Patient Deterioration: An Assessment of Documentation Practices and Factors that Influence Recognition and Response by General Ward Nurses in Coastal Kenya Hospitals

Background: Like most low and middle-income countries, Kenya has limited critical care facilities; thus, patients with complex needs who are more likely to become acutely ill during their hospital stay are managed in the general wards. The general ward nurse caring for these acute and critical patients is expected to recognise, respond, and escalate the deterioration of the patient to prevent a cardiac arrest or death. This study, thus, examined the nurses' vital signs documentation practices regarding the patient deterioration and explored the factors that influence their ability to recognise, respond, and escalate deterioration. 

Methods: This study, conducted in three purposefully selected hospitals in Kenya's coastal region, utilised a mixed methods approach. The study activities included a review of nursing vital signs documentation to examine if, which, where, and how physiological parameters of the patients were documented before clinical deterioration occurred. Further, in-depth, semi-structured interviews were carried out with twenty-four key informants from the three hospitals.  

Results: A total of 405 records were reviewed, 186 (46%), 135 (33%), and 84 (21%) from Coast General and Referral Hospital, Kilifi County Hospital, and Malindi Sub County Hospital, respectively. The most frequently recorded vital signs were the systolic blood pressure and heart rate, where both had been recorded at least once in 89% of the cases 24 hours before patient death. The least recorded were the level of consciousness and the respiratory rate, which had been recorded at 12% and 30%, respectively at least once in the 24 hours before death.  Seven key themes and subthemes emerged from the thematic analysis of the interview data. The themes included availability of resources (to monitor patients and respond timely), working conditions, communication and teamwork, vital signs challenges, patients' conditions, individual nurse characteristics, and training. 

Conclusion: This study provides evidence that there are shortcomings and challenges in the nurses' role in recognising and responding to clinical deterioration. It also provides an opportunity for future research on interventions for improving the nurses’ ability to recognise and respond to a deteriorating patient in the general wards by improving their assessment and management of deterioration.