Background Clinically significant deterioration of patients admitted to general wards is a recognized complication of hospital care. Rapid Response Systems (RRS) aim to reduce the number of avoidable adverse events. The authors aimed to develop a core quality metric for the evaluation of RRS. Methods We conducted an international consensus process. Participants included patients, carers, clinicians, research scientists, and members of the International Society for Rapid Response Systems with representatives from Europe, Australia, Africa, Asia and the US. Scoping reviews of the literature identified potential metrics. We used a modified Delphi methodology to arrive at a list of candidate indicators that were reviewed for feasibility and applicability across a broad range of healthcare systems including low and middle-income countries. The writing group refined recommendations and further characterized measurement tools. Results Consensus emerged that core outcomes for reporting for quality improvement should include ten metrics related to structure, process and outcome for RRS with outcomes following the domains of the quadruple aim. The conference recommended that hospitals should collect data on cardiac arrests and their potential preventability, timeliness of escalation, critical care interventions and presence of written treatment plans for patients remaining on general wards. Unit level reporting should include the presence of patient activated rapid response and metrics of organizational culture. We suggest two exploratory cost metrics to underpin urgently needed research in this area. Conclusion A consensus process was used to develop ten metrics for better understanding the course and care of deteriorating ward patients. Others are proposed for further development. Results Consensus was achieved for ten RRS quality metrics, of which four were related to improving population health, three to enhancing the patient experience of care, two to cost and one to enhancing provider well-being. Level of recommendations were graded as "essential," "recommended", "optional" and "experimental". Terms used in the formulation of recommendations are described in Table 1. Table 2 provides a summary of specific numerators, denominators and inclusion and exclusion criteria to be used when tracking each entity. We are aware that many hospitals use a multi level activation system; for these institutions, we provide guidance in Table 2 as to which warning level should be used for a given metric. Recommendation 1: Hospitals should measure and track cardiac arrests of regular ward patients Type of metric: Clinical outcome, essential Description of metric: A cardiac arrest is defined as an event in which a patient receives chest compression and/or defibrillation for a non-perfusing rhythm. The definitions of terms used in this and other metrics are presented in Table 1. Rationale: Retrospective reviews of in-hospital cardiac arrests (IHCA) consistently show that signs of deterioration are present for several hours before the even...
IMPORTANCE Rapid response teams (RRTs) are foundational to hospital response to deteriorating conditions of patients. However, little is known about differences in RRT organization and function across top-performing and non-top-performing hospitals for in-hospital cardiac arrest (IHCA) care. OBJECTIVE To evaluate differences in design and implementation of RRTs at top-performing and non-top-performing sites for survival of IHCA, which is known to be associated with hospital performance on IHCA incidence. DESIGN, SETTING, AND PARTICIPANTS A qualitative analysis was performed of data from semistructured interviews of 158 hospital staff members (nurses, physicians, administrators, and staff) during site visits to 9 hospitals participating in the Get With The Guidelines-Resuscitation program and consistently ranked in the top, middle, and bottom quartiles for IHCA survival during 2012-2014. Site visits were conducted from April 19, 2016, to July 27, 2017. Data analysis was completed in January 2019. MAIN OUTCOMES AND MEASURES Semistructured in-depth interviews were performed and thematic analysis was conducted on strategies for IHCA prevention, including RRT roles and responsibilities. RESULTS Of the 158 participants, 72 were nurses (45.6%), 27 physicians (17.1%), 27 clinical staff (17.1%), and 32 administrators (20.3%). Between 12 and 30 people at each hospital participated in interviews. Differences in RRTs at top-performing and non-top-performing sites were found in the following 4 domains: team design and composition, RRT engagement in surveillance of at-risk patients, empowerment of bedside nurses to activate the RRT, and collaboration with bedside nurses during and after a rapid response. At top-performing hospitals, RRTs were typically staffed with dedicated team members without competing clinical responsibilities, who provided expertise to bedside nurses in managing patients who were at risk for deterioration, and collaborated with nurses during and after a rapid response. Bedside nurses were empowered to activate RRTs based on their judgment and experience without fear of reprisal from physicians or hospital staff. In contrast, RRT members at non-top-performing hospitals had competing clinical responsibilities and were generally less engaged with bedside nurses. Nurses at non-top-performing hospitals reported concerns about potential consequences from activating the RRT. CONCLUSIONS AND RELEVANCE This qualitative study's findings suggest that top-performing hospitals feature RRTs with dedicated staff without competing clinical responsibilities, that work collaboratively with bedside nurses, and that can be activated without fear of reprisal. These findings provide unique insights into RRTs at hospitals with better IHCA outcomes.
Introduction: Investigations of healthcare workers' implicit attitudes about patient characteristics and differences in delivery of healthcare due to bias are increasingly common.However, there is a gap in our understanding of nurse-specific bias and care disparities. Aims:To identify (a) the types of available evidence, (b) key factors and relationships identified in the evidence and (c) knowledge gaps related to nurse bias (nurse attitudes or beliefs towards a patient characteristic) and nursing care disparities (healthcare disparities related specifically to nursing care).Methods: Authors completed a scoping review using the Joanne Briggs Institute method and PRISMA-SCR checklist. Five databases were searched. After screening, 215 research reports were included and examined. Data were extracted from research reports and assessed for thematic patterns and trends across multiple characteristics.Results: Nurse bias and/or care disparity investigations have become increasingly common over the 38-year span of included reports. Multiple patient characteristics have been investigated, with the most common being race and/or ethnicity, gender and age. Twenty-nine of 215 studies identified a potential relationship between nurse bias regarding a characteristic and nursing care of individuals with that characteristic.Of these studies, 27 suggested the bias was associated with a negative disparate impact on nursing care. Only 12 reports included evaluating an intervention designed to reduce nurse bias or nursing care-related healthcare disparities.Conclusions: Despite increasing research focus on individual bias and disparities in healthcare, the accumulated knowledge regarding nurses has not significantly advanced past a descriptive, exploratory level. Nor has there been a consistent focus on the role of nurses, who represent the largest component of the professional healthcare workforce.Relevance to clinical practice: National and international codes of ethics for nurses require provision of care according to individual, unique patient need, disregarding bias and incorporating patient characteristics into their plan of care.
The purpose of this study was to describe and explore differences between rapid response system events in a Midwestern community hospital through context, mechanism, and outcome factors. The design was a retrospective review of 1,939 adult inpatient events that occurred on medical (62.8%) and surgical units (37.2%) over 92 months. The immediate outcomes of the events were stabilization (59.0%), transfer to a higher level of care (39%), and cardiopulmonary arrest (2%). Nurses activated 94% of all rapid response events; respiratory (38.8%) and cardiac (29.2%) symptoms were the most common triggers, and worry alone triggered 23% of all events. Medical and surgical events were significantly different with regard to antecedents to unit arrival, most common triggers, immediate clinical outcomes, and occurrence during resource-limited times. Understanding rapid response events and differences between medical and surgical units is important to improve early identification of deterioration and thus intervention for vulnerable patients.
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