MR.

RICARDO M PADILLA (Orcid ID : 0000-0002-2025-0053)

Accepted Article Article type : Review

Descriptive Title
Clinical deterioration: a concept analysis

Concise Title
Clinical deterioration

Authors
Ricardo M. Padilla, MSN, RN, CCRN
PhD Student, Adjunct Clinical Professor
Hahn School of Nursing & Health Science
Beyster Institute for Nursing Research
University of San Diego
San Diego, CA, USA;

Ann M. Mayo, DNSc, RN, FAAN

Professor
Hahn School of Nursing & Health Science
Beyster Institute for Nursing Research
University of San Diego
San Diego, CA, USA

Correspondence
Ricardo M. Padilla
PhD Student, Adjunct Clinical Professor
Hahn School of Nursing
Beyster Institute for Nursing Research
University of San Diego
5998 Alcala Park
San Diego, CA, 92110, USA
Telephone: + 1 (619) 260-4548

Email: rpadilla@sandiego.edu

This manuscript and other dissertation research has received funding from the PhD Nursing
Student Dean’s Scholarship from the University of San Diego, Hahn School of Nursing and
Health Science.

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/jocn.14238
This article is protected by copyright. All rights reserved.
 Abstract
Accepted Article Aims and objectives. To present a concept analysis of clinical deterioration and introduce an

operational definition.

Background. Hospitalized patients who endure cardiopulmonary arrest and unplanned

intensive care unit admissions often exhibit physiological signs preceding these events.

Clinical deterioration not promptly recognized can result in increased patient morbidity and

mortality.

A barrier to recognizing and responding to clinical deterioration stems from practice

variations among health care clinicians.

Design. Concept analysis.

Methods. Eight step method of concept analysis proposed by Walker and Avant.

Results. Defining attributes include dynamic state, decompensation, and objective and

subjective determination. Antecedents identified include clinical state, susceptibility,

pathogenesis, and adverse event. Increased mortality, resuscitation, implementation of higher

level of care, and prolonged hospital admission were the consequences identified. Defining

attributes, antecedents, and consequences identified led to an operational definition of clinical

deterioration as a dynamic state experienced by a patient compromising hemodynamic

stability, marked by physiological decompensation accompanied by subjective or objective

findings.

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 Conclusions. Clinical deterioration is a key contributor to inpatient mortality and its
Accepted Article recognition is often underpinned by contextual factors and practice variances. Variation in

the uniformity of the concept of clinical deterioration causes a gap in knowledge and

necessitated clarification of this phenomenon for nursing research and practice.

Relevance to clinical practice. Identifying and intervening on clinical deterioration plays a

vital role in the inpatient setting demonstrated by the dynamic nature of a patients’ condition

during hospitalization. It is anticipated that this concept analysis on clinical deterioration will

contribute to further identification of clinically modifiable risk factors and accompanying

interventions to prevent clinical deterioration in the inpatient setting.

What does this paper contribute to the wider global clinical community?

• Concept clarification of clinical deterioration may lead to improved assessment

practices identifying modifiable risk factors earlier, allowing nurses to intervene prior

to critical situations arising potentially decreasing morbidity and mortality.

• Implications in calling for assistance upon early recognition of change in patient

condition in the acute inpatient setting.

• Creation of an operational definition of clinical deterioration may contribute to

uniformity of the concept ergo decreasing practice variances.

Key words: clinical deterioration, concept analysis, instability, inpatient, failure to rescue,

early warning score, track and trigger, decompensation

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 Clinical Deterioration: A Concept Analysis
Accepted Article Introduction

According to the 2017 American Heart Association report, roughly 209,000 patients

are treated for in-hospital cardiac arrests every year (Benjamin et al., 2017). The majority of

patients who endure in-hospital cardiopulmonary arrest and unplanned intensive care unit

admissions exhibit physiological signs of change hours preceding these acute events

(Ashworth, 2002; Berlot, Pangher, Pettrucci, Bussani, & Lucangelo, 2004; Buist, Bernard,

Nguyen, Moore, & Anderson, 2004; Churpek, Yuen,& Edelson, 2013; Scott, Considine, &

Botti, 2014). Literature has demonstrated that inpatients who suffer cardiopulmonary arrest

can show signs of physiological decay 24 hours prior to arrest and an estimated 23,000 cases

of in-hospital arrest can be avoidable with better care (Beaumont, Luettel, & Thomson, 2008;

Smith et al., 2006). A barrier to recognizing and responding to clinical deterioration stems

from variations as to what constitutes a deteriorating patient (Jones, Mitchell, Hillman, &

Story, 2013; Thompson et al., 2009). Concept clarification is an important step in

characterizing phenomena in nursing science and is often a prerequisite to beginning basic

research (Thofthagen & Fagerstom, 2010). A concept analysis is defined as a breakdown of a

concept into simple elements to promote clarity and a mutual understanding (Foley & Davis,

2017). The aim of this manuscript is to present a concept analysis on clinical deterioration

that utilized the Walker and Avant (2011) method and introduce an operational definition for

clinical deterioration using the results of the concept analysis.

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 Background
Accepted Article Cardiopulmonary resuscitation (CPR) and defibrillation are lifesaving techniques

utilized

in the latter part of the 20th century and integrated into health systems with the endorsement

from the American Heart Association (AHA) (Grimes, Thornell, Clark, & Viney, 2007).

Despite several decades of utilizing CPR within the hospital setting patient outcomes have

remained dismal and there is a recognized need for early identification and intervention of

hospitalized patients at risk (Grimes et al., 2007; Naeem & Montenegro, 2005). Identifying

clinical deterioration plays an important role in the health care industry demonstrated by the

dynamic nature of a patients’ condition during hospitalization (Jones et al., 2013) with

heightened awareness targeting interventions at maintaining and restoring the physiologic

stability of patients (Johnson, 1961; Lebel, Alderson, & Aita, 2014).

Following the two landmark reports To Err is Human (2000) and Crossing the

Quality Chasm (2001) released by the Institute of Medicine, the Institute for Healthcare

Improvement (IHI) followed up with the 100,000 lives campaign (Berwick, Calkins,

McCannon, & Hackbarth, 2006). The IHI is an organization focused on improving the safety

of health care delivery while maintaining quality and costs. While it began in the United

States, many organizations around the globe participate in the IHI (e. g., Canada, England,

Scotland, Denmark, Sweden, Singapore, Latin America, New Zealand, Ghana, Malawi, South

Africa, the Middle East) [Institute for Healthcare Improvement (2017a)]. The 100,000 lives

campaign was an 18-month United States national initiative with a goal of saving 100,000

lives among patients in hospitals through improvements in safety (Berwick et al., 2006).

Because clinical deterioration was not being recognized in hospitals, one of the interventions

from the 100,000 lives campaign was national deployment of Rapid Response Teams (RRTs)

also known as Medical Emergency Teams (METs), which are teams staffed by health care

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 professionals who have critical care expertise (Berwick et al., 2006). The RRT and MET
Accepted Article were introduced specifically to intervene in the care of patients exhibiting clinical

deterioration in non-intensive-care settings (Berwick et al., 2006; Jones et al., 2011; Odell,

Victor, & Oliver, 2009). The RRT and MET have received endorsement from the AHA 2015

recommended guidelines as being effective in reducing inpatient cardiac arrest (Kronick et

al., 2015).

However, being able to identify clinical deterioration is a needed skill among

practicing hospital nurses starting from the pre-licensure level. As nursing students’ progress

through their learning, they are placed in simulated environments and clinical situations

assessing their ability to identify, manage, and respond to clinical deterioration (Cooper et al.,

2010; Fisher & King, 2013; Hart et al., 2015). As nurses transition from novice to expert

they can recognize subtle changes and intuitively grasp situations leading up to clinical

deterioration (Benner, 1982; Tait, 2010). While there is an association between nursing

experience and the identification of patient deterioration clinically (Beaumont et al., 2008;

Tait, 2010), there is a lack in response and recognition of clinical deterioration by nurses,

possibly due to the subjectivity of the concept (Jones et al., 2013).

Aims and Objectives

The aim of this manuscript is to present a concept analysis on clinical deterioration

that utilized the Walker and Avant (2011) method. The objective of the concept analysis was

to introduce an operational definition that could be utilized in research and clinical practice.

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 Methods
Accepted Article Walker and Avant method

Derived from a modified version of Wilson’s (1963) classic concept analysis, Walker

and Avant (2011) decreased the analysis to 8 steps from the original 11. The steps are as

follows: 1. Select concept; 2. Determine the aims of the analysis; 3. Identify all uses of the

concept; 4. Determine the defining attributes (associated terms); 5. Identify a model case

(example demonstrating all defining attributes); 6. Identify other type of cases (borderline,

related, contrary); 7. Identify antecedents (occur prior to concept) and consequences (occur as

a result of a concept); and 8. Define empirical referents (measurable ways to demonstrate a

concept). Albeit the steps are listed sequentially, they are actually iterative (Walker & Avant,

2011). For example, while performing a review of the literature for uses of the concept one

may concurrently identify empirical referents. Along with performing a step-by-step concept

analysis, the writers will introduce an operational definition based on the findings.

Search strategy

As encouraged by Walker & Avant (2011) when performing a concept analysis all

uses of the concept must be considered and not be limited to nursing or medical literature.

Utilizing dictionaries, thesauruses, and other available literature will help identify many

aspects of the concept (Walker & Avant, 2011). In conjunction with identifying uses of the

term, academic databases accessed for this concept analysis included: Academic Search

Premier, CINAHL, Healthsource: Nursing/Academic edition, and PubMed. Search terms

included clinical deterioration, instability, failure to rescue, early warning score, track and

trigger, and decompensation. Limiters included: publication date 2000 through 2017; full

text; English language, inpatient, and scholarly (peer reviewed) journals. Initial database

search yielded 3,134 results and after including limiters this was narrowed down to 446 and

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 exported to EndNote version X7.7.1. A reference search for duplicates was performed in
Accepted Article EndNote checking by article title, author(s), and year published; a total of 90 duplicates were

identified and removed. Three hundred fifty six article abstracts were reviewed. An

additional 8 articles and one book published before the year 2000 were identified from

supporting references and reviewed. As final sources, a total of sixty-one peer reviewed

articles, six books, four definitions from the Meriam-Webster Online Dictionary, and two

other online resource were used in this concept analysis.

Results

Uses of the concept

Following the Walker and Avant process, all uses of the concept of clinical

deterioration and both terms in the phrase were reviewed independently (Walker & Avant,

2011). According to the Merriam-Webster dictionary, the word clinical is defined as: 1).

“relating to or based on work done with real patients; 2). of or relating to the medical

treatment that is given to patients in hospitals, clinics, etc.” Etymologically, clinical is

derived from “Klinikēl,” a late 18th century Greek word directly meaning “bedside”

(Merriam-Webster, n.d.). As per the Merriam-Webster dictionary the word deterioration is

defined as “the act or process of becoming worse.” Etymologically, deterioration is derived

from “Dēteriōrātiō,” a late 17th century Latin word meaning “worse” (Merriam-Webster,

n.d.). The term deterioration has implications beyond medical literature and is used to also

describe a declining process in many structures and systems such as “rust deterioration” and

“the deterioration of academic standards” (Merriam-Webster, n.d.). When combining both

terms together, etymologically, clinical deterioration is “worse at the bedside,” which

coincides with a number of definitions in the current literature.

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 As defined by Jones et al. (2013) a deteriorating patient is one who moves to a
Accepted Article worsened clinical state increasing morbidity and organ dysfunction, incurring a protracted

hospital stay or even death. In an evidence-base practice project on managing clinical

deterioration, Swartz (2011) defined clinical deterioration as the physiological

decompensation that occurs when a patient experiences worsening conditions or an acute

onset of a serious physiologic disturbance. In the literature clinical deterioration is a

complication described in healthcare settings and can develop at any point in a patient’s

hospitalization (Beaumont et al., 2008; McDonnell et al., 2013).

Defining attributes

Designating the defining attributes of a concept is the core of the analysis

(Walker& Avant, 2011). Attributes are clusters of characteristics that establish the true

definitions of a concept (Tofthagen et al., 2010) and represent associated terms allowing

readers more insight (Townsend & Scanlan, 2011). For the concept of clinical deterioration

three defining attributes were identified: dynamic state; decompensation; and subjective and

objective determination.

Dynamic state. Clinical deterioration is a dynamic state demonstrated by variation in

physiological parameters. As a dynamic state, clinical deterioration evolves in a negative

direction. Literature on clinical deterioration is often aimed at monitoring these negative

changes and the associated progression of physiological abnormalities (Beaumont et al.,

2008; Johnstone, Rattray, & Myers, 2007; Jones et al., 2013; Tait, 2010).

Decompensation. Decompensation is a negative dynamic state, but more specifically

the loss of the ability to maintain homeostatic function physiologically or psychologically

(Merriam-Webster, n.d.). Decompensation is a term often used synonymously with clinical

deterioration.

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 Subjective and objective determination. Criterion for distinguishing clinical
Accepted Article deterioration is often determined from objective and subjective observations (Jones et al.,

2013; Prytherch, Smith, Schmidt, & Featherstone, 2010). Monitoring of vital signs is a

standard of practice in health care interactions between clinicians and patients and often a real

time descriptor for clinical deterioration (Andrews & Waterman, 2005; Beaumont et al.,

2008; Buist et al., 2004; Johnstone et al., 2007; Jones et al., 2013; Kirkland et al., 2013;

McDonnell et al., 2012; Tait, 2010). There are well documented objective accounts of

relationships between abnormal vital signs and clinical deterioration leading to increased

mortality (Ashworth, 2002; Buist et al., 2004; Scott et al., 2014; Smith et al., 2006). Intuition

and feeling a sense of “concern” regarding a patient is also described as a determinant for

clinical deterioration (DeVita et al., 2006; Hillman et al., 2005; Jones et al., 2013; Odell,

Victor, & Oliver, 2009) and would be described as a subjective determination of clinical

deterioration.

Case examples

In this stage of the concept analysis case examples will be presented using the

defining attributes to further clarify the concept. Four categories of case examples will be

used to further explicate the concept of clinical deterioration.

Model case. A model case is an example of the concept demonstrating all the

defining

attributes (Walker & Avant, 2011). In explaining model cases Wilson (1963) states “Well if

that

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 isn’t an example of so-and-so, then nothing is” (p. 28). Walker and Avant (2011) suggest
Accepted Article that “model cases can be real life examples, examples found in literature, or ones

constructed” (p. 163). The model case of clinical deterioration was one constructed by the

writers.

Example: Ricky, the Rapid Response Team Registered Nurse (RRT-RN), responds to

a call in the progressive care unit regarding a patient with hypotension. Upon arrival Ricky

notices that all the vital signs are abnormal. Not only is the patient hypotensive but has a

heart rate of 155 beats per minute, an irregular respiratory rate of 44, and an oxygen

saturation of 90%. The primary nurse tells Ricky that the patient was admitted earlier during

the shift for urosepsis and also states that her repeated attempts at contacting the Physician

have not been successful and is why she called for the RRT. The patient is now in a critical

state and physiologically unstable. Ricky looks at the charted vital signs over the last four

hours and notices a declining trend.

Rationale. This is an example of a model case because it entails each of the defining

attributes listed in the concept analysis. The patient has a pathogenic process of urosepsis

and has exhibited a dynamic state evident by abnormality of vital signs. Also noted by the

RRT-RN was an inability to maintain a normal blood pressure, signifying decompensation.

Additional cases

Identifying additional cases is another part of performing a concept analysis. Walker

&

Avant (2011) state that developing other cases that are slightly different from the concept of

interest will assist in determining the final defining attributes. The additional cases used by

the writers will include a borderline case, related case, and a contrary case; all cases were

constructed by the writers.

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 Borderline case. Borderline cases are examples that contain the majority of defining
Accepted Article attributes, but not all of them (Walker & Avant, 2011). Borderline cases generally have one

important feature missing in comparison to the model case (Wilson 1963). These cases are

inconsistent when considering the defining characteristics of the concept and help to conclude

why the model case is consistent (Walker & Avant, 2011).

Example: Matt, a student nurse, asks his preceptor Anne, “Wow, our patient’s heart

rate and temperature are high today, not at all close to the patient’s baseline. Should we be

concerned?” Anne answers, “This is actually part of a normal physiological compensatory

mechanism to fight infection. Although our patient has the potential to get worse while

overcoming pneumonia, his blood pressure is still normotensive.”

Rationale. This is not considered a model case because it is missing one key attribute

which is hemodynamic decompensation. The patient currently is normotensive and

exhibiting normal compensatory mechanisms. However, a dynamic state is present because

of the change from baseline and physiological changes are noted because of the abnormal

vital signs.

Related case. Related cases contain instances of the concept that are associated with

the studied concept but are missing some of the defining attributes (Walker & Avant, 2011).

Related cases are useful to discriminate similarities and differences (Lebel et al., 2014). For

the related case, the concept of derangement was selected for discriminating similarities and

differences. Derangement can be described as the disturbance of normal bodily operations

and functions (Merriam-Webster, n.d.). Derangement shares similar attributes such as a

dynamic state, pathogenesis, and the propensity to decompensate. However, medical

literature on derangement usually encompasses specific systems such as metabolic

derangement, immunologic derangement, and circulatory derangement, to name a few.

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 Example: Shirley sustained no injuries during an automobile accident and was
Accepted Article cleared from the emergency department. Prior to following up with her Primary Medical

Provider (PMP), Shirley noticed that she was feeling malaise and had increased bruising.

Thinking that the malaise was due to the pain medicine she was prescribed and the increased

bruising was from the accident itself, she ignored her symptoms. Upon assessment by her

PMP during a routine follow-up, he noticed that Shirley’s temperament was different based

on having seen her for over 20 years. He checked her vital signs which were all in normal

limits. With suspicion, he ordered some basic lab tests and radiographic studies. Labs results

indicated a complete blood count having many immature white blood cells, a low red blood

cell count, and critically low platelets. Shirley was directly admitted to the hospital and after

more testing received a terminal diagnoses of acute myeloid leukemia (AML).

Rationale. This is not a model case because the abnormal lab values in this case

contributed to a diagnosis of AML, a hematological derangement. While her lab values are

in a dynamic state and Shirley has the potential to physiologically decompensate in the

future, her vital signs currently are within normal limits.

Contrary case. Contrary cases are clear examples of what the concept is not and

contain none of the defining attributes (Walker& Avant, 2011). Contrary casesare helpful

because it is easier to say what something is not versus explaining what it is (Walker &

Avant, 2011).

Example: Jonathon woke up this morning feeling exceptionally well. He started off

his morning routine with a light breakfast then a brisk jog. Approximately one year ago

Jonathon visited his PMP and was upset to find out that he had borderline high cholesterol

and was 15 pounds overweight. Since the visit he restricted his diet for three months and

continues to exercise five times a week. Upon return to his PMP’s office today, his

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 cholesterol lab value had normalized and he had lost 20 pounds. His PMP had congratulated
Accepted Article him on his hard work and stated “Gosh Jonathon…I think this is the healthiest I have ever

seen you!”

Rationale: This is not an example of a model case because it currently meets none of

the defining attributes. While Jonathon’s state of health had been dynamic during the three

months of dieting and exercise, it would be considered to be dynamic in a positive direction.

More importantly for the purposes of this case, his current state of health today would be

considered a stable condition and not dynamic. Although Jonathon was initially informed

that he had borderline high cholesterol and was overweight, he was able to physiologically

overcome those conditions and attain good health. There is currently no evidence of a

negative dynamic or decompensation in his current state of health.

Antecedents and consequences

Performing a concept analysis involves a continuous process where information is

gathered and organized shows a descriptive pattern of themes (Rodgers, 2000; Tofthagen &

Fagerstrom, 2010); such patterns emerge as antecedents and consequences. Identifying terms

as antecedents and consequences helps to differentiate thoseterms from attributes, thus further

refining the category of attributes (Walker& Avant, 2011). Antecedents are phenomena that

occur prior to the concept whereas consequences are phenomena that occur as a result of the

concept (Tofthagen & Fagerstrom, 2010; Walker& Avant, 2011).

Antecedents. Antecedents of clinical deterioration include clinical state; susceptibility;

pathogenesis; and adverse events. Literature highlights clinical deterioration as a condition

experienced by a patient (Andrews & Waterman, 2005; Beaumont et al., 2008; Jones et al.,

2013; McDonnell et al., 2012; Newman, 2017; Scott et al., 2014). Providing that, clinical

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 deterioration can take place anywhere patient care is administered (i.e. hospital
Accepted Article inpatient/outpatient, clinic). Abreast of being a patient, susceptibility to deteriorate has to be

evident. Patients who have acute or preexisting conditions (Swartz, 2011), emergency

admissions to a hospital, surgeries, and recovery from a critical illness are highly susceptible

to clinical deterioration (Beaumont et al., 2008; Bion & Heffner, 2004; Jones et al., 2013;

Newman, 2017).

Pathogenesis is a term meaning the origin and development of disease processes

(Venes & Taber, 2013). In hospitals, clinical deterioration can be preceded by a pathogenic

process and the sequelae from that process is detrimental (Jones et al., 2013; Patiporn et al.,

2017; Rhodes et al., 2017). Finally, a thorough literature review on models to describe

clinical deterioration conducted by Jones et al. (2013) revealed that in 25,000 patient records

reviewed in New Zealand, the United Kingdom, and Canada, 8-17 % were associated with

adverse events and 37-51% of those events were thought to be preventable (Baker et al.,

2004; Davis et al., 2002; Davis et al., 2003; Vincent, Neale, & Woloshynowych, 2001).

Consequences. Consequences for clinical deterioration include increased mortality;

resuscitation; implementation of higher level of care; and prolonged hospital admission. A

growing body of evidence suggest that prolonged unrecognized clinical deterioration

increases cardiopulmonary arrest and mortality (Buist et al., 2004; Jones et al., 2013; Kause

et al., 2004; McDonnell et al., 2012). The National Patient Safety Agency (NPSA) in London

performed an analysis of 425 avoidable deaths in acute hospitals, of which 64 deaths were

associated with patients clinically deteriorating beforehand (Beaumont et al, 2008; NPSA,

2007). Implementation of a higher level care initially starts with increased clinician care and

response from RRTs occurring during various stages of clinical deterioration (Jones et al.,

2011). Following the introduction of RRTs in hospitals, increases in the identification of

clinical deterioration on acute care units have been documented (Jones et al., 2011). Those

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 patients who survive the incident on acute care units are transferred to high levels of care
Accepted Article such as intensive care units and often experience prolonged hospital admissions (Barwise et

al., 2016; Calzavacca et al., 2010; Jones et al, 2013; Smith & Aitken, 2015; Stelfox,

Bagshaw, & Song, 2014).

Empirical referents

Empirical referents are considered classes or categories of potential measurements of

a concept. Identifying probable empirical referents during the process of a concept analysis

helps to validate the concept by providing further meaning (Walker & Avant, 2011). In

trying to describe and even prevent clinical deterioration, researchers and clinicians have

utilized

instruments to predict deterioration (Andrews & Waterman, 2005; Beaumont et al., 2008;

Johnstone et al., 2007; Kirkland et al., 2013; McDonnell et al., 2012; Tait, 2010). Items

within these measurement instruments can represent empirical referents for the concept

clinical deterioration.

Based on the notion that patients exhibit premonitory signs, use of early warning

score (EWS) (Andrews & Waterman, 2005; Beaumont et al., 2008; Morgan, Williams, &

Wright, 1997; Smith el., 2014) and track and trigger (T&T) (Churpek et al., 2013; Johnstone

et al., 2007; Kirkland et al., 2013; McDonnell et al., 2012; Scott et al., 2014) instruments

have been utilized in health care systems globally to assess relevant data. EWS and T&T

systems use physiological parameters for scoring. These data utilized from EWS and T&T

systems are used to identify clinical deterioration and activate RRTs or METs.

Recommendations from the AHA for recognition of clinical deterioration include

electrocardiogram-based telemetry, newer heart and respiratory sensor detection, and

increased clinical surveillance (Kronick et al., 2015).

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 Critical care severity scoring systems have been introduced into clinical practice to
Accepted Article diagnostically predict survivability. Scoring systems generally consist of two parts: a

numerical severity score and a calculated probability of mortality (Bouch & Thompson,

2008). Common severity scoring systems include the Acute Physiology and Chronic health

Evaluation (APACHE) (Knaus et al., 1985), Logistic Organ Dysfunction (LOD) (Le Gall et

al., 1996), Simplified Acute Physiology Score (SAPS) (Le Gall & Lemeshow, 1993),

Multiple Organ Dysfunction Score (MODS) (Marshall et al., 1995) and the Sequential Organ

Failure Assessment (SOFA) Score (Vincent et al., 1996). Using severity scoring has gained

importance in many health care facilities and can guide management modalities (Akbar,

Shahzadi, Khurram, & Khar, 2016). Although mostly utilized in the critical care setting,

severity scoring systems can assess the likelihood of clinical deterioration as well as mortality

in the hospital setting (Bouch & Thompson, 2008).

A systematic review performed by Odell, Victor, & Oliver (2009) found the most

common theme in detecting inpatient clinical deterioration was attributed to intuition, the act

of “knowing,” or having a “gut feeling.” Albeit controversial, intuition has demonstrated to

be a valuable component in clinical decision-making (Nyatanga & De Vocht, 2008).

Intuition has gained notoriety as a tool for resource utilization leading to RRT or MET

activation (Jones, Drennan, Hart, Bellomo, & Web, 2012; Massey, Chaboyer, & Anderson,

2017; Williams, Newman, Jones, & Woodard, 2011).

Operational definition

Theorists introduce readers to defining attributes of concepts through theoretical

definitions. However, many times theoretical definitions are seen as abstract and not

measurable. Thus, operational definitions are constructed because they have measurement

specifications (Walker & Avant, 2011). The following is proposed as an operational

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 definition of clinical deterioration generated from this concept analysis: a dynamic state
Accepted Article experienced by a patient compromising hemodynamic stability, marked by physiological

decompensation accompanied by subjective or objective findings.

Discussion

The Institute for Healthcare Improvement (2017b) reports that failing to recognize

clinical deterioration is a key contributor to increased mortality. Inpatient cardiopulmonary

arrest is often preceded by warning signs and many times can be preventable if intervened

early on (Bion & Heffner, 2004; Buist el al., 2002). Promptly recognizing clinical

deterioration can save lives. It is in the presence of nursing personnel that clinical

deterioration may first be observed, creating multiple strategic opportunities to decrease

mortality and even prevent the transfer of patients to higher and more costly levels of care.

Proactive rounding has been one such nurse-led initiative. When not responding to

RRT calls, RRT-RNs will round on inpatient units identifying patients at high risk for clinical

deterioration. One hospital employing this nurse-led proactive rounding model prepared

nursing assistants to recognize early clinical deterioration by defining trigger alerts (i. e.,

change in heart rate, blood pressure or temperature). On each shift a designated RRT-RN

conducted proactive rounds among all nursing assistants querying them about the

standardized trigger alerts and supporting them in reporting these alerts to the unit RNs. The

unit RNs would subsequently follow up with action steps such as having blood cultures

drawn for a rise in temperature among specific at-risk patient populations (Leach, Kagawa,

Mayo, & Pugh, 2012).

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 Interdisciplinary collaboration among nurses, physicians, respiratory therapists, and
Accepted Article other health care professionals is also crucial for the recognition and communication of the

signs of clinical deterioration. This work would begin with a mutual understanding of the

concept of clinical deterioration. Building on this mutual understanding, the work would be

integrated into education programs and continue into practice. Simulation technology could

be utilized in both education and practice settings, allowing the participants to incrementally

develop both their recognition and communication skills in the context of clinical

deterioration. Case study discussions and debriefing sessions involving additional specialists

would further support learning. For example, the involvement of an infection disease

physician and clinical nurse specialist could provide additional knowledge to the team about

more subtle changes in a patient not yet exhibiting the obvious signs of sepsis.

Conclusion

Although there has been extensive literature and research regarding managing clinical

deterioration (Jones et al., 2013), the main purpose of this manuscript was to provide concept

clarification by way of the Walker and Avant (2011) concept analysis method. Issues

underpinning the recognition of the deteriorating patient are multifaceted (Smith & Aitken,

2015) often including contextual factors and practice variances (Jones et al., 2013). Variation

in the uniformity of the concept of clinical deterioration has created a gap in knowledge and

necessitated clarification of this phenomenon for nursing research and clinical practice.

Attributes, antecedents, consequences, and constructed cases were proposed contributing to

clarification of the concept and development of an operational definition. After performing a

thorough review of the literature and uses of the concept, defining attributes identified

included dynamic state; decompensation; and subjective and objective determination.

Antecedents included clinical state; susceptibility; pathogenesis, and adverse events.

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 Consequences included increased mortality; resuscitation; implementation of higher level of
Accepted Article care; and prolonged hospital admission. Constructed cases and empirical referents were also

identified, allowing the writers to propose an operational definition of clinical deterioration

as: a dynamic state experienced by a patient compromising hemodynamic stability, marked

by physiological decompensation accompanied by subjective or objective findings.

Relevance to Clinical Practice

Concept clarification of clinical deterioration may lead to improved assessment

practices identifying modifiable risk factors earlier, allowing nurses to intervene prior to

critical situations arising in the inpatient setting. Nurses are the forefront of patient care

delivery in the acute inpatient setting and play a pivotal role in recognizing and responding to

clinical deterioration. Nurses are often the first person on the multidisciplinary team to

recognize a change in patient condition and it is detrimental to call for assistance prior to

development of a prearrest state. RRTs or METs were created to further assess clinical

deterioration and can offer assistance with triaging conditions, critical care interventions, and

appropriate and safe transfer to a higher level of care. Intervening on clinical deterioration

promotes multidisciplinary collaboration, process improvement strategies, and ongoing

educational opportunities providing patients the best advantage should they incur this critical

event.

References

Akbar, A., Shahzadi, S., Khurram, M., & Khar, H. B. (2016). Sofa score and outcome:

Experience at a public sector hospital ICU. Pakistan Armed Forces Medical Journal,

66(4), 510-514.

Andrews, T., & Waterman, H. (2005). Packaging: a grounded theory of how to report

physiological deterioration effectively. Journal of Advanced Nursing, 52(5), 473-481.

This article is protected by copyright. All rights reserved.

 Ashworth, S. (2002). A prelude to outreach: Prevalence& mortality of ward patients with
Accepted Article abnormal vital signs. Intensive Care Medicine, 28(S21).

Baker, G. R., Norton, P. G., Flintoft, V., Blais, R., Brown, A., Cox, J., & ... Tamblyn, R.

(2004).

The Canadian Adverse Events Study: the incidence of adverse events among hospital

patients in Canada. CMAJ, 170(11), 1678-86.

Barwise, A., Thongprayoon, C., Gajic, O., Jensen, J., Vitaly, H., Pickering, B. W., &

Herasevich,

V. (2016). Delayed rapid response team activation is associated with increased

hospital mortality, morbidity, and length of stay in a tertiary care institution. Critical

Care Medicine, 44(1), 54-63.

Beaumont, K., Luettel, D., & Thomson, R. (2008). Deterioration in hospital patients: early

signs

and appropriate actions. Nursing Standard, 23(1), 43-48.

Benjamin, E. J., Blaha, M. J., Chiuve, S. E., Cushman, M., Das, S. R., Deo, R., & ... Mackey,

R.

H. (2017). Heart Disease and Stroke Statistics-2017 Update: A Report from the

American Heart Association. Circulation, 135(10), e146-e603.

Benner, P. (1982). From novice to expert. The American Journal of Nursing, 82(3), 402-407.

Berlot, G., Pangher, A., Pettrucci, L., Bussani, R., & Lucangelo, U. (2004). Anticipating

events

of in-hospital cardiac arrests. European Journal of Emergency Medicine, 11(1), 24-8.

Berwick, D., Calkins, D., McCannon, C., & Hackbarth, A. (2006). The 100 000 Lives

Campaign:

This article is protected by copyright. All rights reserved.

 setting a goal and a deadline for improving health care quality. JAMA: Journal of The
Accepted Article American Medical Association, 295(3), 324-327.

Bion, J. F., & Heffner, J., E. (2004). Challenges in the care of the acutely ill. (2004). Lancet,

363(9413), 970-977.

Bouch, D. C., & Thompson, J. P. (2008). Severityscoring systems in the critically ill.

Continuing

Education in Anaesthesia, Critical Care & Pain, 8(5), 181-185.

Buist, M., Bernard, S., Nguyen, T., Moore, G., & Anderson, J. (2004). Association between

clinically abnormal observations subsequent in-hospital mortality: a prospective

study.

Resuscitation, 62(2), 137-41.

Calzavacca, P., Licari, E., Tee, A., Mercer, I., Haase, M., Haase-Fielitz, A., & ... Bellomo, R.

(2010). Features and outcome of patients receiving multiple Medical Emergency

Team reviews. Resuscitation, 81(11), 1509-1515.

Churpek, M. M., Yuen, T. C., & Edelson, D. P. (2013). Predicting clinical deterioration in the

hospital: The impact of outcome selection. Resuscitation, 84(5), 564-568.

Clinical. (n.d.). In Merriam-Webster Online Dictionary. Retrieved from

http://www.merriamwebster.com/dictionary/clinical

Cooper, S., Kinsman, L., Buykx, P., McConnell-Henry, T., Endacott, R., & Scholes, J.

(2010).

Managing the deteriorating patient in a simulated environment: nursing students’

knowledge, skill and situation awareness. Journal of Clinical Nursing, 19(15/16),

2309-2318.

Davis, P., Lay-Yee, R., Briant, R., Ali, W., Scott, A., & Schug, S. (2002). Adverse events in

New Zealand public hospitals I: occurrence and impact. N Z Med J, 115(1167), U271.

This article is protected by copyright. All rights reserved.

 Davis, P., Lay-Yee, R., Briant, R., Ali, W., Scott, A., & Schug, S. (2003). Adverse events in
Accepted Article New Zealand public hospitals II: preventability and clinical context. N Z Med J,

(1183), U624.

Decompensation. (n.d.). In Merriam-Webster Online Dictionary. Retrieved from

http://www.merriam-webster.com/dictionary/decompensation

Derangement. (n.d.). In Merriam-Webster Online Dictionary. Retrieved from

http://www.merriam-webster.com/medical/derangement

Deterioration. (n.d.). In Merriam-Webster Online Dictionary. Retrieved from

http://www.merriam-webster.com/dictionary/deterioration

DeVita, M., Bellomo, R., Hillman, K., Kellum, J., Rotondi, A., Teres, D., & ... Milbrandt, E.

(2006). Findings of the first consensus conference on medical emergency teams.

Critical Care Medicine, 34(9), 2463-2478.

Fisher, D., & King, L. (2013). An integrative literature review on preparing nursing students

through simulation to recognize and respond to the deteriorating patient. Journal of

Advanced Nursing, 69(11), 2375-2388.

Foley, A. S., & Davis, A. H. (2017). A guide to concept analysis. Clinical Nurse Specialist:

The Journal for Advanced Nursing Practice, 31(2), 70-73.

Grimes, C., Thornell, B., Clark, A., & Viney, M. (2007). Developing rapid response teams:

best

practices through collaboration. Clinical Nurse Specialist: The Journal for Advanced

Nursing Practice, 21(2), 85-94.

Hart, P., Brannan, J., Long, J., Brooks, B., Maguire, M., Robley, L., & Kill, S. (2015). Using

combined teaching modalities to enhance nursing students' recognition and response

to

This article is protected by copyright. All rights reserved.

 clinical deterioration. Nursing Education Perspectives, 36(3), 194-196.
Accepted Article Hillman, K., Chen, J., Cretikos, M., Bellomo, R., Brown, D., Doig, G., & ... Flabouris, A.

(2005).

Introduction of the medical emergency team (MET) system: a cluster-randomised

controlled trial. Lancet, 365(9477), 2091-2097.

Institute for Healthcare Improvement. (2017a). History. Retrieved from

http://www.ihi.org/about/Pages/History.aspx

Institute for Healthcare Improvement. (2017b). Rapid response teams. Retrieved from

http://www.ihi.org/Topics/RapidResponseTeams/Pages/default.aspx

Institute of Medicine. (2001). Crossing the quality chasm: a new health system for the 21st

Century. Washington, D.C.: National Academy Press.

Johnson, D. (1961). The significance of nursing care. American Journal of Nursing, 61(11),

63-66.

Johnstone, C., Rattray, J., & Myers, L. (2007). Physiological risk factors, early warning

scoring

systems and organizational changes. Nursing in Critical Care, 12(5), 219-224.

Jones, D., DeVita, M.,& Bellomo, R. (2011). Rapid-response teams. The New England

Journal of Medicine, 365(2), 139-146.

Jones, D., Drennan, K., Hart, G., Bellomo, R., & Web, S. (2012). Rapid Response Team

composition, resourcing and calling criteria in Australia. Resuscitation, 83(5), 563-

567.

Jones, D., Mitchell, I., Hillman, K., & Story, D. (2013). Clinical paper: Defining clinical

deterioration. Resuscitation, 84(8), 1029-1034.

Kause, J., Smith, G., Prytherch, D., Parr, M., Flabouris, A., & Hillman, K. (2004). A

comparison

This article is protected by copyright. All rights reserved.

 of antecedents to cardiac arrests, deaths and emergency intensive care admissions in
Accepted Article Australia and New Zealand, and the United Kingdom—the ACADEMIA study.

Resuscitation, 62(3), 275-282.

Kirkland, L., Malinchoc, M., O'Byrne, M., Benson, J., Kashiwagi, D., Burton, M., & ...

Morgenthaler, T. (2013). A clinical deterioration prediction tool for internal medicine

patients. American Journal of Medical Quality, 28(2), 135-142.

Knaus, W. A., Draper, E. A., Wagner, D. P., Zimmerman, J. E. (1985). APACHE II: A

severity

of disease classification system. Crit Care Med, 13(10), 818-29.

Kohn, L. T., Corrigan, J., & Donaldson, M. S. (1999). To err is human: Building a safer

health

system. Washington, D.C: National Academy Press.

Kronick, S. L., Kurz, M. C., Lin, S., Edelson, D. P.,Berg, R. A., Billi, J. E., & ... Welsford,

M.

(2015). Part 4: Systems of Care and Continuous Quality Improvement: 2015

American Heart Association Guidelines Update for Cardiopulmonary Resuscitation

and Emergency Cardiovascular Care. Circulation, 132, S397-S413.

Leach, L. S. Kagawa, F. Mayo, A, Pugh, C. (2012). Improving patient safety to reduce

preventable deaths: The case of a California safety net hospital. Journal for

Healthcare Quality, 34(2), 64-76.

Lebel, V., Alderson, M., & Aita, M. (2012). Physiological stability: A concept analysis.

Journal

of Advanced Nursing, 68(1), 1995-2004.

Le Gall, J.,& Lemeshow, S. (1993). A new Simplified Acute Physiology Score (SAPS II)

based

This article is protected by copyright. All rights reserved.

 on a European/North American multicenter.. JAMA, 270(24), 2957.
Accepted Article Le Gall, J.R., Klar, J., Lemeshow, S., Saulnier, F., Alberti, C., Asrtigas, A., Teres, D. (1996).

The Logistic organ dysfunction system: A new way to assess organ dysfunction in the

intensive care unit: ICU scoring group. JAMA, 276(10), 802-10.

Marshall, J. C., Cook, D. J., Christou, N. V., Bernard, G. R., Sprung, C. L., & Sibbald, W. J.

(1995). Multiple organ dysfunction score: a reliable descriptor of a complex clinical

outcome. Crit Care Med, 23(10), 1638-52.

Massey, D., Chaboyer, W., & Anderson, D. (2017). What factors influence ward nurses’

recognition of and response to patient deterioration? An integrative review of the

literature. Nurs Open, 4(1), 6–23.

McDonnell, A., Tod, A., Bray, K., Bainbridge, D., Adsetts, D., & Walters, S. (2013). A

before

and after study assessing the impact of a new model for recognizing and responding to

early signs of deterioration in an acute hospital. Journal of Advanced Nursing, 69(1),

41-52.

Morgan, R. J. M., Williams, F., & Wright, M. (1997). An early warning scoring system for

detecting developing critical illness. Clin Intensive Care, 8, 100.

Naeem, N., & Montenegro, H. (2005). Beyond the intensive care unit: A review of

interventions

aimed at anticipating and preventing in-hospital cardiopulmonary arrest.

Resuscitation, 67(1), 13-23.

National Patient Safety Agency. (2007). Safer care for the acutely ill patient: Learning from

Serious incidents. NPSA, London.

Newman, S. (2017). Do not disturb: Vital sign monitoring as a sign of clinical deterioration is

monitored patients. Kentucky Nurse, 65(2), 15-17.

This article is protected by copyright. All rights reserved.

 Nyatanga, B., & De Vocht, H. (2008). Intuition in clinical decision-making: a psychological
Accepted Article penumbra. International Journal of Palliative Nursing, 14(10), 492-496.

Odell, M., Victor, C.,& Oliver, D. (2009). Nurses' role in detecting deterioration in ward

patients: systematic literature review. Journal of Advanced Nursing, 65(10), 1992-

2006.

Patiporn, B., Siriorn, S., Davidson, P. M., Ketsarin, U., Chukiat, V., & Wittaya, C. (2017).

Factors influencing clinical deterioration in persons with sepsis. Pacific Rim

International Journal of Nursing Research, 21(2), 135-147.

Prytherch, D. R., Smith, G. B., Schmidt, P. E., & Featherstone, P. I. (2010). Views: Towards

national early warning score for detecting adult inpatient deterioration. Resuscitation,

81(8), 932-937.

Rhodes, A., Evans, L., Alhazzani, W., Levy, M., Antonelli, M., Ferrer, R., & ... Backer, D.

(2017). Surviving Sepsis Campaign: International Guidelines for Management of

Sepsis and Septic Shock: 2016. Intensive Care Medicine, 43(3), 304-377.

Scott, B., Considine, J., & Botti, M. (2015). Unreported clinical deterioration inemergency

department patients: A point prevalence study. Australasian Emergency Nursing

Journal,

18(1), 33-41.

Smith, D. J., & Aitken, L. M. (2015). Use of a single parameter track and trigger chart and

the

perceived barriers and facilitators to escalation of a deteriorating ward patient: a

mixed

methods study. Journal of Clinical Nursing, 25(1-2), 175-85.

Smith, M. B., Chiovaro, J. C., O'Neil, M., Kansagara, D., Quiñones, A. R., Freeman, M., & ...

This article is protected by copyright. All rights reserved.

 Slatore, C. G. (2014). Early warning system scores for clinical deterioration in
Accepted Article hospitalized patients: a systematic review. Annals of the American Thoracic Society,

11(9), 1454-1465.

Smith, G., Prytherch, D., Schmidt, P., Featherstone, P., Knight, D., Clements, G., &

Mohammed,

M. (2006). Hospital-wide physiological surveillance: A new approach to the early

identification and management of the sick patient. Resuscitation, 71(1), 19-28.

Stelfox, H. T., Bagshaw, S. M., & Song, G. (2014). Characteristics and outcomes for

hospitalized patients with recurrent clinical deterioration and repeat medical

emergency team activation. Critical Care Medicine, 42(7), 1601-1609.

Swartz, C. (2011). A systematic approach to manage clinical deterioration on inpatient units

in the health care system. DNP Practice Inquiry Projects. Paper 26. Retrieved from

http://uknowledge.uky.edu/dnp_etds/26

Tait, D. (2010). Nursing recognition and response to signs of clinical deterioration. Nursing

Management - UK, 17(6), 31-35.

Thompson, C., Bucknall, T., Estabrookes, C. A., Hutchinson, A., Fraser, K., de Vos, R., & ...

Saunders, J. (2009). Nurses’ critical event risk assessments: a judgement analysis.

Journal of Clinical Nursing, 18(4), 601-612.

Tofthagen, R., & Fagerstrøm, L. M. (2010). Rodgers' evolutionary concept analysis - a valid

method for developing knowledge in nursing science. Scandinavian Journal of

Caring

Sciences, 24(1), 21-31.

Townsend, L.,& Scanlan, J. (2011). Self-Efficacy related to student nurses in the clinical

setting: A concept analysis. International Journal of Nursing Education Scholarship,

8(1), 1-15.

This article is protected by copyright. All rights reserved.

 Venes, D., & Taber, C. (2013). Taber's cyclopedic medical dictionary. “Pathogenesis.”
Accepted Article p. 1526. Philadelphia: F.A. Davis.

Vincent, C., Neale, G., & Woloshynowych, M. (2001). Adverse events in British hospitals:

preliminary retrospective record review. BMJ, 322(7285), 517-9.

Vincent, J .L, Moreno, R., Takala, J., Willatts, S., De Mendonça, A., Bruining, H., & ... Thijs,

L.G. (1996). The SOFA (Sepsis-related Organ Failure Assessment) score to describe

organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related

Problems of the European Society of Intensive Care Medicine. Intensive Care Med,

22(7), 707–710.

Walker L., & Avant K. (2011). Strategies for Theory Construction in Nursing, 5th ed. Upper

Saddle River, NJ: Pearson, Prentice Hall.

Williams, D. J., Newman, A., Jones, C., & Woodard, B. (2011). Nurses' perceptions of how

rapid response teams affect the nurse, team, and system. Journal of Nursing Care

Quality, 26(3), 265-272.

Wilson, J. (1963). Thinking with Concepts. New York, NY: Cambridge University Press.

This article is protected by copyright. All rights reserved.