Prioritising Responses Of Nurses To deteriorating patient Observations (PRONTO): a pragmatic cluster randomised controlled trial evaluating the effectiveness of a facilitation intervention on recognition and response to clinical deterioration

Abstract

BackgroundMost hospitals use physiological signs to trigger an urgent clinical review. We investigated whether facilitation could improve nurses’ vital sign measurement, interpretation, treatment and escalation of care for deteriorating patients.MethodsIn a pragmatic cluster randomised controlled trial, we randomised 36 inpatient wards at four acute hospitals to receive standard clinical practice guideline (CPG) dissemination to ward staff (n=18) or facilitated implementation for 6 months following standard dissemination (n=18). Expert, hospital and ward facilitators tailored facilitation techniques to promote nurses’ CPG adherence. Patient records were audited pre-intervention, 6 and 12 months post-intervention on randomly selected days. Escalation of care as per hospital policy was the primary outcome at 6 and 12 months after implementation. Patients, nurses and assessors were blinded to group assignment. Analysis was by intention-to-treat.ResultsFrom 10 383 audits, improved escalation as per hospital policy was evident in the intervention group at 6 months (OR 1.47, 95% CI (1.06 to 2.04)) with a complete set of vital sign measurements sustained at 12 months (OR 1.22, 95% CI (1.02 to 1.47)). There were no significant differences in escalation of care as per hospital policy between study groups at 6 or 12 months post-intervention. After adjusting for patient and hospital characteristics, a significant change from T0 in mean length of stay between groups at 12 months favoured the intervention group (−2.18 days, 95% CI (−3.53 to –0.82)).ConclusionMulti-level facilitation significantly improved escalation as per hospital policy at 6 months in the intervention group that was not sustained at 12 months. The intervention group had increased vital sign measurement by nurses, as well as shorter lengths of stay for patients at 12 months. Further research is required to understand the dose of facilitation required to impact clinical practice behaviours and patient outcomes.Trial registration numberACTRN12616000544471p

Vital sign assessment and nursing interventions in medical and surgical patients with rapid response system triggers

“…• Nurses engage in a range of nursing interventions to manage deteriorating patients (aside from rapid response system activation) that are not well understood, nor well described in the literature to date. randomised controlled trial that tested the effect of a facilitation intervention on nurses' vital sign measurement, interpretation, and escalation of care for deteriorating patients (Bucknall et al, 2022).…”

“…The outcomes of interest were as follows: (i) vital sign assessments at least 8-hourly on every patient; (ii) escalation of care per policy for patients with vital sign abnormalities; and (iii) implemen- Managers at staff meetings and via email, and notification of free online educational courses about recognition and response to deteriorating patients (Bucknall et al, 2017). The intervention wards (n = 18) had an external facilitator across hospitals, an internal hospital facilitator (HFLIP) and two ward facilitators (WFLIPs) per ward for 6 months who used facilitation methods to address barriers and leverage enablers to achieve the desired outcomes (Bucknall et al, 2022). There were no significant differences in any of the three outcomes of interest between intervention and control wards at 6 or 12 months post-intervention (Bucknall et al, 2022).…”

“…There are numerous published studies of vital sign assessment by nurses (Brekke et al, 2019;Bucknall et al, 2022; and nurses' compliance with RRS activation in patients with vital sign abnormalities (Bingham et al, 2015;Bucknall et al, 2022;Bucknall, Jones, Bellomo, Staples, & for the RESCUE Investigators, 2013;Guinane et al, 2013;Shearer et al, 2012). One of the largest studies was the Prioritising Responses of Nurses To deteriorating patient Observations (PRONTO) pragmatic cluster…”

Piloting a Nurse-Led Critical Care Outreach Service to Pre-Empt Medical Emergency Team Calls and Facilitate Staff Learning

“…Research has shown that signs of clinical deterioration, such as abnormal heart rate, respiratory rate, or oxygen saturation can occur several hours before serious adverse events [11,12]. Therefore, earlier recognition of deterioration and escalation is crucial for ward nurses to gain time to stabilize patients and perhaps mitigate serious adverse events [13,14]. Several machine-learning algorithms have been developed to support staff in identifying patterns which can predict patients who may deteriorate in the future [10,15,16].…”

Reporting on implementation trials with null findings: the need for concurrent process evaluation reporting

“…The Prioritising Responses of Nurses to deteriorating patient Observations (PRONTO) trial reported in this issue of BMJ Quality and Safety describes results of a trial that overall, despite a few positive findings among the large number of planned comparisons performed, produced results that supported rather than rejected the study null hypotheses 1. This is a disappointing result for the investigators, who put considerable time and energy into this study; for funders, who hoped to learn how to positively influence the quality and safety of nursing care for seriously ill adults; and for readers, who also hoped to learn how to influence and support high-quality care by ensuring that nurses activate support systems in response to patient deterioration in hospitals.…”