We conducted 58 interviews from February through June 2017. Table 1 describes the number of interview subjects by care area and role. Direct care nursing refers to General Care, Post Anesthesia Care Unit (PACU), and Surgical Intensive Care Unit (SICU) nurses.
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These nurses hold primary responsibility for their assigned patient’s care and are considered the first line at the bedside. Consultation services include Life Safety nurses and Respiratory Therapists (RT). Life Safety nurses are ACLS and PALS certified critical care RNs, who are the first tier of the hospital’s Rapid Response Team (RRT). A Life Safety Consult may be initiated by a frontline nurse whereby a Life Safety nurse comes to the bedside for assessment and provides necessary critical care and referral to a higher level of care. At the physician level, house officers are comprised of interns and residents, designated by their post-graduate year (PGY).
Table 2 provides representative examples of facilitators and barriers to recognition of patient deterioration or complication by clinician type. The primary concepts identified within the recognition domain include 1) use of existing technology to aid in recognition of decline, 2) importance of staff experience level, and 3) acting on clinical intuition alone without supporting physiologic data.
The use of technology that aids in detection of patient deterioration was a common point of emphasis across clinicians. There was uniform agreement that these tools are helpful, but that they do not replace the importance of visual and physical assessment of patients. For example, PACU nurses commented on this socio-technical relationship, reflecting on both alarms being sensitive to alert when vital signs change and having nurses available with their eyes on the patients 24/7 to detect decline.
Respondents cited the importance of staff experience level is for identifying important problems and knowing when to call for help. General care nurses specifically noted that the majority of staff on the floor are inexperienced”both nurses and house officers. An Attending Surgeon stated the barrier is that both the direct care nurse and the junior house officer are the team members with the least amount of experience, yet they are the keystone to early recognition. Some noted the importance of allowing new staff to have teachable moments, however, when issues of patient safety arise, experienced level staff have to intervene and escalate care accordingly.
Clinical intuition is developed over years of experience and may not have traditional physiologic data that accompanies it.
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