments

• Adopt a formal and standardized triage acuity scale(s) (e.g., CTAS) to assist in prioritizing of adult and paediatric client care needs (Bullard, et al., 2017).
• Implement formal strategies to facilitate the reliable reassessment and treatment (if indicated) of triaged clients in waiting areas aligned with their CTAS and / or evolving acuity level.
• Implement formal tracking and follow-up strategies to ensure laboratory and diagnostic testing ordered are completed according to order requirements (Canadian Medical Protective Association, 2021b).
• Adopt a formal best practice protocol to ensure reliable follow-up with clients who have been triaged and left the ED without being seen by a physician or nurse practitioner.
• Adopt best practices for the optimal management of ambulance to hospital offload process (Bain, et al., 2022).

Medical Directives

• Where utilized, adopt evidence-based / best practices to support the development and implementation of medical directives, that include (but not limited to) ensuring:
  • The delegation aligns with provincial / territorial medical and health profession regulatory body standards and scopes of practice;
  • All delegating practitioners are aware of the medical directive and their individual professional accountability associated with the delegation (College of Physicians and Surgeons of Ontario, 2021) (College of Physicians and Surgeons of Ontario, n.d.) (HIROC, 2018).

Facility Design, Space and Security

Strategies for Emergency Departments and General Medical-Surgical Units

• In collaboration with mental health subject matter experts, adopt a best practice mental health environmental hazards checklist for areas/spaces/rooms used to assess or hold / board at risk mental health clients (OHA Task Force on Suicide Prevention, 2017).

Communication

• Adopt a standardized and structured communication framework for intra- and inter-disciplinary team communication (e.g., SBAR). 
• Adopt a standardized and formalized communication process for handovers and transfer of accountability care:
  • Between units, department, and sites;
  • Between care providers;
  • During interfacility transfer.
• Implement strategies to facilitate timely communication to the MRP or physician consultant in the presence of clinical deterioration.
• Implement formal strategies to discourage informal (curbside, hallway chats, heads-up, etc.) reports or consultations with the MRP or other team members (Canadian Medical Protective Association, 2019a) (Chesanow, 2017) (Ownby, 2018).

Documentation

Strategies for Clinical Leadership

• Implement formal strategies to monitor, measure, and improve documentation of client assessments, vital signs, and team communications (Bunting & de Klerk, 2022) (HIROC, 2017).

Strategies for Healthcare Providers

• Ensure complete and timely documentation of:
  • Client assessments and vitals (all, not some), response to interventions, and actions taken; 
  • Client refusals or informed declines (e.g., declined assessment or recommended testing);
  • Utilization of a medical directives (e.g., name of initiator, directive name and / or number, and date time initiated, follow-up on ordered tests);
  • Client teaching and discharge instructions provided (including the name of or copy of printed / electronic discharge instructions);
  • Action taken in response to clients leaving without being seen, leaves against medical advice, and elopements;
  • All scheduled and ad hoc client assessments, checks, and rounds in particular for clients at risk for self-harm or harm to third parties;
  • Reports to and consultation with MRPs (e.g., name of the MRP, date and time the report or consult took place, the level of urgency and concern communicated, the MRP’s anticipated and actual attendance time, orders and recommendations, changes to the care pathway or plan).

Laboratory and Diagnostic Imaging Processes

• Adopt a structured best practice process to support the reliable follow-up on laboratory and diagnostic imaging test results for clients who have been discharged to another unit, site, facility, and / or home when one or more tests results is pending (Canadian Medical Protective Association, 2019b) (Darragh, et al., 2018).

Team Training and Education

• Implement formal strategies to support and enhance the team’s clinical knowledge, skills (technical and non-technical), and practical experience surrounding (but not limited to):
  • Effective practitioner-client communications;
  • Prevention, recognition, and response to clinical deterioration;
  • Escalation of care concerns or care disagreements (chain of command), situational awareness, and psychological safety in the work environment;
  • Shared decision making (informed choice-informed consent) including informed declines;
  • Medical directives (e.g., professional obligations for the delegator and delegate);
  • Anticipated and unanticipated client volume and acuity surges.
• Ensure the scheduled interprofessional and cross-department team training and education strategies consider or involve: 
  • Scheduled interprofessional and cross-department skill drills and simulations;
  • Care providers, programs, areas, or sites with limited experience or opportunities for team based learning; 
  • Unregulated care providers, sitters, locums, travel, agency, contracted care providers in addition to regulated health professions (Smith, Wells, Friese, Krein, & Ghaferi, 2018).

Equipment, Supplies and Technology

• Implement formal strategies to ensure intermittent and continuous physiological monitors are not used as a replacement for bedside observations and assessments (where indicated) and vital sign monitoring.
• Implement formal strategies to:
  • Reduce critical alarm and alert fatigue; 
  • Improve the effectiveness and efficacy of centralized physiological monitoring (where in place).

Monitoring and Measurement

• Adopt a standardized, interdisciplinary, collaborative, and evidence-based protocol for conducting quality of care reviews involving clinical deterioration resulting in client harm or death; incorporate system thinking and human factors concepts into the review process (Burke, Downey, & Almoudaris, 2022) (Amaniyan, Faldaas, Logan, & Vaismoradi, 2020) (Incident Analysis Collaborating Parties, 2012) (Royal College of Emergency Medicine, 2019) (Layani, et al., 2016) (Machen, 2023).
• Implement formal strategies to monitor and measure the effectiveness of, and adherence to:
  • Escalation and chain of command protocols (e.g., do staff feel safe and supported when raising concerns);
  • On-call and second on-call / contingency plans;
  • MRP and consultant’s attendance and response times to requests for a consult or attendance;
  • Utilization of medical directives (O’Neill, et al., 2021).
• Incorporate learning from local, provincial, and national safety incidents and data related to clinical deterioration into local protocols as well as staff and client education and training.  

References

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