Translation of evidence into policy to improve clinical practice: the development of an emergency department rapid response system

Critical care nurses' role in rapid response teams: A qualitative systematic review

AIM

To analyse the qualitative evidence on the role of critical care nurses in rapid response teams.

DESIGN

Qualitative systematic review.

METHODS

This qualitative systematic review employed Bettany-Saltikov and McSherry's guidelines and is reported according to the Enhancing Transparency in Reporting the Synthesis of Qualitative Research checklist. Two pairs of blinded researchers screened the articles. The data were synthesised using a thematic analysis approach.

DATA SOURCES

A systematic literature search was conducted using the CINAHL, Embase and MEDLINE databases.

RESULTS

Seven studies were included, and three main roles were identified: (1) balancing between confidence and fear in clinical encounters, (2) facilitating collaboration and (3) managing challenging power dynamics in decision-making.

CONCLUSION

Critical care nurses possess extensive knowledge and skills in providing critical care to patients experiencing deterioration on general wards. They play a vital role in facilitating collaboration between team members and ward staff. Furthermore, within the rapid response team, critical care nurses assume leadership responsibilities by overseeing the comprehensive coordination of patient care and actively engaging in the decision-making process concerning patient care.

IMPLICATIONS FOR THE PROFESSION

Highlighting the central role of critical care nurses in rapid response teams as well such a team's benefits in healthcare organisations can promote applications for funding to support further quality assurance of rapid response teams and thus enhance patient safety.

IMPACT

Health care organisations can assure the quality of rapid response team by providing economical resources and training. The education providers should facilitate and standardise curriculum for critical care nursing students to achieve necessary knowledge and skills as members in rapid response teams.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Development of Prediction Model for Intensive Care Unit Admission Based on Heart Rate Variability: A Case-Control Matched Analysis

This study aimed to develop a predictive model for intensive care unit (ICU) admission by using heart rate variability (HRV) data. This retrospective case-control study used two datasets (emergency department [ED] patients admitted to the ICU, and patients in the operating room without ICU admission) from a single academic tertiary hospital. HRV metrics were measured every 5 min using R-peak-to-R-peak (R-R) intervals. We developed a generalized linear mixed model to predict ICU admission and assessed the area under the receiver operating characteristic curve (AUC). Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated from the coefficients. We analyzed 610 (ICU: 122; non-ICU: 488) patients, and the factors influencing the odds of ICU admission included a history of diabetes mellitus (OR [95% CI]: 3.33 [1.71-6.48]); a higher heart rate (OR [95% CI]: 3.40 [2.97-3.90] per 10-unit increase); a higher root mean square of successive R-R interval differences (RMSSD; OR [95% CI]: 1.36 [1.22-1.51] per 10-unit increase); and a lower standard deviation of R-R intervals (SDRR; OR [95% CI], 0.68 [0.60-0.78] per 10-unit increase). The final model achieved an AUC of 0.947 (95% CI: 0.906-0.987). The developed model effectively predicted ICU admission among a mixed population from the ED and operating room.

Frequency of and associations with alterations of medical emergency team calling criteria in a teaching hospital emergency department

BACKGROUND

Medical emergency team (METs), activated by vital sign-based calling criteria respond to deteriorating patients in the hospital setting. Calling criteria may be altered where clinicians feel this is appropriate. Altered calling criteria (ACC) has not previously been evaluated in the emergency department (ED) setting.

OBJECTIVES

The objectives of this study were to (i) describe the frequency of ACC in a teaching hospital ED and the number and type of vital signs that were modified and (ii) associations between ACC in the ED and differences in the baseline patient characteristics and adverse outcomes including subsequent MET activations, unplanned intensive care unit (ICU) admissions and death within 72 h of admission.

METHODS

Retrospective observational study of patients presenting to an academic, tertiary hospital ED in Melbourne, Australia between January 1st, 2019 and December 31st, 2019. The primary outcome was frequency and nature of ACC in the ED. Secondary outcomes included differences in baseline patient characteristics, frequency of MET activation, unplanned ICU admission, and mortality in the first 72 h of admission between those with and without ACC in the ED.

RESULTS

Amongst 14 159 ED admissions, 725 (5.1%) had ACC, most frequently for increased heart or respiratory rate. ACC was associated with older age and increased comorbidity. Such patients had a higher adjusted risk of MET activation (odds ratio [OR]: 3.14, 95% confidence interval [CI]: 2.50-3.91, p = <0.001), unplanned ICU admission (OR: 1.97, 95% CI: 1.17-3.14, p = 0.016), and death (OR: 3.87, 95% CI: 2.08-6.70, p = 0.020) within 72 h.

CONCLUSIONS

ACC occurs commonly in the ED, most frequently for elevated heart and respiratory rates and is associated with worse patient outcomes. In some cases, ACC requires consultant involvement, more frequent vital sign monitoring, expeditious inpatient team review, or ICU referral.

Implementation evaluation of a rapid response system in a regional emergency department: a dual-methods study using the behaviour change wheel

BACKGROUND

Failure to recognise and respond to clinical deterioration is a major cause of high mortality events in emergency department (ED) patients. Whilst there is substantial evidence that rapid response teams reduce hospital mortality, unplanned intensive care admissions, and cardiac arrests on in-patient settings, the use of rapid response teams in the ED is variable with poor integration of care between emergency and specialty/intensive care teams.

OBJECTIVES

The aim of this study was to evaluate uptake and impact of a rapid response system on recognising and responding to deteriorating patients in the ED and identify implementation factors and strategies to optimise future implementation success.

METHODS

A dual-methods design was used to evaluate an ED Clinical Emergency Response System (EDCERS) protocol implemented at a regional Australian ED in June 2019. A documentation audit was conducted on patients eligible for the EDCERS during the first 3 months of implementation. Quantitative data from documentation audit were used to measure uptake and impact of the protocol on escalation and response to patient deterioration. Facilitators and barriers to the EDCERS uptake were identified via key stakeholder engagement and consultation. An implementation plan was developed using the Behaviour Change Wheel for future implementation.

RESULTS

The EDCERS was activated in 42 (53.1%) of 79 eligible patients. The specialty care team were more likely to respond when the EDCERS was activated than when there was no activation ([n = 40, 50.6%] v [n = 26, 32.9%], p = 0.01). Six facilitators and nine barriers to protocol uptake were identified. Twenty behaviour change techniques were selected and informed the development of a theory-informed implementation plan.

CONCLUSION

Implementation of the EDCERS protocol resulted in high response rates from specialty and intensive care staff. However, overall uptake of the protocol by emergency staff was poor. This study highlights the importance of understanding facilitators and barriers to uptake prior to implementing a new intervention.