Causes of Nurses' Second Victim Distress: An Objective Analysis.

BACKGROUND: Unanticipated adverse events could harm not only patients and families but also health care professionals. These people are defined as second victims. Second victim distress (SVD) refers to physical, emotional, and professional problems of health care professionals. While positive patient safety cultures (PSCs) are associated with reducing severity of SVD, there is a dearth of research on the association between PSCs and SVD and the mediation effects in those associations. OBJECTIVES: The purpose of this study was to explore the associations between PSCs and SVD and verify the multiple mediation effects of colleague, supervisor, and institutional supports. METHODS: A cross-sectional study using a self-report questionnaire was conducted among 296 nurses in South Korea. The participants were selected by quota sampling in 41 departments including general wards, intensive care units, etc. Descriptive statistics, Pearson's correlation, multiple linear regression, and multiple mediation analysis were conducted using SPSS 25.0 and the PROCESS macros. RESULTS: Nonpunitive response to errors, communication openness, and colleague, supervisor, and institutional supports had negative correlations with SVD (Ps < .05). In the multiple mediation model, a nonpunitive response to error showed a significant direct effect on SVD (direct effect ß = -.26, P < .001). Colleague, supervisor, and institutional supports showed a significant indirect effect between nonpunitive response to error and SVD; colleague (indirect effect ß [Boot LLCI-Boot ULCI] = -.03 [-0.06 to -0.00]), supervisor (.03[0.00 to 0.07]), and institutional support (-.04 [-0.07 to -0.01]). CONCLUSION: The study suggests that establishing nonpunitive organizational cultures is an effective strategy to reduce SVD. The findings highlight the importance of promoting programs that strengthen PSCs in hospitals and prioritizing support resources to reduce SVD among nurses.

Predictors of Repeat Medical Emergency Team Activation in Deteriorating Ward Patients: A Retrospective Cohort Study.

Recurrent clinical deterioration and repeat medical emergency team (MET) activation are common and associated with high in-hospital mortality. This study assessed the predictors for repeat MET activation in deteriorating patients admitted to a general ward. We retrospectively analyzed the data of 5512 consecutive deteriorating hospitalized adult patients who required MET activation in the general ward. The patients were divided into two groups according to repeat MET activation. Multivariate logistic regression analyses were used to identify the predictors for repeat MET activation. Hematological malignancies (odds ratio, 2.07; 95% confidence interval, 1.54-2.79) and chronic lung disease (1.49; 1.07-2.06) were associated with a high risk of repeat MET activation. Among the causes for MET activation, respiratory distress (1.76; 1.19-2.60) increased the risk of repeat MET activation. A low oxygen saturation-to-fraction of inspired oxygen ratio (0.97; 0.95-0.98), high-flow nasal cannula oxygenation (4.52; 3.56-5.74), airway suctioning (4.63; 3.59-5.98), noninvasive mechanical ventilation (1.52; 1.07-2.68), and vasopressor support (1.76; 1.22-2.54) at first MET activation increased the risk of repeat MET activation. The risk factors identified in this study may be useful to identify patients at risk of repeat MET activation at the first MET activation. This would allow the classification of high-risk patients and the application of aggressive interventions to improve outcomes.

Predictive powers of the Modified Early Warning Score and the National Early Warning Score in general ward patients who activated the medical emergency team.

BACKGROUND: The current early warning scores may be insufficient for medical emergency teams (METs) to use in assessing the severity and the prognosis of activated patients. We evaluated the predictive powers of the Modified Early Warning Score (MEWS) and the National Early Warning Score (NEWS) for 28-day mortality and to analyze predictors of 28-day mortality in general ward patients who activate the MET. METHODS: Adult general ward inpatients who activated the MET in a tertiary referral teaching hospital between March 2009 and December 2016 were included. The demographic and clinical characteristics and physiologic parameters at the time of MET activation were collected, and MEWS and NEWS were calculated. RESULTS: A total of 6,729 MET activation events were analyzed. Patients who died within 28 days were younger (mean age 60 vs 62 years), were more likely to have malignancy (72% vs 53%), were more likely to be admitted to the medical department rather than the surgical department (93% vs 80%), had longer intervals from admission to MET activation (median, 7 vs 5 days), and were less likely to activate the MET during nighttime hours (5 PM to 8 AM) (61% vs 66%) compared with those who did not die within 28 days (P < 0.001 for all comparisons). The areas under the receiver operating characteristic curves of MEWS and NEWS for 28-day mortality were 0.58 (95% CI, 0.56-0.59) and 0.60 (95% CI, 0.59-0.62), which were inferior to that of the logistics regression model (0.73; 95% CI, 0.72-0.74; P < 0.001 for both comparisons). CONCLUSIONS: Both the MEWS and NEWS had poor predictive powers for 28-day mortality in patients who activated the MET. A new scoring system is needed to stratify the severity and prognosis of patients who activated the MET.

Derivation and validation of modified early warning score plus SpO2/FiO2 score for predicting acute deterioration of patients with hematological malignancies.

BACKGROUND/AIMS: Scoring systems play an important role in predicting intensive care unit (ICU) admission or estimating the risk of death in critically ill patients with hematological malignancies. We evaluated the modified early warning score (MEWS) for predicting ICU admissions and in-hospital mortality among at-risk patients with hematological malignancies and developed an optimized MEWS. METHODS: We retrospectively analyzed derivation cohort patients with hematological malignancies who were managed by a medical emergency team (MET) in the general ward and prospectively validated the data. We compared the traditional MEWS with the MEWS plus SpO2/FiO2 (MEWS_SF) score, which were calculated at the time of MET contact. RESULTS: In the derivation cohort, the areas under the receiver-operating characteristic (AUROC) curves were 0.81 for the MEWS (95% confidence interval [CI], 0.76 to 0.87) and 0.87 for the MEWS_SF score (95% CI, 0.87 to 0.92) for predicting ICU admission. The AUROC curves were 0.70 for the MEWS (95% CI, 0.63 to 0.77) and 0.76 for the MEWS_SF score (95% CI, 0.70 to 0.83) for predicting in-hospital mortality. In the validation cohort, the AUROC curves were 0.71 for the MEWS (95% CI, 0.66 to 0.77) and 0.83 for the MEWS_SF score (95% CI, 0.78 to 0.87) for predicting ICU admission. The AUROC curves were 0.64 for the MEWS (95% CI, 0.57 to 0.70) and 0.74 for the MEWS_SF score (95% CI, 0.69 to 0.80) for predicting in-hospital mortality. CONCLUSION: Compared to the traditional MEWS, the MEWS_SF score may be a useful tool that can be used in the general ward to identify deteriorating patients with hematological malignancies.

Psychometric Properties of Korean Version of the Second Victim Experience and Support Tool (K-SVEST).

OBJECTIVES: "Second victims" are defined as healthcare professionals whose wellness is influenced by adverse clinical events. The Second Victim Experience and Support Tool (SVEST) was used to measure the second-victim experience and quality of support resources. Although the reliability and validity of the original SVEST have been validated, those for the Korean tool have not been validated. The aim of the study was to evaluate the psychometric properties of the Korean version of the SVEST. METHODS: The study included 305 clinical nurses as participants. The SVEST was translated into Korean via back translation. Content validity was assessed by seven experts, and test-retest reliability was evaluated by 30 clinicians. Internal consistency and construct validity were assessed via confirmatory factor analysis. The analyses were performed using SPSS 23.0 and STATA 13.0 software. RESULTS: The content validity index value demonstrated validity; item- and scale-level content validity index values were both 0.95. Test-retest reliability and internal consistency reliability were satisfactory: the intraclass consistent coefficient was 0.71, and Cronbach α values ranged from 0.59 to 0.87. The CFA showed a significantly good fit for an eight-factor structure (χ = 578.21, df = 303, comparative fit index = 0.92, Tucker-Lewis index = 0.90, root mean square error of approximation = 0.05). CONCLUSIONS: The K-SVEST demonstrated good psychometric properties and adequate validity and reliability. The results showed that the Korean version of SVEST demonstrated the extent of second victimhood and support resources in Korean healthcare workers and could aid in the development of support programs and evaluation of their effectiveness.

A Systematic Review of Early Warning Systems' Effects on Nurses' Clinical Performance and Adverse Events Among Deteriorating Ward Patients.

OBJECTIVE: Early warning systems (EWSs) are an integral part of processes that aim to improve the early identification and management of deteriorating patients in general wards. However, the widespread implementation of these systems has not generated robust data regarding nurses' clinical performance and patients' adverse events. This review aimed to determine the ability of EWSs to improve nurses' clinical performance and prevent adverse events among deteriorating ward patients. METHOD: The PubMed, CINAHL, EMBASE, and Cochrane Library databases were searched for relevant publications (January 1, 1997, to April 12, 2017). In addition, a grey literature search evaluated several guideline Web sites. The main outcome measures were nurses' clinical performance (vital sign monitoring and rapid response team notification) and patients' adverse events (in-hospital mortality, cardiac arrest, and unplanned intensive care unit [ICU] admission). RESULTS: The search identified 888 reports, although only five studies fulfilled the inclusion criteria. The findings of these studies revealed that EWSs implementation had a positive effect on nurses' clinical performance, based on their frequency of documenting vital signs that were related to the patient's clinical deterioration. In addition, postimplementation reductions were identified for cardiac arrest, unplanned ICU admission, and unexpected death. CONCLUSIONS: It seems that EWSs can improve nurses' clinical performance and prevent adverse events (e.g., in-hospital mortality, unplanned ICU admission, and cardiac arrest) among deteriorating ward patients. However, additional high-quality evidence is needed to more comprehensively evaluate the effects of EWSs on these outcomes.

Effects of a simulated emergency airway management education program on the self-efficacy and clinical performance of intensive care unit nurses.

AIM: To examine the effects of a simulated emergency airway management education program on the self-efficacy and clinical performance among nurses in intensive care units. METHODS: A one-group, pre- and post-test design was used. Thirty-five nurses who were working in adult intensive care units participated in this study. The simulation education program included lectures, skill demonstration, skill training, team-based practice, and debriefing. Self-efficacy and clinical performance questionnaires were completed before the program and 1 week after its completion. The data were analyzed by using descriptive statistics and the paired t-test to compare the mean differences between the pre-test and post-test. The scores before and after education were compared. RESULTS: After education, there was a significant improvement in the nurses' self-efficacy and clinical performance in emergency airway management situations. CONCLUSION: Simulation education effectively improved the self-efficacy and clinical performance of the nurses who were working in intensive care units. Based on the program for clinical nurses within a hospital, it will provide information that might advance clinical nursing education.

A risk scoring model based on vital signs and laboratory data predicting transfer to the intensive care unit of patients admitted to gastroenterology wards.

PURPOSE: To compare the ability of a score based on vital signs and laboratory data with that of the modified early warning score (MEWS) to predict ICU transfer of patients with gastrointestinal disorders. MATERIALS AND METHODS: Consecutive events triggering medical emergency team activation in adult patients admitted to the gastroenterology wards of the Asan Medical Center were reviewed. Binary logistic regression was used to identify factors predicting transfer to the ICU. Gastrointestinal early warning score (EWS-GI) was calculated as the sum of simplified regression weights (SRW). RESULTS: Of the 1219 included patients, 468 (38%) were transferred to the ICU. Multivariate analysis identified heart rate≥105bpm (SRW 1), respiratory rate≥26bpm (SRW 2), ACDU (Alert, Confused, Drowsy, Unresponsive) score≥1 (SRW 2), SpO2/FiO2 ratio<240 (SRW 2), creatinine ≥2.0mg/dL (SRW 2), total bilirubin ≥9.0mg/dL (SRW 2), prothrombin time/international normalized ratio (INR) ≥1.5 (SRW 2), and lactate ≥3.0mmol/L (SRW 2) for inclusion in EWS-GI. The area under the receiver operating characteristic curve of the EWS-GI was larger than that of MEWS (0.76 vs. 0.64; P<0.001). CONCLUSIONS: EWS-GI may predict ICU transfer among patients admitted to gastroenterology wards. The EWS-GI should be prospectively validated.

A combination of early warning score and lactate to predict intensive care unit transfer of inpatients with severe sepsis/septic shock.

BACKGROUND/AIMS: The modified early warning score (MEWS) is used to predict patient intensive care unit (ICU) admission and mortality. Lactate (LA) in the blood lactate (BLA) is measured to evaluate disease severity and treatment efficacy in patients with severe sepsis/septic shock. The usefulness of a combination of MEWS and BLA to predict ICU transfer in severe sepsis/septic shock patients is unclear. We evaluated whether use of a combination of MEWS and BLA enhances prediction of ICU transfer and mortality in hospitalized patients with severe sepsis/septic shock. METHODS: Patients with severe sepsis/septic shock who were screened or contacted by a medical emergency team between January 2012 and August 2012 were enrolled at a university-affiliated hospital with ~2,700 beds, including 28 medical ICU beds. RESULTS: One hundred patients were enrolled and the rate of ICU admittance was 38%. MEWS (7.37 vs. 4.85) and BLA concentration (5 mmol/L vs. 2.19 mmol/L) were significantly higher in patients transferred to ICU than those in patients treated in general wards. The combination of MEWS and BLA was more accurate than MEWS alone in terms of ICU transfer (C-statistics: 0.898 vs. 0.816, p = 0.019). The 28-day mortality rate was 19%. MEWS was the only factor significantly associated with 28-day mortality rate (odds ratio, 1.462; 95% confidence interval, 1.122 to 1.905; p = 0.005). CONCLUSIONS: The combination of MEWS and BLA may enhance prediction of ICU transfer in patients with severe sepsis/septic shock.

[Validation of a modified early warning score to predict ICU transfer for patients with severe sepsis or septic shock on general wards].

PURPOSE: To assess whether the Modified Early Warning Score (MEWS) predicts the need for intensive care unit (ICU) transfer for patients with severe sepsis or septic shock admitted to general wards. METHODS: A retrospective chart review of 100 general ward patients with severe sepsis or septic shock was implemented. Clinical information and MEWS according to point of time between ICU group and general ward group were reviewed. Data were analyzed using multivariate logistic regression and the area under the receiver operating characteristic curves with SPSS/WIN 18.0 program. RESULTS: Thirty-eight ICU patients and sixty-two general ward patients were included. In multivariate logistic regression, MEWS (odds ratio [OR] 2.02, 95% confidence interval [CI] 1.43-2.85), lactic acid (OR 1.83, 95% CI 1.22-2.73) and diastolic blood pressure (OR 0.89, 95% CI 0.80-1.00) were predictive of ICU transfer. The sensitivity and the specificity of MEWS used with cut-off value of six were 89.5% and 67.7% for ICU transfer. CONCLUSION: MEWS is an effective predictor of ICU transfer. A clinical algorithm could be created to respond to high MEWS and intervene with appropriate changes in clinical management.