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This study explores the use of early warning scores (EWS) in deteriorating patients. These are widely used tools to measure vital signs and highlight abnormal physiology in acutely unwell patients. Measurements of the process in the management of the deteriorating patient includes time to first assessment of such patients. The level of clinician involved in the subsequent management is also investigated to determine whether escalation of care was appropriate. This work is a retrospective case note analysis of the recognition and management of deteriorating patients prior to critical care admission. Research Questions 1. What violations in the optimum process are associated with sub-optimal recognition and management of deteriorating patients and delayed critical care admission in patients triggering early warning scores in acute care wards? 2. Are there independent variables which can predict the delay in the recognition and management of deteriorating patients and subsequent critical care admission? Methods The literature was reviewed to determine the optimum process of recognition and management of deteriorating patients in acute care wards. A data collection tool was then specifically designed and locally validated to extract objective data from the case records. A sample of 157 patients admitted to critical care from acute wards over a 6 month period were included in the study. The case records were then retrospectively reviewed and information was extracted using the data collection tool. Results The accuracy and frequency of early warning scores were measured and findings demonstrated that 59% of Early Warning Scores (EWS) were miscalculated. The most frequent of those miscalculated were the intermediate scores (4 or 5) (error rate - 52%) followed by the higher scores (6 or more) (error rate - 32%). The least frequently miscalculated were the lower scores (0 -3) (error rate 15%). Descriptive data from the sample such as age, ward, diagnosis, time of hospital admission, time and day of transfer / EWS triggering were included. From the total case records reviewed, 110 patients had abnormal Early Warning Scores (4 or more) and were included in the inferential data analysis. The independent variables related to the processes objectively measurable in the recognition and management of deteriorating patients were included. After descriptive analysis the independent variables were cross-tabulated with the dependent variable using Pearson chi-square. The dependent variable was identified from the literature. This was whether time from triggering an abnormal EWS to critical care admission was delayed more than 6 hours. The subsequent predictor variables were then entered in to a binary logistic regression model for statistical analysis using SPSS version 21 software. Binominal Logistic Regression Analysis identified three significant variables predicting delay of the recognition and management of deteriorating patients. • Frequency of EWS measurement not increased appropriately • Length of stay prior to critical care admission 12-36 hours • If no consultant review during 6 hours of abnormal EWS Implications for Future Practice This study highlights areas of risk in the detection of patients’ clinical deterioration in acute wards. These findings should guide quality improvement to prevent unnecessary morbidity and mortality. As a key area of patient risk included the lack of frequency and accuracy of EWS measurements, staff education is required to ensure staff are given the appropriate knowledge to understand the use of the tool. Regular review of the frequency of measurement is also required as this was statistically significant in the delay to critical care admission. The high risk time from admission of 12-36 hours needs further investigation. This study also highlights the need for senior decision makers to be involved in the care of deteriorating patients to improve outcomes.

The research is situated in a busy intensive care unit in a tertiary referral centre university hospital in Scotland. To date no research appears to have been done with a focus on handover in intensive care, across the professions involved, examining how handover is enacted. This study makes an original contribution to the practical and pedagogical aspects of handover in intensive care both in terms of the methodology used and also in terms of its findings. In order to study handover a mixed methods approach has been adopted and fieldwork has been done in the ethnographic mode. Data has been audio recorded and transcribed and analysed to explore the clinical handovers of patients by doctors and nurses in this intensive care unit. Texts of both handover, and the artefacts involved, are reviewed. Material from journals, books, lectures and websites, including those for health care professionals, patients and relatives, and those in industry are explicated. This study explores the role of material artefacts and texts, such as the intensive care-based electronic patient record, the whiteboards in the doctors’ office, and in the ward, in the enactment of handover. Through analysis of the data I explore some of the entanglements and ontologies of handover and the multiple things of healthcare: patients, information, equipment, activities, texts, ideas, diseases, staff, diagnoses, illnesses, floating texts, responsibility, a plan, a family. The doing of handover is framed theoretically through the empirical philosophy of Mol’s identification of multiple ontologies in clinical practice (Mol, 2002). Each chapter is prefaced by a poem, each of which has relevant socio-material elements embedded in it. The significance of the findings of the research for both patient care and clinical education and learning is surfaced.

The purpose of this quantitative descriptive study was to examine consumer knowledge,attitudes, intention, and beliefs about nurse practitioners(NPs ),to determine whether a relationship existed between knowledge,attitudes, intentions, and beliefs, and demographic variables of age, gender, ethnicity,education,degree, profession, type of insurance, :frequency of visits to a primary care provider in the past 12 months, and consumer exposure to nurse practitioners.A conceptual :framework combining Orem's self care deficit theory and Ajzen and Fishbein's theory of reasoned action.This framework was used to explain the relationship between knowledge,attitudes,intention, beliefs, and behavior and the nurse practitioner's role in intervening to affect change in that relationship.Subjects(n=202)from rural and urban areas responded to a demographic questionnaire,knowledge scale,and a researcher generated tool with Likert type statements rating their attitudes, intentions,and beliefs about nurse practitioners.Descriptive statistics showed that, while most subjects knew that NPs perform traditional nursing roles, only 26 said NPs could perform all functions listed.The majority of respondents did not know that NPs prescribe medications,order and interpret laboratory tests and x-rays, and perform Pap smears and prostate examinations.Most subjects held positive attitudes, intention,and behavioral beliefs regarding NPs.Pearson correlation coefficient was utilized to determine that a significant correlation exists between age and knowledge of the NP role. Relationships between age and intention and age and normative beliefs approached significance.Spearman rank order was utilized to determine that gender was significantly correlated with behavioral beliefs and motivation to comply.The relationship between gender and knowledge approached significance.Using Chi square,a significant correlation was found between a subject's having been treated by a NPand that subject's intention and attitudes regarding NPs.A correlation between having been treated by a NP and knowledge of the NP role approached significance.Using Chi-square, a significant relationship was found between media exposure to NPs and knowledge, intention, attitudes, and behavioral beliefs. No other significant correlations were found.Using ANOV A, the researcher found that a significant difference exists in behavioral beliefs based on rural and urban setting. Mean summed negative behavioral beliefs regarding the role of the NP were significantly higher in urban subjects than in rural subjects. No other significant differences were found in attitudes, intention, or normative beliefs based on urban or rural setting.The conclusions reveal a community wide knowledge deficit regarding the role of the NP. This study has implications for NP education, practice and research.