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ISSNe: 2182.2883 | ISSNp: 0874.

Available: https://doi.org/10.12707/RIV17025

Nursing interventions for the early detection of ward

patients’ clinical deterioration: an integrative review
Intervenções de enfermagem na monitorização da deterioração clínica da pessoa em
enfermaria hospitalar: uma revisão integrativa
Intervenciones de enfermería en la monitorización del deterioro clínico de la persona
en enfermería hospitalaria: una revisión integradora

Catarina Moura Freitas*; Emídio Polónio Preto**; Carla Alexandra Fernandes Nascimento***

Background: Clinical deterioration is sometimes mishandled in hospital wards resulting in increased likelihood of
cardiorespiratory arrest, unplanned intensive care admissions, and death.
Objectives: To identify nursing interventions aimed at the early detection of the clinical deterioration of ward
Methodology: Integrative literature review through the search for published and gray literature in CINAHL,
MEDLINE, and ScienceDirect databases.
Results: A total of 534 documents were identified, of which 11 were selected for data extraction and analysis.
Conclusion: The monitoring of vital signs, either individually or in combination or to obtain an early warning
score, is the most widely performed nursing intervention identified in the literature.

Keywords: clinical deterioration; nursing care; monitoring, physiologic; patient safety

Resumo Resumen
Enquadramento: A deterioração clínica da pessoa nem Marco contextual: El deterioro clínico de la persona
sempre é bem gerida em contexto de enfermaria resul- no siempre se gestiona bien en el contexto de la enfer-
tando numa maior probabilidade de paragem cardior- mería, lo que da como resultado una mayor probabi-
respiratória, internamentos não programados em uni- lidad de parada cardiorrespiratoria, internamientos no
dade de cuidados intensivos e aumento da mortalidade. programados en la unidad de cuidados intensivos y un
Objetivos: Identificar intervenções de enfermagem rea- aumento de la mortalidad.
lizadas na deteção atempada da deterioração clínica da Objetivos: Identificar las intervenciones de enfermería
pessoa em contexto de enfermaria hospitalar. realizadas en la detección temprana del deterioro clínico
Metodologia: Revisão integrativa da literatura, realiza- de la persona en el contexto de la enfermería hospita-
da através da pesquisa de trabalhos publicados e litera- laria.
tura cinzenta nas bases de dados CINAHL, MEDLINE Metodología: Revisión integradora de la literatura, rea-
e ScienceDirect. lizada a través de la investigación de trabajos publicados
Resultados: Identificaram-se 534 resultados, dos quais y literatura gris en las bases de datos CINAHL, ME-
se selecionaram 11 documentos para análise e extração DLINE y ScienceDirect.
dos dados. Resultados: Se identificaron 534 resultados, de los
Conclusão: A avaliação dos sinais vitais, quer de forma cuales se seleccionaron 11 documentos para analizarlos
individual, quer de forma a obter uma avaliação em es- y extraer los datos.
calas de early warning score, são as intervenções de enfer- Conclusión: La evaluación de los signos vitales, tanto
magem realizadas identificadas na literatura. de forma individual, como para obtener una evaluación
en escalas de early warning score, son las intervenciones
Palavras-chave: deterioração clínica; cuidados de en- de enfermería realizadas identificadas en la literatura.
fermagem; monitorização fisiológica; segurança do pa-
ciente Palabras clave: deterioro clínico; atención de enferme-
ría; monitoreo fisiológico; seguridad del paciente
*MSc., RN, Hospital of Santo Espírito da Ilha Terceira, 9700-042, Angra do Heroísmo, Por-
tugal [catarinamfreitas@hotmail.com]. Contribution to the article: literature search; data
collection, analysis, and discussion; article writing.
Address for correspondence: Rua Dr. João Costa nº 11, Santa Luzia, 9700-042, Angra do
Heroísmo, Portugal.
**RN, Intensive Care Unit, Hospital of Santo Espírito da Ilha Terceira, 9700-042, Angra do
Heroísmo, Portugal [eppblack@hotmail.com]. Contribution to the article: data analysis
and discussion; article writing.
***Ph.D., Adjunct Professor, Medical-Surgical/Adult and Elderly Department, Lisbon Scho- Received for publication: 14.03.17
ol of Nursing, 1600-190, Lisboa, Portugal [carla.nascimento@esel.pt]. Contribution to the
article: data analysis and discussion; article writing Accepted for publication: 16.06.17

Revista de Enfermagem Referência Série IV - n.º 14 - JUL./AGO./SET. 2017

pp. 121 - 130

Introduction tion in health institutions and subsequent
intervention (Joshi, Campbell, Gooch,
Patient safety has been the target of growing Anstey, & Landy, 2015). RRSs are aimed
concern worldwide, as it is a fundamental at identifying the clinical condition of the
principle in health care which has a signifi- ward patient in the minutes immediately be-
cant impact on care quality (Edwards, 2005). fore CPA to check if something can be done
Therefore, the National Patient Safety Agen- to prevent clinical deterioration and subse-
cy (2007) considers that the early detection quent ICU admission (Winters & DeVita,
of clinical deterioration is essential to reduce 2015). According to the authors, RRSs are
mortality rates associated with cardiopulmo- based on the early recognition of the clin-
nary arrest (CPA). ical deterioration of the ward patient, thus
Today, hospitalized patients tend to have contributing to the intervention of a multi-
more complex clinical situations and a high- disciplinary critical care team. Its main ob-
er number of comorbidities, which increas- jective is to reduce the occurrence of CPA,
es the likelihood of clinical deterioration thus reducing mortality rates and the need
during hospitalization (Preece, Hill, Hor- for unplanned ICU admissions. According
swill, & Watson, 2012). In this way, it is to the authors, nurses often put RRSs into
possible to infer that ward patients might be motion when they recognize the clinical
in a situation similar to those who are in in- deterioration of the ward patient. Accord-
tensive care units (ICUs), which puts them ing to Benner (2001), the diagnostic and
at risk of experiencing an adverse event such patient-monitoring function is a nursing
as a cardiac and/or cardiopulmonary arrest. intervention that contributes to the promo-
Regardless of the underlying process, the tion of patient safety because it allows for
signs of acute illness are similar because they the early detection of clinical deterioration
reflect changes in the respiratory, cardiac, situations. However, it should be noted that
and neurological systems. Physiological al- aspects such as work overload resulting from
terations, in one or more parameters, are the complexity and increased demands of
associated with a higher likelihood of CPA, caring for critically-ill patients and the lack
unplanned ICU admissions, and death of differentiated and experienced staff to
(Soar et al., 2015). Within this scope, the support decision-making contribute to the
European Resuscitation Council guidelines difficulties in the early identification of ward
suggest a CPA prevention approach focused patients’ clinical deterioration (National Pa-
on the chain of prevention, staff training/ tient Safety Agency, 2007).
education, monitoring and identification of The literature suggests that the majority of
deterioration, and a system that allows ask- adverse events that occur in health care set-
ing for help and getting an effective response tings result from ineffective communication
(Soar et al., 2015). Similarly, the American and situations of misunderstanding within
Heart Association for Cardiopulmonary the team, reducing patient safety (Courte-
Resuscitation and Emergency Cardiovascu- nay, Nancarrow, & Dawson, 2013).
lar Care guidelines (Kronick et al., 2015) In summary, it is more difficult today to de-
recommend the existence of an in-hospital tect and intervene in a situation of clinical
chain of survival. The first link in this chain deterioration in ward patients. Therefore,
depends on an appropriate surveillance sys- the objective of this integrative literature
tem to prevent CPA. If CPA occurs, health review (ILR) was to identify the nursing in-
institutions should have a system that allows terventions aimed at the early detection of
the notification and intervention of a mul- ward patients’ clinical deterioration.
tidisciplinary team specialized in caring for
these critically ill patients.
Considering these aspects as a way to facili- Methodological procedures of
tate the early detection of clinical deteriora- integrative review
tion, Rapid Response Systems (RRSs) have
been implemented to allow for its recogni- To meet the objective set out, the ILR was

Nursing interventions for the early detection of ward

Revista de Enfermagem Referência - IV - n.º 14 -2017 patients’ clinical deterioration: an integrative review

conducted according to the Joanna Briggs lation, context, language, date of publi-
Institute guidelines (Joanna Briggs In- cation, and nursing intervention for de-
stitute [JBI], 2015), based on a research tection of deterioration (Table 1). The
question designed using the PCC (Popu- population was composed of adults aged
lation, Concept, and Context) strategy: 18 to 65 years. An initial search showed a
Which nursing interventions promote the study published in 2005 on nursing inter-
safety of the patient at risk for clinical de- ventions for the detection of clinical de-
terioration in a ward? terioration; for this reason, this date was
The inclusion and exclusion criteria of established as the minimum date possible
studies were defined based on the popu- for inclusion.

Table 1
Inclusion and exclusion criteria
Inclusion criteria Exclusion criteria

Population Adults (18 to 65 years) Pregnant women and pediatric population

Psychiatric and obstetric wards, ICU, emergency
Context Hospital ward
and pre-hospital units
Language Portuguese and English Other languages than those selected
Date of
1 January 2005 to 30 June 2016 Studies published before 2005

Nursing interventions for the early detection of Interventions performed by nursing students and/or
clinical deterioration other nursing categories that do not exist in Portugal

First, searches in conventional online data- in MEDLINE: (MH “Nursing”) OR (MH

bases were performed to identify the most rel- “Nursing Process”) OR (MH “Nursing As-
evant articles on the topic under analysis and sessment”) OR (MH “Patient Care Plan-
the keywords and search terms to be used. ning”) OR (MH “Monitoring, Physiologic”)
The search was conducted in the CINAHL, AND (MH “Hospital Rapid response team”)
MEDLINE, and ScienceDirect databases be- OR “Deteriorating patient”; and in Science-
tween May and July 2016. Two studies found Direct: “Nursing intervention” and “deterio-
in additional searches were also included be- rating patient”, activating the filters for date
cause they met the inclusion criteria. Initially, of publication and full text. Quantitative and
a natural language search was conducted in qualitative primary studies were included, as
the databases using the terms identified in the well as systematic literature reviews, without
keywords of the articles found in the initial restrictions on sample size. However, only ar-
search. Then, descriptors/medical subject ticles with full text available and which were
headings (MeSH) and major headings (MH) not opinion articles were included. The free
were combined using the Boolean operators search and the search on the databases re-
“OR” and “AND”, while considering the ex- trieved 534 articles. Of these, 15 articles were
pression “deteriorating patient” in the full text. removed for being duplicates. The process of
The search strategy used in CINAHL was as article identification and selection is shown in
follows: (MH “Nursing Interventions”) OR Figure 1, and is structured as follows: 1) Crit-
(MH “Nursing Process”) OR (MH “Nurs- ical and reflective reading of titles and sum-
ing Protocols”) OR (MH “Nursing Care maries with the purpose of checking if they
Plans”) OR (MH “Patient Assessment”) met the inclusion criteria; 2) Full-text reading
OR (MH “Monitoring, Physiologic”) AND of the articles and their division according to
(MH “Early Intervention”) OR “Rapid re- the inclusion criteria, having obtained 11 ar-
sponse system” OR “Deteriorating patient”; ticles for data extraction and analysis.

CATARINA MOURA FREITAS et al. Revista de Enfermagem Referência - IV - n.º 14 -2017

Number of articles identified through database

searching (n = 532) Additional articles identified through
+ other sources (n = 2)

Articles excluded for being duplicates

(n = 15)
Number of articles after duplicates removed (n
= 519)

Number of full-text articles excluded for

not meeting the inclusion criteria after
title analysis (n = 287)
Number of articles selected (n = 132)

Number of full-text articles excluded

for not meeting the inclusion criteria
after abstract analysis (n = 104)

Number of full-text articles assessed for

eligibility (n = 28)

Number of articles excluded after full-

text analysis (n = 17)

Number of articles included in the review

(n = 11)

Figure 1. PRISMA Flow chart.

Figure 1. PRISMA Flow chart.

The process of evaluating the methodological quality of the articles was conducted
independently by two reviewers using the JBI - Meta Analysis of Statistics Assessment and
The Review
of evaluating the methodolog-
(MAStARI) earlyand
critical appraisal tools detection
the JBI of clinical deterioration.
- Qualitative Assessment This
ical and
quality of the articles was conducted is often confirmed by the monitoring
Review Instrument critical appraisal tool for studies of quantitative and qualitative, of vi-
independently by two reviewers using the tal parameters such as respiratory rate, heart
JBI -respectively. The information was extracted and synthetized from quantitative and qualitative
Meta Analysis of Statistics Assessment rate, and blood pressure (Andrews & Water-
and studies
Reviewusing the JBI-MAStARI
Instrument (MAStARI)and JBIcriti-
QARI Critical
man,Appraisal Checklist
2005; Liaw, for Interpretive
Scherpbier, &
cal appraisal tools and
Critical Research data the JBI - Qualitative
extraction bas, Table
tools, respectively. & Rethans,
2 includes2011).
data onHowever, authors
the publication
Assessment and Review Instrument critical such as Andrews and Waterman
itself and the methodology used: type of study, study objective, main findings, and identified
(2005) and
appraisal tool for studies of quantitative and Odell (2015) have reported gaps in nurses’
nursing interventions.
qualitative, respectively. The information interventions to conduct a complete mon-
was extracted and synthetized from quan- itoring of vital signs and, although this is a
titative andand
Results qualitative studies using the key nursing intervention, the evidence on
JBI-MAStARI and JBI QARI Critical Ap- monitoring is scarce.
praisal Checklist for Interpretive & Critical According to Aneman (2010), the predicting
The monitoring
Research and recording
data extraction tools, ofrespectively.
vital signs are essential
signs of nursing
instability arefor present
the earlyseveral
2 includes datadeterioration.
of clinical on the publication hours before
This is often confirmed by the clinical
of vital regard-
and the such
methodology used:
as respiratory rate,type
rate, less of progression
and blood to cardiac
pressure (Andrews or cardiopul-
& Waterman,
study, study objective, main findings, and monary arrest, which could enable a timely
2005; Liaw, Scherpbier, Klainin-Yobas, & Rethans, 2011). However, authors such as
identified nursing interventions. intervention. In this review, all studies have
Andrews and Waterman (2005) and Odell (2015)identified have reported gaps in nurses’
the monitoring of interventions
vital signs as a
nursing intervention, whether performed in
Results and interpretation isolation or combined, that enables the cal-
  culation of an Early Warning Score (EWS).
The  monitoring and recording of vital signs According to Benner (2001), an experienced
are essential nursing interventions for the nurse is able to identify the patient’s clin-

Nursing interventions for the early detection of ward

Revista de Enfermagem Referência - IV - n.º 14 -2017 patients’ clinical deterioration: an integrative review

ical deterioration before explicit alterations physical, social, and emotional strengths and
in vital signs by providing an early warning coping resources” (p. 205).
signal; however, nurses recognize the need The purpose of the EWS is to provide an ac-
to confirm these findings. Therefore, in both cessible and systematic way to assess the pa-
literature reviews (S2 and S5), nurses’ intu- tients’ health status and guide the response
ition and use of subjective data emerge as in case of a situation of clinical deteriora-
a way of recognizing the patient’s clinical tion, based on a scoring system of physio-
deterioration and only after these will the logical measures obtained at the time of ad-
nurses assess the vital signs to confirm their mission or in regular monitoring moments
findings. during hospitalization (Capan, Ivy, Rohled-
Since physiological variables are often in- er, Hickman, & Huddleston, 2015). Since
terrelated by compensatory mechanisms, its introduction in health institutions, EWSs
heart rate, respiratory rate, blood pressure, have been updated and modified. Exam-
level of consciousness, pulse oximetry, and ples are the Modified Early Warning Score
urine output should be fully assessed and (MEWS) and the National Early Warning
documented (Aneman, 2010; Smith & Pr- Score (NEWS; Kyriacos et al., 2014). In the
ytherch, 2011). same way as the initial EWS, these scales
Vital signs are currently assessed using elec- result from the monitoring of five physio-
tronic equipment, but there is evidence that, logical parameters: heart rate, respiratory
outside ICUs, respiratory rate is assessed rate, systolic blood pressure, temperature,
through observation, leading to insufficient, and level of consciousness. In addition, the
subjective, and unreliable results (Smith & NEWS includes peripheral oxygen satura-
Prytherch, 2011). S4, S5, S6, and S9 are in tion and supplemental oxygen, and, in some
line with this idea, indicating that observa- institutions, the MEWS includes peripheral
tion, touch, and hearing are used as mon- oxygen saturation, urine output, blood glu-
itoring methods by assessing the patient’s cose and/or analytical levels, and pain. These
skin color, temperature, and respiratory pat- parameters, although they are not part of the
tern (depth and sounds). scale, are considered in situations of clinical
According to Osborne, Douglas, Reid, deterioration (Kyriacos et al., 2014). Taking
Jones, and Gardner (2015), although clini- into account that alterations in heart rate,
cal deterioration requires other nursing in- respiratory rate, blood pressure, and level of
terventions beyond the monitoring of vital consciousness are indicators of physiological
signs, this was the most widely used nursing deterioration, a combined monitoring of
intervention. The authors believe that this these parameters is expected to have a higher
finding is associated with the current focus predictive value than an isolated monitoring
on parameters specified by the RRSs, which (Smith & Prytherch, 2011).
could lead nurses to undervalue the perfor- As already mentioned, vital signs were as-
mance of a more comprehensive patient as- sessed in order to group values and obtain
sessment. If performed, this comprehensive a EWS. In this way, the calculation of the
assessment could allow for the early detec- MEWS to detect clinical deterioration was
tion of subtle changes in the patient’s health also one of the nursing interventions identi-
status. In line with this, Kyriacos, Jelsma, fied in 8 of the 11 reviewed studies (S1, S3,
James, and Jordan (2014) underline that it S4, S5, S6, S7, S8, and S11). As with nurses’
is not enough to assess and record vital signs intuition and use of subjective data, which
because the patient’s safety continues to rely are confirmed by the monitoring of vital
on the nurses’ clinical judgment. Accord- signs, S4 also found that the MEWS was
ing to Tanner (2006), clinical judgment in only calculated to confirm the situation of
nursing requires “an understanding of not clinical deterioration rather than to detect it.
only the pathophysiological and diagnostic The sum of the points assigned to each pa-
aspects of a patient’s clinical presentation rameter results in the EWS, which is used
and disease, but also the illness experience to increase the frequency of monitoring of
for both the patient and family and their vital signs, request the collaboration of more

CATARINA MOURA FREITAS et al. Revista de Enfermagem Referência - IV - n.º 14 -2017

experienced professionals, or call the rapid tal, nurses’ perceptions of the effectiveness
response team (RRT) (Smith & Prytherch, of communication and collaboration with-
2011). The request for differentiated help in the multidisciplinary team increased,
and the activation of an RRT seem to be the number of unplanned ICU admissions
the nursing interventions used to respond increased, and the number of unexpect-
to the identified situation of clinical deteri- ed deaths decreased. However, S6 showed
oration (S3, S4, S5, S6, S7, S8, and S11). that SBAR was used by only one out of 47
The MEWS was considered to be an ef- nurses with training to use it. In turn, in
fective instrument of communication of S3, this tool is considered to be an effective
the clinical deterioration to the physician strategy to increase the number of nurses’
since it allows systematizing findings and clinical observations.
presenting them in an objective manner In view of the above, as stated by Mitchell
(S1, S3, S5, S7, and S11). Although three et al. (2010) it is possible to say that a time-
studies (S3, S6, and S7) mentioned the use ly intervention to prevent or stop the pro-
of the Situation, Background, Assessment, gression of clinical deterioration requires a
Recommendation (SBAR) communication set of interventions that includes the moni-
tool to convey information, different re- toring and interpretation of vital signs, fol-
sults were obtained. S7 concluded that, af- lowed by an effective communication and
ter the introduction of this tool in a hospi- adequate clinical response.

Table 2.
Synthesis of the evidence found
Identified nursing
Study identification Method Study objective Main findings

Participants reported that quanti-

fiable evidence is the most effec-
S1 - Andrews, T., & tive means of referring patients to
Waterman, H. (2005). To identify how doctors, and the Early Warning
Packaging: A grounded ward staff uses vital Score achieves this by improving
Monitoring of vital
theory of how to report signs and the EWS communication among profes-
Qual- signs and calcula-
physiological deteriora- to package physi- sionals. Rather than reporting
itative tion of the EWS so
tion effectively. Journal ological deteriora- changes in individual vital signs,
study. as to package the
of Advanced Nursing, tion effectively to the EWS effectively packages
values together.
52(5), 473–481. facilitate referral to them together. It gives nurses a
doi:10.1111/j.1365- doctors. precise, concise and unambig-
2648.2005.03615.x uous means of communicating
deterioration, and confidence in
using medical language.

Findings were grouped into four

main themes: recognition; re-
S2 - Odell, M., Victor,
cording and reviewing; reporting;
C., & Oliver, D. (2009). To identify and
and responding and rescuing.
Nurses’ role in detecting Liter- critically evaluate
Findings suggest that intuition
deterioration in ward ature studies on nursing
plays an important role in the de- Intuition, validated
patients: Systematic review, practice for the
tection of clinical deterioration, by assessment of
literature review. Journal between detection and man-
and vital signs are used to validate vital signs.
of Advanced Nursing, 1990 and agement of dete-
intuitive feelings. The process is
65(10), 1992–2006. 2007. rioration in ward
complex and influenced by many
doi:10.1111/j.1365- patients.
factors, including nurses’ expe-
rience and education and their
relationship with the team.

Nursing interventions for the early detection of ward

Revista de Enfermagem Referência - IV - n.º 14 -2017 patients’ clinical deterioration: an integrative review

S3 - Mitchell, I. A., To determine
McKay, H., Van Leuvan, whether the in-
C., Berry, R., McCutch- troduction of
eon, C., Avard, B., … a multi-faceted The introduction of a multi-fac-
Monitoring of vital
Lamberth, P. (2010). A intervention (track eted intervention in the ward
Quan- signs, calculation
prospective controlled and trigger system to detect clinical deterioration
titative, of the MEWS,
trial of the effect of a and an education may benefit patients through
pro- activate/notify the
multi-faceted intervention program, COM- the increased monitoring of vital
spective medical response.
on early recognition and PASS©) to detect signs and triggering of a medical
intervention in deterio- clinical deteriora- review following an episode of
rating hospital patients. tion would decrease clinical instability.
Resuscitation, 81(6), the rate of prede-
658–666.doi:10.1016/j. termined adverse
resuscitation.2010.03.001 outcomes.

S4 - Donohue, L. A.,
Nurses detected clinical deteriora-
& Endacott, R. (2010).
tion when assessing their patients
Track, trigger and To examine the
visually, looking for recurring
teamwork: Commu- perceptions of ward Visual assessment
signs and symptoms, and com-
nication of deteriora- Qual- and RRT nurses of the patient;
paring their evolution over time.
tion in acute medical itative about the manage-
Although the EWS was not a key
and surgical wards. study. ment of ward pa- Calculation of the
component of patient assessment,
Intensive and Critical tients with clinical EWS.
it was frequently used to quantify
Care Nursing, 26(1), deterioration.
deterioration when any changes
10–17 doi:10.1016/j.
were detected.

S5 - Liaw, S. Y., Scherp-

bier, A., Klainin-Yobas,
P., & Rethans, J. J. To identify nurses’ Intuition;
Findings identified the educa-
(2011). A review of educational needs Monitoring of vital
Liter- tional need to empower nurses
educational strategies and explore educa- signs.
ature to recognize and intervene in
to improve nurses’ tional strategies to Use of subjective
review, patient deterioration. The review
roles in recognizing enhance their ability data (observation,
between of educational programmes and
and responding to to recognize and touch, and hear-
2000 and their outcomes identified infor-
deteriorating patients. intervene in cases of ing).
2010. mation and strategies in deprived
International Nursing clinical deteriora- Calculation of the
Review, 58(3), 296–303. tion in wards. EWS.

Of the trained nurses, 77% versus

58% of the non-trained group
S6 - Ludikhuize, J., de
assessed the patient immediately.
Jonge, E., & Goossens,
On subsequent assessment, respi-
A. (2011). Measuring
ratory rate was measured twice as
adherence among To evaluate whether
Quan- frequently. No differences were
nurses one year after nurses trained in
titative, found in the measurement of other
training in applying the the use of MEWS Monitoring of vital
pros- vital parameters. The MEWS was
Modified Early Warn- and the SBAR com- signs;
pective, determined by 11% of trained
ing Score and Situa- munication tool are activate/notify the
quasi-ex- nurses. Subsequent notification of
tion-Background-Assess- more effective in medical response.
perimen- the physician was performed by
ment-Recommendation recognizing clinical
tal study. 67% of the trained versus 43% of
instruments. Resusci- deterioration.
the non-trained nurses. The SBAR
tation,782(11), 1428–
communication tool was used by
1433. doi:10.1016/j.re-
only one nurse. Trained nurses are
able to identify a deteriorating pa-
tient and react more appropriately.

CATARINA MOURA FREITAS et al. Revista de Enfermagem Referência - IV - n.º 14 -2017

The introduction of the SBAR
communication tool increased
nurses’ perception of effective Patient (Air-
S7 - De Meester, K.,
communication and collaboration. way; Breathing
Verspuy, M., Monsieurs, To determine how
Nurses were better prepared to and ventilation;
K. G., & Van Bogaert, the use of SBAR
contact and communicate changes Circulation; Dis-
P. (2013). SBAR im- can improve the
to a physician by using SBAR ability; Exposure/
proves nurse-physician perception of an
Quan- items. The number of unplanned environmental
communication and re- effective nurse-phy-
titative ICU admissions increased in the control - ABCDE)
duces unexpected death: sician communi-
study. post-intervention period and the assessment;
A pre and post interven- cation and collab-
number of unexpected deaths Calculation of the
tion study. Resuscitation, oration in serious
decreased. The number of RRT EWS (MEWS);
84(9), 1192–1196. adverse events in
calls remained unchanged. These Communication
doi:10.1016/j.resuscita- hospital wards.
results seem to indicate that the with the physician
introduction of SBAR allows for (through SBAR).
the early detection and response in
case of clinical deterioration.

The calculation of the MEWS

based on vital signs occurred in
S8 - Ludikhuize, J.,
70% on the wards with protocol
Borgert, M., Binnekade,
versus 2% in the control group.
J., Subbe, C., Dongel-
Compliance with the protocol was
mans, D., & Goossens, To study the effect
present in 68% of the assessments
A. (2014). Standardized Quan- of the assessment
versus 4% in the control group. Monitoring of vital
measurement of the titative, protocol (three
There were 90 calls to primary signs;
Modified Early Warning random- times per day) of
physicians on the wards with Calculation of the
Score results in en- ized, the MEWS versus
protocol and 9 calls on the control EWS (MEWS);
hanced implementation quasi-ex- assessment per
wards. On wards with protocol, Activation of the
of a Rapid Response perimen- clinical indication
there were twice as much RRT RRT.
System: A quasi-exper- tal study. on the activation of
calls. The monitoring of vital signs
imental study. Resusci- the RRS.
and calculation of the MEWS,
tation, 85(5), 676–682.
three times per day, results in the
doi: 10.1016/j.resuscita-
improved detection of physiologi-
cal abnormalities and more reliable
activations of the RRT.

Skills used by most nurses in

clinical practice included the
S9 - Osborne, S.,
monitoring of temperature, ox-
Douglas, C., Reid, C.,
To determine ygen saturation, blood pressure,
Jones, L., & Gardner,
nurses’ skills for the breathing effort, skin, wounds,
G. (2015). The primacy Quan-
assessment of hospi- and mental status. Reliance on
of vital signs – Acute titative, Monitoring of vital
talized patients and others and technology (35.77%),
care nurses’ and mid- descrip- signs (including
to identify nurse lack of confidence (5.52%), work
wives’ use of physical tive, assessment of
and workplace pre- area (3.79%), and clinical role
assessment skills: A cross cross-sec- mental status, skin,
dictors of the use of (44.24%) are significant predictors
sectional study. Interna- tional and wounds).
physical assessment of the extent of physical assessment
tional Journal of Nursing study.
to detect patient skill use. Patients’ increasing acuity
Studies, 52(5), 951–
deterioration. requires more than the monitoring
962. doi:10.1016/j.
of vital signs; however, it is nurses’
main intervention when assessing
the patient.

Nursing interventions for the early detection of ward

Revista de Enfermagem Referência - IV - n.º 14 -2017 patients’ clinical deterioration: an integrative review

S10 - Fasolino, T., &
Verdin, T. 15). Nurs-
ing Surveillance and
Physiological Signs of
This study found records of mul-
Deterioration. Med-
tiple physiological measurements
surg Nursing: Official
of systolic and diastolic blood
Journal of the Academy
pressure, heart and respiratory
of Medical-Surgical
rate, and SpO2 within regular
Nurses, 24(6), 397–402. Quan- To determine the Monitoring of
intervals for medical-surgical
Retrieved from http:// titative, impact of nursing vital signs (blood
patients. However, there is no
web.a .ebscohost.com. retro- surveillance on pressure, heart rate,
record of mental status assess-
ez-jmk. statsbiblioteket. spective rapid clinical deteri- respiratory rate,
ment and urine output was only
dk:2048/ehost/pd- study. oration. SpO2).
recorded a few times. Specific
components of nursing surveil-
lance that permit recognition
of patient clinical deterioration
remained unclear.

S11 - Stafseth, S. K.,

Three themes emerged: 1)
Grønbeck, S., Lien, T.,
experiences with the early rec-
Randen, I., & Lerdal, A.
ognition of deterioration using
(2016). The experiences To explore nurses’ Calculation of the
the MEWS, 2) collaboration
of nurses implementing experiences in the EWS;
and knowledge transfer between
the Modified Early Qualita- implementation and
nurses, and 3) a new precise
Warning Score and a tive, ex- use of the MEWS Activation of a
language used to communicate
24-hour on-call Mobile ploratory and the existence more differentiated
with physicians. The use of the
Intensive Care Nurse: study. of an ICU nurse response (ICU
EWS and support were perceived
An exploratory study. providing 24-hour nurse and/or
as improving care for deteriorat-
Intensive and Critical on-call support. RRT).
ing patients and for supporting
Care Nursing, 34,
the collaboration between pro-
33–41. doi: 10.1016/j.

Conclusion be generalized; and only articles written in En-

glish were analyzed.
This ILR aimed to identify the nursing inter- We believe that training in areas such as patient
ventions used for the early detection of hos- physical assessment and team communication
pital ward patients’ clinical deterioration. The are a significant contribution to achieve effective
11 articles analyzed in this review show that nursing interventions in this area. This training,
the monitoring of vital signs, either individu- combined with the use of the best scientific ev-
ally or in combination to obtain a EWS, is the idence available, will allow for a substantiated
most widely used nursing intervention. They clinical judgment and decision-making.
also highlight the importance of intuition and Evidence on this topic is scarce, so we suggest
use of subjective data in patient assessment and that studies should be conducted on nursing
aspects such as the communication of clinical interventions for the early detection of clinical
deterioration and the activation of the RRT/ deterioration. In addition, it would be equally
assistant physician as a result of these interven- important to analyze the results of the imple-
tions. mentation of RRSs in health institutions, since
This study has some limitations: it only includ- they have a recognized impact on reducing
ed articles available through open access in the mortality rates and unplanned ICU admis-
databases searched; three of the studies used sions, thus contributing to patient safety and
qualitative methods and their results cannot leading to health gains in society in general.

CATARINA MOURA FREITAS et al. Revista de Enfermagem Referência - IV - n.º 14 -2017

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Nursing interventions for the early detection of ward

Revista de Enfermagem Referência - IV - n.º 14 -2017 patients’ clinical deterioration: an integrative review


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