Reflections on the Use of Track and Trigger Scores for Recognising Clinical Deterioration

In so many patients suboptimal care was given, so-called adverse events. Adverse events are events like an emergency admission in the intensive care unit, a resuscitation or an unexpected death of the patient. Due to the fact of suboptimal assessment and management of acutely and critically ill patients with signs of clinical deterioration. To help recognising clinical deteriorating patients tools for tracking and responding to patients in these situations were written. International recommendations and national guidelines helped implementing these tools (Royal College of Physicians, 2012; NIVEL, 2013).

The track and trigger scores are used all over the world, despite the lack of evidence. Due to the fact that there are many different track and trigger scores and the research has taken place on a small population. And the fact that many track and trigger scores have a high sensitivity and a low specificity. Which will lead to patients with acute illness that are not recognised and patients who are not actually critically ill, which can lead to a higher workload for nurses (Gao, 2007, Mulligan, 2010).

This is seen in practice as well where it is very difficult to isolate the variables that can impact on patient outcome in complex care settings and thus determine the impact of track and trigger on patient care.

Even though there is evidence to suggest that some track and trigger tools can offer physiological evidence for deterioration on time and trigger action. And every recognised deterioration is one. But the balance between recognising deteriorating patients and not give a higher workload for nurses is complex. To solve this problem we can adjust the track and trigger score to specify the score for our patient population. However experience and literature study show that the ‘professional gaze’ is just as important. The definition of the professional gaze from Tait is: ‘The professional practice of engaging in scanning, selective perception, recognition, diagnosis and response to clinical deterioration’ (Tait, 2009). The use of the professional gaze, an SBAR communication tool, clinical outreach team and continuing professional development are factors that come together to impact on effective patient care.

That is exactly what could be improved in the Netherlands as well; the track and trigger score, the SBAR communication tool and the clinical outreach team were used. But due to the fact that the sensitivity was high and the specificity was low, nurses got a higher workload and did not use the tools. That is where the professional gaze and continuing professional development can help understand the use of the tools and the importance of the professional.

For the future we recommend a stronger focus on developing rapid clinical decision making skills at undergraduate and post graduate level. The international standardisation of a track and trigger score; such as the Early Warning Score. We argue that further research into how these strategies can jointly impact on patient outcome and the economic evaluation of the use and effectiveness of these tools is necessary.