Why don't hospital staff activate the rapid response system (RRS)? How frequently is it needed and can the process be improved?

Abstract

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.

Using Electronic Health Record Data to Develop and Validate a Prediction Model for Adverse Outcomes on the Wards

“…Automatic score generation by the EHR would also decrease the error rate in score calculation that occurs even with simpler vital sign-based systems (26,27). It could also be used to send automatic notifications to physicians and the hospital's RRT, circumventing the "failure to call" problem that has been described in the literature (28,29). Thus, the EHR provides a medium to improve both the risk stratification of patients and the notification of caregivers.…”

Getting more efficient Rapid Response System (RRS) utilization by the use of a general ward based deteriorating patient contract

“…In the first scenario, intense manual observation is likely to lead to skewing of findings by Hawthorne effect and, in the second scenario, observation surveillance by electronic observation capture systems are as yet not widely utilised in the general ward setting. Our previous study found using a snap shot methodology that 42% of all potential RRS activations were in fact not made [10,11]. However, the importance of this is unclear, when the positive and negative predictive value of the various activation criteria, are so low [12][13][14][15]23].…”

“…Six sample wards were selected ( Table 1) that represented a mix of surgical and medical patients, and wards where from our previous study the incidence of end points (cardiac arrest, ICU/HDU admission, and unexpected death) were in the middle range [10,11].…”

“…To better understand this problem, we previously undertook a study to determine the incidence and factors behind the phenomenon of not activating the RRS [10,11]. In the point prevalence part of this study [10], undertaken over a 24 hour period, we found an incidence of failure to activate the RRS of 42%.…”

Rapid response systems and collective (in)competence: An exploratory analysis of intraprofessional and interprofessional activation factors

“…Al-Qahtani et al, 2013;Kwak et al, 2014;Shah, Cardenas, Kuo, & Sharma, 2011). Marshall et al (2011) suggest the difficulty in establishing the effectiveness of the RRS is partially due to the failure of clinical staff to call for help early in all circumstances. However, compliance rates do tend to differ by profession.…”