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Dissertations / Theses on the topic 'Patient Deterioration'
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Ciccarelli, Gregory Alan. "Early warning of patient deterioration in the inpatient setting." Thesis, Massachusetts Institute of Technology, 2013. http://hdl.handle.net/1721.1/100870.
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Thesis (S.M.)--Massachusetts Institute of Technology, Dept. of Electrical Engineering and Computer Science, 2013.Cataloged from PDF version of thesis.
Includes bibliographical references (p. 161-166).
Early signs of patient deterioration have been documented in the medical literature. Recognition of such signs offers the possibility of treatment with sufficient lead time to prevent irreversible organ damage and death. Pediatric hospitals currently utilize simple, human evaluated rubrics called early warning scores to detect early signs of patient deterioration. These scores comprise subjective (patient behavior, clinician's impression) and objective (vital signs) components to assess patient health and are computed intermittently by the nursing staff. At Boston Children's Hospital (BCH), early warning scores are evaluated at least every four hours for each patient. Many hospitals monitor inpatients continuously to alert caregivers to changes in physiological status. At BCH, each hospital bed is equipped with a bedside monitor that continuously collects and archives vital sign data, such as heart rate, respiration rate, and arterial oxygen saturation. Continuous access to these physiological variables allows for the definition of a continuously evaluated early warning score on a reduced rubric. This thesis quantitatively assesses the performance of BCH's current Children's Hospital Early Warning Score (CHEWS). We also apply several standard machine learning approaches to investigate the utility of automatically collected bedside monitoring trend data for prediction of patient deterioration. Our results suggest that CHEWS offers at least a 6-hour warning with sensitivity 0.78 and specificity 0.90 but only with a prohibitively large uncertainty (48 hours) surrounding the time of transfer. Performance using only standard bedside trend data is no better than chance; improvement may require exploiting additional intra-beat features of monitored waveforms. The full CHEWS appears to capture significant clinical features that are not present in the monitoring data used in this study.
by Gregory Alan Ciccarelli.
S.M.
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Hann, Alistair. "Multi-parameter monitoring for early warning of patient deterioration." Thesis, University of Oxford, 2008. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.670068.
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O'Leary, Jessica A. "Recognising paediatric deterioration in a simulated environment." Thesis, Queensland University of Technology, 2015. https://eprints.qut.edu.au/84892/1/Jessica_O%27Leary_Thesis.pdf.
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This thesis examined the impact of high fidelity patient simulation on paediatric critical care nurses' self-efficacy and knowledge for recognising and responding to paediatric deterioration. This research highlights the positive effect simulation education can have on nursing learning outcomes which may influence patient safety through the timely recognition and management of the deteriorating child.
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Harris, Norma Patricia. "Preparing Novice Nurses for Early Recognition Acute Deterioration." ScholarWorks, 2018. https://scholarworks.waldenu.edu/dissertations/6039.
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Hospitalized patients increasingly present with complex health issues that place them at risk for acute patient deterioration (APD). Novice nurses are ill-equipped with the critical clinical skills to function competently in recognizing APD, placing patients at risk for negative health outcomes. This project addressed the need to educate novice nurses to recognize APD and answered the project focused questions that asked if an educational intervention with high-fidelity simulation (HFS) would improve nurse knowledge and clinical confidence in recognizing APD. Benner's novice-to-expert and the constructivism theory were used to guide the project. Based upon a review of the literature, the HFS was developed to provide scenarios in which participants would view APD evolving case studies and demonstrate knowledge and skill for caring for patients with APD. A convenience sample of 11 novice nurses participated in the pre- and posttest design project to determine if knowledge and clinical competence increased. Data from the HFS program were analyzed; results showed no statistically significant change in knowledge or confidence post intervention (p = 0.441). A larger sample size is recommended for future HFS interventions at the site to determine if the program of education will increase knowledge and clinical confidence with future iterations of HFS. The project has the potential to promote positive social change as novice nurses learn to recognize and respond to APD and as APD events are reduced.
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Sosa, Tina M. D. "Optimizing Situation Awareness to Identify and Mitigate Inpatient Clinical Deterioration." University of Cincinnati / OhioLINK, 2021. http://rave.ohiolink.edu/etdc/view?acc_num=ucin1623242068876986.
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Hogg, George. "Can meso-level simulation increase medical students' confidence in recognising and responding to clinical deterioration in adult hospital patients?" Thesis, University of Dundee, 2015. https://discovery.dundee.ac.uk/en/studentTheses/43c02b4e-6b99-48ec-a49e-b44ced566206.
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Recognising Acute Deterioration: Active Response (RADAR) is a simulation based teaching session using simulated patients to portray acutely unwell adult hospital patients. The genesis, development and progress of RADAR will be discussed along with the findings of questionnaires and focus groups from two further cycles of action research. Readers will become aware of the impact which RADAR makes to the evidence and learning surrounding the recognition and assessment of clinical deterioration in adult hospital patients. The study investigated the impact of simulation on medical students’ confidence in recognising and responding to clinical deterioration in adult hospital patients using simulation, simulated patients and moulage (make-up).
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Khalid, Sara. "Data fusion models for detection of vital-sign deterioration in acutely ill patients." Thesis, University of Oxford, 2014. http://ora.ox.ac.uk/objects/uuid:b8e13f5b-065c-4d2d-a8dc-d231109194f4.
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Vital signs can indicate patient deterioration prior to adverse events such as cardiac arrest, emergency admission to the intensive care unit (ICU), or death. However, many adverse events occur in wards outside the ICU where the level of care and the frequency of patient monitoring are lower than in the ICU. This thesis describes models for detection of deterioration in acutely ill patients in two environments: a step-down unit in which patients recovering from an ICU stay are continuously monitored, and a general ward where patients are intermittently monitored following upper gastrointestinal cancer surgery. Existing data fusion models for classification of vital signs depend on a threshold which defines a “region of normality”. Bradypnoea (low breathing rate) and bradycardia (low heart rate) are relatively rare, and so these two types of abnormalities tend to be misclassified by existing methods. In this thesis, techniques for selecting a threshold are described, such that the classification of vital-sign data is improved. In particular, the proposed approach reduces the misclassification of bradycardia and bradypnoea events, and indicates the type of abnormality associated with the deterioration in a patient’s vital signs. Patients recovering from upper gastrointestinal (GI) surgery have a high risk of emergency admission to the ICU. At present in the UK, most intermediate and general wards outside the ICU depend on intermittent, manual monitoring using track-and-trigger systems. Both manual and automated patient monitoring systems are reported to have high false alert rates. The models described in this thesis take into account the low monitoring frequency in the upper GI ward, such that the false alert rate is reduced. In addition to accuracy, early detection of deterioration is a highly desirable feature in patient monitoring systems. The models proposed in this thesis generate alerts for patients earlier than the early warning systems which are currently in use in hospitals in the UK. The improvements to existing models proposed in this thesis could be applied to continuous and intermittently acquired vital-sign data from other clinical environments.
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Shimokawa, Kenichi. "A Patient-Focused Psychotherapy Quality Assurance System: Meta-Analytic and Multilevel Analytic Review." BYU ScholarsArchive, 2010. https://scholarsarchive.byu.edu/etd/2544.
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Outcome research has documented worsening among a minority of the patient population (5 to 10%). In this study a psychotherapy quality assurance system intended to enhance outcomes in patients at risk of treatment failure was reviewed through the use of meta-analytic, mega-analytic, and multilevel analytic techniques. A pooled dataset from six major studies conducted at a large university counseling center and a hospital outpatient setting (N = 6151, mean age = 23.3 years, female = 63.2%, Caucasian = 85%) were re-analyzed to examine the effects of progress feedback on patient outcome. In this quality assurance system, the Outcome Questionnaire-45 was routinely administered to patients to monitor their therapeutic progress and was utilized as part of an early alert system to identify patients at risk of treatment failure. Patient progress feedback based on this alert system was provided to clinicians to help them intervene before treatment failure occurred. Intent-to-treat and efficacy analyses of the effects of feedback interventions were conducted to obtain the estimates of effects expected from implementation of this quality assurance system as a policy as well as in clinical trials. Three forms of feedback interventions—integral elements of this quality assurance system—were effective in enhancing treatment outcome, especially for signal alarm patients. Two of the three feedback interventions were also effective in preventing treatment failure (Clinical Support Tools and the provision of patient progress feedback to therapists). The Clinical Support Tool intervention was effective not only in terms of the amount of outcome enhancing effect, but also in the rate of patient recovery. The current state of evidence appears to support the efficacy and effectiveness of feedback interventions in enhancing treatment outcome.
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Nangalia, V. "ML-EWS - Machine Learning Early Warning System : the application of machine learning to predict in-hospital patient deterioration." Thesis, University College London (University of London), 2017. http://discovery.ucl.ac.uk/1565193/.
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Preventing hospitalised patients from suffering adverse event (AEs) (unexpected cardiac, arrest, intensive care unit admission, surgery or death) is a priority in healthcare. Almost 50% of these AEs, caused by mistakes/poor standards of care, are thought to be preventable. The identification and referral of a patient at risk of an AE to a dedicated rapid response team is a key mechanism for their reduction. Focussing on variables that are routinely collected and electronically stored (blood test data, and administrative data: demographics, date and method of admission, and co-morbidities), along with their trends, I have collected data on ~8 million admissions. I have explained how to navigate the complex ethical and legal landscape of performing such an ambitious data linkage and collection project. Analysing data on ~2 million hospital admissions with an in-hospital blood test result, I have 1. described how these variables (particularly urea and creatinine blood tests, method of admission, and date of admission) influence in-hospital mortality rate in different groups of patient. 2. created four machine learning (ML) models that have the highest accuracy yet described for identifying a patient at risk of an SAE, while at the same time capturing the majority of patients likely to die (high sensitivity). These models ML-Dehydration, ML-AKI, ML-Admission, and ML-Two- Tests, can be applied to admissions with limited data, specific syndromes, or on all patients in hospital at different time points in their hospital trajectory respectively. Their area under the receiver operator curves are 79.6%, 85.9%, 93% and 90.6% respectively. 3. built and deployed a technology platform Patient Rescue that allows for the automated application of any model in any hospital, as well as the communication of rich patient level reports to clinicians, all in real-time. The ML models and the Patient Rescue platform together form the ML – Early Warning System.
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Picone, Meghan C. "Situation Awareness in LPNs: a Pilot Study." eScholarship@UMMS, 2020. https://escholarship.umassmed.edu/gsn_diss/61.
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Purpose: The purpose of this pilot study was to describe situation awareness (SA) among licensed practical nurses (LPNs) working in direct patient care.
Specific Aims: The specific aims for this study are 1) to examine SA scores, as measured by the Situation Awareness Global Assessment Technique (SAGAT), in LPNs working in direct patient care and compare to published data on SA in registered nurses (RNs), 2) to examine the relationship between SA scores and years of LPN experience, 3) to examine differences in SA scores by type of workplace setting and 4) to describe the relationship between levels of satisfaction with simulation, as measured by the Satisfaction with Simulation Experience Scale (SSES) and SA scores among LPNs.
Framework: Situation Awareness Theory, as described by Endsley, was used as the framework for this study.
Design: A cross-sectional, descriptive design using the Situation Awareness Global Assessment Technique was used to gather data from a convenience sample of LPNs.
Results: LPNs (N=24) participated in the study and achieved an average SAGAT score of 72.6%. There were no differences in scores between those LPNs enrolled in an RN program and those who were not enrolled. Individual scores on the SAGAT were comparable or better than scores in a similar study of RNs.
Conclusion: LPNs in this study demonstrated adequate situation awareness.
Key Words: Situation awareness, licensed practical nurse, patient deterioration, clinical simulation
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Harris, Mitchell Wayne. "Providing Patient Progress Information and Clinical Support Tools to Therapists: Effects on Patients at Risk for Treatment Failure." BYU ScholarsArchive, 2011. https://scholarsarchive.byu.edu/etd/3079.
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Patient-focused research systems have been developed to monitor and inform therapists of patients' treatment progress in psychotherapy as a method to enhance patient outcome. The current study examined the effects of providing treatment progress information and problem-solving tools to both patients and therapists during the course of psychotherapy. Three hundred seventy patients at a hospital-based outpatient psychotherapy clinic were randomly assigned to one of two treatment groups: treatment-as-usual, or an experimental condition based on the use of patient/therapist feedback and clinical decision-support tools. Patients in the feedback condition were significantly more improved at termination than the patients in the treatment as usual condition. These findings are consistent with past research on these approaches although the effect size was smaller in this study. Treatment effects were not a consequence of different amounts of psychotherapy received by experimental and control clients. Not all therapists were aided by the feedback intervention.
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Kimball, Kevin Larry. "Toward Determining Best Items for Identifying Therapeutic Problem Areas." BYU ScholarsArchive, 2010. https://scholarsarchive.byu.edu/etd/2519.
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While most clients show improvement in therapy, anomalously, 5% to 10% actually worsen, and a significant minority of clients shows little or no response to therapy. Earlier studies developed clinical support tools (CSTs) designed to provide feedback to therapists about potential problem areas and to improve the likelihood of a positive outcome for clients identified as at-risk for a negative outcome in therapy (Harmon et. al. 2007; Slade, Lambert, Harmon, Smart, & Bailey, 2008; Whipple et al., 2003). While varying from study to study, the CSTs looked at five domains: therapeutic alliance, motivation to change, social support, life events, and perfectionism. More than 100 questions were used to assess these domains. The major goal of this study was to streamline the CST measures to increase efficiency. Toward that end, a new instrument consisting of 37 questions was developed by administering questionnaires to 169 patients at a rural Utah mental health center. In addition, the life events and social support questions were given to 76 students at Brigham Young University and 88 randomly selected residents of Utah County. Using item response analysis and mean scores for each dimension, subscale cut scores were developed for four dimensions: therapeutic alliance, motivation for therapy, social support, and life events. The perfectionism subscale was dropped from the questionnaire because perfectionism was deemed to be too stable to be useful for the intended use of the measure. Cut scores were also developed for each individual question. These subscale and individual item cut scores are intended to help clinicians identify potential problem areas to be explored during the course of therapy.
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Washington, Tiffany K. "The Effects of Using Clinical Support Tools to Prevent Treatment Failure." BYU ScholarsArchive, 2010. https://scholarsarchive.byu.edu/etd/2459.
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To date, outcome research suggests that providing clinicians with patient progress feedback and problem-solving tools is effective in improving therapeutic outcome for clients who are predicted to have a negative treatment outcome. To expand upon this body of research, the current study examined the efficacy of using these problem-solving tools (Clinical Support Tools; CST) to reduce the risk of treatment failure and enhance positive outcome with 118 clients who were not identified as at -risk for a negative outcome. Results of this study indicated that the intervention failed to lower the rate of becoming an at-risk case or to enhance treatment outcome. A possible explanation for the null results observed is poor treatment compliance. Based on the findings of this study, the CST cannot be recommended as an intervention across the broad range of clients who enter treatment. However, qualitative analysis results reflect positive indicators for continued research with at-risk cases.
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Slade, Karstin Lee. "Improving Psychotherapy Outcome: The Use of Immediate Electronic Feedback and Revised Clinical Support Tools." Diss., CLICK HERE for online access, 2008. http://contentdm.lib.byu.edu/ETD/image/etd2556.pdf.
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Wiles, Brenda L. "Using The National Early Warning Score As A Set Of Deliberate Cues To Detect Patient Deterioration And Enhance Clinical Judgment In Simulation." Case Western Reserve University Doctor of Nursing Practice / OhioLINK, 2016. http://rave.ohiolink.edu/etdc/view?acc_num=casednp1458074763.
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Rozental, Alexander. "Negative effects of Internet-based cognitive behavior therapy : Monitoring and reporting deterioration and adverse and unwanted events." Doctoral thesis, Stockholms universitet, Klinisk psykologi, 2016. http://urn.kb.se/resolve?urn=urn:nbn:se:su:diva-135382.
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Internet-based cognitive behavior therapy (ICBT) has the potential of providing many patients with an effective form of psychological treatment. However, despite helping to improve mental health and well-being, far from everyone seem to benefit. In some cases, negative effects may also emerge. The overall aim of the present thesis was to establish the occurrence and characteristics of such incidents in ICBT using a combination of quantitative and qualitative methods. Study I determined deterioration, non-response, and adverse and unwanted events in a sample of 133 patients undergoing ICBT for social anxiety disorder. The results indicated that up to 6.8% fared worse during the treatment period, depending on the self-report measure and time point, as determined using the Reliable Change Index (RCI), while the non-response rate was between 29.3 to 86.5% at post treatment assessment, and 12.9% experienced other negative effects. Study II investigated the responses to open-ended questions on adverse and unwanted events among 556 patients in four separate clinical trials of ICBT; social anxiety disorder, panic disorder, major depressive disorder, and procrastination. In total, 9.3% reported negative effects, with a qualitative content analysis revealing two categories and four subcategories; patient-related, i.e., gaining insight and experiencing new symptoms, and treatment-related, i.e., difficulties applying the treatment interventions and problems related to the treatment format. Study III explored the number of patients achieving reliable deterioration, as determined using the RCI on the individual raw scores of 2866 patients from 29 clinical trials of ICBT. The results showed that the deterioration rate was higher among patients in a control condition, 17.4%, in comparison to treatment, 5.8%. Predictors were related to decreased odds of deterioration for patients receiving treatment; clinical severity at pre treatment assessment, being in a relationship, having a university degree, and being older. As for the control condition, only clinical severity at pre treatment assessment was associated with decreased odds of deterioration. Study IV examined a newly developed self-report measure for monitoring and reporting adverse and unwanted events, the Negative Effects Questionnaire. The results suggested a six-factor solution with 32 items; symptoms, quality, dependency, stigma, hopelessness, and failure. One-third of the patients reported experiencing unpleasant memories, stress, and anxiety, with novel symptoms and a lack of quality in the treatment and therapeutic relationship having the greatest negative impact. The general finding of the present thesis is that negative effects do occur in ICBT and that they are characterized by deterioration, non-response, and adverse and unwanted events, similar to psychological treatments delivered face-to-face. Researchers and clinicians in ICBT are recommended to monitor and report negative effects to prevent a negative treatment trend and further the understanding of what might contribute to their incidents. Future research should investigate the relationship between negative effects and treatment outcome, especially at follow-up, to examine if they are transient or enduring. Also, interviews could be conducted with those achieving reliable deterioration to explore if and how it is experienced by the patients and to see if it is attributed to the treatment interventions or other circumstances.Internetbaserad kognitiv beteendeterapi (IKBT) har goda förutsättningar att kunna bli en form av psykologisk behandling som på ett effektivt sätt hjälper patienter med att hantera sin psykiska ohälsa och förbättra sitt välmående. Trots detta är det dock långtifrån alla som tycks bli bättre. För en del kan det till och med resultera i negativa effekter. Det övergripande syftet med denna avhandling har således varit att undersöka förekomsten av sådana fall och hur dessa uttrycks, såväl med kvantitativa som kvalitativa metoder. Studie I fastställde andelen försämrade, oförändrade samt andra ogynnsamma eller oönskade händelser bland 133 personer som behandlades med IKBT för social ångest. Resultatet visade att uppemot 6,8 % försämrades under sin behandlingsperiod beroende på vilket självskattningsformulär respektive tidpunkt som studerades, beräknat enligt metoden Reliable Change Index (RCI). Likaså var 29,3 % till 86,5 % oförändrade vid eftermätningen samt att 12,9 % rapporterade andra former av negativa effekter. Studie II undersökte svaren på öppna frågor som gällde ogynnsamma eller oönskade händelser bland 556 patienter i fyra olika kliniska studier med IKBT; social ångest, paniksyndrom, egentlig depressionsepisod och prokrastinering. Totalt sett rapporterade 9,3 % att de hade erfarit negativa effekter, vilka analyserades med hjälp av kvalitativ innehållsanalys. Två övergripande kategorier och fyra subkategorier framkom; patientrelaterade, som ökad insikt respektive nya symptom, samt behandlingsrelaterade, som svårigheter att implementera behandlingsinterventionerna respektive problem med behandlingsformatet. Studie III utrönte andelen patienter som försämrades i enlighet med RCI, baserat på insamlad rådata från 2866 personer i 29 olika kliniska studier med IKBT. Resultatet visade att försämring var mer förekommande hos de som var i en kontrollgrupp, 17,4 %, jämfört med de som fick behandling, 5,8 %. Bland de som genomgick behandling existerade det även ett par prediktorer som innebar lägre odds för försämring; större svårigheter vid förmätningen, att befinna sig i en relation, att ha en universitetsutbildning respektive att vara äldre. För de som var i en kontrollgrupp var enbart större svårigheter vid förmätningen relaterat till lägre odds för försämring. Studie IV testade ett nykonstruerat självskattningsformulär; Negative Effects Questionnaire. Resultatet visade på en faktorlösning med sex faktorer och 32 påståenden; symptom, kvalitet, beroende, stigma, hopplöshet respektive misslyckande. En tredjedel av personerna svarade att de hade upplevt obehagliga minnen, stress och ångest, samtidigt som nya symptom och bristande kvalitet i både behandlingen respektive den terapeutiska relationen hade haft störst negativ inverkan på dem. Den generella slutsatsen av denna avhandling är således att negativa effekter förekommer i IKBT och att de kännetecknas av försämring, ett oförändrat tillstånd samt andra ogynnsamma eller oönskade händelser, något som liknar tidigare forskning av psykologisk behandling som bedrivs ansikte-mot-ansikte. Forskare och behandlare i IKBT rekommenderas att övervaka och rapportera negativa effekter i syfte att förhindra en negativ utveckling i behandlingen samt för att öka kunskapen om vad som kan bidra till deras förekomst. Framtida forskning bör undersöka relationen mellan negativa effekter och behandlingsutfall utifrån längre tidsperspektiv för att se om dess påverkan är övergående eller ihållande. Vidare kan till exempel intervjuer utföras med de patienter som har försämrats för att ta reda på om och hur det uppfattas samt huruvida det har förorsakats av behandlingen eller andra omständigheter.
At the time of the doctoral defense, the following paper was unpublished and had a status as follows: Paper 4: In press.
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Andersson, Sandra, and Sofia Johansson. "Sjuksköterskans kompetens och dess påverkan på patientsäkerheten vid försämring av patientens tillstånd : En litteraturstudie." Thesis, Högskolan i Halmstad, Akademin för hälsa och välfärd, 2021. http://urn.kb.se/resolve?urn=urn:nbn:se:hh:diva-44151.
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Bakgrund: Patienter riskerar att försämras i sitt tillstånd på grund av olika faktorer. Sjuksköterskan har en viktig roll i att upptäcka, bedöma och initiera åtgärder för en patient som försämras i sitt tillstånd. Sjuksköterskans kompetens består av kunskap, färdigheter och erfarenheter. Sjuksköterskan ska arbeta för att säkerställa patientsäkerheten inom vården. Syfte: Syftet var att belysa hur sjuksköterskans kompetens kan påverka patientsäkerheten vid försämring av patientens tillstånd. Metod: En litteraturstudie genomfördes genom att söka i relevanta databaser. Elva artiklar valdes ut och bearbetades med inspiration från innehållsanalys. Resultat: Fyra kategorier med tillhörande underkategorier framkom. Huvudkategorierna var: Från sjuksköterskestudent till nyutbildad sjuksköterska, Den yrkeskompetenta sjuksköterskan, Samverkan i vårdteam och Arbetsmiljöns betydelse. Nyutbildade sjuksköterskor upplevde att de hade brist på erfarenhet i att hantera patienter som försämras i sitt tillstånd. Erfarenhet och kontinuitet framkom som betydande för att upptäcka och hantera försämring i patientens tillstånd. Samarbete ökade patientsäkerheten men det förekom brister i kommunikationen mellan läkare och sjuksköterska. Slutsats: Litteraturstudien påvisade att sjuksköterskans kompetens påverkar patientsäkerheten vid försämring av patientens tillstånd. Mer forskning behövs för att undersöka hur detta kan tillämpas inom vården.Background: Nurses have an important role in recognizing and responding to patient deterioration. Nursing competence includes knowledge, skills and experience. The nurse must work to ensure patient safety in healthcare. Aim: The aim of this study was to illustrate how nursing competence affects patient safety during patient deterioration. Method: A literature study was undertaken by searching relevant databases. Eleven articles were selected and analyzed with inspiration from content analysis. Results: Four main categories with associated subcategories emerged. The main categories were From nursing student to newly graduated nurse, The professional and competent nurse, Teamwork and The importance of the working environment. Newly graduated nurses felt they lacked experience when dealing with patient deterioration. Experience and continuity played an important role for nurses when dealing with deterioration. Team collaboration increased patient safety, but there were shortcomings in communication between nurses and doctors. Conclusion: The literary study showed that nursing competence affects patient safety when a patient deteriorates. Further research is needed to establish how this information can be applied in healthcare.
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Duff, Beverley. "Development and evaluation of an integrated clinical learning model to inform continuing education for acute care nurses." Thesis, Queensland University of Technology, 2010. https://eprints.qut.edu.au/42622/1/Beverley_Duff_Thesis.pdf.
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Background Significant ongoing learning needs for nurses have occurred as a direct result of the continuous introduction of technological innovations and research developments in the healthcare environment. Despite an increased worldwide emphasis on the importance of continuing education, there continues to be an absence of empirical evidence of program and session effectiveness. Few studies determine whether continuing education enhances or develops practice and the relative cost benefits of health professionals’ participation in professional development. The implications for future clinical practice and associated educational approaches to meet the needs of an increasingly diverse multigenerational and multicultural workforce are also not well documented. There is minimal research confirming that continuing education programs contribute to improved patient outcomes, nurses’ earlier detection of patient deterioration or that standards of continuing competence are maintained. Crucially, evidence-based practice is demonstrated and international quality and safety benchmarks are adhered to. An integrated clinical learning model was developed to inform ongoing education for acute care nurses. Educational strategies included the use of integrated learning approaches, interactive teaching concepts and learner-centred pedagogies. A Respiratory Skills Update education (ReSKU) program was used as the content for the educational intervention to inform surgical nurses’ clinical practice in the area of respiratory assessment. The aim of the research was to evaluate the effectiveness of implementing the ReSKU program using teaching and learning strategies, in the context of organisational utility, on improving surgical nurses’ practice in the area of respiratory assessment. The education program aimed to facilitate better awareness, knowledge and understanding of respiratory dysfunction in the postoperative clinical environment. This research was guided by the work of Forneris (2004), who developed a theoretical framework to operationalise a critical thinking process incorporating the complexities of the clinical context. The framework used educational strategies that are learner-centred and participatory. These strategies aimed to engage the clinician in dynamic thinking processes in clinical practice situations guided by coaches and educators. Methods A quasi experimental pre test, post test non–equivalent control group design was used to evaluate the impact of the ReSKU program on the clinical practice of surgical nurses. The research tested the hypothesis that participation in the ReSKU program improves the reported beliefs and attitudes of surgical nurses, increases their knowledge and reported use of respiratory assessment skills. The study was conducted in a 400 bed regional referral public hospital, the central hub of three smaller hospitals, in a health district servicing the coastal and hinterland areas north of Brisbane. The sample included 90 nurses working in the three surgical wards eligible for inclusion in the study. The experimental group consisted of 36 surgical nurses who had chosen to attend the ReSKU program and consented to be part of the study intervention group. The comparison group included the 39 surgical nurses who elected not to attend the ReSKU program, but agreed to participate in the study. Findings One of the most notable findings was that nurses choosing not to participate were older, more experienced and less well educated. The data demonstrated that there was a barrier for training which impacted on educational strategies as this mature aged cohort was less likely to take up educational opportunities. The study demonstrated statistically significant differences between groups regarding reported use of respiratory skills, three months after ReSKU program attendance. Between group data analysis indicated that the intervention group’s reported beliefs and attitudes pertaining to subscale descriptors showed statistically significant differences in three of the six subscales following attendance at the ReSKU program. These subscales included influence on nursing care, educational preparation and clinical development. Findings suggest that the use of an integrated educational model underpinned by a robust theoretical framework is a strong factor in some perceptions of the ReSKU program relating to attitudes and behaviour. There were minimal differences in knowledge between groups across time. Conclusions This study was consistent with contemporary educational approaches using multi-modal, interactive teaching strategies and a robust overarching theoretical framework to support study concepts. The construct of critical thinking in the clinical context, combined with clinical reasoning and purposeful and collective reflection, was a powerful educational strategy to enhance competency and capability in clinicians.
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Blanié, Antonia. "Evaluation expérimentale du raisonnement clinique dans le cadre des jeux sérieux pour la formation des professionnels de santé. Comparative value of a simulation by gaming and a traditional teaching method to improve clinical reasoning skills necessary to detect patient deterioration: a randomized study in nursing students Assessing validity evidence for a serious game dedicated to patient clinical deterioration and communication." Thesis, université Paris-Saclay, 2020. http://www.theses.fr/2020UPASS092.
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L’amélioration du raisonnement clinique (RC) est un enjeu essentiel pour la Médecine de demain car il est établi que son utilisation imparfaite conduit à des résultats de soins insuffisants. Le RC est un processus cognitif complexe. Cette activité intellectuelle synthétise l’information obtenue à partir de la situation clinique et l’utilise pour faire une analyse diagnostique et prendre une décision de prise en charge du patient en intégrant les connaissances et expériences antérieures. La formation à cette compétence est donc essentielle. Pour améliorer le raisonnement, une connaissance des mécanismes qui le constituent est nécessaire et une revue de ces mécanismes constitue la partie initiale de cette thèse.La formation des professionnels de santé par la simulation se généralise avec pour objectif « jamais la première fois sur le patient ». En plein essor, le jeu sérieux (JS) représente un outil pédagogique intéressant. Une revue de la littérature sur l’efficacité des JS et plus particulièrement dans le cadre du RC est également incluse dans la partie initiale de cette thèse. Ainsi, les JS sont efficaces et peuvent, entre autres, cibler certaines compétences dont le RC. Cependant, la plupart des études sur le RC dans le cadre des JS, restent subjectives avec des évaluations qualitatives ou des autoévaluations des apprenants ou concernent uniquement le résultat (prise de décision). Par conséquent, la valeur éducative et les modalités des JS dans la formation du RC restent à approfondir.Le JS LabForGames Warning a été développé dans le centre de simulation LabForSIMS pour les étudiants infirmiers et cible la détection de l’aggravation d’un patient et la communication. Cette thèse a pour objectif de tester un mode d’apprentissage utilisant la simulation par les JS afin d’améliorer le RC chez les professionnels de santé.Une 1ère étude a évalué la validité du JS LabForGames Warning selon le cadre théorique proposé par Messick. Elle a démontré que les scores et le temps de jeu ne pouvaient pas différencier le niveau des compétences cliniques des infirmiers.Cependant, les preuves de validité étaient obtenues pour le contenu, le processus de réponse et la structure interne. Même si cette version du jeu ne peut donc pas être utilisée pour une évaluation sommative des étudiants, notre étude montre que ce JS est bien accepté par les étudiants et qu’il peut être utilisé pour la formation au sein d’un programme éducatif.Une seconde étude a évalué l’efficacité de 2 modalités pédagogiques sur l’apprentissage du RC à la détection de l’aggravation clinique d’un patient en comparant un groupe d’étudiants infirmiers formé par simulation avec LabForGames Warning par rapport à un groupe formé par un enseignement traditionnel. Le RC a été évalué par les tests de concordance de script immédiatement et 1 mois après. Cette étude multicentrique randomisée a inclus 146 étudiants infirmiers volontaires. Aucune différence significative n’a été observée sur le RC entre la formation par la simulation avec JS et l’enseignement traditionnel. Cependant, la satisfaction et la motivation étaient meilleures avec l’enseignement par simulation.En conclusion, nous avons tout d’abord confirmé la validité du JS LabForGames Warning en tant qu’outil pédagogique à visée formative et non sommative. Puis, bien qu’aucune différence d’apprentissage du RC n’ait été observée entre la formation par la simulation avec JS et l’enseignement traditionnel, la satisfaction et la motivation étaient meilleures avec l’enseignement par simulation avec le jeu. Les études sont à poursuivre pour préciser les modalités et stratégies pédagogiques des JS dans la formation des professionnels de santé, comme par exemple la place du débriefing, le rôle de la motivation. En effet, en plein essor, les développements technologiques telle que l’intelligence artificielle vont transformer la formation au RC ainsi que les outils pédagogiques disponibles dans les années à venirImprovement of clinical reasoning (CR) is a key issue for the future of medicine because it has been established that imperfect reasoning leads to insufficient care results. CR is a complex cognitive process which synthesizes information obtained from the clinical situation, then uses it to make a diagnostic analysis and take a decision on patient management by integrating previous knowledge and experience. Training for this skill is therefore essential. To improve reasoning, knowledge of the mechanisms which build it up is necessary and a review of these mechanisms constitutes the initial part of this thesis.Training of healthcare professionals through simulation is becoming widespread with the objective of "never the first time on a patient". In rapid expansion, the use of serious games (SG) represents an interesting pedagogical tool. A review of the literature on the effectiveness of SG and more particularly in the context of CR is also included in the initial part of this thesis. Thus, SG is effective and may, among other things, target certain skills, including CR. However, most studies dealing with CR by using SG include qualitative assessments or self-assessments of learners or focus only on the outcome (decision making). Therefore, the educational value and modalities of SG in the training of CR of health professionals remain to be further explored.The SG LabForGames Warning was developed in the LabForSIMS simulation center for nursing students and targets detection of patient deterioration and the ensuing communication. The objective of this thesis is to test a learning mode using SG simulation in order to improve CR in healthcare professionals.The first study evaluated the validity of the SG LabForGames Warning according to the Messick’s Framework. This study showed that scores and playing time could not differentiate the level of clinical skills of nurses. However, evidence of validity was obtained for content, response process and internal structure. Although this version of the game cannot therefore be used for summative evaluation of students, our study shows that this SG is well accepted by students and can be used for training within an educational program.A second study evaluated the effectiveness of 2 teaching modalities on learning CR for the detection of clinical patient deterioration by comparing a group of nursing students trained by simulation with LabForGames Warning compared to a group trained by traditional teaching. CR was assessed by script concordance tests immediately and 1 month later. This randomized multicenter study included 146 volunteer nursing students. No significant difference was observed in CR change between simulation training with SG and traditional teaching. However, satisfaction and motivation were better with simulation instruction.In conclusion, we have confirmed the validity of SG LabForGames Warning as an educational tool with formative and not summative aims. Then, although no difference in learning about CR was observed between simulation training with SG and traditional teaching, satisfaction and motivation were better with simulation teaching with the game. Further studies are needed to clarify the modalities and pedagogical strategies of SG in the training of healthcare professionals, such as the place of debriefing and the role of motivation. Moreover, technological developments such as artificial intelligence might transform CR training and the available pedagogical tools in the coming years
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von, Below Camilla. "When psychotherapy does not help : ...and when it does: Lessons from young adults' experiences of psychoanalytic psychotherapy." Doctoral thesis, Stockholms universitet, Psykologiska institutionen, 2017. http://urn.kb.se/resolve?urn=urn:nbn:se:su:diva-144399.
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The process and outcome of psychoanalytic psychotherapy have been studied for a long time. However, the experiences of patients, particularly in therapies where goals were not met, have not yet been the target of extensive research. Psychoanalytic psychotherapy with young adults might face particular challenges. The overall aim of this thesis was to explore the experiences of young adults in psychoanalytic psychotherapy, with a particular focus on differences between suboptimal therapies and therapies with generally good outcome. The setting was naturalistic, and perspectives of the patient, therapist and observer were combined. Qualitative and quantitative methods were used. Study I explored experiences of psychotherapy process and outcome among seven patients in psychoanalytic psychotherapy, who expressed dissatisfaction. Interviews at termination and 18 months later were analysed using grounded theory and compared to therapist experiences. Patients experienced abandonment with their problems in and after therapy, since therapy according to the patients lacked connections to daily life, as well as flexibility, activity and understanding from the therapist. Therapists presented a different picture of the same therapies, mainly focused on the difficulties of the patients. Study II analysed the experiences of 20 non-improved or deteriorated young adult psychotherapy patients at termination of therapy and 36 months later. Non-improvement and deterioration were calculated based on the reliable change index on self-rating scores. The grounded theory analysis of interviews established spinning one’s wheels as a core category. The relationship to the therapist was described as artificial, although at times helpful. Participants experienced their own activity in life and active components of therapy as helpful, but thought focus in therapy was too much on past experiences. Study III explored the experiences of 17 young adult patients, in psychoanalytic individual or group therapy, overcoming depression. The analysis of interviews from therapy termination and 18 months later indicated that finding an identity and a place in life were perceived as intertwined with symptom relief. Negative experiences included difficulties to change oneself, fear of change, and problems in therapy, such as too little activity on the therapist’s part. The results were discussed in relation to young adulthood, therapeutic alliance, mentalization, and attachment. The conclusion was expressed in a comprehensive process model of suboptimal therapy with young adults, with suggested ways to prevent such a development. The therapist’s meta-communication and correct assessment of the patient’s mentalization capacity from moment to moment are proposed as crucial. Regarding clinical implications, therapists of young adult patients need to establish meta-communication on therapy progress, as even experienced therapists might be unaware of dissatisfaction or deterioration. Meta-communication could be considered part of the treatment itself, as it may foster mentalization and good outcome. Further, the period of young adulthood entails decisions and developing an adult life, and therapists need to make room for this by active interventions.
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Oswald, Sharon. "A retrospective case note analysis of the recognition and management of deteriorating patients prior to critical care admission." Thesis, University of Stirling, 2017. http://hdl.handle.net/1893/27289.
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This study explores the use of early warning scores (EWS) in deteriorating patients. These are widely used tools to measure vital signs and highlight abnormal physiology in acutely unwell patients. Measurements of the process in the management of the deteriorating patient includes time to first assessment of such patients. The level of clinician involved in the subsequent management is also investigated to determine whether escalation of care was appropriate. This work is a retrospective case note analysis of the recognition and management of deteriorating patients prior to critical care admission. Research Questions 1. What violations in the optimum process are associated with sub-optimal recognition and management of deteriorating patients and delayed critical care admission in patients triggering early warning scores in acute care wards? 2. Are there independent variables which can predict the delay in the recognition and management of deteriorating patients and subsequent critical care admission? Methods The literature was reviewed to determine the optimum process of recognition and management of deteriorating patients in acute care wards. A data collection tool was then specifically designed and locally validated to extract objective data from the case records. A sample of 157 patients admitted to critical care from acute wards over a 6 month period were included in the study. The case records were then retrospectively reviewed and information was extracted using the data collection tool. Results The accuracy and frequency of early warning scores were measured and findings demonstrated that 59% of Early Warning Scores (EWS) were miscalculated. The most frequent of those miscalculated were the intermediate scores (4 or 5) (error rate - 52%) followed by the higher scores (6 or more) (error rate - 32%). The least frequently miscalculated were the lower scores (0 -3) (error rate 15%). Descriptive data from the sample such as age, ward, diagnosis, time of hospital admission, time and day of transfer / EWS triggering were included. From the total case records reviewed, 110 patients had abnormal Early Warning Scores (4 or more) and were included in the inferential data analysis. The independent variables related to the processes objectively measurable in the recognition and management of deteriorating patients were included. After descriptive analysis the independent variables were cross-tabulated with the dependent variable using Pearson chi-square. The dependent variable was identified from the literature. This was whether time from triggering an abnormal EWS to critical care admission was delayed more than 6 hours. The subsequent predictor variables were then entered in to a binary logistic regression model for statistical analysis using SPSS version 21 software. Binominal Logistic Regression Analysis identified three significant variables predicting delay of the recognition and management of deteriorating patients. • Frequency of EWS measurement not increased appropriately • Length of stay prior to critical care admission 12-36 hours • If no consultant review during 6 hours of abnormal EWS Implications for Future Practice This study highlights areas of risk in the detection of patients’ clinical deterioration in acute wards. These findings should guide quality improvement to prevent unnecessary morbidity and mortality. As a key area of patient risk included the lack of frequency and accuracy of EWS measurements, staff education is required to ensure staff are given the appropriate knowledge to understand the use of the tool. Regular review of the frequency of measurement is also required as this was statistically significant in the delay to critical care admission. The high risk time from admission of 12-36 hours needs further investigation. This study also highlights the need for senior decision makers to be involved in the care of deteriorating patients to improve outcomes.
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Charton, Emilie. "Analyse longitudinale des données de qualité de vie relative à la santé en cancérologie : vers une standardisation de la méthode du temps jusqu’à détérioration." Thesis, Bourgogne Franche-Comté, 2020. http://www.theses.fr/2020UBFCE003.
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Cette thèse a pour but d’apporter une contribution à l’analyse et la comparaison des données de PROs (« patient-reported outcomes » ou « résultats rapportés par le patient ») dans les essais cliniques en cancérologie, dont l’interprétation reste complexe et non standardisée. Parmi les nombreuses méthodes proposées pour l’analyse longitudinale des données de PROs, figure l’approche du temps jusqu’à détérioration (TJD). Dans le cadre de ce projet, des travaux menés ont fait l’état des définitions du TJD utilisées et mettent en évidence que certaines recommandations n’ont pas été suivies. De plus, la variabilité des définitions utilisées compromet la comparaison des résultats entre les essais cliniques. L’approche du TJD nécessite une définition claire de ce qui est considéré comme une « détérioration », et cela dépendra à la fois de la localisation cancéreuse, de la situation thérapeutique, du score de référence, de la différence minimale cliniquement importante perçue par le patient, ainsi que des règles de censure. Dans l’optique d’optimiser et d’harmoniser les définitions utilisées du TJD, afin d’avoir des résultats comparables, deux macros SAS ont été créées sur la méthode du TJD afin de standardiser les définitions utilisées par la communauté. S’inscrivant dans cette trajectoire, une étude menée sur une cohorte de patientes atteintes d’un cancer du sein en situation adjuvante a conduit à s’intéresser à la première détérioration du patient et à la gestion de l’absence de randomisation à l’inclusion. En parallèle, cette méthode a également été appliquée dans un essai de phase II randomisé chez des patients atteints d’un cancer du pancréas métastatique. L’impact de l’occurrence des données manquantes à l’inclusion dans cet essai a été traité en appliquant une imputation multiple utilisant la méthode de Monte-Carlo par chaînes de Markov. Ces travaux soulignent le besoin de continuer la création de consensus pour l’analyse longitudinale des données de PROs dans les essais cliniques en cancérologieThe purpose/aim of this thesis is to contribute to the analysis and comparison of PROs (« patient-reported outcomes ») data in oncology clinical trials. The interpretation of such results remains complex and unstandardized. One of the many ways to carry out a longitudinal analysis of PRO data is the time to deterioration (TTD) approach. Within of the scope of this project, some of the research examined which definitions of TTD are used and pointed out that some recommendations have not been followed. Moreover, due to the variability of the definitions in use, the comparison of various results from clinical trials is compromised. A clear definition of what is considered to be a « deterioration » is required for the TTD approach. It will depend on many criteria such as the location of the cancer, the therapeutic setting, the reference score, the minimal important difference perceived by the patient, as well as on censoring rules. Two SAS macros were developed on the TTD method as a way to optimize and harmonize the TTD definitions that are being used, as well as to be able to have comparable results and consequently a way to help standardize those definitions. In this perspective, a study conducted on a cohort of adjuvant breast cancer patients led to more focus on the first deterioration of the patient and the management of non-randomization at baseline. In parallel, this method was also implemented for a randomized phase II trial on patients with metastatic pancreatic cancer. During this trial, the impact of the occurrence of missing data at baseline was handled by applying a multiple imputation based on the Markov Chain Monte Carlo method. These works highlight the need to continue developing a consensus for the longitudinal analysis of PROs data in oncology clinical trials
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Smith, Sally Ann. "Decision-making in acute care nursing with deteriorating patients." Thesis, University of Brighton, 2013. https://research.brighton.ac.uk/en/studentTheses/0b2fc4c1-b4b5-42f6-8ee8-2d29343db3b8.
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Concerns have been well documented about deteriorating patients being missed and that care has not been of a sufficient standard to maintain their safety. This 'failure to rescue' remains despite changes in training and critical care experts working with ward staff. little is known about what influences decision-making at the point a patient deteriorates and prior to referring on to an expert. The aim of this study was to understand how nurses reach their clinical decisions while caring for a deteriorating patient and to identify the contextual factors that influence that decision-making process. Using grounded theory methodology the study comprised fieldwork, semi-structured interviews and a focus group; participants were 22 nurses and 2 physiotherapists working in general medical and surgical wards. A pragmatist philosophical tradition informing symbolic interaction guided the interpretive analytical framework of the study. The simultaneous collection, memoing, dimensional analysis of the data and constant comparison of the findings with the body of literature, built an emerging theory of clinical reasoning in acute care situations. Findings suggested that acute care nurses practice in one of 3 modes. They are: • 'Ward routine', where normal ward work takes place and nurses use protocols to deliver care. • 'Crescendo of care' where searching, information gathering, checking findings and efforts to gain control over the clinical situation took place. Nurses' reasoning in this mode was abductive and focused on building a believable case prior to referral. • 'Management of crisis' where the nurse was sure of their concerns, made the referral and continues to seek to confirm concerns. Through the three modes nurses reasoned and made sense of the clinical information they picked up. They spent lime marshalling this data until it served them a believable credible case with which to refer to another professional. This involved negotiating and bargaining to elicit action. The goals in these actions and interactions were to keep the patient and themselves safe. This was underpinned and motivated by their personal and professional beliefs. Throughout the whole decision-making process nurses accounted for every decision and judgement they made until they were convinced and confident in what they believed was happening. Then they made a referral to a more senior professional. This was conceptualised as the theory of mind accounting in clinical reasoning 'Which emerged as the explanation for how nurses clinically reason and make decisions when caring for a patient whose condition is declining. The emerging theory offers an alternative explanation of the way nurses assess and intervene when concerned about a patient. This is significant because timely accurate decision-making is fundamental to providing quality care.
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O'Dell, Amanda. "Detecting and managing the deteriorating ward patient : an exploratory study of nursing practice." Thesis, University of Reading, 2011. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.552991.
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Hospital in-patients can experience unexpected physiological deterioration leading to poor outcomes and death. Although deterioration can be signalled in the patients' physiological symptoms, evidence suggests that ward staff can miss, mis-interpret or mis-manage the signs. Rapid Response systems have been implemented in an attempt to address this problem. These systems consist of two phases. The initial, afferent phase, involves the detection of deterioration and referral decision for more expert help, and the efferent phase, where critical care teams attend the patient for more expert assessment and management. Research has tended to concentrate on the efferent phase of the process, and has failed to show a significant impact on patient outcome. This study was set in a single site, UK district general hospital, and focuses on the afferent phase of detecting the deteriorating ward patient, with the aim of enumerating and describing the phenomena of patient deterioration on the wards, and seeking explanations of nursing practice in observation practices and referral decisions. Utilising Critical Realist philosophy, multiple methods were used, utilising both quantitative and qualitative data collection and analysis, to focus progressively from a high level of inquiry, enumerating and describing cardio-respiratory arrests (CRAs) as a surrogate marker of deterioration, to a deeper level that focussed on nursing practice during the 12 hour period preceding the CRA event, seeking associations between the quality of nursing practice and CRA variables. Lastly, the enquiry concluded in an in- depth Critical Discourse Analysis technique applied to the nursing records pertaining to the CRA event. The findings suggest that the implementation of Rapid Response systems may have been an oversimplified solution to a highly complex problem that involves a multitude of factors. Ward nurses are struggling to detect and adequately manage the deteriorating ward patient. Cultural, organisational and professional influences have contributed to their disempowerment, therefore radical multi-disciplinary collaboration may be the only viable solution.
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Mattsson, Carin, and Malin Sande. "Plötsligt händer det! Vad gör jag? : Nyexaminerade sjuksköterskans utvecklande av kliniskt omdöme." Thesis, Ersta Sköndal högskola, Institutionen för vårdvetenskap, 2016. http://urn.kb.se/resolve?urn=urn:nbn:se:esh:diva-5246.
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Bakgrund: Kliniskt omdöme kan beskrivas som förmågan att på ett insiktsfullt sätt identifiera och agera på en förändring eller ett behov relaterat till patientens hälsotillstånd. Kliniskt omdöme kommer till sin spets i komplexa situationer som exempelvis när en patient plötsligt försämras. Det har skett en akademisering av sjuksköterskeutbildningen som gett sjuksköterskor en stadigare teoretisk grund men det kliniska omdömet behöver utvecklas efter examen. Syfte: Syftet var att beskriva faktorer som påverkar utvecklingen av nyexaminerade sjuksköterskans (NS) kliniska omdöme. Metod: Metoden som användes var litteraturöversikt, baserad på tio vetenskapliga artiklar varav åtta kvalitativ metod och två mixad metod. Artiklarna hämtades ur databaserna CINAHL Complete och PubMed. Resultat: Faktorer som påverkar utvecklingen av NS kliniska omdöme sammanfattas under tre huvudteman: Förvärvandet av kliniska förmågor, Ansvarsfull kommunikation och Integrerat stöd. NS behöver utveckla förmågan att identifiera relevanta förändringar, tolka dem i relation till en helhetsbild av patienten, prioritera åtgärder samt kommunicera med kollegor. Utvecklande av kliniskt omdöme underlättas i ett positivt arbetsklimat med stöd av erfarna sjuksköterskor (ES). Vårderfarenheter ger teoretiska kunskaper en ny mening, vilket också bidrar till utvecklandet av kliniskt omdöme. Diskussion: Resultatet diskuterades med utgångspunkt i Benners teori för hur sjuksköterskans kliniska omdöme utvecklas från novisens till expertens. NS är inte mogen att hantera komplexa kliniska situationer och organisationen måste utformas för att ge NS det stöd som behövs för att utveckla det kliniska omdömet. Tillgången till ES, reflektion och ett rimligt arbetstempo är viktiga stöttande faktorer, men sällan en självklarhet i vården.Background: Clinical judgement can be described as the ability to wisely identify and act upon changes in - or needs of a patient’s - health status. Clinical judgement is most applicable to complex situations such as caring for deteriorating patients. As nursing was included in higher education nurses have acquired a more solid theoretical knowledge base, however their clinical judgement needs to be further developed post graduation. Aim: The aim of was to describe factors influencing the development of newly graduated nurse’s (NN) clinical judgment. Method: The method consists of a literature review based upon ten scientific articles, of which eight were qualitative and two followed a mixed method. The articles were retrieved from CINAHL Complete and PubMed databases. Results: Contributing factors to the development of NN clinical judgment were grouped into three main themes: Development of clinical abilities, Responsible communication and Integrated support. NN needs to develop the ability to recognise relevant changes, relate them to a holistic assessment of the patient and to communicate findings. The development of clinical judgment is supported by a positive work climate and by access to experienced nurses. Caring for patients adds a new dimension to theoretical knowledge and contributes to the development of clinical judgment. Discussion: The results were discussed using Benner´s theory of how the clinical judgement of nurses develops from novice to expert. NN is not able to safely handle complex clinical situations without the support of experienced staff. It is also essential for the development of clinical judgment that NN is given a reasonable workload and opportunities for reflection. However, there may often be a lack of these supporting factors in nursing organisations today.
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Andrews, Thomas. "Making credible : a grounded theory of how nurses detect and report physiological deterioration in acutely ill patients." Thesis, University of Manchester, 2004. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.502597.
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The aim of the study was to investigate how nurses detected and reported physiological deterioration in acutely ill patients. To date there is a paucity of research on how nurses pick up deterioration. The emphasis within the literature tends to be on identifying premonitory signs that may be useful in predicting patients who are in danger of deterioration. Changes in respiratory rate is the most consistent in picking up such patients (Fieselmann et al. 1993; Sax and Charlson 1987; Schein et al. 1990; Smith and Wood 1998) but in common with other signs, it lacks sensitivity and specificity. The sample consisted of 44 nurses, doctors and health care support workers working on a general medical and surgical ward. Data were collected by means of non-participant observations and interviews, using grounded theory as originated by (Glaser and Strauss 1967) and (Glaser 1978). As data were collected, the consistent comparative method and theoretical sensitivity were used as outlined in grounded theory. A theory of "making credible" emerged, together with its sub-core categories of "intuitive knowing", "contextualising" and "grabbing attention". The problem that nurses face in referring patients they suspect are deteriorating is in persuading doctors to come and review them. How nurses deal with this is a three stage process. Through intuitive knowing they pick up that patients have changed in a way that requires a medical assessment. To make the referral more credible, nurses attempt to contextualise changes by establishing baselines of how patients are in terms of their progression and vital signs and continual vigilance. Finally with the backup of colleagues, nurses refer patients by providing as much persuasive information as possible. The whole process is facilitated by knowledge and experience, together with mutual trust and respect. Cautiousness characterises each step.
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Day, Danielle E. "Determining predictors of underlying etiology and clinical deterioration in patients with physiologic instability in the emergency department." Thesis, Boston University, 2013. https://hdl.handle.net/2144/12083.
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Thesis (M.A.)--Boston UniversityShock is a critical state defined by inadequate oxygen delivery to tissues. It is well known in the critical care community that early diagnosis and treatment of shock are crucial to improving patient outcomes. However, in many cases, when a state of circulatory shock has been reached, irreversible damage already occurred. In the present study, we broadened our patient cohort from those with shock to those with physiologic instability with the intent of finding predictive factors that allow us to recognize when a patient is at risk for deterioration or when it is already occurring. These patients included patients with pre-shock, shock, and other forms of dysfunction. The purpose of this study was to determine the predictors of underlying etiology of physiologic instability as well as the likelihood of clinical deterioration in these various states, using elements from the physical exam, history, laboratory values, and vital sign measurements. This study was a prospective observational study of patients, from November 15, 2012 to March 1, 2013, found to have physiologic instability in the emergency department at an urban, academic tertiary-care hospital with 55,000 annual visits. Physiologic instability was defined as any one of the following abnormalities: heart rate (HR) > 130, respiratory rate (RR>24), shock index (SI) > 1, systolic blood pressure (SBP) < 90 mm/hg, and Lactate > 4.0 mmol/L, for a time period of more than five minutes. We identified 540 patients, 74.8% of which were included. Data describing epidemiology, and elements from the patient history and physical exam were abstracted from physician charts and the final etiology of physiologic instability, defined as septic, cardiogenic, hypovolemic, hemorrhagic, or other, was adjudicated by a physician. Blood samples from a subset of our patient group were collected from the hospital hematology laboratory and sent to the Wyss Institute to be analyzed using a novel bacterial detection assay. All of the covariates that data was collected for were analyzed to determine their diagnostic and prognostic value. [TRUNCATED]
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Albutt, Abigail Kathleen. "Is there a role for patients and their relatives in monitoring, detecting and escalating clinical deterioration in hospital?" Thesis, University of Leeds, 2018. http://etheses.whiterose.ac.uk/20121/.
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Measures exist to improve early recognition of, and response to deteriorating patients in hospital. Yet, 11% of deaths in UK hospitals in 2005 were the result of patient deterioration going unrecognised or not being acted on (NPSA, 2007). The thesis aimed to investigate whether patients and relatives can aid health professionals in recognising clinical deterioration. A systematic review was conducted which identified interventions that allow patients and relatives to escalate patient deterioration. However, there is not strong evidence for the clinical effectiveness of these interventions, and a limited understanding of patient and relative ability to recognise patient deterioration. In study 1, health professionals generated potentially feasible and acceptable methods of involving patients and/or relatives in recognising deterioration in hospital. Recording patients’ views on changes in their wellness during routine observation was proposed. Focus groups were held in study 2 with healthcare assistants and patients to develop a questionnaire to capture patients’ and relatives’ ratings of patient wellness. Study 3 piloted approaches to routinely collecting patient wellness ratings using the questionnaire on in-patient wards. Where the researcher attended observation to record patients’ ratings, this was acceptable to most patients. However, there was limited uptake where patients and relatives were invited to complete the questionnaire themselves, and staff were invited to record patients’ wellness ratings during observation. It may be necessary to encourage and support staff to adopt this change in practice. In study 4, the use of behaviour change techniques to encourage staff to routinely record patient-reported wellness in practice were effective on wards showing high previous levels of engagement with the observation system. The clinical effectiveness of routinely recording patient-reported wellness was also explored. Significant associations between patient-reported wellness, and early warning score and vital sign measurements were found, and these were stronger in more acutely unwell patients. Evidence from the thesis suggests that routinely recording patient-reported wellness may be one feasible strategy that could aid health professionals in the early recognition of clinical deterioration.
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Weigold, Florian [Verfasser]. "Antibodies against chemokine receptors CXCR3 and CXCR4 predict progressive deterioration of lung function in patients with systemic sclerosis / Florian Weigold." Berlin : Medizinische Fakultät Charité - Universitätsmedizin Berlin, 2018. http://d-nb.info/1176633147/34.
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Kyriacos, Una. "The development, validation and testing of a vital signs monitoring tool for early identification of deterioration in adult surgical patients." Doctoral thesis, University of Cape Town, 2011. http://hdl.handle.net/11427/11688.
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Patients often exhibit premonitory abnormalities in vital signs before an adverse clinical outcome. Patient survival may depend on the decisions of nurses to call for assistance. There is a paucity of published early warning scores (EWS) literature for general ward use from South Africa. In a public hospital in South Africa, the study aimed to develop, validate and test the impact of implementation of a modified early warning scoring (MEWS) system vital signs chart and training programme designed to improve hospital nurses’ performance in early identification of postoperative clinical and physiological deterioration in adult patients.
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Platt, Michele Angeline. "Making the link : multi-professional care for acutely ill deteriorating patients : a constructivist grounded theory approach." Thesis, University of Warwick, 2015. http://wrap.warwick.ac.uk/76008/.
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The potential for decline in acutely ill and injured patients is ever-present. Rapid response systems exist to facilitate timely actions, but there are continued concerns over failure to rescue. Currently there is little understanding of what happens in ward areas when deterioration occurs and how it is recognised and managed. This study aimed to explore what happens when patients deteriorate, how professionals work together, define and communicate deterioration and make sense of what they say and do. Using constructivist grounded theory; data was gathered over 12 months from 33 multi-professional participants on three wards in one hospital. Data analysis, concurrent with collection, utilised theoretical sampling to identify further sources of data. Constant comparison was used to develop codes and concepts from the transcripts, and NVivo© software facilitated data organisation and an audit-trail. During 26 interviews and 48 hours of observation, 85 cases of patient deterioration were identified. Four concepts emerged from the analysis, 1) being vigilant through surveillance, 2) identifying deterioration and recognising urgency, 3) taking action by escalating and responding, 4) taking action by treating, all connected by a core concept, making the link. The need for support, use of subjective and objective indicators, competing priorities and hierarchical issues influenced the process but application of knowledge was crucial for making the link. Collectively knowing the patient and sharing this multi-professional knowledge was key to making the link and the nurse was ideally placed to facilitate a shared mental model of deterioration across the team. New elements were identified: lay person vigilance, where significant others contributed to the rescue process; and fear of harming patients by a rescue intervention was revealed as a barrier to treating deterioration. Recommendations included protecting and prioritising resources for surveillance, valuing subjectivity and the input of all levels of staff.
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Johnston, Maximilian Joseph. "Exploring and improving the escalation of care process for deteriorating patients on surgical wards in UK hospitals." Thesis, Imperial College London, 2015. http://hdl.handle.net/10044/1/38452.
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Despite impressive progress in technical skills, the rate of adverse events in surgery remains unfavourably high. The variation seen in surgical outcomes may be dependent on the quality of ward-based surgical care provided to post-operative patients with complications, specifically, the recognition, communication and response to patient deterioration. This process can be termed escalation of care and is an under-explored area of surgical research. This thesis demonstrates the impact of delays in the escalation of care process on patient outcome. The facilitators of, and barriers to, escalation of care are then identified and described in the context of the UK surgical department. In order to prioritise areas within the escalation of care process amenable to intervention, a systematic risk assessment was conducted revealing suboptimal communication technology and a lack of human factors education as key failures. To ensure that communication technology intervention was conducted based on evidence, several exploratory studies describe the current methods of communication in surgery and explore areas of innovation and intervention. Following this, a human factors intervention bundle was implemented within a busy surgical department, which successfully improved supervision, escalation of care and safety culture. This thesis describes, for the first time, escalation of care in surgery and outlines important strategies for intervention in this safety-critical process. To date, ward-based care has been one of the most under-researched areas in surgery, despite its clear importance. The tools to improve escalation of care in surgery have been described and initial attempts at implementation have demonstrated great promise. Future use of these strategies should benefit surgeons and other clinical staff of all grades and ultimately, the surgical patient.
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Della, Ratta Carol. "The Journey from Uncertainty to Salient Being| The Lived Experience of Nurse Residents Caring for Deteriorating Patients." Thesis, Adelphi University, 2015. http://pqdtopen.proquest.com/#viewpdf?dispub=3663096.
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Nurse Residency programs have been developed to ease the transition for new graduates to the workplace, one in which they face fast-paced patient encounters such as emergency response situations. During this one year educational experience, nurse residents persistently cite caring for deteriorating patients as a clinical challenge. There is a paucity of research on the unique needs of nurse residents when encountering such challenges. Philosophically underpinning this Hermeneutic study were tenets of Heidegger and Gadamer within which nurse residents' lived experiences of caring for a deteriorating patient were explored. In-depth interviews with eight nurse residents were analyzed and interpreted using Diekelmann's process for narrative analysis. The Journey from Uncertainty to Salient Being described the ontological-existential meaning of participants' lived experiences of caring for a deteriorating patient during their residency year. Three distinct constitutive patterns were identified each with themes: dwelling with uncertainty, building me up, and a new lifeline: salient being. Dwelling with uncertainty was experienced during encounters with deteriorating patients with its deeply felt impact upon nurse residents as they transitioned from student to professional nurse. The pattern of building me up was influenced by the participants' expressed need for, and importance of, trusted relationships with preceptors, nurse colleagues, and/or mentors. Because of these relationships, and through reflection on their experiences, they were able to develop a sense of salience. To situate and explain the study's findings within existing nursing knowledge, these patterns were then compared and contrasted with nurse residency research findings, and theories and research in nursing and sociology such as transition, socialization, professional role development, and role formation. The findings from this study extend and support role adaptation and transition theories. Implications from the study's findings can be used to improve the transition to the professional role, for preceptor development, and for refining nurse residency curricula.
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Eberwine, Julia K. "Methods Used to Assess Critical Care Nurses’ Ability to Detect the Deteriorating Patient and the Perceived Effectiveness of Those Methods." University of Cincinnati / OhioLINK, 2016. http://rave.ohiolink.edu/etdc/view?acc_num=ucin1459438932.
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Burger, Debora. "The development and validation of a modified Situation-Background-Assessment-recommendation (SBAR) communication tool for reporting early signs of deterioration in patients." Master's thesis, University of Cape Town, 2015. http://hdl.handle.net/11427/16553.
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Includes bibliographical referencesBackground: Errors in communication are prevalent in healthcare and affect patient safety and cause unnecessary patient deaths. Reporting early signs of physiological or clinical deterioration could improve patient safety and prevent 'failure to rescue' or unexpected intensive care admissions, cardiac arrest or death. The structured Situation-Background-Assessment-Recommendation (SBAR) communication tool enables nurses to provide doctors with pertinent information about a deteriorating patient in a logical order, based on a complete assessment. In addition, nurses have increased confidence in their findings and are better able to initiate a call and to convince a doctor to provide orders promptly or see a patient. Aim: The aim of this sub-study of a randomized controlled trial was to develop and validate a modified SBAR communication tool incorporating components of a local MEWS vital signs observations chart. Methods: The modified SBAR communication tool was developed following a review of available published examples and validated by employing a mixed methods approach: 1) cognitive interviews (n=3 nurses, 2 doctors), 2) determining the index of content validity with nurses (n=5), physicians (n=5) and surgeons (n=8) and 3) inter-rater reliability testing, with calculation of kappa values (n=2 nurses). Results: Cognitive interviews prompted more changes to the modified SBAR communication tool than determined by the content validity index. For cognitive interviews, there were 15/42 (35.71 %) modifications: 11 items were added (26.19 %) and three removed, (7.14 %) resulting in 49 items whereas for content validity index there were 4/49 (8.16%) modifications, 5/49 (10.20%) items removed and one item added (2.04%). Four of 49 items (8.16%) rated as relevant by <70% of nurses and doctors were revised or deleted. No additional modifications were needed following review by surgeons, as all items were rated as relevant by the pre-determined ≥70% of experts. Inter-rater reliability of the SBAR tool was established by two nurses who were mostly in substantial to full agreement on 37/45 items on the modified tool. The exceptions were: 'Calling from' (Cohen's Kappa-0.05) and 'this is a change from' (Cohen's Kappa-0.07), representing agreement below the level of chance. However, the high percentage agreement and nature of the questions suggest that the questions are sound. Percentage agreement amongst participants for these items was 91 % (95% confidence interval (CI): 71 to 99 ) and 86% (95% CI: 65 to 97 ) respectively. Deciding whether a doctor should see the patient now (Cohen's Kappa 0.09) or in the next 30 minutes, achieved fair agreement (Cohen's Kappa 0.20). This reflects a difference in clinical judgement as the decision when to call for assistance depended on the individual nurse's clinical judgement. IRR was not possible to test on 4/45 items, as those items required a response by the person being summoned. Overall, nine of 42 items were removed, 12 were added and 19 substantially modified, leaving 45 items. Conclusion: The modified SBAR communication tool was valid and reliable for use in a local context in conjunction with the Cape Town Modified Early Warning Score (MEWS) vital EWS) vital signs chart.
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Du, Toit Alida Christina. "The effectiveness of a splint programme in preventing the deterioration of already evident swan neck and boutonniere deformities in patients with rheumatoid arthritis." Master's thesis, University of Cape Town, 1991. http://hdl.handle.net/11427/26623.
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The aim of this study was to establish whether a splint programme is effective in preventing the deterioration of already evident swan neck and boutonniere deformities in rheumatoid arthritis (RA). A randomised clinical trial was done on 34 RA patients with swan neck and 34 RA patients with boutonniere deformities. The literature revealed that several factors such as age, gender, socio-economic status, time after onset of the illness and lifestyle could influence results. Care was taken to allocate, as far as possible equal numbers of patients with these attributes to the experimental and control groups. It became clear from the literature that swan neck and boutonniere deformities could manifest themselves in different forms and stages or grades of deterioration. Various splints to halt the downward spiral of the deformity were recommended, without proper scientific verification, by the authors. No specifications as to which splint was recommended for which form or grade of deformity or instructions for wearing of the splints were included. For the study the PIP hyperextension splint and the three-point-PIP extension splint was chosen for the swan neck and boutonniere deformities respectively. Patients were followed up for one year. Results were marginally positive for the prevent ion of swan neck deformities by the hyperextension splint programme, but results for the three-point PIP extension splint programmes were negative for grade I boutonniere deformities. Loss of flexor muscle strength was evident in almost all the groups (experimental and control) but more so for grade I swan neck and grade I boutonniere deformities. The variability of measurements were found to be large. Many possible sources of variation were identified, which included biological differences between people, different courses the illness could take and a weak test-retest reliability of some goniometer measurements. This fact and the relatively small sample subgroups caused some results to be not significant on the 5% level. From the significant findings, and other not significant tendencies that were too persistent to ignore, linked to the different manifestations and grades of swan neck and boutonniere deformities, recommendations were made. These suggestions will have to be tested by experimentation.
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Tait, Desiree J. R. "A Gadamerian hermeneutic study of nurses' experiences of recognising and managing patients with clinical deterioration and critical illness in a NHS trust in Wales." Thesis, Swansea University, 2008. https://cronfa.swan.ac.uk/Record/cronfa42577.
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Aim: To interpret nurses' experiences of caring for patients with clinical deterioration and critical illness in a Welsh NHS Trust. Methodology: A Gadamerian hermeneutic study drawing on eight in-depth interviews using a purposive sampling technique of nurses who had experienced caring for patients with clinical deterioration. Data collection occurred during 2004. Other data sources included the historical context and the researcher's preunderstandings of the phenomena: clinical deterioration; suboptimal care and critical illness. Data were analysed using a dialogical approach and guided by conditions necessary for Gadamerian hermeneutic interpretation. Findings: The interpretation revealed that recognition of clinical deterioration included general and focused perception of triggers. These included; vigilance in the observation and scanning of patients; perception of clinical deterioration informed by historical and experiential awareness of triggers; and the use of selective combinations of historical, behavioural, interpersonal and physiological triggers. Response to clinical deterioration was influenced by the professional knowledge and confidence of the nurse, organisational culture, workload balance and skill mix. A model of professional gaze emerged that involved a circle of scanning, focused observation, waiting and balancing conditions for an effective response. Conclusions: What is known is that junior medical and nursing staff lack the knowledge, skills and support network required to recognise and respond effectively to patient clinical deterioration in acute hospital settings. The evidence base to support the clinical effectiveness of national guidelines, produced in 2007, for recognising and responding to physiological evidence of clinical deterioration was inconclusive at the time of this study. What this research adds is a model of professional gaze that highlights the complex and professional clinical decision making process involved in nurses' recognition and response to triggers in patient clinical deterioration. This process begins before physiological changes occur and the model provides a structure for recognising clinical concern that can be applied and tested in clinical settings. The model also highlights nurses' strategies for facilitating effective management of these patients.
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McGaughey, Jennifer Margaret. "A realistic evaluation of early warning systems and acute care training for early recognition and management of deteriorating ward-based patients." Thesis, Queen's University Belfast, 2013. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.602463.
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Rapid Response Systems but is dependent upon nurses utilising EWS protocols and applying Acute Life-threatening Events: Recognition and Treatment (ALERT) course best practice guidelines. To date there is limited evidence on the effectiveness of EWS or ALERT as research has primarily focused on measuring patient outcomes (cardiac arrests, lCU admissions) following the implementation of a Rapid Response Team. The aim of this study was to evaluate factors that enabled and constrained the implementation and service delivery of Early Warnings Systems (EWS) and acute care training in practice in order to provide direction for enabling their success and sustainability. The research design was an embedded multiple case study approach of four wards in two hospitals in Northern Ireland. It followed the principles of realist evaluation research which allowed empirical data to be gathered to test and refine RRS programme theory. This approach used a variety of mixed methods to test the programme theories including individual and focus group interviews, observation and documentary analysis of EWS compliance data and ALERT training records . Data synthesis found similar regularities or factors enabling or constraining successful implementation across the case study sites. Findings showed that personal (confidence; clinical judgement; professional accountability; personality). social (ward leadership; communication), organisational (workload; time pressures; staffing levels and skill-mix), educational (constraints on training and experiential learning) and cultural (delegation of observations. referral hierarchy; rigid recording practices) influences impact on EWS and acute care training outcomes. RRS theory refinement using realist evaluation explained what works, for whom in what circumstances. Future service provision needs to consider improved staffing levels; flexible implementation of protocols underpinned by empowerment and clinical judgement; on-going experiential ward-based learning and enhanced clinical leadership to enable the success and sustainability of Rapid Response Systems.
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Dahan, Olivier. "Étude de la détérioration neuropsychologique de l'adulte après irradiation cérébrale : analyse du risque par un modèle mathématique, à partir d'une série rétrospective de 100 patients." Bordeaux 2, 1996. http://www.theses.fr/1996BOR23026.
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Batterbury, Anthony. "Exploring the acuity and dependency of adult ward patients following medical emergency team review: The REMAIN study." Thesis, Queensland University of Technology, 2022. https://eprints.qut.edu.au/234109/1/Anthony_Batterbury_Thesis.pdf.
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Hospitalised patients who deteriorate and require emergency medical review will most likely remain on a general ward after the review. Judgements about the level of care required to safely manage these patients on the ward after medical emergency team review are complex, but rarely incorporate a formal assessment of illness severity. This challenges staff and ward resource allocation practices and patient safety. This study measured the illness severity, in terms of physiological acuity and interventional dependency, of patients after emergency medical review. Novel statistical methods were used to identify then profile patient risk for death and potentially preventable adverse outcomes.
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Lampin, Marie Emilie. "Validation d’un score d’alerte et caractérisation des trajectoires de gravité des patients hospitalisés dans les unités de surveillance continue pédiatriques." Thesis, Lille 2, 2019. http://www.theses.fr/2019LIL2S047.
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Contexte : Les unités de surveillance continue (USC) pédiatriques constituent des structures de soins intermédiaires, entre les services « classiques » de pédiatrie (dits« soins courants ») et les services de réanimation, pour les enfants nécessitant une surveillance continue sans mise en oeuvre de méthode de suppléance. Ces patients sont à haut risque de dégradation et la validation d’un score d’alerte précoce (SAP) dans cette population serait intéressante.Objectifs : 1- Valider un score d’alerte précoce en USC pédiatriques.2- Classifier les malades de ces USC pédiatriques selon leurs caractéristiquesgénérales, leurs affections et les trajectoires de gravité de leur maladie.Méthodes : Etude observationnelle prospective multicentrique régionale dans septUSC pédiatriques françaises incluant tous les enfants consécutifs admis de septembre 2012 à janvier 2014. Validation de trois SAP, recueillis toutes les 8 heures (le Pediatric Advanced Warning Score (PAWS), le Pediatric Early WarningScore (PEWS) et le Bedside Pediatric Early Warning System (Bedside PEWS)) dans la population d’USC en utilisant un modèle linéaire mixte généralisé pourmesures répétées. La cohorte était divisée en échantillon de dérivation (70%) et en échantillon de validation (30%). La discrimination de ces SAP pour la prédiction de l’appel du médecin par l’infirmière en cas de détérioration clinique était mesurée par l’aire sous la courbe ROC. Un modèle mixte linéaire à classes latentes était utilisé pour identifier différentes trajectoires de gravité de ces patients d’USC.Résultats : Un total de 2868 enfants a été inclus pour 14708 observations utilisables pour calculer a posteriori les SAP. La discrimination des trois SAP pour prédire l’appel du médecin était bonne (entre 0,87 et 0,91) sur la cohorte de dérivation et modérée (entre 0,71 et 0,76) sur la cohorte de validation.La défaillance principale à l’origine de l’admission en USC était respiratoire (44%)et l’étiologie infectieuse était la plus fréquente (52%). Les deux diagnostics les plus fréquents étaient l’asthme et la bronchiolite. Dix diagnostics représentaient 58%des patients d’USC. La médiane de durée de séjour était de 1 jour [1-3]. L’analyse en classe latente mettait en évidence différentes trajectoires de gravité : le profil« stable» (60,4%), le profil « amélioration rapide » (6,5%) et le profil« amélioration lente » (33,1%).Conclusion : Les SAP peuvent être utilisés dans les USC pour détecter une détérioration clinique et prédire la nécessité d'une intervention médicale. Trois trajectoires très différentes de gravité ont été identifiées avec une majorité de patients appartenant au profil « stable»Background: Pediatric Intermediate care units (PImCU) are Intermediate care units(ImCU) or high dependency care units (HDC), between regular wards and intensivecare units (ICUs), for children requiring continuous monitoring without active lifesupportingtreatment. These patients are at high risk of deterioration and thevalidation of an early warning score (EWS) in this population would be interesting.Objectives: 1- To validate early warning scores in PImCU2- To classify patients according to their general characteristics, their diagnoses andthe severity trajectories of illness.Methods: Regional multicenter prospective observational study in seven FrenchPImCU including all consecutive children admitted from September 2012 toJanuary 2014. Validation of EWS in PImCU using a general linear mixed modelfor repeated measures. The cohort was divided into derivation (70%) and validation(30%) cohorts. The discrimination to predict physician call by nurse was estimatedby the area under the receiver-operating curve. A latent class linear mixed modelwas used to identify different trajectories of severity of illness of PImCU patients.Results: A total of 2868 children were included for 14708 observations to computea posteriori the EWS. The discrimination of the three EWS for predicting calls tophysicians by nurses was good (range: 0.87–0.91) for the derivation cohort andmoderate (range: 0.71–0.76) for the validation cohort. The primary failure foradmission to PImCU was respiratory (44%) and infectious etiology was the mostcommon (52%). The two most common diagnoses are asthma and bronchiolitis.Ten diagnoses account for 58% of PImCU patients. The median length of stay was1 day [1-3]. The latent class analysis identified different trajectories of severity ofillness: profile "stable" (60.4%), profile "rapid improvement" (6.5%) and profile"slow improvement" (33.1%).Conclusion: SAP can be used in PImCU to detect clinical deterioration and predictthe need for medical intervention. Three very different trajectories of severity wereidentified with a majority of "stable" profile
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Anota, Amelie. "Analyse longitudinale de la qualité de vie relative à la santé en cancérologie." Thesis, Besançon, 2014. http://www.theses.fr/2014BESA3010/document.
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La qualité de vie relative à la santé (QdV) est désormais un des objectifs majeurs des essais cliniques en cancérologie pour pouvoir s’assurer du bénéfice clinique de nouvelles stratégies thérapeutiques pour le patient. Cependant, les résultats des données de QdV restent encore peu pris en compte en pratique clinique en raison de la nature subjective et dynamique de la QdV. De plus, les méthodes statistiques pour son analyse longitudinale doivent être capables de tenir compte de l’occurrence des données manquantes et d’un potentiel effet Response Shift reflétant l’adaptation du patient vis-à-vis de la maladie et de la toxicité du traitement. Ces méthodes doivent enfin proposer des résultats facilement compréhensibles par les cliniciens.Dans cette optique, les objectifs de ce travail ont été de faire le point sur ces facteurs limitants et de proposer des méthodes adéquates pour une interprétation robuste des données de QdV longitudinales. Ces travaux sont centrés sur la méthode du temps jusqu’à détérioration d’un score de QdV (TJD), en tant que modalité d’analyse longitudinale, ainsi que sur la caractérisation de l’occurrence de l’effet Response Shift.Les travaux menés ont donné lieu à la création d’un package R pour l’analyse longitudinale de la QdV selon la méthode du TJD avec une interface facile d’utilisation. Certaines recommandations ont été proposées sur les définitions de TJD à appliquer selon les situations thérapeutiques et l’occurrence ou non d’un effet Response Shift. Cette méthode attractive pour les cliniciens a été appliquée dans le cadre de deux essais de phase précoces I et IL La méthode de pondération par probabilité inversée du score de propension a été investiguée conjointement avec la méthode du TJD afin de tenir compte de l’occurrence de données manquantes dépendant des caractéristiques des patients. Une comparaison de trois approches statistiques pour l’analyse longitudinale a montré la performance du modèle linéaire mixte et permet de donner quelques recommandations pour l’analyse longitudinale selon le design de l’étude. Cette étude a également montré l’impact de l’occurrence de données manquantes informatives sur les méthodes d’analyse longitudinale. Des analyses factorielles et modèles issus de la théorie de réponse à l’item ont montré leur capacité à caractériser la Response Shift conjointement avec la méthode Then-test. Enfin, bien que les modèles à équation structurelles soient régulièrement appliqués pour caractériser cet effet sur le questionnaire de QdV générique SF-36, ils semblent peu adaptés à la structure des questionnaires spécifiques du cancer du groupe « European Organization of Research and Treatment of Cancer » (EORTCHealth-related quality of life (HRQoL) has become one of the major objectives of oncology clinical trials to ensure the clinical benefit of new treatment strategies for the patient. However, the results of HRQoL data remain poorly used in clinical practice due to the subjective and dynamic nature of HRQoL. Moreover, statistical methods for its longitudinal analysis hâve to take into account the occurrence of missing data and the potential Response Shift effect reflecting patient’s adaptation of the disease and treatment toxicities. Finally, these methods should also propose some results easy understandable for clinicians.In this context, this work aimed to review these limiting factors and to propose some suitable methods for a robust interprétation of longitudinal HRQoL data. This work is focused on both the Time to HRQoL score détérioration (TTD) as a modality of longitudinal analysis and the characterization of the occurrence of the Response Shift effect.This work has resulted in the création of an R package for the longitudinal HRQoL analysis according to the TTD with an easy to use interface. Some recommendations were proposed on the définitions of the TTD to apply according to the therapeutic settings and the potential occurrence of the Response Shift effect. This attractive method was applied in two early stage I and II trials. The inverse probability weighting method of the propensity score was investigated in conjunction with the TTD method to take into account the occurrence of missing data depending on patients’ characteristics. A comparison between three statistical approaches for the longitudinal analysis showed the performance of the linear mixed model and allows to give some recommendations for the longitudinal analysis according to the study design. This study also highlighted the impact of the occurrence of informative missing data on the longitudinal statistical methods. Factor analyses and Item Response Theory models showed their ability to characterize the occurrence of the Response Shift in conjunction with the Then- test method. Finally, although the structural équations modeling are often used to characterize this effect on the SF-36 generic questionnaire, they seem not appropriated to the particular structure of the HRQoL cancer spécifie questionnaires of the European Organization of Research and Treatment of Cancer (EORTC) HRQoL group
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Mitchell, Imogen Ann. "Patient deterioration : the effect of humans and systems in one health care system." Phd thesis, 2012. http://hdl.handle.net/1885/156327.
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The failure to recognise and to respond to adult deteriorating patients in general hospital wards leads to unexpected and potentially preventable deaths. Aims. 1. To improve the understanding of the clinical processes and influences involved in managing patient deterioration. 2. To examine the effect of a deteriorating patient intervention on clinical processes and patient outcome. 3. To determine if the effects of a deteriorating patient intervention are sustainable. Methods. Quantitative Studies. i. Observational Study: Clinical processes in 34 patients undergoing 45 Medical Emergency Team reviews were examined retrospectively. ii. lnterventional Study: A prospective controlled trial, before and after a multifaceted intervention for managing patient deterioration was undertaken in two wards in two hospitals for two{u00AD} four month periods. Changes in deteriorating patient clinical processes and outcome were measured. iii. Sustainability Study: Adult patients admitted to two wards in one hospital during three four{u00AD} month periods, one before, one immediately after the patient deterioration intervention and one two years later. Changes in deteriorating patient clinical processes and outcome were measured. Qualitative Studies. i. Behavioural Study: Interviews of 12 healthcare workers involved in the patient deterioration intervention were undertaken to generate a model of why behaviour changed with the installation of the multifaceted intervention for managing patient deterioration. Grounded theory methodology described on page 80 was used. ii. Human Element Study: Focus groups of healthcare workers were held to generate discussion and used to generate a model of the influences on healthcare professionals in managing patient deterioration. Grounded theory methodology was used. Results. Clinical processes for managing patient deterioration were found to be deficient. Deficiencies included infrequent documentation of vital signs, particularly respiratory rate and limited involvement of senior decision makers leaving junior clinicians to manage patient deterioration, which delayed appropriate treatment. The multifaceted intervention significantly improved patient outcome and improved behaviour such as documentation of vital signs, supported by a hospital policy, and timeliness of medical review, triggered by more confident nursing staff underpinned by objective evidence (the modified early warning score) of patient deterioration. Improvement in timeliness of medical review and documentation of vital signs were sustained two years later but patient hospital outcome and the nurses calling for further medical help were not. Further investigation of behaviours that were not sustained revealed that junior medical and nursing staff lacked adequate clinical experience to facilitate timely decision making necessitating input from their consultants. Timely and appropriate communication was hindered through fear, lack of confidence or lack of knowledge and poor consultant approachability. Conclusion. Identified shortcomings in the teamwork managing patient deterioration improved with the installation of a multifaceted intervention and, improved patient hospital outcome. Significant behavioural issues, especially communication with consultants, were identified as likely to hamper further improvement. In an age of shift work and reduced clinical experience, enhanced decision making will need a more intelligent system that can accurately detect patients at risk of patient deterioration and improved access to consultants to gain maximal benefit from the healthcare team.
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(9813164), Marie Le Lagadec. "Identification and management of patient deterioration—Comparing the afferent limb of early warning systems." Thesis, 2021. https://figshare.com/articles/thesis/Identification_and_management_of_patient_deterioration_Comparing_the_afferent_limb_of_early_warning_systems/16915642.
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It is mandated that all Australian hospitals employ a means of detecting patient deterioration, and in doing so, most have chosen to adopt Early Warning Scores (EWS). Over the past three decades, many variations of EWSs have been developed and tested in larger regional/metropolitan hospitals. However, there is a paucity of evidence as to which EWS is most effective in predicting deterioration events in small, poorly resourced regional/rural hospitals. The aim of this study was to inform small, poorly resourced regional/rural hospitals on the selection of the best EWS or class of EWS, to augment patient safety within their context.
This multi-phase retrospective case-controlled study compared the efficiency of 12 existing EWSs using patient data from two small regional private hospitals (Phase 1). Outcomes from Phase 1 informed Phase 2 and the development of a new EWS for use in poorly resourced regional private hospitals. The new EWS was then validated using two independent patient cohorts from small, poorly resourced regional/rural public hospitals (n=7) and large, well-resourced public regional/metropolitan hospitals (n=6).
Results showed that in small regional private hospitals, the aggregated weighted EWS, called Compass, was most effective in identifying deteriorating patients with an Area under the Receiver Operator Characteristic Curve (AUROC) of 0.747 (CI 0.73-0.76). However, Compass had a low sensitivity of 0.44, meaning that less than 50% of the deteriorating patients achieved an emergency call score. Given the suboptimal efficiency of the 12 EWSs tested, a new, more efficient EWS was developed. The first step in developing a new EWS involved determining the ability of the vital signs in predicting patient deterioration. While vital signs are good indicators of patient deterioration, no single vital sign was found to predict patient outcomes strongly. A rapid heart rate and the need for supplementary oxygen were identified as the best indicators of an impending clinical deterioration event in this patient cohort. Based on these findings, a new combination EWS, called MOD-6 was then developed. This was achieved by adding a single trigger component to Compass, extending the existing vital sign trigger threshold ranges and incorporating a graduated weighted scale for supplementary oxygen use. The new combination EWS, MOD-6, was 20% more effective than Compass when used in poorly resourced regional private hospitals. However, when validating the new MOD-6 using two independent patient cohorts from the public sector, the MOD-6 EWS was no more effective than existing EWSs.
This study has produced evidence that EWSs are used differently in large, well-resourced regional/metropolitan hospitals compared to poorly resourced regional/rural hospitals. In the well-resourced hospitals, there is evidence that the EWSs are being used to identify clinical deterioration events, reactively using the EWS scores to guide the escalation of patient care. At the small, poorly resourced hospitals, the EWSs appear to be used proactively to predict patient deterioration and prevent adverse patient events. At these small regional/rural hospitals, staff appear to respond early to changes in the patients’ vital signs, transferring patients out to a better resource facility before triggering an emergency threshold score on the EWS. In conclusion, an aggregated weighted EWS, such as Compass, or a combination EWS such as the new MOD-6 EWS should be considered for implementation in the small, poorly resourced private hospitals. The best indicators of patients requiring transfer out to a higher level of care in this patient cohort are the use of supplementary oxygen and those with tachycardia. Findings from this research will inform nursing practice in small, poorly resourced regional/rural hospitals and positively contribute to patient safety.
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Le, Roux Estelle. "Transfer to higher level of care : a retrospective analysis of patient deterioration, management as well as processes involved." Diss., 2010. http://hdl.handle.net/10500/3915.
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In-patient deterioration is a global phenomena and timely recognition and action improves outcome. Intensive care facilities are scarce and expensive and therefore patient care must be optimal. A retrospective health record analysis was used for this study.
The findings indicated that nursing personnel do not recognize patient deterioration timeuously. However, the implementation of an outreach team and clinical markers training program improved the recognition of patient deterioration in general wards with three hours and 40 minutes.
It is recommended to implement a comprehensive hospital program that addresses the basic knowledge and skills of general ward personnel to observe, recognize, assess and intervene to patients with clinical deterioration. Together with an extensive training program, a basic physiological parameters guideline to activate a team of experts to the bedside, such as an Outreach team, assist nursing personnel to recognize and manage those patients timeuously and ensure treatment in an appropriate level of care.Health Studies
M. A. (Health studies)
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Johal, Jagdeep K. "Staff Nurses' Perceptions of Rapid Response Teams in Acute Care Hospitals." Thesis, 2008. http://hdl.handle.net/1974/1503.
Full textAbstract:
The purpose of the present study were to (a) explore the relationship between the frequency of use of Rapid Response Teams (RRTs) by hospital staff nurses and the support received from RRTs; (b) to investigate staff nurses’ perceptions of their individual level, group level and organizational level learning as a result of single or multiple exposures to the RRT; (c) to identify predictors of learning outcomes and (d) to identify overall impressions and advantages and disadvantages of the RRT. A mail survey was used to collect data. The response responses rate was 33%, 131 registered nurses responded to the survey (pre-test = 12, study = 119). The results of Pearson r correlation suggest that a high frequency of access of RRTs was positively related to process support (r = .25, p < .01). Also, perceived content and process support from RRTs was positively related to maintenance and building of staff nurses’ mental models regarding patient deterioration pertaining to self, group and organization. Multiple regression analyses show that sociodemographic and independent variables predict organizational learning outcomes (mental model maintenance and building). Overall impressions of the RRTs were high. A content analysis of nurses’ comments indicated that there were more advantages to having the RRTs than disadvantages. This study suggests that RRTs are influential in changing nurses’ perceptions about managing patient deterioration. Training programs for RRTs should include both content and process support, which may enhance building and maintaining mental models.Thesis (Master, Nursing) -- Queen's University, 2008-09-25 21:27:44.682
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Lavoie, Patrick. "Contribution d'un débriefing au jugement clinique d'étudiants infirmiers lors de simulations de détérioration du patient." Thèse, 2016. http://hdl.handle.net/1866/18588.
Full text
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Fan, Ju-Sing, and 范渚鑫. "Emergency Department Neurologic Deterioration in Patients with Spontaneous Intracerebral Hemorrhage: The incidence, risk factors, and prognostic significance." Thesis, 2012. http://ndltd.ncl.edu.tw/handle/03234756566939043031.
Full textAbstract:
碩士國立陽明大學
急重症醫學研究所
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OBJECTIVES: To explore the incidence, predictors, and prognostic significance of emergency department (ED) neurologic deterioration in patients with spontaneous intracerebral hemorrhage (SICH). METHODS: Design: Retrospective cohort study. Settings: ED, neurocritical care unit and general intensive care unit of university-affiliated medical center. Patients: Consecutive adult SICH patients treated in our ED from January 2002 through December 2009, identified from the registered stroke data bank, were cross-checked for coding with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) 431 and 432.9. Enrolled patients had SICH with elapsed times of <12 hours and Glasgow Coma Scale (GCS) scores ≥13 on arrival. ED neurologic deterioration was defined as ≥2-point decrease in consciousness noted in any GCS score assessment between ED presentation and admission. Measurements: Comparisons of numerical data were performed using an unpaired t-test (parametric data) or Mann-Whitney U test (non-parametric data).Comparisons of categorical data were done by chi-square tests. Variables with p < 0.1 in univariate analysis were further analyzed using multiple logistic regressions. No variable automated or manual selection methods were used. RESULTS: Among the 619 patients with intracerebral hemorrhage enrolled in the study, 22.6% had ED neurologic deterioration. Independent predictors for ED neurologic deterioration included: regular antiplatelet use; ictus to ED arrival time <3 hours; initial body temperature ≥37.5 ℃, intraparenchymal hemorrhage associated with intraventricular hemorrhage; and presence of a midline shift of greater than 2 mm on CT. ED neurologic deterioration was associated with 1-week mortality, 30-day mortality, and poor neurological outcome on discharge. CONCLUSIONS: Nearly one quarter of SICH patients with an initial GCS of 13-15 had a 2 points or more deterioration of their GCS while in the ED. ED neurologic deterioration was associated with death and poor neurologic outcomes on discharge. Several risk factors that are available early in the patients’ courses appear to be associated with ED neurologic deterioration. By identifying patients at risk for early neurologic decline and intervening early we may be able to improve patient outcomes.
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Abdulmohdi, N. "Investigating nursing students' clinical reasoning and decision making using high fidelity simulation of a deteriorating patient scenario." Thesis, 2019. https://arro.anglia.ac.uk/id/eprint/704906/1/Abdulmohdi_2019.pdf.
Full textAbstract:
The ability of the nurse to make clinical decisions is an integral part of nursing practice and clinical competency. The shortage in clinical placement, the incidences of “failure to rescue” and the emphasis on patient's safety has driven the increased use of simulation in nursing education. Yet, there is a lack of evidence about how simulation affects students’ decision-making skills and the way in which nursing students learn how to make decisions is not well understood.
The aim of this study was to investigate nursing students’ clinical decision making using high fidelity simulation of a deteriorated patient scenario. Twenty-three nursing students in the final year of their nursing degree were recruited for this investigation. A pragmatist approach and a multiphase mixed method design were adopted. The Health Science Reasoning Test (HSRT), think aloud and observations were used in phase1. A semi-structured interview was applied in phase 2 to explore the benefits of this experience on students' clinical practice.
Phase 1 results showed a statistically significant improvement in the overall HSRT score post the simulation experience. The students applied both methods of reasoning, the forward and backward, in a dynamic manner to make decisions. They predominantly used the analytical type of decision making and forward reasoning to respond to a patient's deterioration. The equal application of the analytical and non-analytical types associated with a better effect on the HSRT score. The students were not always effective in cue acquisition and interpretation and these stages were affected by cognitive biases. Phase 2 revealed that simulation promoted deep learning and increased students' self-awareness.
The study draws the attention to the need for a clinical simulation design that based on a theory of decision making. It proposes a framework that has the potential to enhance the effectiveness of clinical simulation in teaching clinical decision making.
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(9796415), Tracy Flenady. "Understanding transgression in respiratory rate observation collection methods in the Emergency Department: A classic grounded theory analysis." Thesis, 2018. https://figshare.com/articles/thesis/Understanding_transgression_in_respiratory_rate_observation_collection_methods_in_the_Emergency_Department_A_classic_grounded_theory_analysis/13445705.
Full textAbstract:
Abnormal respiratory rates are one of the first indicators of clinical deterioration in emergency department patients. Despite the importance of respiratory rate observations, this vital sign is often missing or misrepresented on emergency department observation charts, compromising patient safety. Concurrently, there is a paucity of research reporting why this phenomenon occurs.
This research project employed a classic grounded theory analysis of qualitative data with the aim of developing a substantive theory explaining emergency department registered nurses’ reasoning when they miss or misreport respiratory rate observations. Seventy nine registered nurses currently working in emergency departments within Australia provided detailed responses from individual interviews and open ended responses from an online questionnaire.
Classic grounded theory research methods were utilised, therefore coding was central to the abstraction of data and its reintegration as theory. The three types of constant comparison synonymous with classic grounded theory methods were employed to code data. This overall approach facilitated the identification of the main concern of the participants from the substantive area of interest, and aided in the generation of theory explaining how the participants processed this issue.
The main concern identified was that registered nurses did not want to perform respiratory rate observations at each round, however organizational requirements dictate a value for the respiratory rate be included each time vital signs are collected. The theory ‘Rationalising Transgression’, explains how the participants continually resolve this problem. The study found that despite feeling professionally conflicted, nurses often erroneously record respiratory rate observations, and then rationalise this behaviour by employing several strategies that adjust the significance of the organisational requirement. These strategies include compensating, when nurses believe they are compensating for errant behaviour by adding value to the patient’s outcome. Minimalizing is employed when nurses believe that the patient’s outcome would be no different if they performed and recorded an accurate respiratory rate or not. The Trivialising strategy sanctions negligent behaviour and occurs when nurses ‘cut corners’ to get the job done.
This research reveals that despite years of continuing education regarding best practice guidelines for respiratory rate collection, suboptimal practice continues. Ideally, to combat this transgression, a culture shift must occur regarding nurses’ understanding of acceptable practice methods in regards to patient safety. Nurses must receive education in a way that permeates their understanding of the relationship between the regular collection of accurate respiratory rate observations and optimal patient outcomes.