Do nurses know when to summon emergency assistance?

Inknsiue and Cdrcd Care Nursing (1994) IO, 115-1‘20 B Longman Group Ltd 1994

Do nurses know when to summon emergency assistance? Katharine Daffurn, Anna Lee, Kenneth M. Hillman, Gillian Frances Bishop and Adrian Bauman At Liverpool Hospital in 1989, mortality from cardiopulmonary arrest was 71% in the general wards, and 64% in the Emergency department. In an attempt to identify and treat seriously ill patients before they progressed to cardiac arrest, a medical emergency team (MET) was established. The MET replaced the existing cardiac arrest team and comprised a nurse from the intensive care unit (ICU), a resuscitation registrar (an anaesthetics trainee), a medical registrar and a senior registrar from the ICU. The resuscitation registrar was the team leader. The calling criteria for the MET were based on predetermined physiological variables, abnormal laboratory results, and specific conditions or if nursing or medical staff were concerned by the patient’s condition. A study was conducted 2 years following implementation of the MET system, to determine registered nurses’ (RNs) opinions, knowledge and use of the system. A questionnaire distributed to 141 nurses rostered on the chosen study date revealed a positive attitude the MET, although there was a low awareness regarding the availability of the MET information booklet. 53% of nurses had called the MET in the last 3 months; all would call the team again in the same circumstances. The correct response in three of four hypothetical situations presented was to call the MET. The number of correct responses varied between scenarios from 17-73%. Hypotension did not appear to alert nurses to summon emergency assistance. Some nurses, despite the presence of severe deterioration and patient distress, called the resident rather than the MET. We conclude that despite a favourable attitude towards the MET, nurses may not always follow the predetermined calling criteria and in some instances may not recognise when assistance is required.

Katharine Daffurn RN, SCM, ICU Cert, CCU Cert. BHA, Clinical Nurse Consultant in Intensive Care, Department of Anaesthetics and Intensive Care, Anna Lee BPharm, Dip Hosp Clin Pharm Pratt, MPH, Research Fellow, Critical Care Research Unit, Kenneth M. Hillman MBBS, FRCA, FANZCA, Professor and Chairman, Department of Anaesthetics and Intensive Care, GiWian Francas Bishop MBChB, FANZCA, Deputy Director of Intensive Care, Department of Anaesthetics and Intensive Care, Adrian Bauman MBBS, MPH, PhD, FAFPHM, Associate Professor, Epidemiology and Public Health, Liverpool Health Service, PO Box 103, Liverpool, NSW 2170, Australia (Requests for offprints to KD) Manuscript accepted 2 I February

1994

INTRODUCTION Many hospitals currently employ a cardiac arrest team which functions to resuscitate patients following cardiopulmonary arrest. The use of cardiac arrest teams is well described (Scott 1981, Kay et al 1981). The high failure rate of such an expensive use of medical and nursing resources for cardiopulmonary resuscitation is also well documented (Tunstall et al 1992, McGrath 1987). A recent study in a 1200 bed university tertiary care facility demonstrated

a 70% mortality at the time 115

116

INTENSIVE AND CRITICAL CARE NURSING

of the arrest, with a further 18% of the patients initially resuscitated dying in hospital and only 11% surviving to discharge (Peterson et al 1991). While the outcome of in-hospital cardiopulmonary arrest has been extensively studied (Tunstall et al 1992) the physiological abnormalities preceding arrest are less well defined. It is hypothesised that ‘arrest’ occurring among hospital inpatients is frequently preceded by non-cardiac processes (Schein et al 1990). The identification and treatment of these clinical antecedents may therefore lead to reduction in cardiopulmonary arrest and an improved outcome. A similar concept has been successfully utilised in the management of trauma. The trauma team approach involves rapid response and standardised treatment in order to reduce mortality and the incidence of complications (Deane et al 1990). Further, the circumstances under which nurses summon medical assistance is not well documented. Nurses working in an acute hospital find themselves in an environment of uncertainty. The very nature of their work compels them to make decisions about patients on a regular basis throughout their shift. The nursing decision-making process is poorly understood (Crier 1976). Information transmitted by a single cue such as hypotension or dizziness has been shown to be negligible (Kelly 1964) as nurses use more than one sign to make inferences about the patient’s condition. Past experience of probable outcome of the patient’s presenting state is a factor which determines the action nurses will take (Broderick & Ammentorp 1974, Baumann & Bourbonnais 1982).

THE MEDICAL EMERGENCY TEAM SYSTEM In an attempt to improve the outcome of cardiopulmonary arrest and to define medical emergencies at an early stage, a new and unique initiative, the medical emergency team (MET) was introduced in a 420 bed teaching hospital in South Western Sydney. The MET superseded the existing cardiac arrest team and comprises medical and nursing staff who have undergone train-

ing in the principles of resuscitation. The MET consisted of a nurse from the intensive care unit, a resuscitation registrar (anaesthetics trainee), a medical registrar and senior registrar from the intensive care unit. The MET system was developed utilising the concepts of standardised calling criteria and a rapid response, both of which have operated for cardiopulmonary arrest, and has recently been introduced on wide scale for the early management of trauma (Deane et al 1989). The MET may be alerted in the face of predetermined clinical criteria, which include abnormal physiological variables, abnormal laboratory results, specific conditions and any time nursing or medical staff are worried by a patient’s condition. The aim of the MET system is to promote early intervention to prevent the occurrence of cardiac arrest and its associated morbidity and mortality. Once the team is mobilised the patient is treated according to standardised agreed protocols rather than by doctor discretion. Before introduction of the MET, cardiopulmonary resuscitation trainers already present in each ward and department were instructed in the principles of the system. These trainers were then expected to instruct all nurses employed in the particular ward to ensure a good understanding of the changes which had occurred. Each ward was supplied with a pocket-sized MET booklet consisting of the aim of the system, roles of team members and the predetermined clinical calling criteria. The booklet also contains standard treatment protocols for 21 specific conditions such as acute severe asthma, pulmonary oedema and acute diabetic emergencies. This study was designed to evaluate nursing staff attitudes, awareness and utilisation of the recently introduced medical emergency calling system, in order to assess its value in providing prompt assistance in a range of circumstances.

METHODOLOGY The study involved the distribution of a two-page questionnaire to all nursing staff on duty at the afternoon shift changeover on the chosen study date. Nurses from the intensive care unit (ICU),

INTENSIVE AND CRITICAL CARE NURSING

high dependency unit (HDU) and coronary care unit (CCU), were excluded from the main study, as pilot testing was undertaken in these areas. The remaining critical care areas of the emergency department, recovery and operating theatres were included. Questionnaires were completed and returned within 30min. Members of the research team waited until participants had completed all sections. Page 1 of the questionnaire asked participating nurses to respond to a number of closedended questions regarding their area of work, years of experience and whether they were aware of the MET and the MET information booklet being available on their wards. Nurses were further asked to list three conditions for which the MET could be called and to indicate the reason why they had called the MET, if they had done so within the last 3 months. Nurses who had been involved with the MET recently answered additional questions on how the team had functioned and whether the patient had benefited from MET intervention. Page 2 of the questionaire presented nurses with four hypothetical situations (Appendix). Three of the four situations comprised criteria that should have alerted the nurse to call the MET. Nurses were asked to indicate from a range of options the most appropriate action they should have taken in each of the four situations.

117

ular time. 130 forms were returned completed, a response rate of 92%. Three nurses refused to complete the questionnaire, eight were scrubbed in the operating theatre, seven had reported in sick that day. 36 nurs es rostered as being on duty were not located by the research team at the time of the distribution of the questionnaire. The majority of nurses worked in the genera1 medical and surgical wards (62%), followed by 20% in the Emergency department, operating theatre and recovery and 19% from the maternity unit. 53% of nurses had greater than 5 years experience, 42% from l-5 years leaving 5% with less than 1 year. Most nurses (91%) were aware of the MET, 5 1% of those were aware that the MET information booklet was located in their wards. The conditions listed by nurses for which the MET could be called (Table 1) were predominantly cardiac arrest (26.6%)) followed by respiratory arrest (18.3%), bleeding (9.6%) and fitting (8.9%). All nurses did not take the opportunity provided to list three conditions. Recalling the most recent MET call in which they were involved, 70 nurses gave reasons as to why they had called the team (Table 1). The predominance of actual calls had been for cardiac arrest (28.5%)) respiratory arrest (14.2%), fitting (11.4%) and collapse (8.5%). Nurses recorded that on 93% of the occasions the MET arrived

Table 1

STATISTICAL ANALYSIS Data were coded, entered and edited using Paradox 3.5 database software. Statistical Analysis System (SAS) version 6.04 was used to perform statistical analysis. The questionnaires were analysed using group means and frequency tabulations; 95% confidence intervals (~1) were calculated to compare nurses from different work areas. The level of significance was set at p 5 0.05.

Results The questionnaire was distributed to 141 nurses on duty at the afternoon shift change over. A total of 195 nurses were rostered on duty at that partic-

Reasons for calling the MET. % of nurses r~nsss

Can be called Actually called Condition/reason

(N = 289)

Cardiac arrest 26.6% Respiratory arrest 18.3% Fitting 8.9% Change in observations 6.2% Bleeding 9.6% Respiratory distress 7.2% Myocardial infarction 3.4% Paediatric resuscitation 2.7% Collapse/change in LOC* 6.2% 2.7% Hypoglycaemia 2.4% Non-specific illness Drug overdose 0.6% Anaphylaxis 1 .O% Trauma 1.7% 4.4% Potential deterioration * LOC = level of consciousness.

(N = 70) 28.5% 14.2% 11.4% 2.8% 5.7% 7.1% 0% 2.8% 8.5% 7.1% 7.1% 1.4% 0% 1.4% 2.8%

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INTENSIVE AND CRITICAL CARE NURSING

within

10min

of being

summoned.

Treatment

was instituted by the MET in 86% of cases. Nurses felt that the patient benefited

in 85% of calls. In

the 15% of cases where the nurses believed MET was of no benefit, ed death before

the

the reasons stated includ-

team arrival and failure to resus-

citate. All nurses

indicated

they would call the

MET again in the same circumstances. ity felt the conditions

under which the MET can

be called were appropriate 7% were uncertain

The major-

(93%).

regarding

The remaining

appropriateness

of

the calling criteria.

DISCUSSION Nurses involved in the study have a favourable attitude towards the MET system, although was an unacceptable

availability of the MET information favourable

attitude is reflective

formance

booklet.

by the team which participants

responded

case scenarios presented

gave the nurses the option

from the MET interventions

applied.

All nurses who had been involved in a situation

of either

cumstances.

calling the

7% of nurses were unsure that the MET calling criteria are appropriate.

This uncertainty

All but one of the four hypothetical

indicative of insufficient

education

that should

situations

have alerted

the

ing the benefits of early intervention.

A relatively

large number

of nurses were unaware

are presented

MET

was available

in Table 2. In the acute myocardial

(AMI) scenario,

have called the resident,

47.7% of nurses would 19% would have called

the MET even though there was no indication doing so. When presented drowning,

44.6%

for

with a scenario of near-

of nurses

indicated

correctly

booklet

departments.

may be

of staff regard-

nurse to call the MET. The full range of responses infarction

perstated

rapidly, and in most instances patients

benefited

MET or making a less urgent call for assistance. criteria

The

of adequate

with the MET would call it again in the same cir-

The four hypothetical

contained

there

level of awareness regarding

that the

in their

wards or

This lack of awareness

poses the

question of how relevant such a booklet is to nurses, and whether more concise information be more

helpful.

Ward nurses

would

had utilised

the

MET more often than participating

critical care

that they would call the MET. In the case of post-

staff or nurses

unit. Better

operative

access to medical

hysterectomy,

have called number

the resident,

(16.9%)

41.5%

of nurses would

with a much

indicating

correctly

would call the MET. A high proportion of nurses would quite correctly

smaller that they (71.6%)

call the MET for

from

the maternity

staff in the critical care areas,

which lessens the need to call for emergency tance, and a lesser number of emergencies ring in the maternity

assisoccur-

unit may have contributed

to this, and it highlights

the need to develop sys-

the young boy with acute severe asthma. In these

tems which are responsive to the needs of the gen-

scenarios

eral ward areas.

the MET would have been called from

16.9-71.6% ference

of the time. The only significant

in the response

dif-

was in the hysterectomy

Nurses varied in the responses

to the four sce-

narios with which they were presented.

In the hys-

scenario between critical care and maternity nurs-

terectomy

es, tested at the 95% CI.

as a cue to call the MET. They chose the much less

scenario

nurses

ignored

Table 2 Nurses responses to case scenarios. % of responses (N = 129) Possible actions

MI

Drowning

Hysterectomy

Asthma

A. Call the charge nurse 6. Call the resident C. Do nothing/repeat observations D. Call the MET E. Call the registrar F. None of the above

6.9 41.7 6.2

5.4 26.9 5.4

3.8 41.5 7.7

1.5 10.8 0

19.2 19.2 0

44.6* 15.4 1.5

16.9* 24.6 4.6

71.6’ 14.6 0

*Correct

response in each of these three scenarios was to call the MET.

hypotension

INTENSIVE AND CRITICAL CARE NURSING

Table 3 Correct remonses

for MET scenarios. 96 (95% Cl)

Scenario

All nurses (N = 129)

Wards (N = 80)

Critical care (N = 26)

Maternity (N = 23)

MI Drowning Hysterectomy Asthma

81 45 17 73

85 43 15 76

77 65 35 81

71 29 4 54

(74-87) (36-54) (11-24) (65-80)

(95% Cl) = 95% confidence groups.

intervals.

(77-93) (32-54) (7-23) (66-85) *Statistical

dramatic action of calling the resident.

More critithan maternity nurses would call the MET in the presence of hypotension. Much of

cal care nurses

their work however, is related to the observation of patients for hypotension and its consequences. Nurses have been accused of ‘falsely’ calling for emergency teams which could also explain the reluctance to call the MET in circumstances which do not signal imminent danger for the patient. Overall a change in observations prompted calling the MET in only 2.8% of cases. A twolevel calling system has been suggested, one for less threatening variations in a patient’s condition and the second for severe life-threatening situations. However, it has also been discussed that a system such as this has the potential to produce confusion for new staff (Smith & Hansen 1989). Responses by nurses indicate that the asthma scenario presented a more serious situation. The patient described had an increased respiratory rate, was cyanosed and becoming progressively more short of breath. Obvious patient distress appears to be the trigger compelling

most nurses

to call the MET. It is disconcerting

that not all

nurses would have chosen tion of whether cient

knowledge

likely outcome

this option.

The ques-

this result was related

to insuffi-

lack of awareness or a poor

of the most

ability

severe patient distress requires

to recognise

further

investiga-

tion. In conclusion,

despite

the favourable

attitude

towards the MET system, nurses are not always following the calling criteria. teria, further education

Review of existing cri-

regarding

can be called, and the importance vention towards improving recommended.

119

when the MET of early inter-

outcome

have been

(61-93) (47-84) (x-53)* (66-96)

difference

(53-89) (I l-47) (O-12)* (34-74)

between these two

Acknowledgements We would like to acknowledge the assistance of the two research assistants, Charmain Crispin and Leslee Ince, and Suzie Mazzotta for typing the manuscript. This study was funded, in part, by a grant from the Centre for Nursing Research, School of Nursing, The University of Sydney.

References Broderick M E, Ammentorp W 1979 Information structures: an analysis of nursing performance. Nursing Research 28: 106110 Baumann A., Bourbonnais F 1982 Nursing decision making in critical care areas. Journal of Advanced Nursing 7: 435-446 Deane S A, Gaudry P L, Pearson I, Ledwidge D G, Read C 1989 Implementation of a trauma team. Australian and New Zealand Journal of Surgery 59: 373-378 Crier M R 1976 Decision making about patient care. Nursing Research 25: 105-l 10 Kelly KJ 1964 Part III utilization of the ‘Lens Model’ method to study the inferential process of the nurse. Nursing Research 13: 319-322 Kaye W, Linhares KC, Breault R C 1981 The mega-code for training the advanced cardiac life support teams. Heart Lung IO: 860-865 McCrath R B 1987 In-house cardiopulmonary resuscitation -after a quarter of a century. Annals of Emergency Medicine 16: 1365-1368 Peterson M W, Geist L J, Schwartz DA, Moseley P L 1991 Outcome after cardiopulmonary resuscitation in a medical intensive care unit. Chest 100: 168-174 Schein R M H, Hazday M, Pena M, Ruben B H, Sprung C L 1990 Clinical antecedents to in-hospital cardiopulmonary arrest. Chest 98: 1388-1392 Scott R P T 1981 Cardiopulmonary resuscitation in a teaching hospital: a survey of cardiac arrests occurring ouside intensive care units and emergency rooms. Anaesthesia 36: 526530 Smith E B, Hansen M D 1989 Code green, code blue. Emergency paging euphemisms and the potential for confusion. North Carolina Medical Journal 53: 21-24 Tunstall-Pedoe H, Bailey L, Chamberlain D A, Marsden A K, Ward M E, Zideman D A 1992 Survey of 3765 cardiopulmonary resuscitations in British hospitals (the BRESUS study): methods and overall results. British Medical Journal : 1347-l 35 1

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INTENSIVE AND CRITICAL CARE NURSING

ApP=bx Medical emergencyteam questionnaire The following are four case scenarios. For each separate case indicate by circling ONE of the actions that appear most appropriate. A 65year-old man was admitted to your ward after an anterior myocardial infarct. He has been well and mobilising slowly. He now complains of central chest discomfort, he is sweating and clammy and has a BP 110/70, RR 24/min. His pulse is not easy to feel at his wrist but an apex beat is aproximately SO/min and regular. You would:

a) call the charge nurse b) call the resident c) do nothing and repeat obsevations in 10 min d) call the MET e) call the registrar fI none of the above

his

A byear-old boy has a near drowning in his local swimming pool. He arrives in casualty with the paramedics. He is irritable, has a GCS 12, a temperature of 35.8% normal BP and pulse. His RR is 30/min on 4L/min OZ. You would:

a) call the charge nurse b) call the resident c) do nothing and repeat his obsevations in 10 min d) call the MET e) call the registrar f) none of the above

3. A 41-year old fit and well woman goes to the theatre to have an hysterectomy. she has an uneventful operation and anaesthetic. Her initial set of observations back in your ward show a BP SO/SO, HR 120/min, RR 30/min. She is complaining of dizziness and abdominal pain. You would:

a) b) c)

call the charge nurse call the resident do nothing and repeat obsevations in 10 min d) call the MET e) call the registrar f) none of the above

his

4. A 14yearold boy was admitted to HDU 2 days ago with acute severe asthma. He settled well with salbutamol and steroids. He was transferred to your ward 12 h ago where his obsevations were, BP lOO/SO, HR lOO/min and RR 20/min. Over the last 4 h he has become progressively more short of breath despite hourly nebulised salbutamol. He now has a RR of 40/min and appears blue despite oxygen of 15L/min. You would:

a) b) c)

call the charge nurse call the resident do nothing and repeat obsevations in 10 min d) call the MET e) call the registrar f) none of the above

his