Clinical and Sociocultural Factors Associated With Failure to Escalate Care of Deteriorating Patients

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.

Collaborative practice among general ward staff on escalating care in clinical deterioration: A systematic review

AIM

To understand the issues surrounding collaborative practice and collaboration experiences among general ward staff in the escalation of care for clinically deteriorating patients.

DESIGN

A systematic synthesis without meta-analysis.

REVIEW METHODS

Seven electronic databases (CINAHL, Cochrane, Embase, PsycINFO, PubMed, Scopus and ProQuest Theses and Dissertations) were searched from their inception to 30 April 2022. Two reviewers independently screened titles, abstracts and full text for eligibility. The critical appraisal skill programme, Joanna Briggs Institute checklist for analytical cross-sectional studies and mixed methods appraisal tool were used to appraise the quality of the included studies. Both quantitative and qualitative research data were extracted, analysed and then synthesised using the data-based convergent qualitative synthesis approach. This review adhered to the Synthesis without meta-analysis (SWiM) reporting guidelines.

RESULTS

A total of 17 studies were included. Two themes and six sub-themes were generated: (1) intraprofessional factors-inadequate handover, workload and mutual support, raising and acting on concerns, and seeking help from seniors and (2) interprofessional factors-differences in communication styles, and hierarchical approach versus interpersonal relationships.

CONCLUSIONS

This systematic review highlights the need to address the intra- and interprofessional issues surrounding collaborative practice in escalation of care among general ward staff.

IMPLICATIONS FOR THE PROFESSION

Findings from this review will inform healthcare leaders and educators on the development of relevant strategies and multi-disciplinary training to foster effective teamwork among nurses and doctors, with the goal of improving the escalation of care for patients with clinical deterioration.

NO PATIENT OR PUBLIC CONTRIBUTION

This systematic review did not directly involve patient or public contribution to the manuscript.

Association Between Language Use and ICU Transfer and Serious Adverse Events in Hospitalized Pediatric Patients Who Experience Rapid Response Activation

BACKGROUND

Hospitalized patients and caregivers who use a language other than English have worse health outcomes, including longer length of stay, more frequent readmissions, and increased rates of in-hospital adverse events. Children who experience clinical deterioration (as measured by a Rapid Response Team event) during a hospitalization are at increased risk for adverse events and mortality.

METHODS

We describe the results of a retrospective cohort study using hospital records at a free-standing, quaternary children's hospital, to examine the association of language of care with outcomes (transfer to intensive care, adverse event, mortality prior to discharge) following Rapid Response Team event, and whether increased interpreter use among patients who use a language other than English is associated with improved outcomes following Rapid Response Team event.

RESULTS

In adjusted models, Rapid Response Team events for patients who use a language other than English were associated with higher transfer rates to intensive care (RR 1.1, 95% CI 1.01, 1.21), but not with adverse event or mortality. Among patients who use a language other than English, use of 1-2 interpreted sessions per day was associated with lower transfer rates to intensive care compared to use of less than one interpreted session per day (RR 0.79, 95% 0.66, 0.95).

CONCLUSION

Rapid Response Team events for hospitalized children of families who use a language other than English are more often followed by transfer to intensive care, compared with Rapid Response Team events for children of families who use English. Improved communication with increased interpreter use for hospitalized children who use a language other than English may lead to improvements in Rapid Response Team outcomes.

Human factors in escalating acute ward care: a qualitative evidence synthesis

Background

Identifying how human factors affect clinical staff recognition and managment of the deteriorating ward patient may inform process improvements. We systematically reviewed the literature to identify (1) how human factors affect ward care escalation (2) gaps in the current literature and (3) critique literature methodologies.

Methods

We undertook a Qualitative Evidence Synthesis of care escalation studies. We searched MEDLINE, EMBASE and CINHAL from inception to September 2019. We used the Critical Appraisal Skills Programme and the Grading of Recommendations Assessment-Development and Evaluation and Confidence in Evidence from Reviews of Qualitative Research tool to assess study quality.

Results

Our search identified 24 studies meeting the inclusion criteria. Confidence in findings was moderate (20 studies) to high (4 studies). In 16 studies, the ability to recognise changes in the patient’s condition (soft signals), including skin colour/temperature, respiratory pattern, blood loss, personality change, patient complaint and fatigue, improved the ability to escalate patients. Soft signals were detected through patient assessment (looking/listening/feeling) and not Early Warning Scores (eight studies). In contrast, 13 studies found a high workload and low staffing levels reduced staff’s ability to detect patient deterioration and escalate care. In eight studies quantifiable deterioration evidence (Early Warning Scores) facilitated escalation communication, particularly when referrer/referee were unfamiliar. Conversely, escalating concerning non-triggering patients was challenging but achieved by some clinical staff (three studies). Team decision making facilitated the clinical escalation (six studies).

Conclusions

Early Warning Scores have clinical benefits but can sometimes impede escalation in patients not meeting the threshold. Staff use other factors (soft signals) not captured in Early Warning Scores to escalate care. The literature supports strategies that improve the escalation process such as good patient assessment skills.

PROSPERO registration number

CRD42018104745.

Identifying barriers and facilitators to recognition and response to patient clinical deterioration by clinicians using a behaviour change approach: A qualitative study

BACKGROUND

Failure of clinicians to recognise and respond to patient clinical deterioration is associated with increased hospital mortality. Emergency response teams are implemented throughout hospitals to support direct-care clinicians in managing patient deterioration, but patient clinical deterioration is often not identified or acted upon by clinicians in ward settings. To date, no studies have used an integrative theoretical framework in multiple sites to examine why clinicians' delay identification and action on patients' clinical deterioration.

AIM

To identify barriers and facilitators that influence clinicians' absent or delayed response to patient clinical deterioration using the Theoretical Domains Framework.

METHODS

The Theoretical Domains Framework guided: (a) semi-structured interviews with clinicians, health consumers and family members undertaken at two sites; (b) deductive analyses of inductive themes to identify barriers and facilitators to optimal care. This study complied with the COREQ research guidelines.

FINDINGS

Seven themes identified: (a) information transfer; (b) ownership of patient care; (c) confidence to respond; (d) knowledge and skills; (e) culture; (f) emotion; and (g) environmental context and resources.

DISCUSSION

The Theoretical Domains Framework identified traditional social and professional hierarchies and limitations due to environmental contexts and resources as contributors to diminished interprofessional recognition and impediments to the development of effective relationships between professional groups. Communication processes were impacted by these restraints and further confounded by inadequate policy development and limited access to regular effective team-based training. As a result, patient safety was compromised, and clinicians frustrated.

CONCLUSIONS

These results inform the development, implementation and evaluation of a behaviour change intervention and increase knowledge about barriers and facilitators to timely response to patient clinical deterioration.

RELEVANCE TO CLINICAL PRACTICE

Results contribute to understanding of why clinicians delay responding to patient clinical deterioration and suggest key recommendations to identify and challenge traditional hierarchies and practices that prevent interdisciplinary collaboration and decision-making.