Improving the safety of patient care is a priority for service users, frontline staff, healthcare managers and policymakers (Healthcare Improvement Scotland, 2017). This is especially true in the acute care hospital setting, which is known to be an area where there is a high incidence of preventable harms (Hogan et al, 2012). A specific target area for the prevention of patient harm is the management of the deteriorating patient (Jensen et al, 2018).
In the hours leading up to a cardiac arrest or an admission to an intensive care unit (ICU), many patients on general hospital wards have signs and symptoms of clinical deterioration (McGaughey et al, 2010). Evidence demonstrates that up to 80% of patients could be identified in the 24 hours before one of the above events and that 21-41% of ICU admissions from general ward settings are potentially avoidable (McQuillan et al, 1998; National Confidential Enquiry into Patient Outcome and Death, 2005; Buist et al, 2004). Furthermore, patients transferred unexpectedly to the ICU often have worse clinical outcomes and increased mortality (Jäderling et al, 2013).
To aid in the detection of deteriorating patients, track and trigger (TT) systems have been developed (Cooper et al, 2010; McGaughey et al, 2010). Internationally, various forms of an early warning score (EWS) have been adopted as the standard TT system for use within acute care (Department of Health (Ireland), 2020). These scores, which are widely used, have been shown to improve patient outcomes (Petersen et al, 2016; Jensen et al, 2018). They have also been shown to be the single most significant predictor of referral behaviour for registered nurses in the UK (Rattray et al, 2011).
Although widely adopted, the working of the EWS system has not been fully elucidated (Ludikhuize et al, 2012; Foley and Dowling, 2019). Issues relating to the accuracy of reporting and tool completion rates have been quoted as potential problems (Cretikos et al, 2008; Ludikhuize et al, 2012). The use of technology linked to electronic patient records systems has been proposed as a solution that may aid in the prioritisation of patient care and lead to improvements in accurate documentation and patient safety (Hravnak et al, 2008; Bellomo et al, 2012).
It has been proposed that embedding an electronic EWS within an appropriate patient record may help support workload and facilitate earlier escalation of supportive care (Bellomo et al, 2012). The technology used for this can take many forms, ranging from devices that work as data repositories to those that can provide clinical assessment and decision-making advice (Burns et al, 2018). Previous research has looked at the impact of these systems after implementation, but there is limited evidence regarding how to implement these in the acute care setting.
This study, which was a component of a wider service evaluation, was to explore nursing staff and healthcare support worker views regarding the upcoming implementation of an electronic documentation and reporting system for an EWS in a tertiary referral inner city hospital. The proposed technology consisted of a handheld device with dedicated software, which would be used to complete the EWS in general, acute wards in clinical practice. The new device would also support a structured escalation plan for that individual patient as appropriate.
Aim
To explore nursing staff and healthcare support worker views regarding the upcoming implementation of an electronic documentation and reporting system for an EWS in a tertiary referral inner city hospital. Specifically, to understand from a staff perspective what were the perceived challenges, barriers and facilitators to the implementation of this technology, in order to help improve the change process.
Methods
Setting
This evaluation took place in one inner city teaching hospital in central Scotland. This site is a tertiary referral hospital for burns, pancreatic care and oesophageal surgery. The authors sampled staff from four wards in this hospital. Wards included in this evaluation were: a surgical receiving unit, two orthopaedic wards and an acute medical assessment unit. These wards were chosen because they would be the test sites for the new technology.
The population selected for this study consisted of nursing staff and healthcare support workers in the acute healthcare system who use an EWS on a regular basis and who are involved in the care of acutely ill adults. All nurses and healthcare support workers, regardless of professional experience, could participate.
Data collection
In-depth semi-structured interviews were undertaken with participants in the acute hospital setting. This method of data collection was chosen because this research, and indeed clinical area, is complex and variable across settings and individuals. These contextual accounts of behaviours and attitudes would have been difficult to assemble and recount using any other data-collection method.
Participants were identified and approached in the first instance by the lead nurse or senior charge nurse in the ward environment. They were asked if they were happy to participate and given relevant information about the service evaluation and its purpose. If they were happy to participate they were contacted by the project team and a date and time was made to undertake the interview. Baseline demographics were obtained from all participants including: designation, gender, age and years' experience working in the NHS. Participants were able to see the device and were given an overview of the proposed technology and use before the interview.
In-depth interviews were undertaken by the first author (AI), an experienced emergency nurse, in August 2017. Interviews took place in a private area away from the ward environment, for example, day lounges and staff offices. An interview schedule was created by AI and BJ, an experienced qualitative researcher. It was tested and refined with trained nurses before the interviews commenced. All interviews were audio recorded and transcribed verbatim.
Data analysis
Data analysis was completed by AI and JM; JM is an experienced qualitative researcher and ICU nurse. Data saturation was discussed regularly and was reached after 11 interviews, after consensus was reached within the research team. External peer review was undertaken to enhance the trustworthiness of the data analysis, by reducing researcher bias (Cutcliffe and MacKenna, 2002). This external peer review was undertaken by a senior nurse with a background in both acute care and research (MC). Member checking was also undertaken to ensure dependability of the reported findings (Tobin and Begley, 2004).
Data were analysed, organised and presented using the Consolidated Framework for Implementation (CFIR) (Damschroder et al, 2009). The CFIR is widely used in implementation science. This approach allowed the analysis to be driven by the understanding of important contextual factors of implementing this technology, and how this could be undertaken efficiently. It comprises five constructs (Damschroder et al, 2009):
- Intervention characteristics, which refers to the intervention being implemented in an organisation
- Outer setting, which refers to the economic, political and social context within which the organisation exists
- Inner setting, which refers to the structural, political and cultural contexts through which the implementation occurs
- Characteristics of individuals, which refers to the individuals involved in the implementation
- Process, which refers to the implementation process.
Each of these constructs were reported in relation to perceived barriers and facilitators to the implementation of this new technology. Themes were identified after each transcript was reviewed individually by JM and AI; themes were then distilled until agreement was reached. MC reread all transcripts to ensure that these themes were truly embedded in the data collected.
Ethical considerations
After discussion with the chair of the local ethics committee, it was agreed that this work did not fulfil the criteria for clinical research. This piece of work formed part of a larger service evaluation and was used to drive quality improvement in the clinical setting, thus did not require ethical approval. All participants were asked to complete a consent form to ensure that they were happy with the interview process and the recording of the interview. Furthermore, this service evaluation was registered with the e-health department within the health board.
Results
This evaluation aimed to explore staff views regarding the upcoming implementation of an electronic documentation and reporting system. Table 1 details the demographics of the participants involved in the interviews. A range of staff, including healthcare support workers (n=2), took part. The majority of the participants were female (n=10, 91%) and most participants were staff nurses (n=6, 55%).
Table 1. Participant demographics
| Demographic | Number |
|---|---|
| Designation | |
| Charge nurse | 3 |
| Staff nurse | 6 |
| Healthcare support worker | 2 |
| Gender | |
| Male | 1 |
| Female | 10 |
| Age (years, mean) | 42.2 |
| Years of experience (mean) | 14.8 |
| Ward environment | |
| Surgical receiving unit | 3 |
| Orthopaedic ward | 4 |
| Acute medical assessment | 4 |
A total of 11 interviews were undertaken. Data saturation was achieved at the tenth interview. One further interview was undertaken to ensure no new themes were developed. Each interview lasted between 20 and 25 minutes.
The findings from the interviews were mapped to the CFIR structure. A summary of the findings is presented in Table 2.
Table 2. Findings mapped to Consolidated Framework for Implementation
| Domain of CFIR* | Barriers | Facilitators |
|---|---|---|
| Intervention characteristics |
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| Outer setting |
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| Inner setting |
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| Individuals |
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| Process |
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Intervention characteristics
Participants discussed the perceived benefits of the implementation of this technology and the characteristics that may be of assistance to busy staff in the clinical setting. They noted that the technology could potentially improve time management and give staff the ability to spend more time with patients. How the technology could improve the accuracy of communication and reduce duplication of handwritten documentation was also discussed.
‘I certainly think it's a good way to go about it … I think it's a lot less likely to miss someone with a high EWS.’
The ability to understand physiological trends across a patient's entire hospital encounter, quickly and efficiently, was also seen as an advantage to the implementation of this type of technology. This was highlighted within the context or transitions of care across the hospital setting:
‘Sometimes the EWS aren't recorded by the medics and they are coming up with EWS of 8 or 10 and we don't know that, so that would be good, making us aware.’
‘If you are … especially working in (a ward) where you can have an admission every 10 minutes … you could easily miss [a high EWS].’
During the interviews participants also explored some of the challenges they anticipated with the implementation of the technology. For example, apprehension around the reliability of devices (Table 2).
Outer setting
Within the CFIR, the pillar ‘outer setting’ refers to the economic, political and social context within which the organisation exists and how organisational elements impact the concept under study. Within the present project, there were a number of perceived facilitators and benefits to the implementation of this technology in relation to the overarching organisation.
Participants described how the new technology could potentially improve communication and help understand the patient journey across the hospital setting. Those interviewed also reported perceived challenges to the organisational context, including the availability of devices and the implementation of the technology within in a busy ward setting:
‘You have got pharmacists, doctors, everybody in the ward, who are all using similar computers, so sometimes if they are on it, you can't get access straight away and that can be time consuming.’
The challenges with the reliability of the technology and how this could influence its use in clinical practice were explored by those interviewed, in relation to previous experience of technology:
‘Quite often seems to be down and sometimes it's a challenge getting on it … when it's working it can be very helpful.’
Inner setting
The structural, political, and cultural contexts through which the project occurs is also an essential component of the CFIR. Challenges related to the inner setting in this evaluation included the ward environment and interface with other technologies presently in use (Table 2). However, participants also discussed the facilitators within the inner setting, including the ability to streamline documentation and improve the visibility of the entire ward environment (physically and through the aid itself):
‘You are actually getting more time with your patient, to be able to sit there and pop it in, and you're still getting to look at the rest of the ward.’
‘A couple of weeks ago, it was only a regular set of observations and I completely forgot because we were so busy … I think it might highlight, especially if you've got a sick patient.’
Characteristics of individuals
Both facilitators and barriers to the implementation of this technology in the clinical environment were discussed, from the perspective of their own workload and their experience of technology and computers. Anxieties and barriers related to the use of technology and the time and training that accompanies its use were discussed:
‘I'm not very computer minded.’
‘Hopefully, it's not too time consuming.’
‘I'd just be worried that it got broken or stolen.’
Participants articulated that, despite this, it could still improve the quality of care that they delivered. Staff discussed how it could potentially improve the visibility of the ‘sick patient’ even when the ward was busy (Table 2), again with the potential to improve patient safety.
Process
Finally, the process of implementation of the new technology was discussed, especially in relation to experience of previous technology implementation.
‘It's a bit like everything else, once you get used to it. … When [previous technology implemented in hospital] came in, it was like, “Oh my God, we will never get used to this”.’
‘Hopefully it's not too time consuming … transcribing the information onto handheld devices.’
This was evident in relation to supporting a structured response to elevated EWS and previous experiences of this:
‘I used them in a previous trust and it worked really well, as you've got that to hand and you are able to see the ward as a whole.’
Discussion
The aim of this evaluation was to explore views regarding the upcoming implementation of an electronic documentation and reporting system for an EWS in a tertiary referral inner city hospital. It provides unique insights into how policymakers and managers can support staff and ensure a supportive environment and context, for the safe and effective implementation of this technology.
The use of appropriate technology to improve the quality and safety of care is now firmly established as a key outcome internationally (Cresswell and Sheikh, 2013). However, the adoption of new technology is notoriously slow and difficult within the healthcare setting (Black et al, 2011). This small-scale evaluation has identified barriers and facilitators to the implementation of this technology and potential mechanisms for ensuring the effective implementation of technology in clinical practice. These mechanisms include:
- Adequate availability of devices in the ward environment
- Appropriate training and education
- Suitable time given to adapt to the new technology.
Consistent with previous evidence, the availability and reliability of devices were identified by nurses and healthcare workers as potential barriers to implementation (Alexander and Staggers, 2009). Those implementing new technology should ensure adequate access to and availability of devices. This should centre around more than the absolute number of devices. It is also important to consider the availability of the interfaces with devices (ie central monitors) and where these are positioned, and appropriate systems to manage any issues with the devices should be in place from the outset of implementation. Those implementing technology must also ensure that there is an understanding of the context in which the device/technology is to be implemented. This is especially crucial in the context of the deteriorating patient; similar to previous research, ensuring that the technology systems are appropriate and effective for the role they are intended makes it more likely that they will be adopted in a timely manner (Gagnon et al, 2010). For example, if a central point or monitor is to be used to alert staff about a deteriorating patient, it must be an area that is easily seen—this may be vary across different settings. It has been suggested that end users should be involved in the development of any new clinical information technology, to make sure that the result is appropriate and effective (Alexander and Staggers, 2009).
It is clear that nurses and healthcare support workers were not set against the implementation of technology. They were, however, apprehensive about how it would function in the clinical environment. Training and education are, therefore, crucial within clinical practice to manage and support this potential anxiety and apprehension. Alongside this, staff stated that appropriate time to allow for the implementation of new devices was also key. Time, in relation to the day-to-day use of the technology, also featured within these interviews. Previous evidence has found that new technology must be at least as quick as previous systems (ie completion of the EWS chart) and fit within the workflow, otherwise it is unlikely to be adopted within clinical practice (Boonstra and Broekhuis, 2010). Therefore, this is a crucial mechanism to ensure adoption and diffusion of the technology: it will ensure that the technology is beneficial (time efficient) and that there is appropriate training in its use.
Strengths of this evaluation are that it has provided unique insights into nurses' and healthcare support workers' views about the implementation of technology in relation to EWS, in a busy tertiary referral hospital. It used a systematic and structured approach to analysis, which has provided rich detail about the challenges and facilitators to implementing technology in the acute healthcare environment. It represented staff with a variety of experience from various clinical specialties. However, it is limited in its focus in that it provided information from a single centre. Further, staff from different areas may have different experiences and expectations about the use of technology; specific areas such as critical care and accident and emergency were missing from this evaluation. Although broad learning can be cultivated from this report, it is key that those implementing such technology focus on each individual context for implementation. A strength of this work is that a staff member who was familiar with the new technology undertook the interviews; however, this may have also influenced the responses given by participants. Finally, the authors sampled 11 participants, of whom only a small number were healthcare support workers (n=2). More work on the subject is required with this group of staff, because in some areas they undertake a large proportion of this clinical workload. Furthermore, specific research exploring issues such as infection control and training needs is still required before widespread implementation of this approach.
Conclusion
This evaluation has provided a unique insight into how technology to support the management of the deteriorating patient can potentially be implemented in an effective manner within the acute care environment. It has provided detailed information from a nursing and healthcare support worker perspective about how policymakers and healthcare managers can do this, including adequate training time, and implementation time. More research is required about how these recommendations can be implemented most effectively.
KEY POINTS
- Early warning scores (EWS) are widely used in clinical practice to support decision-making
- There is limited research exploring how best to implement electronic EWS in clinical practice
- Facilitators for smooth implementation included adequate availability of devices in the ward environment, appropriate training and education, and suitable time given to adapt to the new technology
- Challenges to the use of new technology included staff apprehension around training and education needs, and the uncertainty of technological reliability in the clinical setting
- Future research exploring this technology and its implementation is warranted
CPD reflective questions
- How are early warning scores employed in your own institution?
- Which of the positive aspects to new technology discussed here would be most likely to appeal to you? Why do you think this is?
- Consider the challenges to implementation of new technology. Have you encountered any of these in your own institution? How did your team overcome these?