ObjectiveTo explore the causes of failure to activate the rapid response system (RRS). The organisation has a recognised incidence of staff failing to act when confronted with a deteriorating patient and leading to adverse outcomes.DesignA multi-method study using the following: a point prevalence survey to determine the incidence of abnormal simple bedside observations and activation of the rapid response team by clinical staff; a prospective audit of all patients experiencing a cardiac arrest, unplanned intensive care unit admission or death over an 8-week period; structured interviews of staff to explore cognitive and sociocultural barriers to activating the RRS.SettingSouthern Health is a comprehensive healthcare network with 570 adult in-patient beds across four metropolitan teaching hospitals in the south-eastern sector of Melbourne.MeasurementsFrequency of physiological instability and outcomes within the in-patient hospital population. Qualitative data from staff interviews were thematically coded.ResultsThe incidence of physiological instability in the acute adult population was 4.04%. Nearly half of these patients (42%) did not receive an appropriate clinical response from the staff, despite most (69.2%) recognising their patient met physiological criteria for activating the RRS, and being ‘quite’, or ‘very’ concerned about their patient (75.8%). Structured interviews with 91 staff members identified predominantly sociocultural reasons for failure to activate the RRS.ConclusionsDespite an organisational commitment to the RRS, clinical staff act on local cultural rules within the clinical environment that are usually not explicit. Better understanding of these informal rules may lead to more appropriate activation of the RRS.

The rapid response system (RRS) is a patient safety initiative instituted to enable healthcare professionals to promptly access help when a patient's status deteriorates. Despite patients meeting the criteria, up to one-third of the RRS cases that should be activated are not called, constituting a "missed RRS call". Using a case study approach, 10 focus groups of senior and junior nurses and physicians across four hospitals in Australia were conducted to gain greater insight into the social, professional and cultural factors that mediate the usage of the RRS. Participants' experiences with the RRS were explored from an interprofessional and collective competence perspective. Health professionals' reasons for not activating the RRS included: distinct intraprofessional clinical decision-making pathways; a highly hierarchical pathway in nursing, and a more autonomous pathway in medicine; and interprofessional communication barriers between nursing and medicine when deciding to make and actually making a RRS call. Participants also characterized the RRS as a work-around tool that is utilized when health professionals encounter problematic interprofessional communication. The results can be conceptualized as a form of collective incompetence that have important implications for the design and implementation of interprofessional patient safety initiatives, such as the RRS.

BackgroundPatient safety is a fundamental component of good quality health care. Checklists have been proposed as a method of improving patient safety. This systematic review, asked "In acute hospital settings, would the use of safety checklists applied by medical care teams, compared to not using checklists, improve patient safety?"MethodsWe searched the Cochrane Library, MEDLINE, CINAHL, and EMBASE for randomised controlled trials published in English before September 2009. Studies were selected and appraised by two reviewers independently in consultation with colleagues, using inclusion, exclusion and appraisal criteria established a priori.ResultsNine cohort studies with historical controls studies from four hospital care settings were included-intensive care unit, emergency department, surgery, and acute care. The studies used a variety of designs of safety checklists, and implemented them in different ways, however most incorporated an educational component to teach the staff how to use the checklist. The studies assessed outcomes occurring a few weeks to a maximum of 12 months post-implementation, and these outcomes were diverse.The studies were generally of low to moderate quality and of low levels of evidence, with all but one of the studies containing a high risk of bias.The results of these studies suggest some improvements in patient safety arising from use of safety checklists, but these were not consistent across all studies or for all outcomes. Some studies showed no difference in outcomes between checklist use and standard care without a checklist. Due to the variations in setting, checklist design, educational training given, and outcomes measured, it was unfeasible to accurately summarise any trends across all studies.ConclusionsThe included studies suggest some benefits of using safety checklists to improve protocol adherence and patient safety, but due to the risk of bias in these studies, their results should be interpreted with caution. More high quality and studies, are needed to enable confident conclusions about the effectiveness of safety checklists in acute hospital settings.

All health services rely on efficient and accurate communication between health professionals to ensure safe and effective patient care. Our health service introduced a standardised technique, ISBAR (Identify, Situation, Background, Assessment, Request), for telephone communication. We describe and evaluate the implementation of this project; evaluation was undertaken using program logic mapping. Recommendations for other health services planning to introduce communication tools into routine clinical use are also provided.

BackgroundThe rapid response system (RRS) is a process of accessing help for health professionals when a patient under their care becomes severely ill. Recent studies and meta-analyses show a reduction in cardiac arrests by a one-third in hospitals that have introduced a rapid response team, although the effect on overall hospital mortality is less clear. It has been suggested that the difficulty in establishing the benefit of the RRS has been due to implementation difficulties and a reluctance of clinical staff to call for additional help. This assertion is supported by the observation that patients continue to have poor outcomes in our institution despite an established RRS being available. In many of these cases, the patient is often unstable for many hours or days without help being sought. These poor outcomes are often discovered in an ad hoc fashion, and the real numbers of patients who may benefit from the RRS is currently unknown. This study has been designed to answer three key questions to improve the RRS: estimate the scope of the problem in terms of numbers of patients requiring activation of the RRS; determine cognitive and socio-cultural barriers to calling the Rapid Response Team; and design and implement solutions to address the effectiveness of the RRS.MethodsThe extent of the problem will be addressed by establishing the incidence of patients who meet abnormal physiological criteria, as determined from a point prevalence investigation conducted across four hospitals. Follow-up review will determine if these patients subsequently require intensive care unit or critical care intervention. This study will be grounded in both cognitive and socio-cultural theoretical frameworks. The cognitive model of situation awareness will be used to determine psychological barriers to RRS activation, and socio-cultural models of interprofessional practice will be triangulated to inform further investigation. A multi-modal approach will be taken using reviews of clinical notes, structured interviews, and focus groups. Interventions will be designed using a human factors analysis approach. Ongoing surveillance of adverse outcomes and surveys of the safety climate in the clinical areas piloting the interventions will occur before and after implementation.

Objective: To determine if a general ward-based plan to address the deteriorating patient could improve RRS utilization over and above a mandatory organizational policy and procedure. Design: A two stage methodology: First, engagement with ward providers and users of the RRS to generate ward-based interventions; Second, measurement of the incidence of missed/delayed RRS calls, RRS calls, cardiac arrests and unplanned intensive care unit admission both prior to the intervention and 12 months post implementation. Setting: Monash Health is a comprehensive healthcare network with 570 adult in-patient beds across four metropolitan teaching hospitals in the south-eastern sector of Melbourne. Results:The interventions selected for intervention were: (1) a ward based agreement on how to best locally optimize management of the deteriorating patient,(2) an improved communication protocol, and (3) a revision of the education program for staff. Post intervention the aggregate rate of missed/delayed RRS calls reduced across all wards (1.05 to 0.34 per 1000 bed days, p = 0.049). This occurred without a change in the rate of RRS activation (7.98 per 1000 bed days pre-intervention versus 7.85 bed days post-intervention). The incidence of cardiac arrests or unplanned interventions did not change post intervention. Conclusions: Engagement of the users of a system like the RRS activation protocol can improve compliance rates with protocols when the users have ownership of the process.