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NURSING SCIENCE
Systems-based physical assessments: Earlier detection of clinical deterioration and reduced mortality
Article Critique by Joanne Muyco DNP, RN, NE-BC, CNOR
Article Critique by Joanne Muyco DNP, RN, NE-BC, CNOR
Title:
Systems-based physical assessments: Earlier detection of clinical deterioration and reduced mortalityPublished: September 2023 in American Journal of Critical Care
Level of Evidence: Level C: Retrospective observational cohort design
What was the purpose?
Nurses are responsible for performing physical assessments to help recognize and identify early signs of clinical deterioration. This article aimed to evaluate the effectiveness of a nurse quality improvement initiative, the Methodist Proficient Assessment Competency (MPAC), which focused on nurses performing systems-based physical assessments (SPAs). The authors evaluated the elapsed time between clinical deterioration and the rapid response team (RRT) activation before and after the quality improvement initiative. Additionally, the study team assessed whether nurses performing SPAs correlated with the occurrence of two serious adverse events — ICU admissions and death. The study team hypothesized that if nurses focus on conducting a daily SPA on patients, they will recognize changes in patient conditions and initiate earlier interventions to prevent adverse patient outcomes. This will reduce delays in activating the RRT and result in fewer serious adverse events.
What population was studied?
The population studied in this article were patients who received an RRT activation from July 1through December 31, 2017, (before MPAC) and November 1, 2018 through April 30, 2019 (after MPAC). Inclusion criteria were patients at least 18 years of age receiving an RRT activation to an acute care or intermediate care unit. Repeat RRT calls were included unless the repeat activation occurred within 24 hours of the first RRT. Exclusion criteria included patients in departments outside the acute care or intermediate care unit, RRT activations for staff or visitors, and patients whose reason for RRT activation was due to altered mental status.
Was the setting comparable to Houston Methodist? Were the nurses like our nurses?
The setting was Houston Methodist at the Texas Medical Center. It included Houston Methodist patients in the acute care or intermediate care unit.
Did the authors use the appropriate methods?
The authors used a retrospective, single-center, observational cohort study design. This study design was appropriate for comparing two similar patient groups before and after the implementation of MPAC to evaluate patient outcomes. The electronic health records (EHR) were reviewed to assess patient vital signs 24 hours before RRT activation, patient disposition after RRT activation and evaluation, mortality, and the Rothman index at the time of RRT activation and 24 hours before RRT activation. These elements were used to answer the study's primary objective, which was to evaluate the time lapse between clinical deterioration and RRT activation. Additionally, these data elements were also used to meet the secondary aim of the project to assess whether nurses' SPAs correlated to severe adverse patient outcomes before and after the implementation of MPAC. Sample sizes were comparable before (n=536) and after (n=544) were used to compare patient outcomes before and after MPAC implementation.
What were their findings?
The results demonstrated a significant reduction in the mean hours of delay in activating the RRT after the MPAC training, reducing from 11.7 to 9.6 hours. Nurses were able to recognize clinical deterioration more quickly and activate RRT. Additionally, there was a reduction in the percentage of patients transferred to the ICU after RRT activation. Finally, the results showed that the odds of mortality were reduced by 44% after MPAC.
Did the findings make sense?
The findings were logical and aligned with this study's primary and secondary objectives.
How should things change?
Nurses must continue to focus on performing SPAs to ensure early identification of clinical deterioration and initiation of interventions. A continued focus on nurses performing SPAs can help improve physical assessment skills and patient outcomes. Regular competency checks can help support and facilitate continued practice of these critical skills to ensure nurses are always prepared to assess and initiate early interventions.
How is this important for nursing?
Nurses must have a strong foundation in performing physical assessments to promptly identify and respond to patients exhibiting early signs of clinical deterioration. Early recognition and intervention can help improve and promote optimal patient outcomes.
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