Development and Evaluation of a Patient Safety Model

NCT ID: NCT03457272

Last Updated: 2019-10-14

Study Results

Results pending

The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.

Basic Information

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Recruitment Status

COMPLETED

Clinical Phase

NA

Total Enrollment

34556 participants

Study Classification

INTERVENTIONAL

Study Start Date

2017-10-30

Study Completion Date

2018-05-31

Brief Summary

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Despite systems for early detection of critical illness, 12% of patients in the emergency department develop clinical deterioration with an increased risk of death as a result.

There is a need for a intervention to support the identification and clinical management of patients at risk of clinical deterioration earlier hospitalization. The Cincinnati Children's Hospital has introduced a model that systematically complements systems for early detection of critical illness with the assessment of patient and relatives concern, clinical intuition and concern of the staff. In addition, the model includes formalized organizational processes aimed at systematic review of risk patients and early treatment efforts. Studies from United States indicate that the model can lead to reduction of serious incidental events and increase the staff awareness of the situation. The Cincinnati model is designed for children and has not yet been studied in a controlled study.

Purpose To develop and investigate the impact of a Danish patient safety model. Method A literature review is conducted to identify risk factors that should be included in a model aimed at detecting and managing clinical deterioration. A patient safety model is developed on the basis of the literature review and the Cincinnati model and is tested in a pilot study. In a controlled intervention study, the effect is investigated against severe clinical deterioration. The intervention is carried out at the emergency departments at Horsens Regional Hospital and Viborg Regional Hospital with the regional hospitals in Randers and Herning as control departments.

Detailed Description

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Preventing deterioration in acute patients is of great interest internationally. Studies demonstrate that clinical deterioration can be measured up to 24 hours before a heart arrest or intensive care admission in the vital signs. Therefore, the health services have implemented early warning systems to detect deterioration and critical illness.

Despite the systems, 12% of patients in an emergency department still develop severe clinical deterioration with increased risk of death as a result. Research indicates that the reasons for this may be diverse and further action to support the early identification and treatment of patients at risk of deterioration is needed.

Cincinnati Children's Hospital has introduced a patient safety model to ensure identification and mitigation of patient risk through escalated observation, care and treatment depending on the individual's risk for clinical deterioration. The model includes early warning systems, but as something new, it is supplemented with systematic evaluation of more subjective factors such as staff's clinical gaze and concerns, patient/relatives' concerns, communication problems and high risk therapy.

In an observational study, the Cincinnati Situation Awareness model was found to be associated with a near 50% reduction in unsafe intensive care unit transfers and decrease in severe safety events. However, the model has so far not been evaluated in a controlled study or an adult population.

The study will consist of three substudies; the overall study design is based on a framework for implementation of complex interventions following a four-step-process entailing development, pilot test, evaluation and reporting.

Study I. The study will consist of a systematic review and aims to identify risk factors associated with severe clinical deterioration and severe safety events that should ultimately be considered for inclusion in the patient safety model.

The aim of study II is to develop a patient safety model based on the components in the Cincinnati Situation Awareness model and explore its feasibility. The Danish patient safety model is expected to consist of systematic patient risk screening, bed huddles and audits of intensive care unit transfers.

Relevant aspects that should be included in the systematic patient risk screening are identified based on the literature study. A multidisciplinary panel is established to ensure that the choice of risk parameters is made on the basis of risk factors with the highest impact and the applicability to standard care.

A pilot test of the model will be conducted to evaluate the feasibility of methods and procedures based on the principles of the Medical Research Council guidance.

The final model will be investigated in a prospective controlled intervention study design to examine the effect in relation to severe clinical deterioration, safety awareness and serious adverse events (Study III).

The study will follow a Quasi-experimental design. The intervention will be implemented at the Emergency Departments and Intensive Care Units at Horsens and Viborg Regional Hospitals with the Emergency Departments at Herning and Randers Regional Hospitals as controls.

A positive outcome is expected to increase patient safety by reducing patients with severe deterioration, serious adverse events and increase staff safety awareness.

Conditions

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Emergency Medicine

Study Design

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Allocation Method

NON_RANDOMIZED

Intervention Model

PARALLEL

The study consists of two intervention and two control departments. The intervention consists of a risk assesment to ensure systematic and standardized identification of patients in risk of clinical deterioration and a decision support algorithm. Actions are undertaken on the basis of the standardized decision support and when a patient is determined to be at risk escalation plans are activated. As part of the intervention, huddles are conducted and patients at risk are interdisciplinarily discussed.
Primary Study Purpose

PREVENTION

Blinding Strategy

NONE

Study Groups

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New risk assessment

New risk assesment

Group Type EXPERIMENTAL

New risk assessment

Intervention Type OTHER

Consists of a simple physiological scoring system and an assessment of patients who should assist healthcare professionals in identifying patients at risk of clinical deterioration earlier and support timely response and escalation of observation, care and treatment and thereby prevent the development of severe clinical deterioration.

The patients included in the study will be monitored using the new risk assessment tool with different intervals according to the patients' conditions. Underlying the tool are algorithms of action for intervention in the critically ill patient, inter professional guidelines and guidance for standardized monitoring, escalation plans and huddles.

Standard

Standard risk assessment

Group Type NO_INTERVENTION

No interventions assigned to this group

Interventions

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New risk assessment

Consists of a simple physiological scoring system and an assessment of patients who should assist healthcare professionals in identifying patients at risk of clinical deterioration earlier and support timely response and escalation of observation, care and treatment and thereby prevent the development of severe clinical deterioration.

The patients included in the study will be monitored using the new risk assessment tool with different intervals according to the patients' conditions. Underlying the tool are algorithms of action for intervention in the critically ill patient, inter professional guidelines and guidance for standardized monitoring, escalation plans and huddles.

Intervention Type OTHER

Eligibility Criteria

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Inclusion Criteria

* Adult somatic patients (≥18 years) admitted to the participating Emergency Departments

Exclusion Criteria

* Patients with injuries caused by trauma
* Patients received with cardiac arrest, as a surgical or medical call (can participate if admitted to the Emergency Department and not directly transferred to the Intensive Care Unit)
* Patients hospitalized with a psychiatric diagnosis as the primary cause of admission
Minimum Eligible Age

18 Years

Eligible Sex

ALL

Accepts Healthy Volunteers

No

Sponsors

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Horsens Hospital

OTHER

Sponsor Role collaborator

Central Jutland Regional Hospital

OTHER

Sponsor Role collaborator

Randers Regional Hospital

OTHER

Sponsor Role collaborator

Herning Hospital

OTHER

Sponsor Role collaborator

Aarhus University Hospital

OTHER

Sponsor Role collaborator

University of Aarhus

OTHER

Sponsor Role lead

Responsible Party

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Responsibility Role SPONSOR

Principal Investigators

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Gitte B Tygesen, PhD student

Role: PRINCIPAL_INVESTIGATOR

Regionshospitalet Horsens

Locations

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Herning Regional Hospital

Herning, , Denmark

Site Status

Horsens Regional Hospital

Horsens, , Denmark

Site Status

Randers Regional Hospital

Randers, , Denmark

Site Status

Viborg Regional Hospital

Viborg, , Denmark

Site Status

Countries

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Denmark

Other Identifiers

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18296453

Identifier Type: -

Identifier Source: org_study_id

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