1Faculty of Health, University of Technology Sydney, Ultimo, Australia
2School of Nursing, Johns Hopkins University, Baltimore, MD, USA
Systemic and structural issues of rapid response system (RRS) models can hinder implementation. This study sought to understand the ways in which acute care clinicians (physicians and nurses) experience and negotiate care for deteriorating patients within the RRS.
Physicians and nurses working within an Australian academic health centre within a jurisdictional-based model of clinical governance participated in focus group interviews. Verbatim transcripts were analysed using thematic content analysis.
Thirty-four participants (21 physicians and 13 registered nurses [RNs]) participated in six focus groups over five weeks in 2014. Implementing the RRS in daily practice was a process of informal communication and negotiation in spite of standardised protocols. Themes highlighted several systems or organisational-level barriers to an effective RRS, including (1) responsibility is inversely proportional to clinical experience; (2) actions around system flexibility contribute to deviation from protocol; (3) misdistribution of resources leads to perceptions of inadequate staffing levels inhibiting full optimisation of the RRS; and (4) poor communication and documentation of RRS increases clinician workloads.
Implementing a RRS is complex and multifactorial, influenced by various inter- and intra-professional factors, staffing models and organisational culture. The RRS is not a static model; it is both reflexive and iterative, perpetually transforming to meet healthcare consumer and provider demands and local unit contexts and needs. Requiring more than just a strong initial implementation phase, new models of care such as a RRS demand good governance processes, ongoing support and regular evaluation and refinement. Cultural, organizational and professional factors, as well as systems-based processes, require consideration if RRSs are to achieve their intended outcomes in dynamic healthcare settings.
Berwick DM, Nolan TW, Whittington J. The triple aim: care, health and cost. Health Affairs. 2008;27(3):759-769.
Rihari-Thomas J, Newton P, Sibbritt D, et al. Managing the deteriorating patient: a historical perspective and implications for the Australian practice setting. Sydney: University of Technology; 2015.
Jung B, Daurat A, De Jong A, et al. Rapid response team and hospital mortality in hospitalized patients. Intensive Care Med. 2016;42(4):494-504. doi:10.1007/s00134-016-4254-2
The Australian Institute of Health and Welfare. Indicators of Australia's health. Canberra: Australian Government; 2014.
Hillman K, Chen K, Creticos M, et al. MERIT study investigators, Introduction of the medical emergency team (MET) system: a cluster randomised controlled trial. Lancet. 2005;365(9477):6.
ANZICS-CORE MET dose investigators, Jones D, Drennan K, et al. Rapid Response Team composition, resourcing and calling criteria in Australia. Resuscitation. 2012;83(5):563-567. doi:10.1016/j.resuscitation.2011.10.023
Rivers P, Saundra G. Health care competition, strategic mission, and patient satisfaction: research model and propositions. J Health Organ Manag. 2008;22(6):627-641. doi:10.1108/14777260810916597
Gluyas H. Effective communication and teamwork promotes patient safety. Nurs Stand. 2015;29(49):50-57. doi:10.7748/ns.29.49.50.e10042
Davidson P, Halcomb E, Hickman L, et al. Beyond the rhetoric: what do we mean by a 'model of care'? J Adv Nurs. 2006;23(3):47-55.
Carayona P, Wetternecka T, Rivera-Rodriguezd J, et al. Human factors systems approach to healthcare quality and patient safety. Appl Ergon. 2014;45(1):14-25.
Foote S. Rapid response teams. Am J Nur. 2010;110(9):13.
13. Jones D, DeVita M, Bellomo R. Rapid-Response Teams. N Engl J Med. 2011;365(2):139-146. doi:10.1056/NEJMra0910926
Jones D, McIntyre T. Nurses' attitudes to a medical emergency team service in a teaching hospital. Qual Saf Health Care. 2006;15(6):427-432.
Adamson B, Kenny D, Wilson-Barnett J. The impact of perceived medical dominance on the workplace satisfaction of Australian and British nurses. J Adv Nurs. 1995;21(1):172-183.
Kenny D, Adamson B. Medicine and the health professions: Issues of dominance, autonomy and authority. Aust Health Rev. 1992;15(3):319-334.
Benoita C, Zadoroznyjb M, Hallgrimsdottira H, et al. Medical dominance and neoliberalisation in maternal care provision: The evidence from Canada and Australia. Soc Sci Med. 2010;71(3):475-481.
Jones D, King L, Wilson C. A literature review: factors that impact on nurses' effective use of the medical emergency team (MET). J Clin Nurs 2009;18(24):3379-3390. doi:10.1111/j.1365-2702.2009.02944.x
Kitzinger J. The methodology of focus groups: the importance of interaction between research participants. Sociol Health Illn. 1994;16(1):103-121. doi:10.1111/1467-9566.ep11347023
Astroth K, Woith W, Stapleton S, et al. Qualitative exploration of nurses' decisions to activate rapid response teams. J Clin Nurs. 2013;22(19-20):6. Doi:10.1111/jocn.12067
Azzopardi P, Kinney S, Moulden A, et al. Attitudes and barriers to a Medical Emergency Team system at a tertiary paediatric hospital. Resuscitation 2011;82(2):167-174. doi:10.1016/j.resuscitation.2010.10.013
NHS National Institute for Health and Clinical Excellence. Acutely ill patients in hospital: Recognition of and response to acute illness in adults in hospital. London: NHS, 2007.
Australian Commission on Safety and Quality in Healthcare. Recognising and responding to clinical deterioration:use of observation charts to identify clinical deterioration. Sydney: Australian Commission on Safety and Quality in Healthcare; 2009.
Jacques T, Harrison G, McLaws M, et al. Signs of critical conditions and emergency responses (SOCCER): a model for predicting adverse events in the inpatient setting. Resuscitation. 2006;69(2):175-183. doi:10.1016/j.resuscitation.2005.08.015
South East Sydney Illawarra Area Health Service. Patient with acute condition for escalation (PACE): management of the deteriorating adult inpatient. Sydney: South East Sydney Illawarra Area Health Service; 2009.
NSW Ministry of Health. Public Hospital Medical Officers Award. Sydney: NSW Ministry of Health, 2015.
Vaismoradi M, Jones J, Turunen H, et al. Theme development in qualitative content analysis and thematic analysis. J Nurs Educ Pract. 2016;6(5):100-110. doi:10.5430/jnep.v6n5p100
Bendassolli P. Theory building in qualitative research: reconsidering the problem of induction. Qual Soc Res. 2013;14(1):25.
Cabana M, Rand S, Powe N, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282(15):145814-145867.
Sandroni C, Cavallaro F. Failure of the afferent limb: a persistent problem in rapid response systems. Resuscitation. 2011;82(7):797-798. doi:10.1016/j.resuscitation.2011.04.012
Barwise A, Thongprayoon C, Gajic O, et al. Delayed rapid response team activation is associated with increased hospital mortality, morbidity, and length of stay in a tertiary care institution. Crit Care Med. 2016;44(1):54-63.
Mozo M, Gordo V. Innovation in the management of intensive care units: this is the right time. Medicina Intensiva. 2016;40:263-265.
Abella A, Enciso V, Torrejón C, et al. Effect upon mortality of the extension to holidays and weekend of the "ICU without walls" project. A before-after study. Medicina Intensiva. 2015;40:273-279.
Endacott R, Chaboyer W, Edington J, et al. Impact of an ICU liaison nurse service on major adverse events in patients recently discharged from ICU. Resuscitation. 2009;81(2010):198-201.
Jones D, Bellomo R, De Vita M. Effectiveness of the medical emergency team: the importance of dose. Crit Care. 2009;13(313):1-7. doi:10.1186/cc7996
Pirret A. The role and effectiveness of a nurse practitioner led critical care outreach service. Intensive Crit Care Nurs. 2008;2008(24):375-382. doi:10.1016/j.iccn.2008.04.007
The Royal Australian College of General Practitioners. Results of RACGP key feature problems exam announced East Melbourne: The Royal Australian College of General Practitioners; 2015. http://www.racgp.org.au/yourracgp/news/media-releases/results-of-racgp-key-feature-problems-exam-announced/. Accessed October 1, 2016. Updated October 23, 2015.
Shulruf B, Wilkinson T, Weller J, et al. Insights into the Angoff method: results from a simulation study. BMC Med Educ. 2016;16:134. doi:10.1186/s12909-016-0656-7
Kitto S, Marshall S, McMillan S, et al. Rapid response systems and collective (in)competence: An exploratory analysis of intraprofessional and interprofessional activation factors. J Interprof Care. 2015;29(4):340-346.
Theilen U, Leonard P, Jones P, et al. Regular in situ simulation training of paediatric medical emergency team improves hospital response to deteriorating patients. Resuscitation. 2013;84(2003):218-222. doi:10.1016/j.resuscitation.2012.06.027
White K, Scott I, Vaux A, et al. Rapid response teams in adult hospitals: Time for another look? Intern Med J. 2015;45(12):1211-1120. doi:10.1111/imj.12845