Design and Development of a Proactive Rapid Response System

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.

Information displays for automated surveillance algorithms of in-hospital patient deterioration: a scoping review

OBJECTIVE

Surveillance algorithms that predict patient decompensation are increasingly integrated with clinical workflows to help identify patients at risk of in-hospital deterioration. This scoping review aimed to identify the design features of the information displays, the types of algorithm that drive the display, and the effect of these displays on process and patient outcomes.

MATERIALS AND METHODS

The scoping review followed Arksey and O'Malley's framework. Five databases were searched with dates between January 1, 2009 and January 26, 2022. Inclusion criteria were: participants-clinicians in inpatient settings; concepts-intervention as deterioration information displays that leveraged automated AI algorithms; comparison as usual care or alternative displays; outcomes as clinical, workflow process, and usability outcomes; and context as simulated or real-world in-hospital settings in any country. Screening, full-text review, and data extraction were reviewed independently by 2 researchers in each step. Display categories were identified inductively through consensus.

RESULTS

Of 14 575 articles, 64 were included in the review, describing 61 unique displays. Forty-one displays were designed for specific deteriorations (eg, sepsis), 24 provided simple alerts (ie, text-based prompts without relevant patient data), 48 leveraged well-accepted score-based algorithms, and 47 included nurses as the target users. Only 1 out of the 10 randomized controlled trials reported a significant effect on the primary outcome.

CONCLUSIONS

Despite significant advancements in surveillance algorithms, most information displays continue to leverage well-understood, well-accepted score-based algorithms. Users' trust, algorithmic transparency, and workflow integration are significant hurdles to adopting new algorithms into effective decision support tools.

Automated rapid response system activation-Impact on nurses' attitudes and perceptions towards recognising and responding to clinical deterioration: Mixed-methods study

AIM

To explore general ward nurses' attitudes and perceptions towards recognising and responding to clinical deterioration in a hospital with automated rapid response system activation.

BACKGROUND

There is growing interest in deploying automated clinical deterioration notification systems to reduce delayed or failed recognition and response to clinical deterioration of ward patients. However, little is known about its impact on ward nurses' perspectives and work patterns.

DESIGN

A mixed-methods study.

METHODS

Online survey of 168 registered nurses and individual interviews with 10 registered nurses in one acute hospital in Singapore. The study adhered to the STROBE checklist for cross-sectional studies and the COREQ guidelines for qualitative studies.

RESULTS

Many nurses (38.1%) rarely performed patient assessments or observations other than vital signs assessment to assess for early signs of clinical deterioration. About 30% were worried about being criticised for calling the primary team doctors. Four themes emerged from the qualitative analysis: automated rapid response system activation as a safety net, being more cautious with vital signs monitoring, the NEWS2 alone is inadequate, and ward nurses as the 'middleman' between the intensive care unit outreach nurse and primary team doctors.

CONCLUSIONS

Although nurses value the automated rapid response system activation as a safety net to minimise delays in accessing urgent critical care resources, it does not address the sociocultural barriers inherent in escalation of care. Although the automated system led nurses to be more cautious with vital signs monitoring, it does not encourage them to perform comprehensive patient assessments to detect early signs of deterioration.

RELEVANCE TO CLINICAL PRACTICE

Nurse education on assessing for clinical deterioration should focus on the use of broader patient assessment skills other than vital signs. Sociocultural barriers to escalation of care remain a key issue that needs to be addressed by hospital management.

NO PATIENT OR PUBLIC CONTRIBUTION

No patients, service users, care-givers or members of the public were involved in the study.

Construct and clinical verification of a nurse-led rapid response systems and activation criteria

Background

Effective team leadership and good activation criteria can effectively initiate rapid response system (RRS) to reduce hospital mortality and improve quality of life. The first reaction time of nurses plays an important role in the rescue process. To construct a nurse-led (nurse-led RRS) and activation criteria and then to conduct a pragmatic evaluation of the nurse-led RRS.

Methods

We used literature review and the Delphi method to construct a nurse-led RRS and activation criteria based on the theory of “rapid response system planning.” Then, we conducted a quasi-experimental study to verify the nurse-led RRS. The control group patients were admitted from August to October 2020 and performed traditional rescue procedures. The intervention group patients were admitted from August to October 2021 and implemented nurse-led RRS. The primary outcome was success rate of rescue.

Setting

Emergency department, Gansu Province, China.

Results

The nurse-led RRS and activation criteria include 4 level 1 indicators, 14 level 2 indicators, and 88 level 3 indicators. There were 203 patients who met the inclusion criteria to verify the nurse-led RRS. The results showed that success rate of rescue in intervention group (86.55%) was significantly higher than that in control group (66.5%), the rate of cardiac arrest in intervention group (33.61%) was significantly lower than that in control group (72.62%), the effective rescue time of intervention group (46.98 ± 12.01 min) was shorter than that of control group (58.67 ± 13.73 min), and the difference was statistically significant (P < 0.05). The rate of unplanned ICU admissions in intervention group (42.85%) was lower than that in control group (44.04%), but the difference was not statistically significant (P > 0.05).

Conclusions

The nurse-led RRS and activation criteria can improve the success rate of rescue, reduce the rate of cardiac arrest, shorten the effective time of rescue, effectively improve the rescue efficiency of patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-022-01087-7.

A reference guide to rapidly implementing an institutional dashboard for resource allocation and oversight during COVID-19 pandemic surge

Objectives

We develop a dashboard that leverages electronic health record (EHR) data to monitor intensive care unit patient status and ventilator utilization in the setting of the COVID-19 pandemic.

Materials and methods

Data visualization software is used to display information from critical care data mart that extracts information from the EHR. A multidisciplinary collaborative led the development.

Results

The dashboard displays institution-level ventilator utilization details, as well as patient-level details such as ventilator settings, organ-system specific parameters, laboratory values, and infusions.

Discussion

Components of the dashboard were selected to facilitate the determination of resources and simultaneous assessment of multiple patients. Abnormal values are color coded. An overall illness assessment score is tracked daily to capture illness severity over time.

Conclusion

This reference guide shares the architecture and sample reusable code to implement a robust, flexible, and scalable dashboard for monitoring ventilator utilization and illness severity in intensive care unit ventilated patients.