English title dissertation JUST WORRY; exploring triggers used by nurses to identify surgical patients at risk for clinical deterioration
Name PhD (surname first) Gooske Douw
Doctor is (has been) nurse
Date of promotion 04/10/2018
University Radboud Universiteit Nijmegen
Promotores Promotoren: Prof. dr. J.G. van der Hoeven Prof. dr. L. Schoonhoven, Universiteit Utrecht Copromotoren: Dr. G. Huisman - de Waal Dr. A.R.H van Zanten, Ziekenhuis Gelderse Vallei
Abstract (English)

The aim of this thesis is to explore nurses’ worry and its role in the process of early recognition of deteriorating surgical ward patients, in order to empower nurses to call for assistance at an early stage.
Rapid Response Systems are implemented to improve patient outcomes through early recognition and treatment of deteriorating general ward patients. Nurses play a crucial role in this process. Next to deviating vital signs, more subtle signs trigger nurses to worry about a patient’s condition. Based on a systematic review (chapter 2) we summarized these signs in nine indicators: the Dutch-Early-Nurse-Worry-Indicator-Score (DENWIS) and studied the role of nurses’ worry and DENWIS as indicators of deterioration. Nurses of three surgical wards in a University affiliated teaching hospital, participated in the study. For one year, they prospectively scored (each surgical patient in every shift) if they were worried about a patient’s condition and which DENWIS indicators were present. Vital signs were measured following the local early warning score protocol. Other data were collected in retrospect from patient files. Our studies show that:
a) nurses foresee deterioration and act adequately upon their worry even when vital signs are normal or slightly deviating from normal values (chapter 3)
b) worry and DENWIS indicators improve the local early warning score and are both individually and combined, good predictors of unplanned intensive care unit admissions or unexpected mortality (chapter 4)
c) even in an early stage when vital signs are normal or deviate only slightly from normal values (chapter 5)
d) several months after implementation of DENWIS, patients were admitted to the intensive care unit less ill and there was a significant reduction in ICU-length of stay (chapter 6).
We objectified nurses’ worry providing a tool to support nurses in daily practice optimizing detection and communication (during nurses’ shift handover, doctors’ rounds, or when calling for assistance) of deterioration even at an early stage. The clear description of subtle signs of deterioration makes communication transparent and transferrable and will promote agreement in judgement of a patient’s condition. DENWIS gives input for tools, such as Situation Background Assessment Recommendation (SBAR), that structure communication. Our results suggest that escalation protocols would benefit from including worry and DENWIS. The promising results should be validated in other hospital settings and further research should establish the most effective use of worry and DENWIS.

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