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

Olsen, Siri Lerstøl; Søreide, Eldar; Hillman, Ken; Hansen, Britt Sætre

doi:10.1016/j.resuscitation.2019.08.034

Cited by 64 publications

(83 citation statements)

References 59 publications

(205 reference statements)

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…This lack of compliance has been termed “afferent limb failure” (ALF) (Johnston, Arora, King, Stroman, & Darzi, 2014; Trinkle & Flabouris, 2011). There is an abundance of literature describing the potential causes of ALF (Olsen, Søreide, Hillman, & Hansen, 2019; Treacy & Stayt, 2019; Wood, Chaboyer, & Carr, 2019) but paucity of work reporting interventions to target it (Bucknall et al., 2017; Connell et al., 2016; Duff, Massey, Gooch, & Wallis, 2018). Further, most of the interventions described are educational with methodological limitations including risks of bias and/or consistently poor detailing of the development process, suggesting that these interventions may have been developed pragmatically (i.e., based on clinician or researcher intuition) rather than using a replicable method.…”

Section: Introductionmentioning

confidence: 99%

Patterns of behaviour in nursing staff actioning the afferent limb of the rapid response system (RRS): A focused ethnography

Smith

Cartwright

Dyson

et al. 2020

Journal of Advanced Nursing

View full text Add to dashboard Cite

Aim To improve understanding of afferent limb behaviour in acute hospital ward settings, to define and specify who needs to do what differently and to report what afferent limb behaviours should be targeted in a subsequent multi‐phase, theory‐based, intervention development process. Design Focused ethnography was used including direct observation of nursing staff enacting afferent limb behaviours and review of vital signs charts. Methods An observation guide focused observation on “key moments” of the afferent limb. Descriptions of observations from between 7 January 2019–18 December 2019 were recorded in a field journal alongside reflexive notes. Vital signs and early warning scores from charts were reviewed and recorded. Field notes were analysed using structured content analysis. Observed behaviour was compared with expected (policy‐specified) behaviour. Results Observation was conducted for 300 hr. Four hundred and ninety‐nine items of data (e.g., an episode of observation or a set of vital signs) were collected. Two hundred and eighty‐nine (58%) items of data were associated with expected (i.e. policy‐specified) afferent limb behaviour; 210 (42%) items of data were associated with unexpected afferent limb behaviour (i.e. alternative behaviour or no behaviour). Ten specific behaviours were identified where the behaviour observed deviated (negatively) from policy or where no action was taken when it should have been. One further behaviour was seen to expedite the assessment of a deteriorating patient by an appropriate responder and was therefore considered a positive deviance. Conclusion Afferent limb failure has been described as a problem of inconsistent staff behaviour. Eleven potential target behaviours for change are reported and specified using a published framework. Impact Clear specification of target behaviour will allow further enquiry into the determinants of these behaviours and the development of a theory‐based intervention that is more likely to result in behaviour change and can be tested empirically in future research.

show abstract

Section: Introductionmentioning

confidence: 99%

Patterns of behaviour in nursing staff actioning the afferent limb of the rapid response system (RRS): A focused ethnography

Smith

Cartwright

Dyson

et al. 2020

Journal of Advanced Nursing

View full text Add to dashboard Cite

show abstract

“…Evidence suggests the early signs of patient clinical deterioration are often not identified or acted upon in a timely manner by nurses and medical officers in general medical‐surgical wards (Liaw et al, 2015; Petersen et al, 2017), thereby reducing the effectiveness of emergency response teams (Chen et al, 2009). Absent or delayed detection by clinicians may result from fear of reprimand, lack of knowledge about the role of emergency response teams, inadequate monitoring and observation, heavy workloads and limited access to supportive and knowledgeable leaders (Allen, 2020; Olsen et al, 2019).…”

Section: Introductionmentioning

confidence: 99%

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

Walker

Boorman

Vaux

et al. 2021

Journal of Clinical Nursing

View full text Add to dashboard Cite

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.

show abstract

“…Predictable and potentially avoidable life-threatening events are debriefed and investigated with root cause analysis; the lessons learned are shared and contribute to revisions of guidance and education. [17,[64][65][66][67][68][69] We would recommend keeping records of staff who participate in each form of training to help target staff areas that need more or different input. Multimodal educational opportunities, in particular active learning within the real clinical context, are needed for different learning styles.…”

Section: Discussionmentioning

confidence: 99%

“…This culture change is a hard outcome to measure, but we believe it is important. [17,61,65] The main limitation of this study, from a single specialist centre, is the before and after bias for which we have tried to compensate by comparing rates and accounting for time trends. There were also many system changes over the study period, and it is not certain that the PEW system implementation in uenced the outcomes.…”

Section: Discussionmentioning

confidence: 99%

Quality Improvement Implementation and Maintenance of a Paediatric Early Warning System

Duncan¹,

Oliver²,

Emms³

et al. 2020

Preprint

View full text Add to dashboard Cite

Background: Paediatric Early Warning (PEW) systems have led to earlier identification and escalation of treatment with subsequent admission to Paediatric Intensive Care (PIC) in deteriorating children. The impact on reductions in cardiac arrest and mortality vary between the heterogeneous studies, showing both unchanged and reduced cardiac arrest, morbidity and mortality. Identifying and managing critical illness on wards is a complex and dynamic process involving technology, human interaction, cultural context and environment. We introduced a PEW system to reduce potentially avoidable cardiac arrest and death.Methods: We report an Implementation Science Quality Improvement (QI) natural experiment using the Medical Research Councils (MRC) Guidelines for Developing and Evaluating Complex Interventions, Action Research, Action Research Theory and methods. The aim of this program was to identify learning, refinement and improvement opportunities to reduce poor outcomes. The interventions were 1) developing an observation and monitoring policy to standardise practice and provide a template for optimal care, 2) standardized charting with an embedded PEW score, 3) clinical skills training, 4) clinical process audit and feedback and 5) outcome surveillance.The process measures were 1) timeliness and impact for unplanned Paediatric Intensive Care (PIC) admissions, 2) clinical assessment skills and 3) chart completion compliance. The outcome measures included 4) total and predictable cardiac arrests and 5) hospital mortality. Data collection started in 2004, the PEW system was implemented in 2008, and the outcomes were reported through 2018.Results: In our specialist children’s hospital, we completed six improvement cycles over 10 years. 1) Timely PIC admissions improved after implementation (39% to 92%). Patients with unplanned PIC admissions had significantly lower severity of illness and mortality but a longer length of stay. 2) Routine clinical observation accuracy improved (66 to 82%) following multimodal training. 3) Chart completion compliance improved (87 to 99%). In 2018, 2% of observations had missing or inaccurate parameters with a consequent inaccurate total PEW score. 4) The total cardiac arrest rate was significantly reduced (0.36 to 0.16 per 1000 admissions). The small numbers of predictable cardiac arrests showed a decreasing trend. 5) Hospital mortality was significantly reduced (3.46 to 2.24 per 1000 admissions). Outcomes improved approximately 18 months after implementation and have not changed significantly since 2010 despite increasing critical care resources in and out of PIC. The impact of the PEW system on these outcomes is possible but not conclusive.Conclusion: Implementation of the PEW system as a complex intervention using QI methods is associated with improved clinical skill accuracy, chart compliance and detection of deterioration associated with more timely unplanned PIC admissions. These improvements were associated with a significant reduction in cardiac arrest and mortality.

show abstract

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

Cited by 64 publications

References 59 publications

Patterns of behaviour in nursing staff actioning the afferent limb of the rapid response system (RRS): A focused ethnography

Patterns of behaviour in nursing staff actioning the afferent limb of the rapid response system (RRS): A focused ethnography

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

Quality Improvement Implementation and Maintenance of a Paediatric Early Warning System

Contact Info

Product

Resources

About