A multi-facetted patient safety resource-A qualitative interview study on hospital managers' perception of the nurse-led Rapid Response Team

AIM

To explore hospital managers' perceptions of the Rapid Response Team.

DESIGN

An explorative qualitative study using semi-structured individual interviews.

METHODS

In September 2019, a qualitative interview study including nineteen hospital managers at three managerial levels in acute care hospitals was conducted. Interview transcripts were analysed with an inductive content analysis approach, involving researcher triangulation in data collection and analysis processes.

FINDINGS

One theme, 'A resource with untapped potential, enhancing patient safety, high-quality nursing, and organisational cohesion' was identified and underpinned by six categories and 30 sub-categories.

CONCLUSION

The Rapid Response Team has an influence on the organization that goes beyond the team's original purpose. It strengthens the organization's dynamic cohesion by providing clinical support to nurses and facilitating learning, communication and collaboration across the hospital. Managers lack engagement in the team, including local key data to guide future quality improvement processes.

IMPLICATIONS

For organizations, nursing, and patients to benefit from the team to its full potential, managerial engagement seems crucial.

IMPACT

This study addressed possible challenges to using the Rapid Response Team optimally and found that hospital managers perceived this complex healthcare intervention as beneficial to patient safety and nursing quality, but lacked factual insight into the team's deliverances. The research impacts patient safety pointing at the need to re-organize managerial involvement in the function and development of the Rapid Response Team and System.

REPORTING METHOD

We have adhered to the COREQ checklist when reporting this study. "No Patient or Public Contribution".

Are we deskilling or reskilling our hospital ward clinicians?

Rapid reponse teams emerged 27 years ago to identify deteriorating patients and reduce preventable harm. There are concerns that such teams have deskilled hospital staff. However, over the past 20 years, there have been marked changes in hospital care and workplace requirements for hospital staff. In this article, we contend that hospital staff have been reskilled rather than deskilled.

Implementation and Outcomes of a Difficult Airway Code Team Composed of Anesthesiologists in a Korean Tertiary Hospital: A Retrospective Analysis of a Prospective Registry

BACKGROUND

In 2017, we established an airway call (AC) team composed of anesthesiologists to improve emergency airway management outside the operating room. In this retrospective analysis of prospectively collected data from the airway registry, we describe the characteristics of patients attended to and practices by the AC team during the first 4 years of implementation.

METHODS

All AC team activations in which an airway intervention was performed by the AC team between June 2017 and May 2021 were analyzed.

RESULTS

In all, 359 events were analyzed. Activation was more common outside of working hours (62.1%) and from the intensive care unit (85.0%); 36.2% of AC activations were due to known or anticipated difficult airway, most commonly because of acquired airway anomalies (n = 49), followed by airway edema or bleeding (n = 32) and very young age (≤ 1 years; n = 30). In 71.3% of the cases, successful intubation was performed by the AC team at the first attempt. However, three or more attempts were performed in 33 cases. The most common device used for successful intubation was the videolaryngoscope (59.7%). Tracheal intubation by the AC team failed in nine patients, who then required surgical airway insertion by otolaryngologists. However, there were no airway-related deaths.

CONCLUSIONS

When coupled with appropriate assistance from an otolaryngologist AC system, an AC team composed of anesthesiologists could be an efficient way to provide safe airway management outside the operating room.

TRIAL REGISTRATION

Clinical Research Information Service Identifier: KCT0006643.

Obstetric Emergencies requiring Rapid response team activation: A retrospective cohort study in a high-risk tertiary care centre

OBJECTIVE

The purpose of this study was to better understand obstetric codes requiring rapid response team (RRT) activation by examining their incidence, indications, team response and patient outcomes.

METHODS

This was a retrospective study in peripartum women who required activation of "Code 77 (C77)" (obstetric emergency), "Code Blue (CB)" (cardiopulmonary compromise) or "Code Omega (CO)" (massive transfusion) during hospitalization during January 2014-May 2018. Hospital database and health records were interrogated to identify and review cases. Data on code characteristics, resuscitative measures, and maternal/ neonatal outcomes were collected.

RESULTS

147 codes were identified (C77, n=110; CO, n=25; CB, n=12) during the study period, with an incidence of 1:203 deliveries (C77 - 1:271 deliveries, CO - 1:1,194 deliveries and CB - 1:2,488 deliveries). The common indications for C77 were cord prolapse (33%) and fetal bradycardia (32%), and for CO and CB were postpartum hemorrhage (84%) and cardiac arrest (42%), respectively. Most (67%) codes occurred afterhours. The median (IQR) decision-to-delivery interval (DDI) was 8 (5, 15) min after C77. Emergency cesarean delivery (CD) was performed after 57% of obstetric emergencies and general anesthesia was administered in 63% of CDs. Maternal and neonatal mortality rates were 0.68% and 7%, respectively. Major maternal morbidity was seen in 33% cases. Debrief was documented in 4% codes.

CONCLUSION

RRT activation was required more commonly in C77 than in CO or CB. Their response time and DDIs were rapid. Mortality was low, however, one-third parturients had major morbidity. We suggest closer patient monitoring, immediate availability of resources, and appropriate documentation and debriefing.

Safety, speed, and effectiveness of air transportation for neonates

BACKGROUND

In Japan, 44.3% of neonates are delivered in private clinics without an attending pediatrician. Obstetricians in the clinics must resuscitate asphyxiated neonates in unstable condition, such as respiratory failure, and they are frequently transferred to tertiary perinatal medical centers. There has been no study comparing the physiological status and prognosis of neonates transported by ambulance with those transported by helicopter.

METHODS

Medical and transport records were used to compare the physiological status of neonates transported to Kagoshima City Hospital by land and those transported by air between January 1, 2013, and December 31, 2017.

RESULTS

Data from 425 neonates transferred by land and 143 by air were analyzed. There were no significant differences between the two groups in mean gestational age, mean birthweight, fetal blood pH, Apgar score, or the Score for Neonatal Acute Physiology with Perinatal Extension-II (SNAPPE-II) on arrival to the tertiary center (16.3 ± 15.4 [95% confidence interval (CI): 13.2-17.7] vs 16.4 ± 15.4 [95% CI: 13.9-19.0], respectively; P = 0.999); both groups had SNAPPE-II score 10-19, indicating no difference in mortality risk. The times to starting first aid and to admission to the intensive care unit were significantly reduced in neonates transported by air than by land. In subgroup analysis of patients of a gestational age ≤28 weeks, all cases of severe intraventricular hemorrhage (IVH) were observed in the land transportation group.

CONCLUSIONS

Neonatal transportation by air is as safe as land transportation, and time to first aid and intensive care are significantly reduced by transportation by air than by land. Air transport could also contribute to the prevention of IVH in neonatal transportation.

Improving medical emergency system: Results of a multi-professional questionnaire

OBJECTIVE

This study aimed to identify ways to improve the Medical Emergency System (MES) in its different components and infer Medical Emergency Team (MET) activation failure causes.

METHODS

A questionnaire regarding opinions and attitudes towards the MES was conducted, targeting all professionals at the hospital, which has an implemented MES with Basic Life Support (BLS) since 1998.

RESULTS

Thirty two percent (n=585) of hospital professionals answered, from these 37.8% were neither doctors nor nurses. In mean six years passed since the BLS certification, yet 102 professionals (17.4%) had not done it. A relevant percentage admitted to not being familiarized with the different components of the MES (activation criteria 16.4%, telephone number 4.1%, content of the resuscitation trolleys 42.4% and defibrillator-monitor 47.4%), percentages lessened among those had taken the BLS course. The majority highly valued MET, however 83 (23%) could not confirm that debriefingand 17 (4.4%) that allocation of tasks happened after and during activation, respectively. When activating MET 52 (18.1%) admitted fear of criticism and 38 (13.3%) agreed that they needed validation by another professional, factors not influenced by BLS course completion. Excessive workload as a barrier to recognize ill patients was pointed by 127 (45.7%) of the respondents.

CONCLUSION

Despite educational and auditing efforts, the MES is not fully integrated into hospital culture. BLS certification for all professionals and non-technical skills of MET were identified has major areas for MES improvement. Unfamiliarity with activation criteria, fear of criticism and excessive workload were identified as failure of activation causes.

Non-invasive continuous haemodynamic monitoring and response to intervention in haemodynamically unstable patients during rapid response team review

INTRODUCTION

During rapid response team (RRT) management of haemodynamic instability (HI), continuous non-invasive haemodynamic monitoring may provide supplemental physiological information.

OBJECTIVES

To continuously and non-invasively obtain the cardiac index (CI) and mean arterial pressure (MAP) in patients with HI at baseline and during RRT management using the ClearSight™ device.

METHODS

We performed a prospective observational study in adult patients managed by the RRT for tachycardia or hypotension or both. We assessed changes from baseline in heart rate (HR), MAP, CI, stroke volume index (SVI) and systemic vascular resistance index (SVRI) (i) at 5-minutely intervals up to 20 min, and (ii) over the entire 20-min period. We analysed patients by RRT trigger (tachycardia/hypotension) and intervention (fluid bolus therapy [FBT]/ no FBT).

RESULTS

We successfully recorded the CI in 47 of 50 (94%) patients. RRT reviews triggered by hypotension rather than tachycardia had a lower baseline HR (-45.4 bpm, p = <0.0001), MAP (-16.1 mmHg, p = 0.0007) and CI (1.0 L/min/m², p = 0.0025). Compared to baseline, in the tachycardia group, there was a small increase in MAP overall and at the 15-20 min time-block from 83.2 mmHg to 87.1 mmHg (+3.9 mmHg, p = 0.0066) and 85.5 mmHg (+2.3 mmHg, p = 0.0061), respectively. In those who received FBT, there was a statistically significant increase in MAP overall and at the 15-20 min time-block compared to baseline, from 70.1 mmHg to 73.5 mmHg (+3.4 mmHg, p = 0.0036) and 74.3 mmHg (+4.2 mmHg, p = 0.0037), respectively. However, there were no statistically significant changes in mean HR, CI, SVI, or SVRI when comparing baseline to the entire 20-min period or 5-min time-blocks within any group.

CONCLUSIONS

Continuous non-invasive measurement of haemodynamics during RRT management for HI was possible for 20 min. Patients with hypotension rather than tachycardia had lower baseline HR, MAP and CI values. There was a statistically significant but small increase in MAP at the 15-20 min time-block and overall, for both the tachycardia and FBT groups.

Insight into hospital ward nurses' concerns about patient health and the corresponding Medical Emergency Team nurse response

AIM

This study aims to understand the concerns of nurses when making MET calls which did not fulfil the vital sign criteria, and the MET nurses subsequent responses to these calls.

METHODS

This was a retrospective report-based study. Research material included nursing reports and MET forms related to MET calls made due to nurses' concern. Inductive content analysis was used to identify observations, which were then quantified based on the research material.

FINDINGS

From a total of 546 MET calls, 39 visits (7%) were due to nurses' concern. In these 39 visits, the vital sign criteria did not reach the alert threshold, but nurses made the call due to subjective worry. In 13% of visits, the alert concern was inadequate contact with the doctor. MET nurses responded to the alert by providing clinical and indirect nursing; more specifically, they performed examinations and nursing interventions and collaborated with other professionals.

CONCLUSION

A nurse's worry is influenced by subjective changes in the patient's condition or an inadequate doctor's response rather than objective physiological measurements. A MET nurse's ability to assess patient condition, respond to nurses' calls, and acknowledge justified alerts help MET nurses support concerned nurses and encourage them to contact the MET if necessary.

National Early Warning Score vs Rapid Response Team criteria-Prevalence, misclassification, and outcome

PURPOSE

The purpose of this study was to examine the prevalence of deviating vital parameters in general ward patients using rapid response team (RRT) criteria and National Early Warning Score (NEWS), assess exam duration, correct calculation and classification of risk score as well as mortality and adverse events.

METHODS

Point prevalence study of vital parameters according to NEWS and RRT criteria of all adult patients admitted to general wards at a Scandinavian university hospital with a mature RRT.

PRIMARY OUTCOME

prevalence of at-risk patients fulfilling at least one RRT criteria, total NEWS of 7 or greater or a single NEWS parameter of 3 (red NEWS).

SECONDARY OUTCOMES

mortality in-hospital and within 30 days or adverse events within 24 hours.

RESULTS

We assessed 598 (75%) of 798 admitted patients and examiners captured a fulfilled RRT calling criterion in 50 patients (8.4%), 36 (6.0%) had NEWS ≥ 7, 34 with a red NEWS parameter. Red NEWS occurred in 112 patients (18.7%). Secondary outcomes were fulfilled in 49 patients (8.2%). Mortality overall was 6.5% within 30 days, 1.8% in hospital. In 134 patients (22.4%) the manual calculation of score for NEWS was incorrectly performed by examiner.

CONCLUSION

Even with a mature RRT in place, we captured patients with failing physiology in general wards reflecting afferent limb failure. Manual calculation of NEWS is frequently incorrect, possibly leading to misclassification of patients at risk.

Impact of nighttime Rapid Response Team activation on outcomes of hospitalized patients with acute deterioration

Background

Rapid Response Teams (RRTs) are groups of healthcare providers that are used by many hospitals to respond to acutely deteriorating patients admitted to the wards. We sought to identify outcomes of patients assessed by RRTs outside standard working hours.

Methods

We used a prospectively collected registry from two hospitals within a single tertiary care-level hospital system between May 1, 2012, and May 31, 2016. Patient information, outcomes, and RRT activation information were stored in the hospital data warehouse. Comparisons were made between RRT activation during daytime hours (0800–1659) and nighttime hours (1700–0759). The primary outcome was in-hospital mortality, analyzed using a multivariable logistic regression model.

Results

A total of 6023 RRT activations on discrete patients were analyzed, 3367 (55.9%) of which occurred during nighttime hours. Nighttime RRT activation was associated with increased odds of mortality, as compared with daytime RRT activation (adjusted OR 1.34, 95% CI 1.26–1.40, P = 0.02). The time periods associated with the highest odds of mortality were 0600–0700 (adjusted OR 1.30, 95% CI 1.09–1.61) and 2300–2400 (adjusted OR 1.34, 95% CI 1.01–1.56). Daytime RRT activation was associated with increased odds of intensive care unit admission (adjusted OR 1.40, 95% CI 1.31–1.50, P = 0.02). Time from onset of concerning symptoms to RRT activation was shorter among patients assessed during daytime hours (P < 0.001).

Conclusions

Acutely deteriorating ward patients assessed by an RRT at nighttime had a higher risk of in-hospital mortality. This work identifies important shortcomings in health service provision and quality of care outside daytime hours, highlighting an opportunity for quality improvement.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2005-1) contains supplementary material, which is available to authorized users.

Clinician and manager perceptions of factors leading to ward patient clinical deterioration

BACKGROUND

Improving the timely recognition and response to clinical deterioration is a critical challenge for clinicians, educators, administrators and researchers. Clinical deterioration leading to Rapid Response Team review is associated with poor patient outcomes. A range of factors associated with clinical deterioration and its outcomes have been identified, and may help with early identification of deteriorating patients. However, the relative importance of each factor on the development of clinical deterioration is unknown.

OBJECTIVE

To identify the relative importance of factors contributing to the development of clinical deterioration in ward patients, as perceived by health professionals who have experience in recognising or responding to clinical deterioration, or in the management, administration or governance of RRSs.

METHODS

A written questionnaire containing 12 pre-determined factors was provided to participants. Participants were asked to rank the items from most to least important contributors to ward patient deterioration. The study took place during a session of the Australia and New Zealand Intensive Care Society Rapid Response Team conference.

RESULTS

A final sample of 233 (83% response rate), returned the questionnaire. The sample comprised specialist ICU registered nurses with direct patient contact (64%), ICU consultant doctors (17%), ICU nurse managers (7%), hospital administrators (2%), ICU registrars (2%), quality coordinators (2%) and non-hospital staff (4%). The patient's presenting illness/main diagnosis was the highest ranked factor, followed by pre-existing co-morbidities, seniority of nursing ward staff, medical documentation, senior medical staff, and interdisciplinary communication. Almost two-thirds of participants ranked patient characteristics as the most important contributor to clinical deterioration.

CONCLUSION

Health professionals who have experience in recognising or responding to clinical deterioration, or in the management, administration or governance of RRSs perceive that patient characteristics such as the patient's primary diagnosis and comorbidities to be the most important contributors to clinical deterioration.

Rapid Response Team activation for pediatric patients on the acute pain service

INTRODUCTION

Untreated pain or overly aggressive pain management may lead to adverse physiologic consequences and activation of the hospital's Rapid Response Team. This study is a quality improvement initiative that attempts to identify patient demographics and patterns associated with Rapid Response Team consultations for patients on the acute pain service.

METHODS

A retrospective review of all patients on the acute pain service from February 2011 until June 2015 was cross-referenced with inpatients requiring consultation from the Rapid Response Team. Two independent practitioners reviewed electronic medical records to determine which events were likely associated with pain management interventions.

RESULTS

Over a 4-year period, 4872 patients were admitted to the acute pain service of whom 135 unique patients required Rapid Response Team consults. There were 159 unique Rapid Response Team activations among 6538 unique acute pain service consults. A subset of 27 pain management-related Rapid Response Team consultations was identified. The largest percentage of patients on the acute pain service were adolescents aged 12-17 (36%). Compared to this age group, the odds of Rapid Response Team activation were higher among infants <1 year old (odds ratio = 2.85; 95% confidence interval: 1.59, 5.10; P < .001) and adults over 18 years (odds ratio = 1.68; 95% confidence interval: 1.01, 2.80; P = .046).

DISCUSSION

Identifying demographics and etiologies of acute pain service patients requiring Rapid Response Team consultations may help to identify patients at risk for clinical decompensation.

Safety and efficacy of nurse-controlled analgesia in patients less than 1 year of age

Background

The management of acute pain presents unique challenges in the younger pediatric population. Although patient-controlled devices are frequently used in patients ≥6 years of age, alternative modes of analgesic delivery are needed in infants.

Objective

To examine the safety and efficacy of nurse-controlled analgesia (NCA) in neonates less than 1 year of age.

Methods

Data from patients <1 year of age receiving NCA as ordered by the Acute Pain Service at our institution were collected over a 5-year period and reviewed retrospectively. The primary outcomes were activation of the institution’s Rapid Response Team (RRT) or Code Blue, signifying severe adverse events. Pain score after NCA initiation was a secondary outcome.

Results

Among 338 girls and 431 boys, the most common opioid used for NCA was fentanyl, followed by morphine and hydromorphone. There were 39 (5%) cases involving RRT or Code Blue activation, of which only one (Code Blue) was activated due to a complication of NCA (apnea). Multivariable logistic regression demonstrated morphine NCA to be associated with greater odds of RRT activation (OR=3.29, 95% CI=1.35, 8.03, P=0.009) compared to fentanyl NCA. There were no statistically significant differences in pain scores after NCA initiation across NCA agents.

Conclusion

NCA is safe in neonates and infants, with comparable efficacy demonstrated for the three agents used. The elevated incidence of RRT activation in patients receiving morphine suggests caution in its use and consideration of alternative agents in this population.

Etiology of postanesthetic and postsedation events on the inpatient ward: data from a rapid response team at a tertiary care children's hospital

INTRODUCTION

The goal of this study was to identify the etiology of events and demographics of patients that experience complications requiring activation of the Rapid Response Team (RRT) during the first 24 h following anesthetic care.

METHODS

We performed a retrospective review of the Quality Improvement database from the Department of Anesthesiology & Pain Medicine at Nationwide Children's Hospital. The database was searched to identify those patients who had a RRT evaluation activated within 24 h of receiving anesthesia or procedural sedation. These patients' charts were reviewed to obtain demographic information, etiology of the RRT call, and outcomes.

RESULTS

The study cohort included 106 RRT calls that were made over a 3-year period. Six patients were excluded from analysis due to incomplete datasets. One hundred patients remained for analysis including 60 males and 40 females. Patients ranged in age from 0.08 to 31.21 years (7.8 ± 7.7 years, median 5.3 years). Seventy-one patients were American Society of Anesthesiologists' (ASA) status 3 or 4 and 29 patients were ASA status 1 or 2. Five calls were made for patients who had undergone procedural sedation while the other 95 were on patients who received general anesthesia. The average time to the RRT call after the end of anesthetic care was 11.4 ± 6.6 h. Respiratory concern was the most common reason for RRT initiation, accounting for 71 of the 100 calls. Forty-nine patients had a recent respiratory illness, chronic respiratory-related disease, or history of preterm birth. Fifty patients (50%) were transferred to a higher level of care following the RRT consult. There was no significant difference between age, gender, ASA status, or etiology of the event for patients transferred vs. those who were not. A significant difference was noted in the Pediatric Early Warning Score of patients transferred to a higher level of care in comparison to patients who remained on the floor (4 ± 2 vs. 3 ± 2, P = 0.0097).

CONCLUSION

RRT calls were most common for respiratory concerns. High ASA status, general anesthesia administration, and the presence of acute or chronic conditions prior to anesthetic administration predispose a patient to perioperative complications resulting in the need for an RRT call.

Medical Emergency Team: How do we play when we stay? Characterization of MET actions at the scene

BACKGROUND

The creation, implementation and effectiveness of a medical emergency team (MET) in every hospital is encourage and supported by international bodies of quality certification. Issues such as what is the best composition of the team or the interventions performed by the MET at the scene and the immediate outcomes of the patients after MET intervention have not yet been sufficiently explored. The purpose of the study is to characterize MET actions at the scene and the immediate patient outcome.

METHODS

Retrospective cohort study, at a tertiary care, university-affiliated, 600-bed hospital, in the north of Portugal, over two years.

RESULTS

There were 511 MET activations: 389 (76%) were for inpatients. MET activation rate was 8.6/1,000 inpatients. The main criteria for activation were airway threatening in 143 (36.8%), concern of medical staff in 121 (31.1%) and decrease in GCS > 2 in 98 (25.2%) patients; MET calls for cardiac arrest occurred in 68 patients (17.5%). The median (IQR) time the team stayed at the scene was 35 (20-50) minutes. At the scene, the most frequent actions were related to airway and ventilation, namely oxygen administration in 145 (37.3%); in circulation, fluid were administered in 158 (40.6%); overall medication was administered in 185 (47.5%) patients. End-of-life decisions were part of the MET actions in 94 (24.1%) patients. At the end of MET intervention, 73 (18.7%) patients died at the scene, 190 (60.7%) stayed on the ward and the remaining 123 patients were transferred to an increased level of care. Crude hospital mortality rate was 4.1% in the 3 years previously to MET implementation and 3.6% in the following 3 years (p < 0.001).

DISCUSSION

During the study period, the rate of activation for medical inpatients was significantly higher than that for surgical inpatients. In our hospital, there is no 24/7 medical cover on the wards, with the exception of high-dependency and intensive care units; assuming that the number of unplanned admissions and chronic ill patients is greater in medical wards that could explain the difference found, which prompts the implementation of a 24/7 ward residence. The team stayed on site for half an hour and during that time most of the actions were simple and nurse-driven, but in one third of all activations medical actions were taken, and in a forth (24%) end-of-life decisions made, reinforcing the inclusion of a doctor in the MET. A significant decrease in overall hospital mortality rate was observed after the implementation of the MET.

CONCLUSIONS

The composition of our MET with an ICU doctor and nurse was reinforced by the need of medical actions in more than half of the situations (either clinical actions or end-of-life decisions). After MET implementation there was a significant decrease in hospital mortality. This study reinforces the benefit of implementing an ICU-MET team.

A review of inpatient ward location and the relationship to Medical Emergency Team calls

OBJECTIVE

To identify the relationship between in-hospital location and patient outcomes as measured by Medical Emergency Team calls.

STUDY DESIGN

A narrative systematic review of the literature.

DATA SOURCES

A systematic search of the literature was conducted in October 2014 using the electronic databases: Embase, Cochrane, Medline, CINAHL, Science Direct and Google Scholar for the most recent literature from 1997 to 2014.

INCLUSION CRITERIA

Non-randomised study designs such as case control or cohort studies were eligible. Articles were selected independently by two researchers using a predetermined selection criterion.

DATA SYNTHESIS

The screening process removed manuscripts that did not meet the inclusion criteria resulting in an empty review with one manuscript meeting most of the criteria for inclusion. The protocol was revised to a narrative synthesis including a broader scope of studies. The search strategy was expanded and modified to include manuscripts of any study design that comprise both inlier and outlier patients. Two manuscripts were selected for the narrative synthesis.

CONCLUSION

Two recently published studies investigated the incidence of MET calls for outlier patients, and whilst MET calls were increased in outlier hospital patients, definitive conclusions associated with patient outcomes cannot be made at this time due to paucity of studies.

Emergency care within hospitals: can it be done more efficiently?

INTRODUCTION

Cardiac Arrest Teams (CATs) are frequently activated by nurses when patients experience 'false arrests' (FAs). In those cases activation of the Rapid Response Team (RRT) might be more efficient. The authors determined the level of urgency of FAs to find a scope for improvement in efficiency within emergency care.

METHODS

CAT-activations for FAs in a university hospital from September 2009 to 2012 were retrospectively analysed and classified as urgent or less-urgent.

RESULTS

In 26% (107/405) the CAT was activated for FAs. Calls were classified as urgent in 43% (46/107). Less urgent calls comprised 57% (61/107) of the FAs, difference 14% (95%CI: 1% to 26%).

CONCLUSIONS

A significant part of the CAT-activations for FAs were less urgent and an RRT-activation might be more efficient. To minimise the CAT-activations for FAs, nurses need to recognise early patients who clinically deteriorate. Therefore, nurses should use the Modified Early Warning Score correctly.

The epidemiology of adult Rapid Response Team patients in Australia

Rapid Response Teams (RRT) are specialised teams that review deteriorating ward patients in an attempt to prevent morbidity and mortality. Most studies have assessed the effect of implementing an RRT into a hospital. There is much less literature on the characteristics and outcomes of RRT patients themselves. This article reviews the epidemiology of adult RRT patients in Australia and proposes three models of RRT syndromes. The number of RRT calls varies considerably in Australian hospitals from 1.35 to 71.3/1000 hospital admissions. Common causes of RRT calls include sepsis, atrial fibrillation, seizures and pulmonary oedema. Approximately 20% of patients to whom an RRT has responded have more than one RRT call, and up to one-third have issues around end-of-life care. Calls are least common overnight. Between 10 to 25% of patients are admitted to a critical care area after the call. The in-hospital mortality for RRT patients is approximately 25% overall but only 15% in patients without a limitation of medical therapy. RRT syndromes can be conceptually described by the trigger for the call (e.g. hypotension) or the clinical condition causing the call (e.g. sepsis). Alternatively, the RRT call can be described by the major theme of the call: "end-of-life care", "requiring critical care" and "stable enough to initially remain on the ward". Based on these themes, education strategies and quality improvement initiatives may be developed to reduce the incidence of RRT calls, further improving patient outcome.

Standardized measurement of the Modified Early Warning Score results in enhanced implementation of a Rapid Response System: a quasi-experimental study

PURPOSE

To study the effect of protocolized measurement (three times daily) of the Modified Early Warning Score (MEWS) versus measurement on indication on the degree of implementation of the Rapid Response System (RRS).

METHODS

A quasi-experimental study was conducted in a University Hospital in Amsterdam between September and November 2011. Patients who were admitted for at least one overnight stay were included. Wards were randomized to measure the MEWS three times daily ("protocolized") versus measuring the MEWS "when clinically indicated" in the control group. At the end of each month, for an entire seven-day week, all vital signs recorded for patients were registered. The outcomes were categorized into process measures including the degree of implementation and compliance to set monitoring standards and secondly, outcomes such as the degree of delay in physician notification and Rapid Response Team (RRT) activation in patients with raised MEWS (MEWS≥3).

RESULTS

MEWS calculations from vital signs occurred in 70% (2513/3585) on the protocolized wards versus 2% (65/3013) in the control group. Compliance with the protocolized regime was presents in 68% (819/1205), compliance in the control group was present in 4% (47/1232) of the measurements. There were 90 calls to primary physicians on the protocolized and 9 calls on the control wards. Additionally on protocolized wards, there were twice as much RRT calls per admission.

CONCLUSIONS

Vital signs and MEWS determination three times daily, results in better detection of physiological abnormalities and more reliable activations of the RRT.