What stops hospital clinical staff from following protocols? An analysis of the incidence and factors behind the failure of bedside clinical staff to activate the rapid response system in a multi-campus Australian metropolitan healthcare service

Abstract

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.

“Deterioration to Door Time”: An Exploratory Analysis of Delays in Escalation of Care for Hospitalized Patients

“…17 We postulate that there are likely systemrelated and patient-related factors that influence this relationship and contribute to what has come to be known as Bfailure to rescue.^1 8,19 System-related factors may include general inpatient floor staffing models and provider-patient ratios, 20 temporal issues including the time of day and day of the week at which deterioration occurs, 21 adherence to vital sign monitoring protocols, 22 and ICU bed availability. 7,23,24 There are also cultural barriers preventing staff from calling for assistance, [25][26][27][28] and nurse/physician providers often do not accurately self-assess the quality of their care for clinically deteriorating patients. 28 Patient factors, such as severity of illness, age, 29 medical comorbidities, and the number and type of specific criteria heralding deterioration 12,13,30 may all play a role as well.…”

Multisite analysis of the timing and outcomes of unplanned transfers from subacute to acute care

“…Studies of adult ward patients show 15%-67.9% of patients have one or more abnormal observation 20,22 and 3%-9% of ward patients fulfil rapid response system activation criteria at any point in time. [23][24][25] Whether the high rates of physiological abnormalities in the present study cohort is a function of the older patient group, clinical deterioration or both warrants further investigation. These findings raise questions about the need for contextspecific systems for identifying and responding to deterioration in subacute care akin to rapid response systems in acute care settings.…”

Designing a Critical Care Nurse–Led Rapid Response Team Using Only Available Resources: 6 Years Later

“…Because failure of bedside staff to call the RRT when activation criteria are present has been associated with adverse events, the RRT should support the staff initiating the response and consider no call inappropriate. 11,24,49 If nurses fear disapproval, believe they have adequate resources to manage the patient, or presume they should be able to handle the patient themselves, initiation of the RRT is unlikely. 42,49 Nonjudgmental appraisal of RRT occurrences mitigates fear of reproach for unwarranted calls.…”

“…11,24,49 If nurses fear disapproval, believe they have adequate resources to manage the patient, or presume they should be able to handle the patient themselves, initiation of the RRT is unlikely. 42,49 Nonjudgmental appraisal of RRT occurrences mitigates fear of reproach for unwarranted calls. An "unnecessary" call still offers opportunities for teaching and mentoring less-experienced clinicians.…”

“…3,35,42,43,46 The mean RRT call duration of 24 minutes in 2012 is similar to what some others have reported. 15,32,46,48,49 Factors contributing to shorter RRT calls include familiarity with the RRT process, development of cohesiveness and trust among team members, and acquisition of expertise by both nurses from general care areas and RRT members through repeated experience of the RRT process. 12,46 This ICU consistently reports the highest mean APACHE scores within the 24-hospital system.…”