Re-designing a rapid response system: effect on staff experiences and perceptions of rapid response team calls.

BACKGROUND: Rapid Response Team (RRT) calls are clinical crises. Clinical and time pressures can hinder effective liaison between staff who call the RRT ('users') and those responding as part of the RRT ('members'). Non-technical skills (NTS) training has been shown to improve communication and cooperation but requires time and financial resources that may not be available in acute care hospitals. Rapid Response System (RRS) re-design, aiming to promote use of NTS, may provide an alternative approach to improving interactions within RRTs and between members and users. METHODS: Re-design of an existing mature RRS was undertaken in a tertiary, metropolitan hospital incorporating the addition of: 1) regular RRT meetings 2) RRT role badges and 3) a structured member-to-user patient care responsibility "hand-off" process. To compare experiences and perceptions of calls, users and members were surveyed pre and post re-design. RESULTS: Post re-design there were improvements in members' understanding of RRT roles (P = 0.03) and responsibilities (P < 0.01), and recollection of introducing themselves to users (P = 0.02). For users, after the re-design, there were improvements in identification of the RRT leader (P < 0.01), and in the development of clinical plans for patients remaining on the ward at the end of an RRT call (P < 0.01). However, post-re-design, fewer users agreed that the structured hand-off was useful or that they should be involved in the process. Both members and users reported fewer experiences of conflict at RRT calls post-re-design (both P < 0.01). CONCLUSION: The RRS re-design yielded improvements in interactions between members in RRTs and between RRT members and users. However, some unintended consequences arose, particularly around user satisfaction with the structured hand-off. These findings suggest that refinement and improvement of the RRS is possible, but should be an ongoing iterative effort, ideally supported by staff training. TRIAL REGISTRATION: NCT01551160. Registered: 12th March 2012.

Modifications to predefined rapid response team calling criteria: prevalence, characteristics and associated outcomes.

OBJECTIVE: Standardised rapid response team (RRT) calling criteria may not be applicable to all patients, and thus, modifications of these criteria may be reasonable to prevent unnecessary calls. Little data are available regarding the efficacy or safety of modifying RRT calling criteria; therefore, this study aimed to detail the prevalence and characteristics of modifications to RRT call triggers and explore their relationship with patient outcomes. DESIGN AND OUTCOME MEASURES: A pilot retrospective cohort study within a convenience sample of patients attended by a hospital RRT between July and December 2014; rates of repeat RRT calling and in-hospital mortality were compared between patients with and without modifications to standard calling criteria. Secondary analyses examined four different types of modifications, narrowing or widening of existing physiological calling criteria, to observations without defined calling criteria, and others. All analyses were performed using multivariable regression. RESULTS: During the study period, 673 patients had RRT calls, of whom 620 (91.2%) had data available for analysis. The majority of study patients (393; 63.4%) had modifications documented. Patients with modifications were more likely to have repeat RRT calls (odds ratio [OR], 2.86; 95% CI, 1.69-4.85) and experience in-hospital mortality (OR, 2.16; 95% CI, 1.31-3.57) versus patients without modifications. In the secondary analyses, although all classes of modification had higher rates of repeat calling, none reached statistical significance. Mortality was associated with having modifications that were more conservative than the standard calling criteria (adjusted OR, 2.81; 95% CI, 1.31-6.08). CONCLUSION: Modifications to standard calling criteria were frequently made, but did not seem to prevent further RRT calls and were associated with increased mortality. These findings suggest that modifications should be made with caution.

Reasons for Repeat Rapid Response Team Calls, and Associations with In-Hospital Mortality.

BACKGROUND: Previous publications noted increased mortality risk in patients subject to repeat rapid response team (RRT) calls. These patients were examined as a homogenous group, but there may be many reasons for repeat calls. Those potentially preventable by the rapid response system have not been investigated. METHODS: In a retrospective cohort study, patients with potentially preventable repeat calls were classified into two categories: type 1 (patients who had a repeat call following an initial call that ended despite the patient still triggering RRT calling criteria [T1-PRC]) and type 2 (patients with a repeat call within 24 hours of an initial call and for the same reason [T2-PRC]). In-hospital mortality for these patients and for those with repeat calls for all other reasons (ORC) were compared to patients with only a single call during their admission (SC). RESULTS: Mortality occurred in 31 (43.7%) T1-PRC, 13 (15.1%) T2-PRC, 56 (28.9%) ORC, and 289 (13.9%) SC patients. Univariate odds ratios (ORs), in comparison to SC patients, were 4.81 (95% confidence interval [CI]: 2.96-7.81; p < 0.001), 1.10 (95% CI: 0.60-2.02; p = 0.75), and 2.52 (95% CI: 1.80-3.52; p < 0.001), respectively. Mortality effects persisted for the T1-PRC and ORC groups after adjustment for patient, admission, and initial call characteristics with ORs of 4.07 (95% CI: 2.36-7.01; p < 0.001) and 2.29 (95% CI: 1.57-3.34; p < 0.001), respectively. CONCLUSION: This study found that repeat calls following an initial call that ended with ongoing breach of predefined calling criteria were strongly associated with increased mortality. This highlights the risk to patients when the RRT leaves reversible clinical deterioration unresolved at the end of a call.

Perceptions of interactions between staff members calling, and those responding to, rapid response team activations for patient deterioration.

Objectives The aim of the present study was to investigate experiences of staff interactions and non-technical skills (NTS) at rapid response team (RRT) calls, and their association with repeat RRT calls. Methods Mixed-methods surveys were conducted of RRT members and staff who activate the RRT (RRT users) for their perceptions and attitudes regarding the use of NTS during RRT calls. Responses within the survey were recorded as Likert items, ranked data and free comments. The latter were coded into nodes relating to one of four NTS domains: leadership, communication, cooperation and planning. Results Two hundred and ninety-seven (32%) RRT users and 79 (73.8%) RRT members provided responses. Of the RRT user respondents, 76.5% had activated the RRT at some point. Deficits in NTS at RRT calls were revealed, with 36.9% of users not feeling involved during RRT calls and 24.7% of members perceiving that users were disinterested. Unresolved user clinical concerns, or persistence of RRT calling criteria, were reasons cited by 37.6% and 23%, respectively, of RRT users for reactivating an RRT to the same patient. Despite recollections of conflict at previous RRT calls, 92% of users would still reactivate the RRT. The most common theme in the free comments related to deficiencies in cooperation (52.9%), communication (28.6%) and leadership (14.3%). Conclusions This survey of RRT users and members revealed problems with RRT users' and members' interactions at the time of an RRT call. Both users and members considered NTS to be important, but lacking. These findings support NTS training for RRT members and users. What is known about the topic? Previous surveying has related experiences of criticism and conflict between clinical staff at RRT activations. This leads to reluctance to call the RRT when indicated, with risks to patient safety, especially if subsequent RRT activation is necessary. Training in NTS has improved clinician interactions in simulated emergencies, but the exact role of NTS during RRT calls has not yet been established. What does this paper add? The present survey examined experienced clinicians' perceptions of the use of NTS at RRT calls and the effect on subsequent calling. A key finding was a disparity between perceptions of how RRT members interact with those activating the RRT (RRT users) and their performance of NTS. This was reflected with unresolved RRT user clinical concern at the time of a call. In turn, this affected RRT users' attitudes and intentions to reactivate the RRT. Formal handover was considered desirable by both RRT users and members. What are the implications for practitioners? The interface between the RRT and those who call the RRT is crucial. This survey shows that RRT users desire to be included in the management of the deteriorating patient and have their concerns addressed before completion of RRT attendance. Failure to do so results in repeat activations to the same patient, with the potential for adverse patient outcomes. Training to include NTS, especially around handover, for RRT members may address this issue and should be explored further.