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Wei Ling Chua, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore Address reprint requests to: Wei Ling Chua, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore. Level 1, Clinical Research Centre, Block MD11 10 Medical Drive, Singapore 117597. Tel: +65-6516-7456; Fax: +65-6776-7135; E-mail: Search for other works by this author on: Min Ting Alicia See,Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore Search for other works by this author on: Helena Legido-Quigley,Saw Swee Hock School of Public Health, National University of Singapore, Singapore London School of Hygiene and Tropical Medicine, London, UK Search for other works by this author on: Daryl Jones,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia University of Melbourne, Melbourne, VIC, Australia Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia Search for other works by this author on: Augustine Tee,Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore Search for other works by this author on: Sok Ying LiawAlice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore Search for other works by this author on: Received: 01 December 2016 Revision received: 06 June 2017 Accepted: 26 October 2017 Published: 21 November 2017
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Navbar Search Filter Microsite Search Term Search AbstractPurpose To synthesize factors influencing the activation of the rapid response system (RRS) and reasons for suboptimal RRS activation by ward nurses and junior physicians. Data sources Nine electronic databases were searched for articles published between January 1995 and January 2016 in addition to a hand-search of reference lists and relevant journals. Study selection Published primary studies conducted in adult general ward settings and involved the experiences and views of ward nurses and/or junior physicians in RRS activation were included. Data extraction Data on design, methods and key findings were extracted and collated. Results of data synthesis Thirty studies were included for the review. The process to RRS activation was influenced by the perceptions and clinical experiences of ward nurses and physicians, and facilitated by tools and technologies, including the sensitivity and specificity of the activation criteria, and monitoring technology. However, the task of enacting the RRS activations was challenged by seeking further justification, deliberating over reactions from the rapid response team and the impact of workload and staffing. Finally, adherence to the traditional model of escalation of care, support from colleagues and hospital leaders, and staff training were organizational factors that influence RRS activation. Conclusion This review suggests that the factors influencing RRS activation originated from a combination of socio-cultural, organizational and technical aspects. Institutions that strive for improvements in the existing RRS or are considering to adopt the RRS should consider the complex interactions between people and the elements of technologies, tasks, environment and organization in healthcare settings. IntroductionThere has been a growing body of research that focus on recognizing and responding to clinically deteriorating patients in general ward settings in the past decade [1–4]. Much of this interest was prompted by studies that demonstrated patient deterioration not being recognized and responded to in a timely manner [5–10]. This lapse in patient care has led to an increase risk and incidences of serious adverse events such as unplanned admissions to intensive care units, in-hospital cardiopulmonary arrests, and unexpected deaths [11, 12]. Improving timely recognition and prompt interventions is therefore pivotal to the provision of safe and quality care to a deteriorating patient before his condition becomes life-threatening [13]. International concerns over delays or failure to recognize and escalate care for clinically deteriorating ward patients have led to the widespread implementation of a hospital-wide patient safety initiative known as the rapid response system (RRS) in acute hospitals [14, 15]. The RRS is designed with afferent and efferent components, and mechanisms for quality control, audit and administration [16]. The afferent arm involves monitoring and identifying deteriorating patients using a set of activation criteria, commonly known as the Early Warning Scoring System (EWSS), which is based on abnormal vital signs and/or observations such as threatened airway, declined neurological status and staff concerns (‘worried’ criterion) [17–19]. Once a patient meets the activation criteria, the efferent arm, i.e. the rapid response team (RRT) or medical emergency team (MET), comprising personnel with critical care expertise and diagnostic skills, will be activated to swiftly bring critical care expertise to the deteriorating patient [13, 17]. The RRS bypasses the traditional hierarchical escalation of care by sanctioning bedside nurses and junior physicians to promptly access senior medical assistance, outside the primary physician team’s chain of command [13, 16, 20]. Theoretically, the RRS offers significant advantages over the traditional referral model of care and potentially decreases resuscitation events in general wards [21]. However, two decades of research still demonstrate mixed evidence on the effectiveness of the RRS in achieving their stated aims to reduce resuscitation events outside of the ICU, unplanned ICU admissions and hospital mortality [22–28]. Some proponents have questioned the existence of the tangible benefits of the RRS and suggested the need for higher level research and randomized controlled trials while others argued that the benefits are self-evident. Several authors have also attributed the conflicting evidence regarding the effectiveness of the RRS to delay or failure in ward clinicians to activate the RRT despite patients fulfilling the activation criteria [24, 27, 29–32]. An epidemiology review of adult RRT patients in Australia revealed that close to 50% of the activations were delayed [33]. Apart from cognitive failure to recognize the need for RRS activation, socio-cultural factors and professional hierarchies are also strong reasons that impede adherence to the RRS protocol [34–39]. Existing studies found that junior physicians were reluctant to breach the traditional system of patient management while ward nurses feared being reprimanded if they bypassed attending physicians [21, 31, 40]. This highlights the need for a detailed analysis to understand individual and work system issues that may prevent frontline ward clinicians from activating the RRS. Therefore, this review aims to synthesize and summarize the factors influencing an activation of the RRS by ward nurses and junior physicians in general wards. This review is also anticipated to identify reasons for suboptimal activation of the RRS, and highlight gaps for further research. MethodsThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used to guide the reporting of this systematic review [41]. Eligibility criteriaThe eligibility criteria are outlined in Table 1. Table 1 Eligibility criteria for inclusion of articles in the review
PICOS, Population, Phenomena of Interest, Context, Study design; RRS, rapid response system. Table 1 Eligibility criteria for inclusion of articles in the review
PICOS, Population, Phenomena of Interest, Context, Study design; RRS, rapid response system. Information sourcesA comprehensive search was performed included searching relevant electronic databases (CINHAL, PubMed, Cochrane Library, EMBASE, Scopus, ScienceDirect, Web of Science, PsycINFO and ProQuest Dissertations & Theses database), mining the reference lists of selected articles, and hand-searching Resuscitation and BMJ Quality & Safety, which are known for publishing articles related to the RRS and/or patient deterioration. SearchThree broad search key concepts were developed: RRS, EWSS and deteriorating ward patients. Thesaurus terms of these concepts were used. Search terms were used singly and/or in combination (Appendix 1 contains the full search strategy). Literature that was published between January 1995 and January 2016 was searched. The year 1995 was chosen as the cut-off date as it marked the first published literature outlining the concept of the RRS [42]. Study selectionOne reviewer (WLC) screened the titles and abstracts of relevant articles before conducting a full-text review while meeting regularly with the two other reviewers (MTAS & SYL) to discuss article eligibility. Reasons for exclusion were recorded. Data extractionA data extraction form was developed to catalog the author(s), publication year, study aims, country and setting of study, sample, methods for data collection and data analyses, and relevant key findings. Data were extracted independently by WLC, then reviewed by SYL. Differences were resolved by discussions among the two reviewers. Quality assessmentAll included studies were appraised independently by WLC and MTAS using the Critical Appraisal Skills Programme [43] for qualitative studies, Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument [44] for quantitative studies, and Mixed Methods Appraisal Tools [45] for mixed-method studies. Articles were scored against each item in the appraisal checklist by scores of not met (‘0’), partially met (‘0.5’), fully met (‘1’), or unsure. A total study quality percentage was tabulated. Depending on the total appraisal score, the included articles were classified as low (<50%), medium (50–70%), or high (>70%) quality. The results were compared and disagreements were resolved by consultation with SYL. Data synthesisData synthesis adopted the integrated design for mixed research synthesis [46] and the hybrid process of inductive and deductive thematic analysis [47]. The synthesis began with converting the extracted quantitative findings into qualitative forms, i.e. free codes, and, together with the extracted qualitative findings, was subjected to the inductive portion of a hybrid thematic analysis. Themes that explored the relevance of the categories of codes in the context of the research question were developed. The deductive portion involved categorizing the inductively developed themes into a conceptual framework [47]. While the process was initially undertaken by WLC, the groupings were further refined by discussions with the co-authors and rechecking of the included studies. ResultsSearch resultsThe search strategy yielded 9524 records after removing duplicated articles. Following the review of titles and abstracts, 83 articles were selected for full-text review, from which 53 articles were excluded, leaving 30 studies for this review [21, 37–40, 48–72] (Fig. 1). Figure 1  PRISMA flow diagram of study selection process. Study characteristicsStudies originated from the United States (US) (n = 14), Australia (n = 10), the United Kingdom (n = 2), along with one study each from Canada, Finland, Greece, and Italy. The study setting included acute and tertiary care (n = 19), community hospitals (n = 4), and mixed-settings (n = 7). Eight studies were multi-site studies. The median sample sizes were 32 participants for qualitative studies, 246 participants for quantitative studies and 407 medical record reviews and 10 participants for mixed-method studies. The population studied included ward nurses (n = 16), physicians (n = 1), both nurses and physicians (n = 7), a mixture of healthcare professionals (n = 4), and general ward patients (n = 2). There were 15 quantitative, 12 qualitative and 3 mixed-methods studies. Most quantitative studies were self-administered survey-based studies (n = 12), except for one study, which employed face-to-face surveys. Reviews of medical records and RRT activations were used in five studies, with three of these studies using record review in conjunction with a qualitative approach (mixed-method studies). Qualitative data were collected through interviews (n = 9) and focus groups (n = 3). Table 2 summarizes the included studies. Table 2. Summary of study characteristics (n = 30)
RRT, rapid response team; US, United States; NS, not specify; MET, medical emergency team; RRS, rapid response system; RN, registered nurse; UK, United Kingdom; ICU, intensive care unit; CCOT, critical care outreach team; MEWS, modified early warning system; METal, medical emergency team alert. Table 2. Summary of study characteristics (n = 30)
RRT, rapid response team; US, United States; NS, not specify; MET, medical emergency team; RRS, rapid response system; RN, registered nurse; UK, United Kingdom; ICU, intensive care unit; CCOT, critical care outreach team; MEWS, modified early warning system; METal, medical emergency team alert. Quality assessmentThe overall quality assessment of the study was medium (n = 18) to high (n = 12) (Appendix 2), with a substantial overall agreement of 83.3% between WLC and MTAS (Kappa = 0.658, P < 0.001). The studies were generally good at providing clear research aims, congruity between the research aims and research design, providing details on the sample, and outlining the data collection and data analysis methods. More than half of the qualitative studies had inadequate clarifications for ethical issues and failed to consider the effect of the researcher–participant relationship. The main weaknesses of the quantitative studies were the lack of considerations for confounders and insufficient psychometric evaluation of the different questionnaires administered. Only five studies addressed confounders using a statistical approach [21, 64, 67, 68, 72]. More than half of the studies have limited generalizability, given the small sample size and non-response bias due to poor response rates. All the mixed-method studies had inadequate justifications for the need of a mixed-method design to address their research questions and did not consider the limitations associated with integration of qualitative and quantitative data. Synthesis of resultsThe Systems Engineering Initiative for Patient Safety (SEIPS) model of work system and patient safety developed by Carayon et al. is used as a conceptual framework to understand the barriers and facilitators to activation of the RRS by ward nurses and junior physicians [73]. The SEIPS model provides a framework for understanding the impact of work system factors on healthcare processes and patient outcomes [73]. The factors identified were grouped into 10 themes, which were then categorized into the five interacting components of the work systems of the SEIPS model: the person[s] using various tools and technologies to perform tasks in an environment under certain organizational conditions [73]. The interaction of these components of the work systems influences the processes of RRS activation, which in turn affects patient outcomes. At the same time, feedback loops between the process and outcomes, and the work systems can inform problems and opportunities for modifying the work systems [73, 74]. Figure 2 depicts an adapted graphical representation of a ward clinician’s work system that influences RRS activation. Factors influencing RRS activation were distributed across person, tools and technologies, tasks, and organization. No factor was identified in the environment component. Table 3a–3d provides an explanation and supporting evidence for each of the factors identified Table 3a Person-related factors influencing an activation of the rapid response system by ward nurses and junior physicians
Table 3a Person-related factors influencing an activation of the rapid response system by ward nurses and junior physicians
Table 3b Tools and technology-related factors influencing an activation of the rapid response system by ward nurses and junior physicians
Table 3b Tools and technology-related factors influencing an activation of the rapid response system by ward nurses and junior physicians
Table 3c Task-related factors influencing an activation of the rapid response system by ward nurses and junior physicians
Table 3c Task-related factors influencing an activation of the rapid response system by ward nurses and junior physicians
Table 3d Organization-related factors influencing an activation of the rapid response system by ward nurses and junior physicians
Table 3d Organization-related factors influencing an activation of the rapid response system by ward nurses and junior physicians
Fig. 2 The application of SEIPS model to ward clinicians’ work system in the activation of the rapid response system. Dotted arrows and box: No identified interacting relationship between physical environment and the rest of the work system components (person, tools and technologies, tasks and organization). Descriptions of work system components (adapted from SEIPS model by Carayon et al. [73]). PE: Physical, cognitive, or psychosocial characteristics or conditions of an individual at the center of the work system. TT: Objects or instruments that the person(s) uses to do work or assist people in doing work (RRS activation). TA: Characteristics of the task such as difficulty, variety and sequence of work performed by the person(s) to accomplish the objectives. OR: Organizational conditions governing or influencing the way the person(s) performs tasks using tools and technologies in a specific environment. EN: Physical characteristics of the environment where work is performed. ‘Person’, which refers to ward nurses and junior physicians in this review, is at the center of the work system. The process to activation of the RRS was found to be affected by person-related factors such as perceptions of the benefits and drawbacks of the RRS, clinical expertise, and support received from colleagues and hospital leadership in the activation of the RRS (Table 3a). Although the process was also aided by ‘tools and technologies’, there was apprehension about the ability of the tools and technologies to support early recognition of patient deterioration and RRS activation, particularly on the issues of sensitivity and specificity of the activation criteria and the limitations of the monitoring technology (Table 3b). The enactment of activating the RRS was made complex with the ‘task’ of seeking justification and affirmation, deliberating over reactions from the RRT, and taking into consideration the workload and staffing (Table 3c). Adherence to the traditional model of escalation of care and staff education were powerful ‘organizational’ factors that influenced the way ward clinicians used tools and technologies, and performed their tasks of activating the RRS (Table 3d). The findings from this systematic review led us to confirm that the process to the activation of the RRS is complex and multifactorial, but underpinned by well-defined themes in the work systems of ward clinicians. DiscussionThis is the first systematic review to synthesize evidence on the factors influencing RRS activation by junior physicians and ward nurses. Using the SEIPS model, we found that the elements of person, tools and technologies, tasks, and organization were associated with RRS activation. No factor associated with physical work environment was identified. This may be due to a lack of awareness and studies examining the ergonomics of workplace on RRS activations. Nevertheless, our findings validate and expand upon the findings of a previous literature review on factors that affect nurses’ effective use of the RRT [75]. The application of the SEIPS model enabled a clearer connection of the interactions of different factors in the work systems factors which influences the recognition of the need for RRT and activation of the RRS (processes) to effectively avert adverse events (outcome) resulting from uninterrupted clinical deterioration. For example, ward nurses’ adherence to the traditional model of escalation of care was associated with their fear of criticism for ‘incorrect’ activations. Their fear of criticism is linked to a combination of insufficient clinical experience (person-related), inadequacy in the activation criteria (tools and technological-related), and dismissive responses from RRT members (task-related), which often leads to ward nurses hankering after an affirmation for RRS activation. Experienced nurses were found to be more confident and capable in recognizing the need for RRT interventions based on their intuitions. Hence, they were often consulted by their juniors when an affirmation is needed. The inadequacy of the activation criteria to detect subtle and early deterioration highlights that acquiescent reliance on the activation criteria, with vital signs derangements as the optimal cue for RRS activation, can marginalize other assessment cues [76, 77]. Overreliance on vital signs abnormalities also risks devaluing the merit of subjective data and intuitive senses within assessment reflecting early deterioration [78]. Patient assessment using sensory skills such as visual observation, palpation and listening, which aid early detection of deterioration before vital signs changes are evident, should not be compromised or replaced with electronic monitoring equipment [79–81]. It is thus essential that clinicians are equipped with the ability to conduct and interpret appropriate patient assessments. Furthermore, an overreliance on automated patient monitoring can lead to a tendency to have strong belief in the accuracy of the monitoring technology with a low degree of suspicion of error [82]. This could cause nurses to be less vigilant to patients’ deteriorating conditions, thus likely to jeopardize patient safety [82]. Similar to the ward nurses, adherence to the traditional model of calling attending physicians first was the biggest barrier for junior physicians. Our findings suggest that this barrier could be attributed to their perception of threatened deskilling due to the presence of the RRT. Resistance from the medical profession towards the acceptance of the RRS due to perceived disruptive effects on junior physicians’ education and clinical autonomy can be linked to the professional socialization in medicine education where physicians laid claims to their expertise and jurisdictions over patient management [85, 86]. As such, RRS activation could be deemed as incompetent and at odds with the socialization process of becoming an independent practitioner. An initiation of the RRS involves a complex cultural system of change, which is superimposed on professional norms and boundaries in a strictly hierarchical context [83]. This initiative may be difficult to adopt unless all healthcare practitioners within an organization collectively agree to use the system [84]. Thus, hospital leaders play an essential role in transforming individual thinking, organizational culture and professional hierarchy in medicine. While it takes time for attitudes and behaviors to alter, and organizational cultural changes to be embedded, hospital leaders can introduce some quick wins as the first steps towards garnering support and acceptance from stakeholders of the RRS [87]. Implications for clinicians and policymakers, and future researchOur findings demonstrate that frontline clinicians were convinced about the value of the RRS. However, timely RRS activations should be encouraged with appropriate support. Given that junior nurses’ first course of action when uncertain about the need for a RRS activation was to seek affirmation from senior nurses, an adequate skill mix of experienced nurses on shift thus becomes apparent. The considerable amount of time spent justifying RRS activation limits the RRS as an early intervention to clinical deterioration. Thus, further work is required to integrate relevant patient assessment skills and early cues of deterioration into the EWSS activation criteria, as well as equip clinicians with a more clinically specified understanding of the ‘worried’ criterion that is less open to subjective interpretation [21, 88, 89]. Future studies can also examine the impact of clinicians’ decision-making process on timely RRS activations and patient outcome. The lack of substantial evidence on the influence of monitoring technology also recommends research to assess the impact of monitoring technology on timely activations and patient outcome. Socio-cultural barriers such as adherence to the traditional hierarchical escalation of care, fear of criticism and negative behaviors of the RRT responders could be mediated by hospital leaders. This can be achieved through continuous training coupled with appropriate education and training methods to encourage teamwork and clinicians to respond responsibly, clear RRS protocols, and continuously support advocating RRS activations. An exploration of other viable modes of education and training methods is warranted. Literature has highlighted that certain cultures tend to adopt vertical hierarchies in their working relationships [90], which could potentially be an obstacle to RRS activation. Future studies should be conducted beyond a non-Western context, which was not included in this review. It is also paramount that hospital leaders periodically evaluate their hospital RRS. An important aspect not to be overlooked is the perspectives of ward nurses and junior physicians, who are key users of the RRS. Understanding the impact of the RRS on junior physicians’ medical education holds strong promise to enhance the implementation process of the RRS in institutions and improve physicians’ acceptance of the RRS. Researchers may seek to develop a tool to help hospital leaders identify core factors to improve each hospital’s RRS. Lastly, this review recommends the adoption of human factors ergonomics perspectives to understand the interactions between the end-users of the RRS and other elements of the work system to further optimize and mitigate obstacles associated with the RRS. LimitationsDespite an exhaustive literature search, the exclusion of studies that evaluated the effectiveness or impact of the RRS on patient outcomes, which may contain additional insights, may have been missed. Secondly, most of the quantitative studies were cross-sectional surveys that provided information about attributes at a single time-point. It is likely that the perceptions of responders will change overtime. Thirdly, there are variations in the RRS implemented across the included studies i.e. the maturity of the RRS and different composition of the RRT (physician-led RRT versus nurse-led RRT). This may have an influence on ward clinicians’ decisions to activate the RRT. Fourthly, as most of the studies did not report the RRS activation rates, we could not analyze the identified factors in relation to the activation frequency. Lastly, the use of a different conceptual model might have resulted in different themes identified. ConclusionThis systematic review has demonstrated that RRS activation is a complex intervention that involves navigating through the way clinicians interact with the interplay of socio-cultural, political and organizational considerations. Activations of the RRS were found to be influenced by key factors that include frontline clinicians’ perceptions of the RRS and their clinical judgment, support from colleagues and hospital leaders, adequacy of the activation criteria, attitudes and responses of the RRT members, adherence to the traditional model of escalation of care, and staff training and education. Institutions should consider these factors in the implementation of their RRS and develop strategies to improve the utilization of the RRS. More research efforts, along with clinical practice implications, should be central to improving suboptimal activations of the RRS. Supplementary materialSupplementary material is available at International Journal for Quality in Health Care online. AcknowledgmentsWe thank the NUHS Medical Publications Support Unit, Singapore, for providing editing services to this manuscript. References1
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Supplementary data |
Which patient is most likely to benefit from using a rapid response team (rrt)?
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