Current practices and identified needs of clinicians, family members and patients during acute deterioration in the Emergency Department.

Abstract

Introduction: The publication of the National Safety and Quality Health Service Standards has nationally recognised of the importance of family involvement throughout the entire patient journey, including during episodes of deterioration. Evidence suggests that clinicians perceive family presence during episodes of acute deterioration to be a common day-to-day practice. However, there is no research describing the characteristics and interactions of those involved when family are included during a patient’s episode of acute deterioration. Further, there is currently no published research that explores the family members’ and patients’ perceptions of family presence during acute deterioration.

Aims: To explore the characteristics and interactions of clinicians, patients and family members during management of the deteriorating adult patient in the Emergency Department. An understanding of actual current practices and identification of clinician, family member and patient needs during acute patient deterioration was sought.

Methods: Non-participatory observation of five clinical deterioration episodes occurred in a single study site in Melbourne, Australia. Following this 22 semi-structured, individual interviews were conducted with 11 clinicians, 6 family members and 5 patients involved in the observed episodes of clinical deterioration.

Results: Presence, roles and engagement describe current practices of managing family during patient deterioration. ‘Presence’ pertained to where family members were physically situated during the episode of patient deterioration and was classified as no presence, physical presence and/or therapeutic presence. ‘Roles’ pertained to the ‘activity’ adopted by the doctor, nurse or family member during the patient’s deterioration. Participants transitioned between primary, secondary and tertiary roles. ‘Engagement’ describes the depth of interaction and connection experienced between participants and was observed to be either superficial or deep engagement. Clinicians practiced family presence at four different levels – novice, transitioning, pursuer and expert. These practice levels were characterised by the clinician’s emotional response to having family present, acceptance of family inclusion, relationships with the family and ability to manage both clinical deterioration and family engagement.

Needs identified by clinicians, family members and patients were patient safety, information and understanding, and emotional safety and reassurance. ‘Patient safety’ was the need for patient stabilisation to be the priority for both clinicians and family members. ‘Information and understanding’ pertained to all participants needing some form of understanding of the deterioration event. Lastly, ‘emotional safety and reassurance’ referred to how each person emotionally responded to the deterioration event.

Conclusion: Current practices of managing families during episodes of acute deterioration are complex and multifaceted. There is a fluid interplay between presence, roles and engagement during a patient’s episode of deterioration. Further, clinicians, families and patients have multiple needs while experiencing family presence during episodes of acute deterioration.