Review of 20 Years of Continuous Quality Improvement of a Rapid Response System, at Four Institutions, to Identify Key Process Responsible for Its Success

Association of rapid response system with clinical outcomes after surgery under general anesthesia

BACKGROUND

In this population-based cohort study involving a nationwide database from South Korea, we aimed to determine whether rapid response system (RRS) implementation is associated with mortality and morbidity after surgery under general anesthesia.

METHODS

Patients who underwent surgery under general anesthesia at the hospital between January 1, 2021, and December 31, 2021. Patients admitted to hospitals with an RRS were categorized into the RRS group, whereas those without an RRS were categorized into the non-RRS group. The endpoints were 30-day mortality, 90-day mortality, and CPR performance in the event of cardiac arrest.

RESULTS

A total of 1,416,844 patients who underwent surgery under general anesthesia were included. The RRS and non-RRS groups included 512,911 and 903,933 patients, respectively. After propensity score (PS) matching, 447,998 patients were included in both groups (223,999 patients per group). In the PS-matched cohort, compared with the non-RRS group, the RRS group had 7 % (odds ratio [OR]: 0.93, 95 % confidence interval [CI]: 0.89, 0.97; P = 0.001), 6 % (OR: 0.94, 95 % CI: 0.91, 0.97; P < 0.001), and 9 % (OR: 0.91, 95 % CI: 0.83, 0.98; P = 0.020) lower incidences of 30-day mortality, 90-day mortality, and CPR, respectively.

CONCLUSIONS

The RRS group had lower 30-day and 90-day mortality rates than the non-RRS group after surgery under general anesthesia. Moreover, RRS was associated with a lower rate of CPR episodes resulting from cardiac arrest in patients undergoing general anesthesia after surgery.

Realist synthesis of a rapid response system in managing mental state deterioration in acute hospital settings

Mental state deterioration in patients poses significant challenges in healthcare, potentially resulting in adverse outcomes for patients and continued reliance on restrictive interventions. Implementing evidence-based approaches such as a rapid response system that prioritises early identification and intervention can effectively manage adverse outcomes. However, little is known regarding the effectiveness of these interventions. The objective of this synthesis was to test and refine initial programme theories by synthesising evidence to understand what works, for whom and under what circumstances. Based on the realist synthesis methodology, we searched EMBASE, CINAHL, MEDLINE, the Cochrane Library and grey literature for evidence to inform contexts, mechanisms and outcomes on the functioning of a rapid response model. We identified 28 relevant sources encompassing peer-reviewed journal articles and grey literature. This synthesis identified three important elements that contribute to the effectiveness of a rapid response system for managing mental state deterioration: care processes, therapeutic practices and organisational support. Essential elements include improving confidence and clinical skills through training, timely assessment and intervention, teamwork, communication and the creation of governance structures for monitoring and evaluation. To ensure the effectiveness, an organisation must adopt a comprehensive approach that incorporates organisational support, resource allocation, training, clear communication channels and commitment to continuous quality improvement. However, implementing interventions within a complex healthcare system requires thoughtful consideration of the organisational culture and governance structures. By taking a comprehensive and holistic approach to improvement initiatives, organisations can strive to achieve optimal outcomes in managing mental state deterioration and improving patient care.

Rapid Response Systems

The hospital rapid response system (RRS) is a patient safety and quality intervention that responds quickly to clinical deteriorations on general wards with the goal of preventing cardiopulmonary arrests, reducing hospital mortality, and facilitating triage and level of care escalations. The RRS is one of the first organized, and systematic, elements of the "ICU without walls" model. RRSs have been shown to be effective in preventing deterioration to cardiopulmonary arrest on general hospital wards and reducing total and unexpected hospital mortality. Recent studies have demonstrated that this benefit can be enhanced through targeted improvements and modifications of existing RRSs.

The third Medical Emergency Teams - Hospital outcomes in a day (METHOD3) study: The application of quality metrics for rapid response systems around the world

Aim

This cross-sectional study aimed to assess the readiness of international hospitals to implement consensus-based quality metrics for rapid response systems (RRS) and evaluate the feasibility of collecting these metrics.

Methods

A digital survey was developed and distributed to hospital administrators and clinicians worldwide. The survey captured data on the recommended quality metrics for RRS and collected information on hospital characteristics. Statistical analysis included descriptive evaluations and comparisons by country and hospital type.

Results

A total of 109 hospitals from 11 countries participated in the survey. Most hospitals had some form of RRS in place, with multiple parameter track and trigger systems being commonly used. The survey revealed variations in the adoption of quality metrics among hospitals. Metrics related to patient-activated rapid response and organizational culture were collected less frequently. Geographical differences were observed, with hospitals in Australia and New Zealand demonstrating higher adoption of core quality metrics. Urban hospitals reported a lower number of recorded metrics compared to metropolitan and rural hospitals.

Conclusion

The study highlights the feasibility of collecting consensus-based quality metrics for RRS in international hospitals. However, variations in data collection and adoption of specific metrics suggest potential barriers and the need for further exploration. Standardized quality metrics are crucial for effective RRS functioning and continuous improvement in patient care. Collaborative initiatives and further research are needed to overcome barriers, enhance data collection capabilities, and facilitate knowledge sharing among healthcare providers to improve the quality and safety of RRS implementation globally.

The United Kingdom's National Early Warning Score: should everyone use it? A narrative review

This review critiques the benefits and drawbacks of the United Kingdom's National Early Warning Score (NEWS). Potential developments for the future are considered, as well as the role for NEWS in an emergency department (ED). The ability of NEWS to predict death within 24 h has been well validated in multiple clinical settings. It provides a common language for the assessment of clinical severity and can be used to trigger clinical interventions. However, it should not be used as the only metric for risk stratification as its ability to predict mortality beyond 24 h is not reliable and greatly influenced by other factors. The main drawbacks of NEWS are that measuring it requires trained professionals, it is time consuming and prone to calculation error. NEWS is recommended for use in acute UK hospitals, where it is linked to an escalation policy that reflects postgraduate experience; patients with lower NEWS are first assessed by a junior clinician and those with higher scores by more senior staff. This policy was based on expert opinion that did not consider workload implications. Nevertheless, its implementation has been shown to improve the efficient recording of vital signs. How and who should respond to different NEWS levels is uncertain and may vary according to the clinical setting and resources available. In the ED, simple triage scores which are quicker and easier to use may be more appropriate determinants of acuity. However, any alternative to NEWS should be easier and cheaper to use and provide evidence of outcome improvement.

Using Vital Signs to Place Acutely Ill Patients Quickly and Easily into Clinically Helpful Pathophysiologic Categories: Derivation and Validation of Eight Pathophysiologic Categories in Two Distinct Patient Populations of Acutely Ill Patients

BACKGROUND

Early warning scores reliably identify patients at risk of imminent death, but do not provide insight into what may be wrong with the patient or what to do about it.

OBJECTIVE

Our aim was to explore whether the Shock Index (SI), pulse pressure (PP), and ROX Index can place acutely ill medical patients in pathophysiologic categories that could indicate the interventions required.

METHODS

A retrospective post-hoc analysis of previously obtained and reported clinical data for 45,784 acutely ill medical patients admitted to a major regional referral Canadian hospital between 2005 and 2010 and validated on 107,546 emergency admissions to four Dutch hospitals between 2017 and 2022.

RESULTS

SI, PP, and ROX values divided patients into eight mutually exclusive physiologic categories. Mortality was highest in patient categories that included ROX Index value < 22, and a ROX Index value < 22 multiplied the risk of any other abnormality. Patients with a ROX Index value < 22, PP < 42 mm Hg, and SI > 0.7 had the highest mortality and accounted for 40% of deaths within 24 h of admission, whereas patients with a PP ≥ 42 mm Hg, SI ≤ 0.7, and ROX Index value ≥ 22 had the lowest risk of death. These results were the same in both the Canadian and Dutch patient cohorts.

CONCLUSIONS

SI, PP, and ROX Index values can place acutely ill medical patients into eight mutually exclusive pathophysiologic categories with different mortality rates. Future studies will assess the interventions needed by these categories and their value in guiding treatment and disposition decisions.

[Hemodynamic Monitoring 2.0 - What is Possible on Normal Wards?]

Life threatening events after surgery often occur on the ward. These events could be prevented by early detection of clinical deterioration of patients' health status during ward care. Therefore, an adequate monitoring could help to identify patients at risk, since there is an imbalance of monitoring intensity and the occurrence of life-threatening events during hospital stay.Additional monitoring on the general ward could lead to more patient safety. The practicability of additional monitoring needs to be considered, and therefore the use of available monitoring systems on the ward is limited. Capillary refill time (CRT) and the passive leg raise test (PLR) seem to be usable intermittent monitoring techniques.Continuous monitoring systems ensure a better detection of unwanted events and hemodynamic trends. However, the increased workload for the nursing staff and tethered monitors are unfavorable. Future trends of developing wireless monitoring systems are of paramount importance in this respect. Controlling artefacts is crucial for the successful balance between false alarms and "missed events". An adequate reaction is needed when detecting adverse events to avoid a "failure to rescue".