我们不谈沟通：为什么仅靠技术无法拯救病情恶化的患者 | BMJ Qual Saf.

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When a hospitalised patient begins to deteriorate clinically, prompt detection and early intervention by trained clinicians is critical for preventing in-hospital cardiac arrest. This is a common event that affects nearly 300 000 patients annually in the USA1 and is associated with a high risk of death and neurological disability among survivors. A broad range of strategies have been proposed for the early detection and management of the deteriorating patient. Early warning systems (EWS) are an example of one strategy. EWS use clinical prediction models to identify patients who are likely to be deteriorating, with triggers and protocols for detecting and escalating care for such patients.2 3

The use of EWS to monitor patients is now widespread, and two papers in this month’s issue of BMJ Quality & Safety address this topic in different ways. First, Blythe and colleagues conducted a scoping review of real-time automated clinical deterioration alerts, which are part of an EWS, and importantly also sought evidence of their impact on patient outcomes.4 In contrast, Crotty and colleagues reported on implementation of an EWS algorithm and associated virtual nurse monitoring team, and sought to understand nursing perspectives on it using qualitative methods.5

The research question for the scoping review asked whether prediction models providing real-time clinical deterioration alerts lead to improved patient outcomes, compared with standard care. The authors followed a rigorous process for selecting studies, extracting data and synthesising the findings of the 18 included studies. There was heterogeneity in who the alerts were directed to, with some studies sending alerts to nurses in charge, others to a rapid response team, a remote-monitoring nurse, physicians, a bedside nurse or a central nursing station. A range of outcomes were investigated including mortality, in-hospital cardiac or pulmonary arrest, intensive care unit admission and length of stay. Only 5 of the 18 studies used what were deemed robust study designs, and of these, only one reported a statistically significant improvement in patient outcomes. One of the conclusions of this review was that among studies reporting multiple improvements in patient outcomes, the type of EWS was not as important as who the alerts were directed to, and that alerts directed to a dedicated surveillance nurse or the patient’s physician were associated with better outcomes.

Crotty and colleagues’ single-site qualitative study investigated EWS from the perspective of bedside nurses. An EWS had been implemented 1 year previously, supplemented by a centralised team of nurses who virtually monitored alerts and informed nursing staff accordingly. The authors conducted 28 focus groups on six inpatient units, with a total of 227 nursing staff taking part. Units were stratified by alert frequency, ranging from less than 50 alerts per month to over 100 alerts per month. Data were analysed using a grounded theory approach. Six principal themes emerged: alert timeliness, lack of accuracy, workflow interruptions, actionability of alerts, underappreciation of core nursing skills and the opportunity cost of deploying the EWS programme.

The scoping review was unable to identify a consistent improvement in patient outcomes with an EWS, and the six principal themes noted above offer some possible reasons for why that might be. Another reason might be that we have not paid enough attention to communication among clinicians. Communication is defined as an interpersonal process where shared understanding develops between communicators to generate an effect or action.6 7 Nurses—the 24-hour surveillance system for hospitalised patients—are often the first to detect early signs of patient deterioration.8 9 As suggested by both Blythe and Crotty and their colleagues, the nurse may be aware of the patient’s clinical decline even before the EWS alert. However, the detection of clinical deterioration must be communicated to others, and this communication can be fraught and/or ineffective.

Many factors influence the communication needed to prompt appropriate action. For example, urgency has a major influence on communication but it manifests in different ways, all of which have implications for what gets communicated, to whom and how. First, nurses and physicians may have different perspectives on the same clinical situation that affect their perceptions of what is important or urgent.10 11 Nurses’ sense of urgency is often based on their subjective knowledge of the patient and the context of the situation, whereas for physicians, urgency is often based on objective clinical data.10 11 Second, the experience levels of both nurses and physicians can influence what they perceive to be urgent and worthy of raising the alarm. It is only through experience that clinicians (including both physicians and nurses) learn about the large variation in physiological parameters that constitute ‘normal’ for one patient and severe decline in another. Third, urgency can be dependent on the relationship between a nurse and a physician. A physician who has a good relationship with a nurse will be more likely to trust that nurse, believe them when they say the situation is urgent and appreciate their core nursing skills. Indeed, this is one of the key findings in the study by Crotty and colleagues. However, the same physician may choose not to respond to another nurse’s message either because their relationship is poor or because they do not know each other at all, with potential implications for patient safety.11 Finally, patient acuity and the number of patients being cared for by a nurse or a physician vary, which can also affect perceptions of urgency. A hospital nurse usually cares for far fewer patients than a physician. As a result, the sickest patient on the nurse’s panel may not be as sick as the sickest patient on the physician’s panel, so that what is ‘urgent’ becomes relative rather than absolute.

Other factors that influence communication include inexperience, and a perceived hierarchy that sometimes places physicians in a ‘superior’ standing relative to nurses. Because of inexperience or fear of speaking up, nurses may have difficulty communicating their concerns (as we have seen in our own work12) using indirect language characterised as ‘hint and hope’13 rather than direct communication.14 15 Nurses’ use of indirect language further suggests uncertainty about next steps, which would influence the actionability of EWS alerts. The use of indirect communication can be confusing to physicians who may also be looking for more objective data. Communication may be further hampered or rendered ineffective by factors such as limited time, lack of inclination to discuss with others or lack of certainty about the concern, which can lead to poor patient care decisions due to incomplete information.16

Finally, any discussion of communication needs to consider the medium used to convey a message. The use of pagers remains prevalent in North American hospitals and the use of other communication technologies continues to grow.17 18 However, there is little evidence that communication technologies facilitate effective communication between health professionals, in part because pagers and other communication technologies that allow information to flow in only one direction are still in use.19 Such technologies do not facilitate communication because they cause unnecessary interruptions, contribute to gaps in information exchange and create workarounds with the potential for adverse events.20

All of these issues related to communication have potential to increase conflict between physicians and nurses who prioritise or interpret information differently,11 or disagree on the need for action, such as calling a rapid response team to the bedside.21 22 It’s not just physicians and nurses though. If we want to improve patient outcomes, we must pay attention to dynamics behind professional teams (from all disciplines) working together and acknowledge team dynamics and communication as an integral part of the care delivery process. Unfortunately, effective interventions for improving communication in urgent clinical situations are not yet available, so research in this area is sorely needed. In summary, technologies such as EWS are useful when considered as adjuncts to the monitoring and surveillance that nurses provide. However, they can never replace nurses or overcome some fundamental interpersonal challenges, such as those affecting clinician communication. We need to talk about communication to bring attention to that critical element, which is responsible for marshalling resources to the bedside when a patient starts to deteriorate.

全文翻译（仅供参考）

当住院患者的临床症状开始恶化时，训练有素的临床医生的及时发现和早期干预对于预防院内心脏骤停至关重要。这是一个常见的事件，每年在美国影响近 300 000 名患者1，并且与幸存者的死亡和神经残疾的高风险有关。已经提出了广泛的策略来早期发现和管理恶化的患者。早期预警系统 (EWS) 是一种策略的示例。EWS 使用临床预测模型来识别可能恶化的患者，并使用触发器和协议来检测和升级对此类患者的护理。2 3

使用 EWS 来监测患者现在很普遍，本月出版的BMJ 质量与安全中的两篇论文以不同的方式讨论了这个主题。首先，Blythe 及其同事对实时自动临床恶化警报进行了范围审查，这是 EWS 的一部分，重要的是还寻求证据证明它们对患者结果的影响。4相比之下，Crotty 及其同事报告了 EWS 算法和相关虚拟护士监控团队的实施情况，并试图使用定性方法了解护理方面的观点。5

范围审查的研究问题询问与标准护理相比，提供实时临床恶化警报的预测模型是否会改善患者的预后。作者遵循严格的过程来选择研究、提取数据和综合 18 项纳入研究的结果。向谁发出警报存在异质性，一些研究向负责护士发送警报，其他研究向快速反应团队、远程监控护士、医生、床边护士或中央护理站发送警报。调查了一系列结果，包括死亡率、院内心脏或肺骤停、重症监护病房入院和住院时间。18 项研究中只有 5 项使用了被认为是稳健的研究设计，其中，只有一位报告了患者预后的统计学显着改善。这篇综述的一个结论是，在报告患者预后多项改善的研究中，EWS 的类型并不像警报针对谁重要，并且针对专门的监测护士或患者医生的警报与更好的结果。

Crotty 及其同事的单点定性研究从床边护士的角度调查了 EWS。EWS 已于 1 年前实施，由一个集中的护士团队补充，他们虚拟监控警报并相应地通知护理人员。作者在六个住院病房开展了 28 个焦点小组，共有 227 名护理人员参加。单位按警报频率分层，从每月不到 50 个警报到每月超过 100 个警报不等。使用扎根理论方法分析数据。出现了六个主要主题：警报及时性、缺乏准确性、工作流程中断、警报的可操作性、对核心护理技能的低估以及部署 EWS 计划的机会成本。

范围审查无法确定 EWS 患者预后的持续改善，上述六个主要主题提供了一些可能的原因。另一个原因可能是我们没有足够重视临床医生之间的沟通。沟通被定义为一个人际交往过程，在这个过程中，沟通者之间产生共同的理解以产生效果或行动。6 7护士——针对住院患者的 24 小时监控系统——通常最先发现患者病情恶化的早期迹象。8 9正如 Blythe 和 Crotty 及其同事所建议的那样，护士甚至可能在 EWS 警报之前就意识到患者的临床症状下降。然而，临床恶化的检测必须传达给其他人，而这种沟通可能令人担忧和/或无效。

许多因素会影响促使采取适当行动所需的沟通。例如，紧迫性对沟通有重大影响，但它以不同的方式表现出来，所有这些都对沟通的内容、对象和方式都有影响。首先，护士和医生可能对同一临床情况有不同的看法，这会影响他们对重要或紧急事项的看法。10 11护士的紧迫感通常基于他们对患者的主观了解和情境背景，而对于医生而言，紧迫感通常基于客观的临床数据。10 11其次，护士和医生的经验水平会影响他们认为紧急和值得发出警报的事情。只有通过经验，临床医生（包括医生和护士）才能了解生理参数的巨大变化，这些变化对一名患者构成“正常”而另一名患者严重下降。第三，紧迫性可能取决于护士和医生之间的关系。与护士关系良好的医生更有可能信任该护士，当他们说情况紧急时会相信他们，并欣赏他们的核心护理技能。事实上，这是 Crotty 及其同事在研究中的主要发现之一。然而，11最后，患者的敏锐度和护士或医生护理的患者数量各不相同，这也会影响对紧迫性的看法。医院护士照顾的病人通常比医生少得多。因此，护士小组中病情最严重的患者可能不像医生小组中病情最严重的患者那样严重，因此“紧急”变得相对而不是绝对。

影响沟通的其他因素包括缺乏经验，以及有时将医生置于相对于护士的“优越”地位的感知等级。由于缺乏经验或害怕说出来，护士可能难以使用以“提示和希望”为特征的间接语言13而不是直接沟通来表达他们的担忧（正如我们在自己的工作中看到的12 ）。14 15护士对间接语言的使用进一步表明了下一步的不确定性，这将影响 EWS 警报的可操作性。间接沟通的使用可能会使可能也在寻找更客观数据的医生感到困惑。由于时间有限、缺乏与他人讨论的意愿或对所关注的问题缺乏确定性等因素，沟通可能会进一步受到阻碍或无效，这可能会因信息不完整而导致患者护理决策不佳。16

最后，任何关于交流的讨论都需要考虑用于传达信息的媒介。寻呼机的使用在北美医院仍然很普遍，其他通信技术的使用也在继续增长。17 18然而，几乎没有证据表明通信技术促进了卫生专业人员之间的有效沟通，部分原因是寻呼机和其他只允许信息流向一个方向的通信技术仍在使用中。19此类技术不利于沟通，因为它们会造成不必要的干扰，造成信息交流的空白，并创造可能发生不良事件的变通办法。20

所有这些与沟通相关的问题都有可能增加医生和护士之间的冲突，他们以不同的方式优先处理或解释信息，11或不同意采取行动的必要性，例如召集快速响应团队到床边。21 22但这不仅仅是医生和护士。如果我们想改善患者的治疗效果，我们必须关注专业团队（来自所有学科）背后的动力，并承认团队动力和沟通是护理提供过程中不可或缺的一部分。不幸的是，目前还没有有效的干预措施来改善紧急临床情况下的沟通，因此迫切需要这方面的研究。总之，EWS 等技术在被视为护士提供的监测和监视的辅助手段时很有用。然而，他们永远无法取代护士或克服一些基本的人际挑战，例如影响临床医生沟通的挑战。我们需要谈论沟通以引起对这一关键因素的关注。

【编者注】

早期识别救治潜在危重症患者是一系列的策略组合，是组合拳而不是单一招式。

机器学习和人工智能只能作为工具去辅助，最核心的还是医护人员。

我们关注的重点除了开发出更灵敏便捷的识别工具，还要有怎样用好用对这些工具。

后者，可能比前者更为重要。

原文链接：

https://qualitysafety.bmj.com/content/early/2022/07/22/bmjqs-2022-014798

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