A measure of facilitators and barriers to rapid response team activation

A systematic review of the facilitators and barriers to rapid response team activation

BACKGROUND

Outcomes associated with rapid response teams (RRTs) are inconsistent. This may be due to underlying facilitators and barriers to RRT activation that are affected by team leaders and health systems.

AIMS

The aim of this study was to synthesize the published research about facilitators and barriers to nurse-led RRT activation in the United States (U.S.).

METHODS

A systematic review was conducted. Four databases were searched from January 2000 to June 2023 for peer-reviewed quantitative, qualitative, and mixed methods studies reporting facilitators and barriers to RRT activation. Studies conducted outside the U.S. or with physician-led teams were excluded.

RESULTS

Twenty-five studies met criteria representing 240,140 participants that included clinicians and hospitalized adults. Three domains of facilitators and barriers to RRT activation were identified: (1) hospital infrastructure, (2) clinician culture, and (3) nurses' beliefs, attributes, and knowledge. Categories were identified within each domain. The categories of perceived benefits and positive beliefs about RRTs, knowing when to activate the RRT, and hospital-wide policies and practices most facilitated activation, whereas the categories of negative perceptions and concerns about RRTs and uncertainties surrounding RRT activation were the dominant barriers.

LINKING EVIDENCE TO ACTION

Facilitators and barriers to RRT activation were interrelated. Some facilitators like hospital leader and physician support of RRTs became barriers when absent. Intradisciplinary communication and collaboration between nurses can positively and negatively impact RRT activation. The expertise of RRT nurses should be further studied.

Exploration of Ward-Based Nurses' Perspectives on Their Preparedness to Recognize Clinical Deterioration: A Scoping Review

BACKGROUND

Despite initiatives in the early recognition of clinical deterioration, the incidence of failure to recognize clinical deterioration in patients continues to occur contributing to the ongoing rise of in-hospital mortality and morbidity.

OBJECTIVE

The aim of the study was to explore and appraise the research evidence that related to ward-based nurses' preparedness to recognize the clinically deteriorating patient.

METHODS

A scoping review was undertaken as this approach enabled the researchers to investigate the breadth of the available evidence through broad inclusion criteria. A comprehensive database search was conducted through the Cochrane Library; Cumulative Index to Nursing and Allied Health Literature; MEDLINE; ProQuest; PubMed; and Wiley Online Library. Each article was critically appraised and analyzed using a critical appraisal tool and thematic analysis, respectively. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews checklist.

RESULTS

Twelve primary sources of literature met the eligibility criteria. Through thematic analyses 6 primary themes were identified: implication of experience on preparedness; interprofessional and intraprofessional relationships; knowledge of calling criteria, process and procedures; requirement for a supportive system and culture; existence of hierarchy within healthcare impacting care; and clinical deterioration as an education opportunity.

CONCLUSIONS

This review identified central issues that impacted on ward-based nurses' preparedness. Further development of collaborative, supportive professional relationships across-and-within disciplines is needed. Effective use of clinical deterioration situations as educational opportunities would also assist nurses' preparedness through skill and knowledge development. However, more research evidence will be needed because of the limited data available on the topic.

Frontline Nurses' clinical judgment in recognizing, understanding, and responding to patient deterioration: A qualitative study

BACKGROUND

Early warning systems and rapid response teams have been widely implemented in hospitals worldwide to facilitate early recognition and response to patient deterioration. Unfortunately, evidence suggests that these interventions have made little impact on unexpected cardiac or respiratory arrest, hospital mortality, unplanned admission to intensive care units, or hospital length of stay. These programs depend on nurses recognizing at risk patients and initiating a timely response. Although physiologic abnormalities commonly precede serious adverse events, nurses often fail to recognize or respond effectively. Clinical judgment is a critical component in the effective response to deterioration, yet little is known about factors that influence nurses' clinical judgment in these situations. Noticing, interpreting, and responding are aspects of clinical judgment and are essential to preventing further patient deterioration and serious adverse events.

OBJECTIVE

To describe medical-surgical nurses' perceptions of factors that influenced their clinical judgment in situations of patient deterioration.

DESIGN

A qualitative descriptive design using individual, semi-structured interviews. Tanner's Clinical Judgment Model served as the framework for interview questions and data analysis.

PARTICIPANTS

A purposive sample of 20 medical-surgical registered nurses were recruited from 10 adult medical-surgical units at an academic medical center hospital in the United States.

METHODS

Telephone interviews occurred between March and July 2018. A directed approach to content analysis was used to code the transcribed data and identify themes.

RESULTS

Eight themes related to each aspect of clinical judgment emerged from the analysis: Knowing the patient, Experience matters, Lots of small points where the system can fail, Making sense of the data, Something doesn't go together, Caught in the middle, Culture of teamwork, and Increased nursing workload. An overarching theme was Nurses' keen sense of responsibility. Findings revealed that factors within the nurse, the patient, and the work environment influence each component of noticing, interpreting, and initiating an effective response to deteriorating patients.

CONCLUSIONS

Findings have implications for health care systems regarding interventions to support timely recognition and response to deterioration. Nurses' clinical judgment and factors that influence each aspect (noticing, interpreting, and responding) should be a key consideration in organizational efforts to improve the overall response to patient deterioration. Research is needed to enhance understanding of the contextual factors that impact nurses' clinical judgment to inform interventions to support timely recognition and response.

Vital signs and early warning score monitoring: perceptions of clinical staff about current practices and introducing an electronic rapid response system

Aims and objectives

This study investigated clinical staff perceptions of learning about current monitoring practices and the planned introduction of an electronic system for patient monitoring. The aim of this research was to evaluate the perceptions of clinical staff (nurses and doctors) about the perceived strengths and weaknesses of the current state of the rapid response system (RRS) and how those strengths and weakness would be affected by introducing an electronic RRS.

Methods

This research applied a descriptive study methodology. Two detailed sessions on demonstration on the electronic RRS for measuring and recording vital signs and the electronic Early Warning System (EWS) were followed by two structured surveys administered through an online portal (SurveyMonkey) for nurses and doctors working at Taranaki District Health Board. The study was planned and conducted between October 2020 and May 2021 at Taranaki Base Hospital, New Plymouth, New Zealand.

Results

We found that the perceptions of clinical staff were a combination of key practice issues with current manual monitoring, expectations of improved visibility of vital sign charts, better communication between staff and thus improved patient care with the introduction of an electronic system. A majority (24, 60%) of nurses reported that, when called to assess deteriorating patients, the responders arrive at bedside within 5–30 min and an additional 11 (27%) said the responders arrive within 5 min. That is a collective 87% responder arrival within 30 min

Conclusion

Staff believe that an electronic RRS could improve communication, speed up decision making and have a positive impact on patient outcomes.

Exploration of a rapid response team model of care: A descriptive dual methods study

BACKGROUND

Avoidable in-patient clinical deterioration results in serious adverse events and up to 80% are preventable. Rapid response systems allow early recognition and response to clinical deterioration.

OBJECTIVE

To explore the characteristics of a collaborative rapid response team model.

DESIGN

Dual methodology was used for this descriptive study.

SETTING

The study was conducted in a 500-bed tertiary referral hospital (Sydney, Australia).

PARTICIPANTS

Inpatients (>17 years) who received a rapid response team activation were included in an electronic medical audit. Participants were rapid response team members and nurses and medical doctors in two in-patient wards.

METHODS

A 12-month (January-December 2018) retrospective electronic health record audit and semi-structured interviews with nurses and medical doctors (July-August 2019) were conducted. Descriptive statistics summarised audit data. Interviews were transcribed and analysed thematically.

RESULTS

The rapid response team consulted for 2195 patients. Mean patient age was 67.9 years, and 46% of the sample was female. Activations (n = 4092) occurred most often in general medicine (n = 1124, 70.8%) units. Overall, 117 patients had >5 activations. The themes synthesised from interviews were i) managing patient deterioration before arrival of the rapid response team; ii) collaboratively managing patient deterioration at the bedside; iii) rapid response team guidance at the bedside; and iv) 'staff concern' rapid response activation.

CONCLUSIONS

Some patients received many activations, however few required treatment in critical care. The rapid response model was collaborative and supportive. The themes revealed a focus on patient safety, optimising early detection, and management of patient deterioration.

Development of an evidence-based ESCALATION system for recognition and response to paediatric clinical deterioration

AIM

The aim of this study was to develop an evidence-based paediatric early warning system for infants and children that takes into consideration a variety of paediatric healthcare contexts and addresses barriers to escalation of care.

METHODS

A three-stage intervention development framework consisted of Stage 1: evidence review, benchmarking, stakeholder (health professionals, decision-makers, and health consumers) engagement, and consultation; Stage 2: planning and coproduction by the researchers and stakeholders using action research cycles; and Stage 3: prototyping and testing.

RESULTS

A prototype evidence-based system incorporated human factor principles, used a structured approach to patient assessment, promoted situational awareness, and included family as well as clinician concern. Family involvement in detecting changes in their child's condition was supported by posters and flyers codesigned with health consumers. Five age-specific observation and response charts included 10 weighted variables and one unweighted variable (temperature) to convey a composite early warning score. The escalation pathway was supported by a targeted communication framework (iSoBAR NOW).

CONCLUSION

The development process resulted in an agreed uniform ESCALATION system incorporating a whole-system approach to promote critical thinking, situational awareness for the early recognition of paediatric clinical deterioration as well as timely and effective escalation of care. Incorporating family involvement was a novel component of the system.

The development and psychometric evaluation of the Clinicians' Attitudes towards Responding and Escalating care of Deteriorating patients scale

BACKGROUND

Validated measures of ward nurses' safety cultures in relation to escalations of care in deteriorating patients are lacking.

OBJECTIVES

This study aimed to develop and evaluate the psychometric properties of the Clinicians' Attitudes towards Responding and Escalating care of Deteriorating patients (CARED) scale for use among ward nurses.

METHODS

The study was conducted in two phases: scale development and psychometric evaluation. The scale items were developed based on a systematic literature review, informant interviews, and expert reviews (n = 15). The reliability and validity of the scale were examined by administering the scale to 617 registered nurses with retest evaluations (n = 60). The factor structure of the CARED scale was examined in a split-half analysis with exploratory and confirmatory factor analyses. The internal consistency, test-retest reliability, convergent validity, and known-group validity of the scale were also analysed.

RESULTS

A high overall content validity index of 0.95 was obtained from the validations of 15 international experts from seven countries. A three-factor solution was identified from the final 22 items: 'beliefs about rapid response system', 'fears about escalating care', and 'perceived confidence in responding to deteriorating patients'. The internal consistency reliability of the scale was supported with a good Cronbach's alpha value of 0.86 and a Spearman-Brown split-half coefficient of 0.87. An excellent test-retest reliability was demonstrated, with an intraclass correlation coefficient of 0.92. The convergent validity of the scale was supported with an existing validated scale. The CARED scale also demonstrated abilities to discriminate differences among the sample characteristics.

CONCLUSIONS

The final 22-item CARED scale was tested to be a reliable and valid scale in the Singaporean setting. The scale may be used in other settings to review hospitals' rapid response systems and to identify strategies to support ward nurses in the process of escalating care in deteriorating ward patients.

Perceived Barriers to Rapid Response Team Activation Among Nurses

The purpose of this literature review was to investigate the major barriers nurses face when it is necessary to seek additional assistance and resources by calling the rapid response team (RRT) in order to manage and stabilize a clinically deteriorating patient. A total of 40 articles were reviewed. Eight barriers were identified as having an impact on RRT activation, either causing a delay in activation time or preventing activation altogether: a lack of consistent RRT education among nurses, the established hierarchy in the hospital, an uncertainty about when to call the RRT if clinical deterioration is subtle or gradual rather than abrupt, a perceived need to justify a decision to call the RRT, the increased workload for both the ICU nurse and the medical-surgical nurse, negative past experiences with RRTs, an unsupportive unit culture, and less nursing experience. Suggestions for overcoming these barriers include RRT education for nurses and physicians in addition to fostering a supportive unit culture.

Empowering nurses to activate the rapid response team

All clinical nurses need to be prepared to recognize deterioration in a patient's clinical status and activate the rapid response team when appropriate. This article explores the clinical nurse's role in recognizing and responding to deterioration in a patient's condition with a focus on hospital-based nurses practicing on a medical-surgical unit.

Nurses' Perceptions of Barriers to Rapid Response System Activation: A Systematic Review

BACKGROUND

The rapid response system (RRS) was designed to identify and intervene on patients exhibiting clinical deterioration in the non-critical-care setting but is not always effectively activated by nurses, leading to adverse patient outcomes.

OBJECTIVES

The objective of this systematic review was to explore nurses' perceived barriers to RRS activation in the acute adult inpatient setting.

METHOD

A systematic review was completed utilizing the Preferred Reporting Items for Systematic Reviews and Meta-analysis checklist. Six different search terms were used in the following electronic databases: Academic Search Premier, the Cumulative Index to Nursing and Allied Health Literature, Healthsource: Nursing/Academic Edition, MEDLINE, and PubMed. Limiters applied to search methods included years 2007 to current, full text, scholarly (peer reviewed), and English language. This review was further limited to quantitative studies in the adult inpatient setting.

RESULTS

The initial electronic database search yielded 149 articles. After duplicate exclusion, 87 article abstracts were reviewed for inclusion and eligibility, and a total of 8 articles were used for this systematic review. Themes to nurses' perceived barriers to RRS activation include RRS activator-responder interaction, physician influence, nurse education, and nurse experience.

DISCUSSION

Nurses play a vital role in patient care by providing continuous surveillance and are the frontline for early detection including prompt intervention should a patient's condition deteriorate. Inconsistent RRS activation has been associated with negative patient outcomes. Exploring nurses' perceived barriers to RRS activation may contribute to interventions that lead to nurses appropriately activating the RRS and potentially decreasing adverse patient outcomes.

Rapid response systems

INTRODUCTION

Rapid response systems are commonly employed by hospitals to identify and respond to deteriorating patients outside of the intensive care unit. Controversy exists about the benefits of rapid response systems.

AIMS

We aimed to review the current state of the rapid response literature, including evolving aspects of afferent (risk detection) and efferent (intervention) arms, outcome measurement, process improvement, and implementation.

DATA SOURCES

Articles written in English and published in PubMed.

RESULTS

Rapid response systems are heterogeneous, with important differences among afferent and efferent arms. Clinically meaningful outcomes may include unexpected mortality, in-hospital cardiac arrest, length of stay, cost, and processes of care at end of life. Both positive and negative interventional studies have been published, although the two largest randomized trials involving rapid response systems - the Medical Early Response and Intervention Trial (MERIT) and the Effect of a Pediatric Early Warning System on All-Cause Mortality in Hospitalized Pediatric Patients (EPOCH) trial - did not find a mortality benefit with these systems, albeit with important limitations. Advances in monitoring technologies, risk assessment strategies, and behavioral ergonomics may offer opportunities for improvement.

CONCLUSIONS

Rapid responses may improve some meaningful outcomes, although these findings remain controversial. These systems may also improve care for patients at the end of life. Rapid response systems are expected to continue evolving with novel developments in monitoring technologies, risk prediction informatics, and work in human factors.