Page - 123 - in Applied Interdisciplinary Theory in Health Informatics - Knowledge Base for Practitioners

1. The drivers for improvement of junior doctor communication systems in the context of the deteriorating ward patient Deficiencies exist in clinician detection and management of the deteriorating hospital ward patient despite organisational and educational interventions [1], which may be addressed by improving inter-clinician communication. Deterioration in this sense refers to life-threatening or potentially life-threatening changes. Nurses are usually the first hospital clinicians to detect deterioration via observation and measuring physiological changes. They then notify doctors, usually juniors on the ward team primarily responsible for that individual patient’s hospital care. These doctors are important in initiating investigations, therapies and escalating patients to clinicians with greater experience or resources to treat deteriorating patients. Nursing or medical mistakes in this process can and do result in adverse patient outcomes [2]. Rapid response systems (RRS) are hospital level interventions which have been widely adopted internationally to improve the process of detection, clinician communication and clinical management [1]. They consist of afferent and efferent limbs, and an administrative component. Afferent limbs function mostly by defining thresholds for single or grouped physiological observations to trigger closer patient observation and clinician communication. Efferent limbs are the triggered clinician responses, ranging from attendance of ward doctors and nurses to a formalised group of more experienced ward and specialty area clinicians, e.g. medical emergency teams. This may culminate in patient transfer to higher acuity hospital units for the care of highly ill patients, e.g. intensive care units. Despite widespread RRS adoption, there is mixed evidence regarding RRS efficacy in decreasing adverse patient outcomes [1]. RRS afferent limb sensitivity is poor unless high false negative rates are accepted. This increases clinician work by requiring closer observation which does not change management [3]. There is also controversy about how well physiological observations in themselves identify deteriorating patients [4] assuming that they are correctly documented [5]. RRS efferent limbs via medical emergency teams may also cause unintended and counterproductive effects on clinician communication e.g. antagonism between ward and medical emergency teams [6]. This situation has now been complicated further by electronic alerting systems, often based on RRSs. These attempt to overcome some of the difficulties encountered in collecting and disseminating patient data for the afferent limb [7]. Research on electronic alerting systems is heterogenous and has shown mixed results. In addition, electronic alerting system studies vary in what criteria were used to trigger alerts, which clinician receives alerts and how [7]. Consequently, it cannot be said that RRS is an entirely benign intervention, or that electronic alerting systems clearly improve the detection and management of the deteriorating ward patient. Focusing on junior doctors in particular, there are multiple reasons why they may not detect and manage deteriorating ward patients appropriately [8]. Despite undergraduate medical education interventions [9], junior doctors still often feel unprepared working in hospitals, especially with acutely unwell patients [10]. They need to adapt their theoretical knowledge to clinical environments and medical hierarchies, as well as being able to do procedural skills [11]. Inter-clinician communication is also an area that junior doctors find difficult. However, there has been little investigation into general junior doctor communication prior, parallel or alternative to RRS activation [12]. There is widespread ward non-compliance with RRS afferent limbs, including delayed escalation of deteriorating ward patients [13]. It is not just the most junior doctors who may be hesitant to warn senior doctors of patient deterioration [11]; more experienced junior J.Liangetal. / JuniorDoctorCommunicationSystemsand theDCMT 123