Nursing interventions for the early detection of ward patients’ clinical deterioration: an integrative review

Background: Clinical deterioration is sometimes mishandled in hospital wards resulting in increased likelihood of cardiorespiratory arrest, unplanned intensive care admissions, and death. Objectives: To identify nursing interventions aimed at the early detection of the clinical deterioration of ward patients. Methodology: Integrative literature review through the search for published and gray literature in CINAHL, MEDLINE, and ScienceDirect databases. Results: A total of 534 documents were identified, of which 11 were selected for data extraction and analysis. Conclusion: The monitoring of vital signs, either individually or in combination or to obtain an early warning score, is the most widely performed nursing intervention identified in the literature.


Introduction
Patient safety has been the target of growing concern worldwide, as it is a fundamental principle in health care which has a significant impact on care quality (Edwards, 2005).Therefore, the National Patient Safety Agency (2007) considers that the early detection of clinical deterioration is essential to reduce mortality rates associated with cardiopulmonary arrest (CPA).Today, hospitalized patients tend to have more complex clinical situations and a higher number of comorbidities, which increases the likelihood of clinical deterioration during hospitalization (Preece, Hill, Horswill, & Watson, 2012).In this way, it is possible to infer that ward patients might be in a situation similar to those who are in intensive care units (ICUs), which puts them at risk of experiencing an adverse event such as a cardiac and/or cardiopulmonary arrest.Regardless of the underlying process, the signs of acute illness are similar because they reflect changes in the respiratory, cardiac, and neurological systems.Physiological alterations, in one or more parameters, are associated with a higher likelihood of CPA, unplanned ICU admissions, and death (Soar et al., 2015).Within this scope, the European Resuscitation Council guidelines suggest a CPA prevention approach focused on the chain of prevention, staff training/ education, monitoring and identification of deterioration, and a system that allows asking for help and getting an effective response (Soar et al., 2015).Similarly, the American Heart Association for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care guidelines (Kronick et al., 2015) recommend the existence of an in-hospital chain of survival.The first link in this chain depends on an appropriate surveillance system to prevent CPA.If CPA occurs, health institutions should have a system that allows the notification and intervention of a multidisciplinary team specialized in caring for these critically ill patients.Considering these aspects as a way to facilitate the early detection of clinical deterioration, Rapid Response Systems (RRSs) have been implemented to allow for its recogni-tion in health institutions and subsequent intervention (Joshi, Campbell, Gooch, Anstey, & Landy, 2015).RRSs are aimed at identifying the clinical condition of the ward patient in the minutes immediately before CPA to check if something can be done to prevent clinical deterioration and subsequent ICU admission (Winters & DeVita, 2015).According to the authors, RRSs are based on the early recognition of the clinical deterioration of the ward patient, thus contributing to the intervention of a multidisciplinary critical care team.Its main objective is to reduce the occurrence of CPA, thus reducing mortality rates and the need for unplanned ICU admissions.According to the authors, nurses often put RRSs into motion when they recognize the clinical deterioration of the ward patient.According to Benner (2001), the diagnostic and patient-monitoring function is a nursing intervention that contributes to the promotion of patient safety because it allows for the early detection of clinical deterioration situations.However, it should be noted that aspects such as work overload resulting from the complexity and increased demands of caring for critically-ill patients and the lack of differentiated and experienced staff to support decision-making contribute to the difficulties in the early identification of ward patients' clinical deterioration (National Patient Safety Agency, 2007).The literature suggests that the majority of adverse events that occur in health care settings result from ineffective communication and situations of misunderstanding within the team, reducing patient safety (Courtenay, Nancarrow, & Dawson, 2013).In summary, it is more difficult today to detect and intervene in a situation of clinical deterioration in ward patients.Therefore, the objective of this integrative literature review (ILR) was to identify the nursing interventions aimed at the early detection of ward patients' clinical deterioration.

Methodological procedures of integrative review
To meet the objective set out, the ILR was conducted according to the Joanna Briggs Institute guidelines (Joanna Briggs Institute [JBI], 2015), based on a research question designed using the PCC (Population, Concept, and Context) strategy: Which nursing interventions promote the safety of the patient at risk for clinical deterioration in a ward?The inclusion and exclusion criteria of studies were defined based on the popu-lation, context, language, date of publication, and nursing intervention for detection of deterioration (Table 1).The population was composed of adults aged 18 to 65 years.An initial search showed a study published in 2005 on nursing interventions for the detection of clinical deterioration; for this reason, this date was established as the minimum date possible for inclusion.First, searches in conventional online databases were performed to identify the most relevant articles on the topic under analysis and the keywords and search terms to be used.
The search was conducted in the CINAHL, MEDLINE, and ScienceDirect databases between May and July 2016.Two studies found in additional searches were also included because they met the inclusion criteria.Initially, a natural language search was conducted in the databases using the terms identified in the keywords of the articles found in the initial search.Then, descriptors/medical subject headings (MeSH) and major headings (MH) were combined using the Boolean operators "OR" and "AND", while considering the expression "deteriorating patient" in the full text.
The search strategy used in CINAHL was as follows: (MH "Nursing Interventions") OR (MH "Nursing Process") OR (MH "Nursing Protocols") OR (MH "Nursing Care Plans") OR (MH "Patient Assessment") OR (MH "Monitoring, Physiologic") AND (MH "Early Intervention") OR "Rapid response system" OR "Deteriorating patient"; in MEDLINE: (MH "Nursing") OR (MH "Nursing Process") OR (MH "Nursing Assessment") OR (MH "Patient Care Planning") OR (MH "Monitoring, Physiologic") AND (MH "Hospital Rapid response team") OR "Deteriorating patient"; and in Science-Direct: "Nursing intervention" and "deteriorating patient", activating the filters for date of publication and full text.Quantitative and qualitative primary studies were included, as well as systematic literature reviews, without restrictions on sample size.However, only articles with full text available and which were not opinion articles were included.The free search and the search on the databases retrieved 534 articles.Of these, 15 articles were removed for being duplicates.The process of article identification and selection is shown in Figure 1, and is structured as follows: 1) Critical and reflective reading of titles and summaries with the purpose of checking if they met the inclusion criteria; 2) Full-text reading of the articles and their division according to the inclusion criteria, having obtained 11 articles for data extraction and analysis.

Results and interpretation
The monitoring and recording of vital signs are essential nursing interventions for the early detection of clinical deterioration.This is often confirmed by the monitoring of vital parameters such as respiratory rate, heart rate, and blood pressure (Andrews & Waterman, 2005;Liaw, Scherpbier, Klainin-Yobas, & Rethans, 2011).However, authors such as Andrews and Waterman (2005)

Results and interpretation
The  Jones, and Gardner (2015), although clinical deterioration requires other nursing interventions beyond the monitoring of vital signs, this was the most widely used nursing intervention.The authors believe that this finding is associated with the current focus on parameters specified by the RRSs, which could lead nurses to undervalue the performance of a more comprehensive patient assessment.If performed, this comprehensive assessment could allow for the early detection of subtle changes in the patient's health status.In line with this, Kyriacos, Jelsma, James, and Jordan (2014) underline that it is not enough to assess and record vital signs because the patient's safety continues to rely on the nurses' clinical judgment.According to Tanner (2006), clinical judgment in nursing requires "an understanding of not only the pathophysiological and diagnostic aspects of a patient's clinical presentation and disease, but also the illness experience for both the patient and family and their physical, social, and emotional strengths and coping resources" (p.205).
The purpose of the EWS is to provide an accessible and systematic way to assess the patients' health status and guide the response in case of a situation of clinical deterioration, based on a scoring system of physiological measures obtained at the time of admission or in regular monitoring moments during hospitalization (Capan, Ivy, Rohleder, Hickman, & Huddleston, 2015).Since its introduction in health institutions, EWSs have been updated and modified.Examples are the Modified Early Warning Score (MEWS) and the National Early Warning Score (NEWS; Kyriacos et al., 2014).In the same way as the initial EWS, these scales result from the monitoring of five physiological parameters: heart rate, respiratory rate, systolic blood pressure, temperature, and level of consciousness.In addition, the NEWS includes peripheral oxygen saturation and supplemental oxygen, and, in some institutions, the MEWS includes peripheral oxygen saturation, urine output, blood glucose and/or analytical levels, and pain.These parameters, although they are not part of the scale, are considered in situations of clinical deterioration (Kyriacos et al., 2014).Taking into account that alterations in heart rate, respiratory rate, blood pressure, and level of consciousness are indicators of physiological deterioration, a combined monitoring of these parameters is expected to have a higher predictive value than an isolated monitoring (Smith & Prytherch, 2011).As already mentioned, vital signs were assessed in order to group values and obtain a EWS.In this way, the calculation of the MEWS to detect clinical deterioration was also one of the nursing interventions identified in 8 of the 11 reviewed studies (S1, S3, S4, S5, S6, S7, S8, and S11).As with nurses' intuition and use of subjective data, which are confirmed by the monitoring of vital signs, S4 also found that the MEWS was only calculated to confirm the situation of clinical deterioration rather than to detect it.The sum of the points assigned to each parameter results in the EWS, which is used to increase the frequency of monitoring of vital signs, request the collaboration of more experienced professionals, or call the rapid response team (RRT) (Smith & Prytherch, 2011).The request for differentiated help and the activation of an RRT seem to be the nursing interventions used to respond to the identified situation of clinical deterioration (S3, S4, S5, S6, S7, S8, and S11).
The MEWS was considered to be an effective instrument of communication of the clinical deterioration to the physician since it allows systematizing findings and presenting them in an objective manner (S1, S3, S5, S7, and S11).Although three studies (S3, S6, and S7) mentioned the use of the Situation, Background, Assessment, Recommendation (SBAR) communication tool to convey information, different results were obtained.S7 concluded that, after the introduction of this tool in a hospi-tal, nurses' perceptions of the effectiveness of communication and collaboration within the multidisciplinary team increased, the number of unplanned ICU admissions and the number of unexpected deaths decreased.However, S6 showed that SBAR was used by only one out of 47 nurses with training to use it.In turn, in S3, this tool is considered to be an effective strategy to increase the number of nurses' clinical observations.In view of the above, as stated by Mitchell et al. (2010) it is possible to say that a timely intervention to prevent or stop the progression of clinical deterioration requires a set of interventions that includes the monitoring and interpretation of vital signs, followed by an effective communication and adequate clinical response.Qualitative study.
To examine the perceptions of ward and RRT nurses about the management of ward patients with clinical deterioration.
Nurses detected clinical deterioration when assessing their patients visually, looking for recurring signs and symptoms, and comparing their evolution over time.
Although the EWS was not a key component of patient assessment, it was frequently used to quantify deterioration when any changes were detected.
Visual assessment of the patient; To identify nurses' educational needs and explore educational strategies to enhance their ability to recognize and intervene in cases of clinical deterioration in wards.
Findings identified the educational need to empower nurses to recognize and intervene in patient deterioration.The review of educational programmes and their outcomes identified information and strategies in deprived areas.
Intuition To explore nurses' experiences in the implementation and use of the MEWS and the existence of an ICU nurse providing 24-hour on-call support.
Three themes emerged: 1) experiences with the early recognition of deterioration using the MEWS, 2) collaboration and knowledge transfer between nurses, and 3) a new precise language used to communicate with physicians.The use of the EWS and support were perceived as improving care for deteriorating patients and for supporting the collaboration between professionals.

Calculation of the EWS;
Activation of a more differentiated response (ICU nurse and/or RRT).

Conclusion
This ILR aimed to identify the nursing interventions used for the early detection of hospital ward patients' clinical deterioration.The 11 articles analyzed in this review show that the monitoring of vital signs, either individually or in combination to obtain a EWS, is the most widely used nursing intervention.They also highlight the importance of intuition and use of subjective data in patient assessment and aspects such as the communication of clinical deterioration and the activation of the RRT/ assistant physician as a result of these interventions.This study has some limitations: it only included articles available through open access in the databases searched; three of the studies used qualitative methods and their results cannot be generalized; and only articles written in English were analyzed.We believe that training in areas such as patient physical assessment and team communication are a significant contribution to achieve effective nursing interventions in this area.This training, combined with the use of the best scientific evidence available, will allow for a substantiated clinical judgment and decision-making.
Evidence on this topic is scarce, so we suggest that studies should be conducted on nursing interventions for the early detection of clinical deterioration.In addition, it would be equally important to analyze the results of the implementation of RRSs in health institutions, since they have a recognized impact on reducing mortality rates and unplanned ICU admissions, thus contributing to patient safety and leading to health gains in society in general.
Nursing interventions for the early detection of ward patients' clinical deterioration: an integrative review

Table 1
Inclusion and exclusion criteria and Odell (2015)have reported gaps in nurses' interventions +The process of evaluating the methodological quality of the articles was conducted independently by two reviewers using the JBI -Meta Analysis of Statistics Assessment and Review Instrument (MAStARI) critical appraisal tools and the JBI -Qualitative Assessment and Review Instrument critical appraisal tool for studies of quantitative and qualitative, respectively.The information was extracted and synthetized from quan-

Table 2 .
Synthesis of the evidence found