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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
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Buch Applied Interdisciplinary Theory in Health Informatics - Knowledge Base for Practitioners"
Applied Interdisciplinary Theory in Health Informatics
Knowledge Base for Practitioners
- Titel
- Applied Interdisciplinary Theory in Health Informatics
- Untertitel
- Knowledge Base for Practitioners
- Autoren
- Philip Scott
- Nicolette de Keizer
- Andrew Georgiou
- Verlag
- IOS Press BV
- Ort
- Amsterdam
- Datum
- 2019
- Sprache
- englisch
- Lizenz
- CC BY-NC 4.0
- ISBN
- 978-1-61499-991-1
- Abmessungen
- 16.0 x 24.0 cm
- Seiten
- 242
- Kategorie
- Informatik