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Introduction: Research show that patients frequently display abnormal vital signs as much as 48h before a serious adverse event occur, such as cardiac arrest or unplanned intensive care unit admission. Therefore, early recognition of these changes trough vital sign examination is essential in the prevention of deterioration. However, deterioration is often missed.Aim: The aim was to investigate to what extent nurses in the general ward are documenting vital signs prior to patient deterioration. Methods: A systematic literature review was done usingthe databases PubMed and CINAHL. Inclusion criteria: general ward and publication 2010-2020, exclusion criteria:emergency department, acute admission ward, paediatric ward, psychiatric ward, interventions and continuousmonitoring. Critical appraisalusingtools from Joanna Briggs Institute. PRISMA statement for reporting of systematic reviews.Results: Nine studies were included. It was seen that the fraction of cases who had vital signs documented prior to deterioration was diverse, although never complete. Some studies showed an acceptable fraction of patients who weremonitoredin the hours prior to deterioration, but it was seen that the monitoring did not always escalate as the patient got worse. The vital signs most frequently documentedwereheart rate and pulse, thoughstill missing in a large fraction of charts. Respiratory rate was documented less than the other vital signs.Conclusions: This study suggests that documentation of vital signs prior to deterioration is diverse but often incomplete. Further research is needed to understand what can be done to improve vital sign documentation on general wards.

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This study examined the interactions of individuals who showed symptom improvement and those who showed symptom deterioration during the course of 12-14 sessions of group process psychotherapy. Both general group themes, as well as themes specific to improvers and deteriorators were found. General group themes included (a) an initial difficulty distinguishing between improvers and deteriorators, and (b) a tendency for group to focus on past or future focus versus present group issues. Specific themes for deteriorators included (a) substantial early disclosure in the group process, (b) open praise of the process of group, (c) the stated expectation of sharing deep personal information, (d) focus on others as well as questioning themselves, (e) concerns that were focused on family of origin, and (f) special interactions with group leaders. Specific themes for improvers included (a) initial hesitance in joining in the group process, (b) initiation of group time without apology, (c) tendency to announce and take credit for positive life changes, and (d) tendency to be checked in with by leaders and other members of group. Findings suggested the difference between deterioration and improvement may be subtle and thus difficult for group leaders to detect. Although the differences were not immediately apparent, a deeper examination of group process did reveal distinct interaction patterns for deteriorators that were different than those of improvers. These patterns of interactions for deteriorators and improvers are discussed. The general and specific themes found in this study are also examined in terms of the variables commonly examined in group (i.e. client variables, leader variables, and group variables) that may have contributed to the outcomes of group members. Clinical implications, limitations and future research directions are also discussed.

While the beneficial effects of psychotherapy have been well documented, the fact remains that 5 to 10 percent of clients get worse while in treatment (Lambert & Ogles, 2004) and a large minority of patients show little response (Hansen, Lambert, & Forman, 2003). The effects of four interventions, aimed at reducing deterioration and enhancing positive outcomes were examined in an Immediate Electronic Feedback sample of 1101 patients whose outcome was contrasted across experimental groups and with two archival groups: the Week-Delayed Feedback group, consisting of archival data from 1374 patients and the treatment-as-usual control group consisting of archival data from 1445 patients. Results indicate that feedback to therapists improved outcome across clients, especially for signal-alarm cases. Therapist feedback effects were enhanced by the use of manually based Clinical Support Tools, but not by providing direct feedback to clients about their progress. There were no significant differences in outcome between the Week-Delayed CST feedback and the 2-Week-Delayed CST feedback groups; however, clients in the Week-Delayed CST feedback condition, attended 3 less sessions, on average, than their 2-Week-Delayed CST feedback counterparts. Furthermore, a significantly greater number of people in the Week-Delayed CST Feedback group ended treatment in the Recovered/Improved classification of the Jacobson/Truax model.

To date, outcome research suggests that providing clinicians with patient progress feedback and problem-solving tools is effective in improving therapeutic outcome for clients who are predicted to have a negative treatment outcome. To expand upon this body of research, the current study examined the efficacy of using these problem-solving tools (Clinical Support Tools; CST) to reduce the risk of treatment failure and enhance positive outcome with 118 clients who were not identified as at -risk for a negative outcome. Results of this study indicated that the intervention failed to lower the rate of becoming an at-risk case or to enhance treatment outcome. A possible explanation for the null results observed is poor treatment compliance. Based on the findings of this study, the CST cannot be recommended as an intervention across the broad range of clients who enter treatment. However, qualitative analysis results reflect positive indicators for continued research with at-risk cases.

While most clients show improvement in therapy, anomalously, 5% to 10% actually worsen, and a significant minority of clients shows little or no response to therapy. Earlier studies developed clinical support tools (CSTs) designed to provide feedback to therapists about potential problem areas and to improve the likelihood of a positive outcome for clients identified as at-risk for a negative outcome in therapy (Harmon et. al. 2007; Slade, Lambert, Harmon, Smart, & Bailey, 2008; Whipple et al., 2003). While varying from study to study, the CSTs looked at five domains: therapeutic alliance, motivation to change, social support, life events, and perfectionism. More than 100 questions were used to assess these domains. The major goal of this study was to streamline the CST measures to increase efficiency. Toward that end, a new instrument consisting of 37 questions was developed by administering questionnaires to 169 patients at a rural Utah mental health center. In addition, the life events and social support questions were given to 76 students at Brigham Young University and 88 randomly selected residents of Utah County. Using item response analysis and mean scores for each dimension, subscale cut scores were developed for four dimensions: therapeutic alliance, motivation for therapy, social support, and life events. The perfectionism subscale was dropped from the questionnaire because perfectionism was deemed to be too stable to be useful for the intended use of the measure. Cut scores were also developed for each individual question. These subscale and individual item cut scores are intended to help clinicians identify potential problem areas to be explored during the course of therapy.

Outcome research has documented worsening among a minority of the patient population (5 to 10%). In this study a psychotherapy quality assurance system intended to enhance outcomes in patients at risk of treatment failure was reviewed through the use of meta-analytic, mega-analytic, and multilevel analytic techniques. A pooled dataset from six major studies conducted at a large university counseling center and a hospital outpatient setting (N = 6151, mean age = 23.3 years, female = 63.2%, Caucasian = 85%) were re-analyzed to examine the effects of progress feedback on patient outcome. In this quality assurance system, the Outcome Questionnaire-45 was routinely administered to patients to monitor their therapeutic progress and was utilized as part of an early alert system to identify patients at risk of treatment failure. Patient progress feedback based on this alert system was provided to clinicians to help them intervene before treatment failure occurred. Intent-to-treat and efficacy analyses of the effects of feedback interventions were conducted to obtain the estimates of effects expected from implementation of this quality assurance system as a policy as well as in clinical trials. Three forms of feedback interventions—integral elements of this quality assurance system—were effective in enhancing treatment outcome, especially for signal alarm patients. Two of the three feedback interventions were also effective in preventing treatment failure (Clinical Support Tools and the provision of patient progress feedback to therapists). The Clinical Support Tool intervention was effective not only in terms of the amount of outcome enhancing effect, but also in the rate of patient recovery. The current state of evidence appears to support the efficacy and effectiveness of feedback interventions in enhancing treatment outcome.

Researchers have found evidence that when clinicians use an evidence-based feedback system that uses Clinical Support Tools (CST) for not-on-track clients, deterioration rates fall and success rates improve (Shimokawa et al., 2010). Despite multiple studies finding evidence in support of using the CST, there has been a discrepancy between effect sizes (i.e., d = 0.5; Simon et al., 2012). As such, further replicate of these past studies is needed to discover if small effect sizes still persist and if so, what possible variables may contribute to inconsistent findings. For the current study, it was predicted that the use of the CST would result in significantly lower OQ-45 scores at treatment termination after controlling for the intake OQ-45 score. Additionally, previous research indicated that the combined intervention of the progress feedback plus CST would significantly reduce deterioration rates with those NOT. Out of 1,122 participants, 172 were randomly assigned to one of two conditions: The CST feedback group (n = 71) and the no CST feedback group (n = 101). There was not a significant difference in the mean OQ-45 scores for the CST feedback group (M = 2.39, SD = 20.95) and the no CST feedback group (M = 4.17, SD = 19.74). The results of this study raise questions about how regularly the therapists were monitoring their clients' progress feedback and whether the CST are effective. Additionally, the author evaluates the timing of when the CST were administered to clients and when therapists reviewed the feedback.

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