When patients (and families) raise the alarm: Patient and family activated rapid response as a safety strategy for hospitals

Impact of implementing a patient and carer escalation system for clinical deterioration in general wards: A systematic review

OBJECTIVES

To consolidate evidence on the impact of implementing a patient and carer escalation system.

METHODS

Six electronic databases (MEDLINE (OvidSP), CINAHL, Embase, PsycINFO, Scopus, and Web of Science) were searched from 01 January 2012 until 26 May 2024. Two reviewers independently screened articles that reported on the implementation and evaluation of patient and carer escalation of care system. The Critical Appraisal Skills Programme tool, Joanna Briggs Institute critical appraisal tools, and the Mixed Methods Appraisal Tool were used to appraise the quality of the included studies. A convergent integrated synthesis approach and thematic analysis were adopted for data synthesis.

RESULTS

Eighteen studies are included in this review. Five main themes emerged from the data analysis: (1) enhanced patient safety versus burden on patients and carers; (2) forging partnerships between healthcare professionals, patients and carers; (3) empowerment of patients and carers; (4) perception of professional competence being questioned and undermined; (5) potential strain on healthcare resources. Enhancement of patient's safety was found to be the prominent result of this review followed by the demand in resources to improve the implementation of patient and carer escalation systems.

CONCLUSIONS

This review illustrates the growing interest in implementing patient and carer escalation systems to empower patients and carers to escalate clinical concerns in hospitals.

IMPLICATIONS FOR CLINICAL PRACTICE

Successful implementation of patient and carer escalation systems is necessitated by the integration of formal education for healthcare professionals, patients and carers. Further high-quality research to develop the metrics of patient and carer escalation system effectiveness is warranted.

"Because I couldn't understand and respond": A mixed-method study examining the impact of language barriers on patient experiences of intensive care unit outreach team care

BACKGROUND

Almost 10% of hospitalised patients experience acute deterioration requiring emergency intervention. Language barriers can impede patient assessment and health outcomes.

OBJECTIVE

The objective of this study was to explore the experiences of adult inpatients whose preferred language was not English, who received care from the intensive care unit (ICU) outreach team.

METHODS

An explanatory sequential two-phase mixed-method design was used. A retrospective audit was undertaken to explore characteristics of and outcomes for recipients of ICU outreach team care, according to preferred language. In phase two, interpreter-mediated interviews were conducted with former patients whose preferred language was not English to explore their experience of critical illness and care by the ICU outreach team.

RESULTS

From 4234 inpatients who received care from the ICU outreach team in 2022, there was a mean of 3.54 episodes of care (1-565) per patient. Those whose preferred language was not English had a higher proportion of admissions from the emergency department and were more likely to have a medical emergency team call as their first outreach episode of care but less likely to be admitted to the ICU. Vietnamese and Mandarin were the next most common languages spoken after English. Twenty-two former patients or delegated relatives were interviewed. Not all recalled receiving care from the ICU outreach team. There was strong support for involvement of professional interpreters for critical conversations and to aid autonomy. Family members acted as lay interpreters and fulfilled familial and cultural obligations, but visitor restrictions impeded this.

CONCLUSION

Patient deterioration requires an emergent response. This research demonstrates the importance of identifying and overcoming language barriers for patients in a way that protects and preserves patient autonomy and ensures information accuracy. Where time and the patient's condition allows, use of professional interpreters must become the norm.

Paediatric family activation rapid response (FARR) in acute care: a qualitative study for developing a multilingual application (app) intervention

BACKGROUND

Delayed recognition of clinical deterioration can result in harm to patients. Parents/carers can often recognise changes in the child's condition before healthcare professionals (HCPs). To mitigate the risk of failure to rescue and promote early intervention, family-activated rapid response (FARR) systems are part of family-integrated care. Mechanisms for parents/carers to escalate concerns regarding their child's clinical status remain limited to direct verbal communication, which may impede those with communication/linguistic challenges.

AIM

To develop a digital multilingual intervention by which families/carers can escalate their concerns directly to the rapid response team while in acute paediatric care.

METHODS

A single-centre qualitative, co-design app development study was conducted. Evidence synthesis from a systematic review of the international literature informed interviews on intervention prototype development using co-design focus groups. Participant recruitment targeted underserved communities for multilingual functionality validity. Data were analysed using qualitative content analysis.

RESULTS

Thirty parents/carers (n=16) and HCPs (n=14) participated in the study. Three themes were generated from the data analysis: (1) relational considerations; communication, professional and parental attributes, and collaborative working; (2) technology considerations; app content, usage and outcomes; and (3) individual and environmental considerations; parental and professional elements, and workload. A FARR app prototype was developed based on the data.

CONCLUSION

The prototype app provides a platform to develop a coordinated and consistent technological approach to paediatric FARR that acknowledges cultural nuances and preferences, ensuring that parents can communicate in a manner that aligns with their cultural background and communication abilities, thereby enhancing the quality of care delivered.

Understanding the enablers and barriers to implementing a patient-led escalation system: a qualitative study

BACKGROUND

The management of acute deterioration following surgery remains highly variable. Patients and families can play an important role in identifying early signs of deterioration but effective contribution to escalation of care can be practically difficult to achieve. This paper reports the enablers and barriers to the implementation of patient-led escalation systems found during a process evaluation of a quality improvement programme Rescue for Emergency Surgery Patients Observed to uNdergo acute Deterioration (RESPOND).

METHODS

The research used ethnographic methods, including over 100 hours of observations on surgical units in three English hospitals in order to understand the everyday context of care. Observations focused on the coordination of activities such as handovers and how rescue featured as part of this. We also conducted 27 interviews with a range of clinical and managerial staff and patients. We employed a thematic analysis approach, combined with a theoretically focused implementation coding framework, based on Normalisation Process Theory.

RESULTS

We found that organisational infrastructural support in the form of a leadership support and clinical care outreach teams with capacity were enablers in implementing the patient-led escalation system. Barriers to implementation included making changes to professional practice without discussing the value and legitimacy of operationalising patient concerns, and ensuring equity of use. We found that organisational work is needed to overcome patient fears about disrupting social and cultural norms.

CONCLUSIONS

This paper reveals the need for infrastructural support to facilitate the implementation of a patient-led escalation system, and leadership support to normalise the everyday process of involving patients and families in escalation. This type of system may not achieve its goals without properly understanding and addressing the concerns of both nurses and patients.

Patient safety and hospital visiting at the end of life during COVID-19 restrictions in Aotearoa New Zealand: a qualitative study

BACKGROUND

Visiting restrictions were enacted in Aotearoa New Zealand to reduce transmission of COVID-19 and protect the healthcare system. This research aimed to investigate the experiences of families and clinicians of hospital visiting for people with palliative and end-of-life care needs during restrictions.

METHODS

Semistructured interviews were completed between March and October 2021 with family members and clinicians who had personally experienced enactment of visiting restrictions during pandemic restrictions. A critical realist ontology was used to approach data analysis, sorting and coding to generate themes.

RESULTS

Twenty-seven participants were interviewed, 13 being families who had experienced bereavement of a family member during the restrictions: seven nurses or physicians and seven being non-bereaved family members. Four themes were generated: patient safety-(re)defining the 'Visitor'; the primacy of SARS-CoV-2-patient safety and negotiating risk; dying alone: enduring harms; and agency, strategies and workarounds.

CONCLUSION

Visitor rights and visitor policy at the end of life require greater protection during a pandemic. Transparent, coherent, publicly available evidence-based guidelines that key stakeholders, including patients, families and ethicists, are included in producing, are urgently required. We want to avert a legacy of disenfranchised grief in future pandemics.

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.

Call 4 Concern: the impact of a patient-and-relative-activated service

The aim of this project was to introduce and evaluate the Call 4 Concern© (C4C) service, which provides patients and relatives with direct access to critical care outreach services (CCOS). This allows patients and relatives an additional platform to raise concerns related to the clinical condition and facilitate early recognition of a deteriorating patient. The introduction of Call 4 Concern at a district general hospital was inspired by the Royal Berkshire Hospital, where staff have been pioneering the service in the UK since 2009. They were able to demonstrate the potential to prevent clinical deterioration and improve the patients' and relatives' experiences. The project was originally inspired by the Condition H(elp) system in the USA, which was set up following the death of an 18-month-old child who died of preventable causes. Similar tragic cases in the USA and the UK have prompted campaigning by affected families, resulting in the widespread adoption of comparable services. The project was rolled out in the authors' trust for all adult inpatients. There was a 2-week implementation phase to raise awareness. Between 22 February 2022 and 22 February 2023, the CCOS team received 39 C4C referrals, representing approximately 2.13% of the total CCOS activity. Clinical deterioration of a patient was prevented in at least three cases, alongside overwhelming positive feedback from service users.

Paediatric family activated rapid response interventions; qualitative systematic review

BACKGROUND

Failure to recognise deterioration early which results in patient death, is considered failure to rescue and it is identified as one of the leading causes of harm to patients. It is recognised that patients and their families can often recognise changes within the child's condition before healthcare professionals. To mitigate the risk of failure to rescue and promote early intervention, family-activated rapid response systems are becoming widely acknowledged and accepted as part of family integrated care.

OBJECTIVE

To identify current family-activated rapid response interventions in hospitalised paediatric patients and understand mechanisms by which family activation works.

METHODS

A narrative systematic review of published studies was conducted. Seven online databases; AMED, CINHAL, EMBASE, EMCARE, HMIC, JBI, and Medline were searched for potentially relevant papers. The critical appraisal skills programme tool was used to assess methodological rigor and validity of included studies.

RESULTS

Six studies met the predefined inclusion criteria. Five telephone family activation interventions were identified; Call for Help, medical emergency-teams, Condition HELP, rapid response teams, and family initiated rapid response. Principles underpinning all interventions were founded on a principal of granting families access to a process to escalate concerns to hospital emergency teams. Identified interventions outcomes and mechanisms include; patient safety, empowerment of families, partnership working/ family centred care, effective communication and better patient outcomes. Interventions lacked multi-lingual options.

CONCLUSION

Family activation rapid response system are fundamental to family integrated care and enhancing patient safety. Underlying principles and concepts in delivering interventions are transferable across global healthcare system.