JONA
Volume 43, Number 7/8, pp 377-381
Spotlight on Leadership
Recognition of Chnical
Deterioration
A Clinical Leadership Opportunity for Nurse Executive
Colleen Swartz, DNP, MBA,
Recognition and avoidance of fur-
ther clinical deterioration can be
termed a critical success factor in
every care delivery model. As care
resources become more constrained
and allocated to the most critical of
patients, some patients are being
shifted to less intense and costly
care settings where continuous phys-
iologic monitoring may not be an
option. Nurse executives are facing
these complex issues as they work
with clinical experts to develop sys-
tems of safety in the patient care
arena. A systematic review of the
literature related to the recogni-
tion of clinical deterioration is
needed to identify areas for further
leadership, research, and practice
advancements
More than 100 years ago. Sir
William Osier noted, "If you listen
carefully to the patient they will
Author Affiliation: Chief Nurse Exec-
utive, University of Kentucky Healthcare,
Lexington.
The author declares no conflicts of
interest.
Correspondence: Dr Swartz, University
of Kentucky Healthcare, 800 Rose Street,
N-105, Lexington, KY 40536 {chswar2@
email.uky.edu).
Supplemental digital content is available
for this article. Direct URL citations appear
in the printed text and are provided in the
HTML and PDF versions of this article on the
journal's Web site (vvww.jonajournal.com).
DOI: 10.1097/NNA.0b013e31829d606a
JONA • Vol. 43, No. 7/8 • July/August 2013
tell you the diagnosis."' Even in the
earlier years of clinical practice, the
need to assimilate key messages sig-
naling the care provider to take ac-
tion was a clear and basic tenet of
quality patient care. Recognition
and avoidance of further clinical
deterioration are critical success
factors in every care delivery model.
As care resources become more con-
strained and allocated to the most
critical patients, care is being shifted
to less intense and costly settings
where continuous physiologic mon-
itoring or increased nursing staff-
ing levels may not be an option. The
application of clinical gestalt and in-
tuition by the care providers may
not overcome the inadequacies of
insufficient monitoring and assess-
ment. Nurse executives are facing
these complex issues as they work
with clinical experts to develop sys-
tems of safety in patient care. A
systematic review of the literature
related to the recognition of clini-
cal deterioration is indicated to fo-
cus areas for further research and
practice advancements.
Methods
The CINAHL EBSCO and PubMed
databases were searched for topics
related to clinical deterioration pub-
lished between 1985 and 2010. Key
words and concepts used included
Copyright © 2013 Wolters Kluwer Health I
Lippincotr Williams & Wilkins
deterioration, rapid response teams,
medical emergency teams, resuscita-
tion, and combinations of key con-
cepts and words including response
to deterioration, resuscitation of de-
terioration, and recognition of dete-
rioration. Results were limited to
those presented in English.
An evidence summary table was
created mapping samples, methods,
findings, and grades of evidence (see
Table, Supplemental Digital Gsntent 1,
http://links.lww.com/JONA/A230).
The grading or strength of evidence
was ranked according to specific
criteria developed by Stetler and
colleagues.^
Recognition of Deterioration
Preceding Events
Buisf' defined "clinical futue cycles"
of care that occur when much
clinical activity is directed at the
patient, but little of this activity
relieves the dire circumstances ex-
perienced by the patient. These pro-
tracted cycles of care are a result of
clinical culture, under appreciation
of patient physiologic signaling
and, perhaps, the increasingly cha-
otic and frenetic pace experienced
by frontline caregivers, usually reg-
istered nurses (RNs). In addition,
in teaching hospitals, the changing
complexion of medical resident
377
 Spothght on Leadership
training has resulted in a reduction
in resident availability (especially
senior level residents) to discuss and
deploy the necessary interventions
to avert clinical deterioration.'' In
nonteaching hospitals, the availabil-
ity of resources such as hospitalists,
nocturnists, and especially intensiv-
ists has become increasingly challeng-
ing based on physician manpower
availability and cost concerns.^'''
The literature is replete with
data regarding delays in deteriora-
tion recognition. These findings are
present in literature related to cardio-
ptalmonary arrest antecedents,^'^'"
genesis, and deployment of rapid
response teams (RRTs) or medical
evaluation teams (METs)^'^'^'''^^ and
in recent interest in technology sup-
porting the interpretation of deterio-
ration and alerting of clinicians. ' ^
Key findings from each manuscript
are noted in brief in the annotated
bibliography as well as delineation
whether they are descriptive or in-
terventional studies (see Table, Sup-
plemental Digital Content 2, which
shows the annotated bibliography,
http://links.lww.com/JONA/
22-26
The absence of relevant infor-
mation has not been supported as
the problem, but the response to
the information remains an area of
concern. Hillman and colleagues
identified that half of hospital deaths
in their sample had physiologic
abnormalities documented within
8 hotirs of death, and the same per-
centage had abnormalities in the
period between 8 and 48 hotirs.
Almost one-third of patients had
the same serious abnormalities for
the whole 48-hour period before
death. More than 60% of patients
had identifiable deterioration of
vital signs before death. A similar
flnding was noted by Eranklin and
Mathew* in that 66% of patients
378
had documented clinical deterio-
ration within 6 hours of the car-
diopulmonary arrest. Unplanned
intensive care tuiit (ICU) admission
has been studied regarding the pre-
emptive period leading up to the
admission.^ A significant worsen-
ing of respiratory rate was noted
in the 24 hours leading to ICU ad-
tnission. The authors also noted
that medical and nursing staff
were aware of the patient deterio-
ration but did not provide the
appropriate treatment. A seminal
article by Schein et al'" demon-
strated that 84% of the patients
had documented observations of
clinical deterioration or new com-
plaints within 8 hours of arrest.
Seventy percent of patients had
either deterioration of respiratory
or mental function during the study
period. Consistent findings were
presented by Smith and Wood"
in that 5 1 % of patients with in-
hospital cardioptilmonary arrest had
premonitory signs. Similarly, another
study analyzing pre-cardiac arrest
diaries of events noted that 76%
of critical event patients had insta-
bility documented for more than
1 hour before the event, with a
median duration of 6.5 hours.^^
Resource Deployment
The MET or RRT is a concept that
has been implemented as a system
solution to address deterioration for
more than a decade. Only 2 interven-
tion studies were found related to the
impact of MET. The Medical Emer-
gency Response and Intervention Trial
study conducted in Australia ran-
domized 23 hospitals with the inter-
vention of introduction of MET. The
restilts demonstrated that MET calls
greatly increased, but there was no
signiflcant impact on incidence of car-
diac arrest, unplanned ICU admis-
sion, or tmexpected death. Relative to
JONA • Vol. 43, No. 7/8 • July/August 2013
recognition of clinical deterioration,
the authors noted that in the un-
planned ICU admission group, 50%
had documented identifying criteria
more than 15 minutes before the event,
but only 30% of the patients had
called the emergency team.'^ Chan
et aP^ demonstrated a statistically
significant reduction in hospital mor-
tality in wards where the MET ser-
vice was operating and demonstrated
equivocal findings regarding hospi-
tal length of stay. A more recent sys-
tematic review and meta-analysis
regarding RRTs demonstrated that
collective implementation of RRT
for adttlts was associated with a 33.8%
reduction in rates of non-ICU-treated
arrest. The pooled estimate regarding
mortality trended toward the null and
was not associated with lower mor-
tality rates.^^ Several other system-
atic reviews suggested no consistent
improvement in cUnical outcomes,
and some studies were noted to have
poor methodological quality.^^"''^
Potential Barriers
Studies identify barriers in prompt
reporting of clinical deterioration.
These barriers should be of partic-
ular concern to nurse leaders and
ntarse executives. Consistent themes
include a lack of perception that
the crisis was severe enough to war-
rant response and concerns regard-
ing potential reprimand if the nurse
bypassed physician notification in
calling an RRT.^''^^ Multiple layers
of medical residents can compli-
cate the relationship and reporting
between nurse and physician in
teaching environments. One char-
acteristic that could contribute to
suboptimal care was the concept of
physicians and/or nurses expe-
riencing information overload and
thereby eroding perceptions regard-
ing appropriate priorities and ac-
t i o n s . ' " ' " ' " Even with firm MET

guidelines in place, a timely call
for assistance given clinical deterio-
ration remains problematic. Al-
though the MET or RRT intuitively
makes sense in providing a systemic
response to deterioration, the activa-
tion of the team remains problematic,
even in a mature/sophisticated sys-
tem with evolved MET guidelines
for activation.
Automation of Responses
Automation has been suggested as
a vehicle to overcome many of the
barriers noted above. Several recent
studies demonstrate real potential
in a single-channel, integrated mon-
itoring system that could analyze
conduction patterns of physiologic
disturbance and report potential
deterioration episodes to the appro-
priate individuals or team.^'''^^'^'*
Track and trigger systems use cul-
tivated information from patient
vital signs, integrated with a set of
decision rules to discriminate be-
tween survivors and nonsurvivors
using area under receiver operating
characteristic curve.^'""' The vari-
ables needed to ensure prediction
of clinical deterioration and an ac-
curate early warning system con-
tinue to evolve. The sensitivity and
specificity of any model require crit-
ical appraisal and relevance to the
patient population. Future research
and maturation of track and trig-
ger systems are areas where nurse
leaders can import clinical leader-
ship and relevance to the practicing
RN, adding value to the critical
thinking required to preempt a
deterioration event.
Implications for Nurse Leaders
Countermeasures to Optimize
Early Recognition
Strategic considerations should be
implemented to prioritize and im-
JONA • Vol. 43, No. 7/8 • July/August 2013
Spothght on Leadership
plement effective countermeasures
in the prevention or early detec-
tion of clinical deterioration. Ini-
tially, the ideal state would be to
define certain physiologic values
or trends that are early predictors
of deterioration and automate the
response based on a track and trigger
system. Providing automation in
this area would serve to neutralize
many of the obstacles, such as fear
of reprimand and lack of recogni-
tion. Automation and implemen-
tation of a track and trigger system
are predicated on timely retrieval
and entry of physiologic data. Nurs-
ing practice and workflow become
an essential focal point for nurse
executives. Prompt and timely re-
cording of physiologic data is crit-
ical to optimize an early-warning
system. Device integration at the
bedside, especially in those areas
where continuous physiologic mon-
itoring is not conducted, should
be prioritized. The ease of work-
flow for the RN and the unlicensed
assistive personnel is vital to the
success of early-warning systems.
Creating standard work around
this process and ensuring account-
ability related to standard adher-
ence are areas of concentration for
the nurse executive and nursing
leadership. Ongoing and continu-
ous monitoring of patient condi-
tion is an area of clinical practice
seated firmly in the nursing domain.
Leveraging technology to assist in
critical thinking of the RN is a po-
tent countermeasure that can re-
sult in systemic improvement in
clinical care.
Any change in the care deliv-
ery model should be undertaken
with an eye toward unintended con-
sequences. Early-warning systems
certainly have appeal given the po-
tential impact on the early detection
of deterioration. However, gener-
ating yet another alarm for the
clinician to triage and potentially
act upon certainly adds to an al-
ready complex landscape of critical
thinking. In April 2013, The Joint
Commission released a sentinel event
alert on medical device alarm safety
in hospitals.^^ The number of alarm
signals for inpatients in the current
care environment easily reaches hun-
dreds per day. The frequent alarms
can quickly overwhelm the clini-
cian, especially given the fact that
between 85% and 99% do not
require intervention.^^ The issue
of alarm management has been re-
ported by the ECRI Institute since
2007. The RN at the bedside is
typically the professional receiving,
integrating, and making key deci-
sions based on alarm inputs. The
area of alarm management, alarm
fatigue, clinical information systems,
and meaningful use of clinical infor-
mation generated by alarms provides
fertile ground for future research as
technology evolves and provides op-
portunities for improved clinical care.
Communication Strategies
The complexity of clinical care and
the need for strong and coordi-
nated interprofessional teams has
become essential to achieve optimal
clinical outcomes. Clinical assess-
ment in a complex environment
with multiple competing priorities
and information overload at times
continues to be one of the most
value-added processes that RNs
provide. Communication and co-
ordination of care is 1 of the pri-
mary functions of the professional
nurse. The sophistication of the
critical thinking needed for this
surveillance is often primarily ac-
quired through experience. Creating
standard work to guide nurse-to-
physician communication regard-
ing deterioration is essential for
379
successful surveillance and disrup-
tion of the futile cycle of deteriora-
tion. Creative educational activities
and competency establishment are
rich opportunities for nurse execu-
tives. Setting a tone for clinical pro-
ficiency in this domain of care will
impact every patient across the care
system. Another essential consider-
ation is the awareness of the RN
that a track and trigger system is
running and alerting the nurse that
the system has issued an early-
warning alert to the identified res-
cue team. Alerting the nurse then
allows the nurse to respond con-
comitantly with the rescue team
to refine assessment skills and en-
gage actively in any necessary res-
cue. Nurses with critical thinking
skills maintaining a high index of
suspicion for clinical deteriora-
tion can certainly add value to the
quest for a high-quality, low-cost
care model.
Educational Opportunities
Historically, much of the skill ac-
quisition around critical thinking
in the deterioration cycle has come
from cumulative clinical experience
and often from situations where
deterioration was allowed to cycle
until patient harm resulted. Nurse
leaders can set a learning environ-
ment where this skill is acquired
and honed to an exacting and pre-
cise skill set that significantly contrib-
utes to improved clinical outcomes
and prevention of harm.
Simulation is a potential op-
portunity to allow practice of the
skill in a safe environment. Simu-
lation allows the RN to apply crit-
ical thinking and decision making
with resulting variation in expres-
sion of outcome given the decision
path chosen. Instruction should also
be considered around the compe-
tency acquisition of communication
380
effectiveness when a deterioration
event occurs. Early recognition of
deterioration and then prompt
and accurate reporting can cer-
tainly promote an active and re-
sponsive system of care.
Conclusion
Today's inpatient care units are
overflowing with complex, acutely
ill patients with the potential, at
any time, for physiological insta-
bility. When destabilization occurs
and clinical deterioration becomes
evident, the system responsiveness
must be failsafe. To create a sys-
tem of precise, nonsubjective trig-
gering of rescue systems, attention
must be given by nurse leaders to
communication, education, and pro-
cess development that automate
the triggering. This review of the
literature demonstrates that knowl-
edge of the deterioration is not the
primary issue. The actionable data
are present. Nursing leaders have
opportunities for development of
systems to address these vulnera-
bilities and opportunities. The
execution of response to clinical
deterioration presents a potential
barrier to quality care based on
multiple variables. Nurse executives
must develop structures to support
nursing autonomy and clinical em-
powerment. Interprofessional edu-
cation and collaboration on multiple
levels including simulation sessions
will enable nurses to access physi-
cians and other providers in non-
threatening communication patterns
to discuss the signs and symptoms
of clinical demise. The quest for a
high-reliability organization is one
that requires standard work devel-
opment, then mechanisms for ex-
acting and refining the execution
of the work. Today's care environ-
ments are dynamic and highly vol-
atile. Introducing mechanisms to
JONA • Vol. 43, No. 7/8 • July/August 2013
reduce variation in care and creating
reliable processes require equally
dynamic and versatile clinical lead-
ership by the nurse executive. The
nurse executive should set in motion
a surveillance system to maximize
the patient's opportunity for exem-
plary clinical outcomes. Equipping
the RN with tools and competen-
cies for early detection of deterio-
ration and supporting the effective,
timely, and compelling communica-
tion of the data will create a counter-
measure for clinical deterioration
with the highest likelihood of pre-
venting patient harm.
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