title: Multi-Tiered Observation and Response Charts: Prevalence and Incidence of Triggers, Modifications and Calls, to Acutely Deteriorating Adult Patients.
abstract: BACKGROUND
  Observation charts are the primary tool for recording patient vital signs. They have a critical role in documenting triggers for a multi-tiered escalation response to the deteriorating patient. The objectives of this study were to ascertain the prevalence and incidence of triggers, trigger modifications and escalation response (Call) amongst general medical and surgical inpatients following the introduction of an observation and response chart (ORC).
  
  
  METHODS
  Prospective (prevalence), over two 24-hour periods, and retrospective (incidence), over entire hospital stay, observational study of documented patient observations intended to trigger one of three escalation responses, being a MER-Medical Emergency Response [highest tier], MDT-Multidisciplinary Team [admitting team], or Nurse-senior ward nurse [lowest tier] response amongst adult general medical and surgical patients.
  
  
  RESULTS
  
  
  
  BACKGROUND
  416 patients, 321 (77.2%) being medical admissions, median age 76 years (IQR 62, 85) and 95 (22.8%) Not for Resuscitation (NFR). Overall, 193 (46.4%) patients had a Trigger, being 17 (4.1%) MER, 45 (10.8%) MDT and 178 (42.8%) Nurse triggers. 60 (14.4%) patients had a Call, and 72 (17.3%) a modified Trigger.
  
  
  BACKGROUND
  206 patients, of similar age, of whom 166 (80.5%) had a Trigger, 122 (59.2%) a Call, and 91 (44.2%) a modified Trigger. PREVALENCE and incidence of failure to Call was 33.2% and 68% of patients, respectively, particular for Nurse Triggers (26.7% and 62.1%, respectively). The number of Modifications, Calls, and failure to Call, correlated with the number of Triggers (0.912 [p<0.01], 0.631 [p<0.01], 0.988 [p<0.01]).
  
  
  CONCLUSIONS
  Within a multi-tiered response system for the detection and response to the deteriorating patient Triggers, their Modifications and failure to Call are common, particularly within the lower tiers of escalation. The number of Triggers and their Modifications may erode the structure, compliance, and potential efficacy of structured observation and response charts within a multi-tiered response system.
authors.affiliation: Intensive Care Unit, Royal Adelaide Hospital and Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia.
authors.forename: Arthas
authors.initials: A
authors.lastname: Flabouris
authors.affiliation: Department of Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia.
authors.forename: Savvy
authors.initials: S
authors.lastname: Nandal
authors.affiliation: School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, SA, Australia.
authors.forename: Luke
authors.initials: L
authors.lastname: Vater
authors.affiliation: School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, SA, Australia.
authors.forename: Katerina
authors.initials: K
authors.lastname: Flabouris
authors.affiliation: Intensive Care Unit, Royal Adelaide Hospital, and School of Medicine, University of Adelaide, Adelaide, SA, Australia.
authors.forename: Alice
authors.initials: A
authors.lastname: O'Connell
authors.affiliation: Department of Medicine, Royal Adelaide Hospital and School of Medicine, University of Adelaide, Adelaide, SA, Australia.
authors.forename: Campbell
authors.initials: C
authors.lastname: Thompson
mesh_terms: D000328:Adult; D000368:Aged; D003710:Demography; D004630:Emergencies; D005260:Female; D006801:Humans; D015994:Incidence; D033183:Interdisciplinary Communication; D008297:Male; D008499:Medical Records; D010343:Patient Admission; D015995:Prevalence; D013223:Statistics as Topic; D013997:Time Factors