The rapid response system: an integrative review

The impact of mandated use early warning system tools on the development of nurses' higher-order thinking: A systematic review

AIM

Ascertain the impact of mandated use of early warning systems (EWSs) on the development of registered nurses' higher-order thinking.

DESIGN

A systematic literature review was conducted, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist (Page et al., 2021).

DATA SOURCES

CINAHL, Medline, Embase, PyscInfo.

REVIEW METHODS

Eligible articles were quality appraised using the MMAT tool. Data extraction was conducted independently by four reviewers. Three investigators thematically analysed the data.

RESULTS

Our review found that EWSs can support or suppress the development of nurses' higher-order thinking. EWS supports the development of higher-order thinking in two ways; by confirming nurses' subjective clinical assessment of patients and/or by providing a rationale for the escalation of care. Of note, more experienced nurses expressed their view that junior nurses are inhibited from developing effective higher-order thinking due to reliance on the tool.

CONCLUSION

EWSs facilitate early identification of clinical deterioration in hospitalised patients. The impact of EWSs on the development of nurses' higher-order thinking is under-explored. We found that EWSs can support and suppress nurses' higher-order thinking. EWS as a supportive factor reinforces the development of nurses' heuristics, the mental shortcuts experienced clinicians call on when interpreting their subjective clinical assessment of patients. Conversely, EWS as a suppressive factor inhibits the development of nurses' higher-order thinking and heuristics, restricting the development of muscle memory regarding similar presentations they may encounter in the future. Clinicians' ability to refine and expand on their catalogue of heuristics is important as it endorses the future provision of safe and effective care for patients who present with similar physiological signs and symptoms.

IMPACT

This research impacts health services and education providers as EWS and nurses' development of higher-order thinking skills are essential aspects of delivering safe, quality care.

NO PATIENT OR PUBLIC CONTRIBUTION

This is a systematic review, and therefore, comprises no contribution from patients or the public.

Automated rapid response system activation-Impact on nurses' attitudes and perceptions towards recognising and responding to clinical deterioration: Mixed-methods study

AIM

To explore general ward nurses' attitudes and perceptions towards recognising and responding to clinical deterioration in a hospital with automated rapid response system activation.

BACKGROUND

There is growing interest in deploying automated clinical deterioration notification systems to reduce delayed or failed recognition and response to clinical deterioration of ward patients. However, little is known about its impact on ward nurses' perspectives and work patterns.

DESIGN

A mixed-methods study.

METHODS

Online survey of 168 registered nurses and individual interviews with 10 registered nurses in one acute hospital in Singapore. The study adhered to the STROBE checklist for cross-sectional studies and the COREQ guidelines for qualitative studies.

RESULTS

Many nurses (38.1%) rarely performed patient assessments or observations other than vital signs assessment to assess for early signs of clinical deterioration. About 30% were worried about being criticised for calling the primary team doctors. Four themes emerged from the qualitative analysis: automated rapid response system activation as a safety net, being more cautious with vital signs monitoring, the NEWS2 alone is inadequate, and ward nurses as the 'middleman' between the intensive care unit outreach nurse and primary team doctors.

CONCLUSIONS

Although nurses value the automated rapid response system activation as a safety net to minimise delays in accessing urgent critical care resources, it does not address the sociocultural barriers inherent in escalation of care. Although the automated system led nurses to be more cautious with vital signs monitoring, it does not encourage them to perform comprehensive patient assessments to detect early signs of deterioration.

RELEVANCE TO CLINICAL PRACTICE

Nurse education on assessing for clinical deterioration should focus on the use of broader patient assessment skills other than vital signs. Sociocultural barriers to escalation of care remain a key issue that needs to be addressed by hospital management.

NO PATIENT OR PUBLIC CONTRIBUTION

No patients, service users, care-givers or members of the public were involved in the study.

The ACCELERATE Plus (assessment and communication excellence for safe patient outcomes) Trial Protocol: a stepped-wedge cluster randomised trial, cost-benefit analysis, and process evaluation

BACKGROUND

Nurses play an essential role in patient safety. Inadequate nursing physical assessment and communication in handover practices are associated with increased patient deterioration, falls and pressure injuries. Despite internationally implemented rapid response systems, falls and pressure injury reduction strategies, and recommendations to conduct clinical handovers at patients' bedside, adverse events persist. This trial aims to evaluate the effectiveness, implementation, and cost-benefit of an externally facilitated, nurse-led intervention delivered at the ward level for core physical assessment, structured patient-centred bedside handover and improved multidisciplinary communication. We hypothesise the trial will reduce medical emergency team calls, unplanned intensive care unit admissions, falls and pressure injuries.

METHODS

A stepped-wedge cluster randomised trial will be conducted over 52 weeks. The intervention consists of a nursing core physical assessment, structured patient-centred bedside handover and improved multidisciplinary communication and will be implemented in 24 wards across eight hospitals. The intervention will use theoretically informed implementation strategies for changing clinician behaviour, consisting of: nursing executive site engagement; a train-the-trainer model for cascading facilitation; embedded site leads; nursing unit manager leadership training; nursing and medical ward-level clinical champions; ward nurses' education workshops; intervention tailoring; and reminders. The primary outcome will be a composite measure of medical emergency team calls (rapid response calls and 'Code Blue' calls), unplanned intensive care unit admissions, in-hospital falls and hospital-acquired pressure injuries; these measures individually will also form secondary outcomes. Other secondary outcomes are: i) patient-reported experience measures of receiving safe and patient-centred care, ii) nurses' perceptions of barriers to physical assessment, readiness to change, and staff engagement, and iii) nurses' and medical officers' perceptions of safety culture and interprofessional collaboration. Primary outcome data will be collected for the trial duration, and secondary outcome surveys will be collected prior to each step and at trial conclusion. A cost-benefit analysis and post-trial process evaluation will also be undertaken.

DISCUSSION

If effective, this intervention has the potential to improve nursing care, reduce patient harm and improve patient outcomes. The evidence-based implementation strategy has been designed to be embedded within existing hospital workforces; if cost-effective, it will be readily translatable to other hospitals nationally.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ID: ACTRN12622000155796. Date registered: 31/01/2022.

How do nurses use early warning system vital signs observation charts in rural, remote and regional health care facilities: A scoping review

INTRODUCTION

Physiological signs of clinical deterioration are known to occur in the hours preceding a serious adverse event. As a result, track and trigger systems known as early warning systems (EWS) were introduced and routinely implemented as patient observation tools to trigger an alert in the presence of abnormal vital signs.

OBJECTIVE

The objective aimed to explore the literature pertaining to EWS and their utilisation in rural, remote and regional health care facilities.

DESIGN

The Arksey and O'Malley's methodological framework was used to guide the scoping review. Only studies reporting on rural, remote and regional health care settings were included. All four authors participated in the screening, data extraction and analysis process.

FINDINGS

Our search strategy yielded 3869 peer-reviewed articles published between 2012 and 2022, with six studies ultimately included. Collectively, the studies included in this scoping review examined the complex interaction between patient vital signs observation charts and recognition of patient deterioration.

DISCUSSION

Whilst rural, remote and regional clinicians use EWS to recognise and respond to clinical deterioration, noncompliance dilutes the tool's effectiveness. This overarching finding is informed by three contributing factors: documentation, communication and challenges specific to the rural context.

CONCLUSION

The success of EWS relies on accurate documentation and effective communication within the interdisciplinary team to support appropriate responses to clinical patient decline. More research is required to understand the nuances and complexities of rural and remote nursing and to address challenges associated with the use of EWS in rural health care settings.

Balancing responsibilities, rewards and challenges: A qualitative study illuminating the complexity of being a rapid response team nurse

AIM AND OBJECTIVE

To explore Rapid Response Team nurses' perceptions of what it means being a Rapid Response Team nurse including their perceptions of the collaborative and organisational aspects of the rapid response team (RRT).

BACKGROUND

For more than 20 years, RRT nurses have been on the frontline of critical situations in acute care hospitals. However, a few studies report nurses' perceptions of their role as RRT nurses, including collaboration with general ward nurses and physicians. This knowledge is important to guide development and adjustment of the RRT to benefit both patients' safety and team members' job satisfaction.

DESIGN

Qualitative focus group interviews.

METHODS

A qualitative approach was applied. Throughout 2018 and across three regions and three acute care settings in Denmark, eight focus group interviews were conducted in which 27 RRT nurses participated. Transcribed interviews were analysed using inductive content analysis. Reporting of this study followed the COREQ checklist.

RESULTS

One overarching theme 'Balancing responsibilities, rewards, and challenges' was derived, comprising six categories: 'Becoming, developing and fulfilling the RRT nurse role', 'Helping patients as the core function of RRT', 'The RRT-call at its best', 'The obvious and the subtle RRT tasks', 'Carrying the burden of the RRT', and 'Organisational benefits and barriers for an optimal RRT'.

CONCLUSION

Being a RRT nurse is a complex task. Nurses experience professional satisfaction and find it meaningful helping deteriorating patients. The inadequate resources available to train general ward staff how to manage basic clinical tasks are an added stress to nurses.

RELEVANCE TO CLINICAL PRACTICE

Organisational managers need a better understanding of the necessary staffing requirements to attend patients' needs, train staff and handle the increasing acuity of ward patients. Failure to do so will be detrimental to patient outcomes and compromise RRT nurses' job satisfaction.

Exploration of a rapid response team model of care: A descriptive dual methods study

BACKGROUND

Avoidable in-patient clinical deterioration results in serious adverse events and up to 80% are preventable. Rapid response systems allow early recognition and response to clinical deterioration.

OBJECTIVE

To explore the characteristics of a collaborative rapid response team model.

DESIGN

Dual methodology was used for this descriptive study.

SETTING

The study was conducted in a 500-bed tertiary referral hospital (Sydney, Australia).

PARTICIPANTS

Inpatients (>17 years) who received a rapid response team activation were included in an electronic medical audit. Participants were rapid response team members and nurses and medical doctors in two in-patient wards.

METHODS

A 12-month (January-December 2018) retrospective electronic health record audit and semi-structured interviews with nurses and medical doctors (July-August 2019) were conducted. Descriptive statistics summarised audit data. Interviews were transcribed and analysed thematically.

RESULTS

The rapid response team consulted for 2195 patients. Mean patient age was 67.9 years, and 46% of the sample was female. Activations (n = 4092) occurred most often in general medicine (n = 1124, 70.8%) units. Overall, 117 patients had >5 activations. The themes synthesised from interviews were i) managing patient deterioration before arrival of the rapid response team; ii) collaboratively managing patient deterioration at the bedside; iii) rapid response team guidance at the bedside; and iv) 'staff concern' rapid response activation.

CONCLUSIONS

Some patients received many activations, however few required treatment in critical care. The rapid response model was collaborative and supportive. The themes revealed a focus on patient safety, optimising early detection, and management of patient deterioration.

Development of a comprehensive model for the role of the rapid response team nurse

OBJECTIVE

To develop a comprehensive model of the role of the rapid response team nurse.

DESIGN

Using an experience-based co-design approach, qualitative data concerning the categories and components of the role of the rapid response team nurse were generated via workshops and one-on-one interviews with service users and providers. The appropriateness of the comprehensive model was evaluated through an online survey.

SETTING

Forty-six tertiary hospitals across South Korea. A total of 114 rapid response team service providers and users were recruited using convenience sampling.

FINDINGS

The comprehensive model included the requirements, facilitating factors, barriers, and outcomes as well as the roles and tasks of rapid response team nurses. The key roles in the final model were found to be: 1) Screening of patients with acute exacerbation, 2) Professional support for emergencies, 3) Education for service users, 4) Consultation for high-risk patient care, 5) Support for patient and family decision-making, 6) Coordination between departments, and 7) Management of the rapid response team. These roles contain 57 specific tasks. Rapid response team professionals finalised the model by evaluating the appropriateness of its components.

CONCLUSION

An experience-based co-design approach was used to develop a comprehensive model that reflects the insights and needs of rapid response team service users and providers. We recommend that the model be validated and supplemented by data from different institutions and countries.

A systematic review of rapid response applications based on early warning score for early detection of inpatient deterioration

AIM

The aim of this study was to investigate the effectiveness of current rapid response applications available in acute care settings for escalation of patient deterioration. Current challenges and barriers, as well as key recommendations, were also discussed.

METHODS

We adopted PRISMA review methodology and screened a total of 559 articles. After considering the eligibility and selection criteria, we selected 13 articles published between 2015 and 2019. The selection criteria were based on the inclusion of studies that report on the advancement made to the current practice for providing rapid response to the patient deterioration in acute care settings.

RESULTS

We found that current rapid response applications are complicated and time-consuming for detecting inpatient deterioration. Existing applications are either siloed or challenging to use, where clinicians are required to move between two or three different applications to complete an end-to-end patient escalation workflow - from vital signs collection to escalation of deteriorating patients. We found significant differences in escalation and responses when using an electronic tool compared to the manual approach. Moreover, encouraging results were reported in extensive documentation of vital signs and timely alerts for patient deterioration.

CONCLUSION

The electronic vital signs monitoring applications are proved to be efficient and clinically suitable if they are user-friendly and interoperable. As an outcome, several key recommendations and features were identified that would be crucial to the successful implementation of any rapid response system in all clinical settings.