Recognizing and Responding to Deterioration in Complex Patients: A Case Study Analysis and Recommendations

The essay discusses the case study of Jenny, a patient with complex problems in the emergency department. It highlights the lack of recognition and response to her deteriorating condition, leading to inadequate intervention. The case study evaluation reveals the negligence of healthcare staff in providing appropriate care. Ethical principles and recommendations for improving recognition and response systems, leadership approaches, and organizational policies are discussed. Continuous monitoring, improved knowledge and skills, and effective communication are recommended for better patient outcomes.

Coroner’s Case Study
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Introduction:
Emergency department patients are associated with complex problems. Hence, it is necessary
to recognise and respond appropriately to the patient to escalate care to these complex
patients. In this essay, case study of Jenny is going to be discussed. Symptoms exhibited by
Jenny will be reported and intervention planned by the healthcare staff will also be discussed.
Jenny’s intervention was associated with several drawbacks like healthcare staff’s lack of
knowledge and lack of adequate staff members. Based on the triggers identified in the
Jenny’s case, recommendations will be made for escalating care to him. Appropriate
leadership approaches will be identified which would be beneficial in escalating her care.
Recognition and response to deterioration in complex clients :
It is very important to recognise clearly the clinical and deteriorating condition of the
complex condition of the patient to respond effectively. Inappropriate recognition and
response to these patients would increase risk in such patients. It would lead to burden on the
patient’s family and hospital, decrease in the disability-adjusted life years, increased duration
of stay in the hospital, reduced quality of life and augmented morbidity and mortality. Timely
reorganisation and response to patient condition is not only helpful in improving patient care
but also helpful in reducing major adverse events. Increasing awareness about reorganisation
and response among nurse would be helpful in improving patient outcome. Detailed and
holistic analysis of the patient through incorporation of professionals from different
disciplines like medical, pharmaceutical, physical health and nutrition would be helpful in
accurate recognising and responding to the patients with complex needs (Massey, Chaboyer,
and Anderson). Literature comprising of identification of gaps in the knowledge and relevant
research proved helpful in improving patient outcome in the complex patients. It is necessary
for the healthcare professionals to identify transition of patient from one clinical state to
another state. Hence, accurate recognition of clinical state can be identified to respond
effectively to the complex patients. Literature reported that nurse’s experience to negotiate
clinical, organizational and system barriers proved beneficial in reducing clinical
deterioration. Overlap and acknowledgement of the clinical condition of the patient is the
hurdle for recognizing the patient condition. Effective patient assessment and accurate
escalation of the patient care requirements proved beneficial in improving patient outcome
(Allen, Elliott, and Jackson D, 2017).
Case study evaluation:
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Jenny was admitted to the hospital with complains like headache, dizziness and aches. On
arrival to ED her, vital signs normal for temperature, respiratory rate and oxygen saturation
were determined. However, her respiratory rate, pulse rate and blood pressure exhibited
deviation from the normal range. These values indicate, she might be associated with
cardiovascular conditions. Since, she was exhibiting dizziness; doctor prescribed her with IV
fluids (Jahn, Langhagen, and Heinen, 2015). After 1 hour, her vital signs were again
recorded. Her all vital signs were almost same like baseline; however, it has been observed
that her blood pressure dropped drastically. Based on the vital signs values at first hour,
doctors decided to administer her with additional IV fluids. Despite administration of IV
fluids, her blood pressure keeps on dropping. Moreover, she exhibited tachycardia,
significant lethargy, increased fever, headache and no urine output. However, till evening no
decision was taken to administer medications for her. There was not enough staff to monitor
her condition. In most of the cases, rapid alterations in the vital signs mainly occur due to the
infection (Quinten, van Meurs, Ter Maaten, and Ligtenberg, 2016). However, no blood tests
were ordered to detect presents of infection in Jenny. Since, her blood pressure was dropping
at fast space; it was sure her condition was deteriorating her condition at faster rate and it was
affecting most of the vital organs. In such cases, it is essential for the physician to give proper
recommendations for the nursing staff to provide appropriate intervention to Jenny. However,
physician did not recommend nursing staff for appropriate intervention. Hence, Jenny
remained untreated for most of the duration. ADDS chart provide information related to the
accurate clinical condition of the patient and most of appropriate recommendations for the
patient (Joshi, Campbell, Landy, Anstey, and Gooch, 2017). However, staff members taking
care of Jenny did not follow recommendations mentioned on the ADDS chart.
Case of Jenny could have been monitored in an effective manner; if appropriate
recommendations would have been made in the timely manner. Jenny’s condition was
deteriorating very fast due to meningococcal infection; however, treatment related to the
infections was not provided to her in timely manner. It is essential to provide intervention for
infection at the appropriate time because untreated infection can produce complex clinical
condition in the patient through affecting multiple organs (Larsen and Petersen, 2017). Her
infection remained untreated because healthcare staff were not giving proper attention to her
and available healthcare staff was inexperienced to recognise her exact condition and provide
appropriate intervention to her. Nurse in ED should have called an emergency or produce her
data on ADDS chart; when her blood pressure dropped significantly within first hour of ED
admission. Nurse in the ED did not recognise deteriorating condition and her condition was
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transforming to the more complex condition. Doctor in the ED reviewed her chart orders
further administered IV fluids and extended her hospital stay. However, doctor did not order
any other medications. It indicates that doctor also did not recognise her deteriorating
condition. This was critical time point where wrong decision making for Jenny further
deteriorated her condition. Doctor should be final decision maker in providing care to the
patient (Williams and Ritsema, 2014). If doctor was not able to take effective decision;
deterioration of patient is bound to happen. In case of Jenny also, same matter happened and
her condition get deteriorated very rapidly before taking any corrective action. Moreover,
doctor was not available for monitoring condition of Jenny; however, he was available on
call. His availability on call might not be beneficial because his presence and monitoring of
Jenny’s condition might be helpful in improving her condition.
Jenny was not exhibiting any serious symptoms. Hence, healthcare professionals were
assessing her vital signs and based on common symptoms like headache, lethargy and aches;
she was being administered with IV solution to manage her lethargy. Her vital signs were
being monitored on the regular basis; however, blood tests were not ordered for further
investigation. Since, blood tests were not performed further investigation was not provided to
her. It indicates her actual problem was not recognised; hence, appropriate treatment was not
provided to her. It has been observed that in case of Jenny both blood pressure and
respiratory rate increased significantly. However, her SpO2 remains in the normal range.
Usually, reduced SpO2 levels lead to increased breathing rate (Tamura, 2019). In such
scenario, accurate recognition of the clinical condition of the Jenny is necessary. However,
her clinical condition has not been evaluated accurately due to negligence of healthcare staff.
Moreover, most of the healthcare staff were busy with the management of gastroenteritis
outbreak. From the case study, it was evident that her family members were not available
during her treatment period. All these circumstances made, her critical condition more
complex and final outcome was her death.
According to legal and ethical principal of nursing, patient’s safety and prevention of injury
or damage are of prime importance (Rashvand et al., 2017). However, in case of Jenny, this
principal was not followed. It is mandatory to deliver standard health care services through
prevention of any types mistakes. There should be organised approach to address issues like
risk management, systematic deficiency and augmentation in patient safety (Skaggs, Daniels,
Hodge, and DeCamp, 2018). It is mandatory to deliver standard curative and life sustaining
treatment in case of rapidly deteriorating patients like Jenny. Ethical principles states that
there should be effective clinical decision making to avoid wrong provision of intervention.
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In case of Jenny, decision making was wrong because further assessment was done beyond
vital signs. Ethics in the healthcare services are important to address ethical dilemmas and to
make appropriate judgement (Haahr, Norlyk, Martinsen, and Dreyer, 2019). However,
nursing staff in case of Jenny were in dilemma whether they should participate in
management of gastroenteritis outbreak or should take care of rapidly deteriorating patient
like Jenny. They could have made proper judgement by allocating experienced staff for
providing care to Jenny. Nurse’s primary commitment should be patient and nurse should
provide nursing service with compassion and inherent dignity. Nurse should not leave patient
unattained or untreated (Johansson, Wåhlin, Magnusson, and Hanson, 2019). However, in
case of Jenny, it has been observed that Jenny remain untreated adequately for the longer
duration; though her deteriorating condition was known to the service providers.
Recommendations:
It is evident that there was no established system for recognising and responding to the
clinical deterioration. Clinicians and other healthcare staff should implement effective
recognition and response system. Standard 9 of the National Safety and Quality Health
Service (NSQHS) is related to ‘Recognising and Responding to Clinical Deterioration in
Acute Health Care Standard’. This standard can be effectively implemented in conjunction
with other standard 1 and 2. Standard 1 is related to ‘Governance for Safety and Quality in
Health Service Organisations’ and standard 2 is related to ‘Partnering with Consumers’
(Twigg, Duffield, and Evans, 2013). It is necessary to implement organisation wide
recognition and responding system consistent with National Consensus Statement.
Appropriate action would have taken in timely manner for the recognition and responding to
the clinical condition of the Jenny. Accurate assessment and relevant intervention to Jenny in
timely manner would have improved her condition. Moreover, effective communication with
family members would have helped in proper decision making and responding to the
deteriorating condition of Jenny. However, from the case study it was evident that family
members of Jenny were not available for communication. Hence, healthcare staff members
were not able to communicate with them for decision making and responding to her
deteriorating condition. Usually sudden deterioration of clinical condition of the patient is
associated with physiological and clinical abnormalities. Hence, it would have been
beneficial to assess physiological and clinical abnormalities of Jenny to recognise her
deterioration. Early recognition of the abnormalities in patient would have been helpful in
early stabilisation of Jenny and recovery of her condition. Inappropriate recognition of
warning signs of clinical deterioration might be due to several factors like inconsistent
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observations and non-understanding of the physiological observations, nonexistence of
effective organisational system for responding to the deterioration, un-killed workforce to
recognise deterioration and failure to communicate to the higher authorities related to
deterioration (Odell, 2015). In case of Jenny, all these factors were responsible for the
inappropriate recognition and responding to her deterioration. Hence, improvement in all
these factors can be recommended for the improvement in outcome in the patients like Jenny.
Healthcare staff should consider continuous monitoring of physiological alterations,
improvement in the knowledge about signs and symptoms about deterioration, improvement
in the formal systems to effectively respond to deterioration, improvement in the knowledge
and skills for the management of deteriorating patients and effective communication through
ADDS and handover (Dawson, King, and Grantham, 2013).
Different leadership approaches like democratic, transformational, coaching, and situational
can be helpful in improving care to deteriorating patients like Jenny. Democratic leadership
would have enhanced participation of nurses of all levels in escalating care to Jenny. In this
leadership, leader collect information, response and ideas from nurses of all levels; hence, it
would be helpful in improving knowledge of all the nurses in escalating care to the
deteriorating patients. Transformational leadership would have been beneficial in providing
care to Jenny because all the nurses get encouragement, motivation and positive thinking in
providing care deteriorating patient. Hence, in the absence of leader also they can provide
effective care to the deteriorating patient. In coaching type of leadership, leader focuses on
the development of subordinate nurses. Hence, this type of leadership would have been
beneficial in providing care to Jenny because it was observed that those nurses who were
taking care of Jenny were not well aware of all the procedures in escalating care. Situational
leadership would provide flexible and transformative environment according to the clinical
requirements (Mannix, Wilkes, and Daly, 2013; Stanley and Stanley, 2018).
It is essential for the organisation to make arrangements to develop, implement, maintain
organisation wide recognition and response system. It is recommended to implement policies,
procedures and protocols for documentation of observations, provision of care, provision of
rapid response system and effective communication of clinical deterioration. It is essential
that collected clinical data of the patient should be timely presented to the doctor to plan
effective intervention. However, in case of Jenny clinical information was not communicated
to doctor in the timely manner. All the information should be entered in the ADDS chart in
the timely manner and this chart should be followed carefully. There should be accurate
mentioning of the thresholds of the physiological parameters which indicate abnormality.
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Attention should be given to identify the physiological triggers which escalate care. There
should be development and implementation of mechanisms to intensify care provision and
emergency should be called for deteriorating patients. There should be audit on the regular
basis to identify the failure to escalate care (Butler and Hupp, 2016). Maximum efforts should
be made to seek emergency assistance and for implementation of escalation process
appropriately. In case of Jenny, it was difficult to seek emergency assistance due to lack of
adequate nursing staff because most of the staff members were busy with the management of
gastroenteritis outbreak. Hence, recommendations should be made for the recruitment of the
specialised staff for the emergency department. These specialised members should
specifically be trained and skilled for emergency department. Adequacy of staff members and
other resources for the emergency services should be regularly audited for fulfilling the
deficiencies (Jin and Yi, 2019). Efficient system should be in place so that minimum one
doctor should be on-site or in close proximity to the deteriorating patient. However, in case of
Jenny, doctor was not physically available; however, available through phone. Physical
availability of doctor on-site would have prevented deterioration of Jenny and the same
would be applicable in future also. It is recommended that patient’s deteriorating condition
should be informed to the family members. It can be helpful in the recognition of the
deteriorating condition of the patient and decision making in seeking response for patient.
Advance care plans and treatment limiting orders should be in place and staff members
should be aware of these aspects. Implementation of these practices would be helpful in
future; even if, in the absence of doctor (Owens and Koch, 2015).
Conclusion:
Recognising deteriorating condition of the patient with complex condition and responding in
effective manner is the useful strategy for improving safe care to the patient. Jenny was
admitted to the hospital with symptoms like fever, leathery and aches. Hence, vital signs were
determined and IV normal saline was being administered to her. It was evident that her blood
pressure keeps on reducing very rapidly. However, her deteriorating condition was not
recognised appropriately and her care was not escalated adequately. Appropriate care was
not provided to her because existing healthcare staff were not adequately skilled to provide
intervention; moreover, inadequate number of healthcare staff was also responsible for her
inadequate care. Since, appropriate care was not provided to her; possible recommendations
were made for providing appropriate care to her. It was recommended that improvement in
communication and leadership would be helpful in escalating appropriate care to him.
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