We Are Not There Yet: A Qualitative System Probing Study of a Hospital Rapid Response System

Objectives The capability of a hospital’s rapid response system (RRS) depends on various factors to reduce in-hospital cardiac arrests and mortality. Through system probing, this qualitative study targeted a more comprehensive understanding of how healthcare professionals manage the complexities of RRS in daily practice as well as identifying its challenges. Methods We observed RRS through in situ simulations in 2 wards and conducted the debriefings as focus group interviews. By arranging a separate focus group interview, we included the perspectives of intensive care unit personnel. Results Healthcare professionals appreciated the standardized use of the National Early Warning Score, when combined with clinical knowledge and experience, structured communication, and interprofessional collaboration. However, we identified salient challenges in RRS, for example, unwanted variation in recognition competence, and inconsistent routines in education and documentation. Furthermore, we found that a lack of interprofessional trust, different understandings of RRS protocol, and signs of low psychological safety in the wards disrupted collaboration. To help remedy identified challenges, healthcare professionals requested shared arenas for learning, such as in situ simulation training. Conclusions Through system probing, we described the inner workings of RRS and revealed the challenges that require more attention. Healthcare professionals depend on structured RRS education, training, and resources to operate such a system. In this study, they request interventions like in situ simulation training as an interprofessional educational arena to improve patient care. This is a relevant field for further research. The Consolidated Criteria for Reporting Qualitative Studies Checklist was followed to ensure rigor in the study.publishedVersio

Reduction in omission events after implementing a Rapid Response System: a mortality review in a department of gastrointestinal surgery

Background Hospitals worldwide have implemented Rapid Response Systems (RRS) to facilitate early recognition and prompt response by trained personnel to deteriorating patients. A key concept of this system is that it should prevent ‘events of omission’, including failure to monitor patients’ vital signs, delayed detection, and treatment of deterioration and delayed transfer to an intensive care unit. Time matters when a patient deteriorates, and several in-hospital challenges may prevent the RRS from functioning adequately. Therefore, we must understand and address barriers for timely and adequate responses in cases of patient deterioration. Thus, this study aimed to investigate whether implementing (2012) and developing (2016) an RRS was associated with an overall temporal improvement and to identify needs for further improvement by studying; patient monitoring, omission event occurrences, documentation of limitation of medical treatment, unexpected death, and in-hospital- and 30-day mortality rates. Methods We performed an interprofessional mortality review to study the trajectory of the last hospital stay of patients dying in the study wards in three time periods (P1, P2, P3) from 2010 to 2019. We used non-parametric tests to test for differences between the periods. We also studied overall temporal trends in in-hospital- and 30-day mortality rates. Results Fewer patients experienced omission events (P1: 40%, P2: 20%, P3: 11%, P = 0.01). The number of documented complete vital sign sets, median (Q1,Q3) P1: 0 (0,0), P2: 2 (1,2), P3: 4 (3,5), P = 0.01) and intensive care consultations in the wards ( P1: 12%, P2: 30%, P3: 33%, P = 0.007) increased. Limitations of medical treatment were documented earlier (median days from admission were P1: 8, P2: 8, P3: 3, P = 0.01). In-hospital and 30-day mortality rates decreased during this decade (rate ratios 0.95 (95% CI: 0.92–0.98) and 0.97 (95% CI: 0.95–0.99)). Conclusion The RRS implementation and development during the last decade was associated with reduced omission events, earlier documentation of limitation of medical treatments, and a temporal reduction in the in-hospital- and 30-day mortality rates in the study wards. The mortality review is a suitable method to evaluate an RRS and provide a foundation for further improvement.publishedVersio

Succeeding with Rapid Response Systems in Hospitals: A mixed methods research project

Background: Modern hospital care is both advanced and complicated with multiple opportunities for medical errors including serious adverse events. Rapid Response Systems (RRSs) have been implemented in hospitals globally to prevent serious adverse events, such as cardiopulmonary arrest or death through systematic patient monitoring, early detection of deterioration (afferent limb), and timely response by competent personnel (efferent limb). An RRS also has two governance limbs, for ensuring resources (administrative limb) and follow up on quality (quality limb). Although RRSs have been found to be effective in many hospitals, patients still experience omission events; lack of monitoring, delayed or missing recognition of deterioration, and delayed or lack of response to deterioration. The concept of the RRS constitutes the conceptual framework of this thesis. The overall aim of this PhD project was to increase the knowledge of how to prevent omission events in hospitals through succeeding with an RRS. Methodology: This thesis uses a sequential mixed-methods design consisting of two qualitative studies and one quantitative study, and an integrated synthesis of their findings. The first study, a systematic review, included 21 qualitative papers that presented perceptions of healthcare professionals from different parts of the world, regarding facilitators and barriers of a hospital RRS. The second and third studies were both conducted in a Norwegian university hospital. In the second study, focus group interviews were conducted in two wards in the context of RRS simulation training, and separately in the intensive care unit to add the perspective of the efferent limb. Qualitative analyses were performed to provide an understanding of how healthcare professionals manage the complexities of an RRS in daily practice as well as identifying its challenges. In the third study a mortality review of diseased patients in two wards of a Department of Gastrointestinal Surgery were conducted. Quantitative analyses were performed to compare results from three time periods before- and after the implementation (2012) and further development (2016) of an RRS. Mortality rates for patients admitted to the study wards in the period of 2010–2019 are presented. Finally, this thesis presents a qualitative synthesis integrating the results of the three studies, addressing a thesis research question of how hospital organisations with an RRS can better prevent omission events. Results: Paper I highlights the importance of the administrative and quality improvement limbs. When these limbs were poorly connected to the operative limbs it led to unclear protocols, poor logistics, inconsistent education of healthcare professionals, and a lack of resources, including staff and beds. Furthermore, this paper emphasises the complexity of operating the afferent limb, ensuring regular monitoring, using scoring systems as intended in addition to managing a variety of documentation systems in busy hospital wards. Moreover, the paper reveals how the collaboration between the afferent and efferent limbs is vulnerable. Criticism and disrespectful behaviour down the hierarchy was frequently reported. This paper provides an international overview of barriers and facilitators of an RRS and influenced the aim, design, and research questions of Studies 2 and 3. Paper II reports how healthcare professionals value combining a scoring system with clinical competence to discover deterioration. However, their ability to recognise deterioration was variable. Structured communication supported escalation when a patient was deteriorating, whereas variability in knowledge regarding the RRS and documentation routines impeded timely detection and escalation. Competing tasks, crowded units, and fear of criticism when calling the efferent limb from the intensive care unit disrupted collaboration. This paper illuminates the value of simulation training to probe a hospital RRS and as an arena to improve consistent use of the RRS and interprofessional collaboration. These findings contributed to the development of the aim and design of Study 3. Paper III reports how patient demographics did not change during the three time periods studied in the mortality review. After implementation and development of the RRS, there was a significant increase in documented vital signs, earlier documentation of limitations of medical treatment, an increase in reviews by healthcare professionals from the intensive care unit, without an increase in transfers to the intensive care unit, and a decrease in the number of patients experiencing omission events. This was associated with a significant decrease in in-hospital mortality, as well as 30-day mortality rates. The integrated synthesis of the three studies underlines the need for hospital organisations to take overall responsibility for adequate resourcing. This includes competent personnel, necessary equipment, and comprehensive and user-friendly technological solutions for monitoring and documentation. Furthermore, the RRS protocol needs to be customised to the organisation. The trigger criteria and the structure of the efferent limb must be wisely chosen, and a clear RRS protocol is essential. Finally, hospital organisations need to ensure continuous follow up of quality and improvement. The chosen RRS structure, how it is used by healthcare professionals, and defined outcome measures should be continuously evaluated, and results fed back to healthcare professionals. Identified challenges need to be acknowledged and addressed. Conclusions: Through studying the perceptions of healthcare personnel internationally and nationally, performing a mortality review and integrating the findings from the three studies, this thesis contributes to increased knowledge on how to prevent omission events in hospitals through succeeding with an RRS. This thesis demonstrates that leadership, taking the overall responsibility in the hospital organisation is essential to ensure adequate resources, including the alignment of workload and staffing, and providing user-friendly monitoring and documentation systems. Developing an environment where healthcare personnel can build competence in clinical evaluation and interprofessional collaboration is fundamental. Furthermore, a conscious choice of RRS structure, including trigger criteria, and efferent limb structures, described in a clear RRS protocols is needed. Continuous quality follow-up enabling improvements and adjustments of the RRS is warranted to prevent omission events, and thus minimise the occurrence of serious adverse events

Succeeding with rapid response systems - a never-ending process: A systematic review of how health-care professionals perceive facilitators and barriers within the limbs of the RRS

Background Meta-analyses show that hospital rapid response systems (RRS) are associated with reduced rates of cardiorespiratory arrest and mortality. However, many RRS fail to provide appropriate outcomes. Thus an improved understanding of how to succeed with a RRS is crucial. By understanding the barriers and facilitators within the limbs of a RRS, these can be addressed. Objective To explore the barriers and facilitators within the limbs of a RRS as described by health-care professionals working within the system. Methods The electronic databases searched were: EMBASE, MEDLINE, CINAHL, Epistemonikos, Cochrane, PsychInfo and Web of Science. Search terms were related to RRS and their facilitators and barriers. Studies were appraised guided by the CASP tool. Twenty-one qualitative studies were identified and subjected to content analysis. Results Clear leadership, interprofessional trust and collaboration seems to be crucial for succeeding with a RRS. Clear protocols, feedback, continuous evaluation and interprofessional training were highlighted as facilitators. Reprimanding down the hierarchy, underestimating the importance of call-criteria, alarm fatigue and a lack of integration with other hospital systems were identified as barriers. Conclusion To succeed with a RRS, the keys seem to lie in the administrative and quality improvement limbs. Clear leadership and continuous quality improvement provide the foundation for the continuing collaboration to manage deteriorating patients. Succeeding with a RRS is a never-ending process.publishedVersio