escalation of care, instability, medical emergency team, patient deterioration, simulation



  1. Ozekcin, Linda R. DNP, RN, CCRN, CCNS
  2. Tuite, Patricia PhD, RN, CCNS
  3. Willner, Kathleen MSN, RN
  4. Hravnak, Marilyn PhD, RN, ACNP-BC, FCCM, FAAN


Purpose/Objectives: The specific aim of this quality improvement project was to improve acute care nurses' ability to assess deteriorating patients, recognize signs of instability and immediate critical treatment, and escalate care in a timely manner.


Background: Early identification of and treatment of patient deterioration can improve patient and hospital/system spheres of clinical nurse specialist influence.


Rationale: An earlier response to clinical deterioration may result in improved patient outcomes.


Description: A clinical nurse specialist devised and implemented a 2-phase education program-e-learning module and simulation scenarios utilizing a PDSA (plan, do, study, act) cycle framework. Education effectiveness was assessed by knowledge and performance of critical activities for instability identification, notification, and recognition, including an SBAR (situation, background, assessment, recommendation) communication approach. The simulation phase included group participation in 2 instability scenarios with an intervening debriefing using a gather-analyze-summarize (GAS) approach. Effectiveness was assessed via pre-education and posteducation knowledge surveys and assessment of time to critical actions in the simulation scenarios. Time to achievement of critical actions in the scenarios was determined by quantifying the baseline time for the simulation to run and the percentage of that time into the scenario at which the critical action was made.


Outcome: Project participants were 35 nurses divided into 10 simulation groups. A paired-samples Student t test demonstrated that the group mean pretest score of 56.5% (SD, 17%) increased to 84.6% (SD, 10%), a significant increase of 27.9% (P < .0001). In the scenarios, participants decreased the time to application of the first correct critical intervention from 37% in scenario 1 to 25% in scenario 2, and the time to escalate care decreased from 66% of scenario time to 61%.


Conclusion: Use of e-learning, simulation with organized debriefing, and SBAR communication can improve instability recognition and communication resulting in improved knowledge and decreased time to critical actions.