A Rapid Response Mobile Application Improves First-Year Resident Clinical Performance During Simulated Care Events: A Randomized Controlled Trial.

BACKGROUND: Rapid response teams (RRTs) are critical to the timely and appropriate management of acutely decompensating patients. In the academic setting, the vital role of RRT leader is often filled by a junior resident physician who may lack the necessary medical knowledge and experience. Cognitive aids help improve guideline adherence and may support resident performance as they transition into leadership roles. OBJECTIVE: This study evaluated the impact of a rapid response mobile application on intern performance during simulated rapid response events. DESIGN: This randomized controlled trial compared the performance of interns in two simulated rapid response scenarios with and without access to the rapid response mobile application. The scenarios included anaphylaxis and supraventricular tachycardia (SVT). Simulations were video recorded and coded by trained raters. PARTICIPANTS: Interns in all specialties at our institution. MAIN MEASURES: Outcomes included (1) time to ordering critical medications (epinephrine and adenosine), (2) overall clinical performance using a checklist-based performance measure, and (3) usability of the mobile application. Enrollment and data collection occurred between November 2022 and February 2023. KEY RESULTS: Forty-four interns from 12 specialties were randomized to the intervention group (N = 22) and the control group (N = 22). Time to order critical medications was significantly reduced in the intervention group compared to control for anaphylaxis (P < 0.005) and SVT (P < 0.005). The intervention group had significantly higher performance scores compared to the control group for the anaphylaxis portion (P < 0.006). Usability scores for the rapid response toolkit were good. CONCLUSIONS: Access to a rapid response mobile application improved the quality of care administered by interns during two simulated rapid response scenarios as determined by a decrease in time to ordering critical medications and improved performance scores. The intervention group found the mobile application to be usable. This work adds to existing literature supporting the use of technology-based cognitive aids to improve patient care.

Nurse-led medical emergency response reduces code blue team activations in non-hospitalized patients.

Objective: We describe the creation of a two-tier emergency response system with a nurse-led first responder program titled "MET-RN" (Medical Emergency Team-Registered Nurse) created for ambulatory settings supported by a critical care code blue team for escalation of care. This observational study evaluated the clinical characteristics and effects of a MET-RN program on the code blue response. Methods: A retrospective review of the MET-RN response data was assessed from January 2016 to June 2021. Data collected included time of call, call location, patient comorbidities, triage category (minor, urgent, or emergent), activation trigger, interventions performed, duration of the event, and patient disposition. In instances where the patient was admitted to the hospital, the discharge diagnosis and emergency department (ED) triage score were collected. Differences were tested using analysis of variance (ANOVA) F-tests, with Tukey post-hoc testing where applicable. Results: MET-RN responded to 6,564 encounters from January 2016 to June 2021. The most frequent trigger call was dizziness/lightheadedness, with a prevalence of 12.0%. 33.9% of the patients seen by MET-RN were transported to the ED for further evaluation. Establishing a MET-RN system led to an estimated median of 58.3% reduction in utilization of the code blue team per quarter. Conclusion: The creation of MET-RN first responder system enabled the ambulatory areas to receive minor, urgent, and emergent patient care support, leading to a decrease in utilization of the code blue team for the hospital. A two-tiered response system resulted in an improved allocation of hospital resources and kept critical care teams in high-acuity areas while maintaining patient safety.

A novel structured debriefing program for consensus determinations of in-hospital cardiac arrest predictability and preventability.

AIM: Hospital rapid response systems aim to stop preventable cardiac arrests, but defining preventability is a challenge. We developed a multidisciplinary consensus-based process to determine in-hospital cardiac arrest (IHCA) preventability based on objective measures. METHODS: We developed an interdisciplinary ward IHCA debriefing program at an urban quaternary-care academic hospital. This group systematically reviewed all IHCAs weekly, reaching consensus determinations of the IHCA's cause and preventability across three mutually exclusive categories: 1) unpredictable (no evidence of physiologic instability < 1 h prior to and within 24 h of the arrest), 2) predictable but unpreventable (meeting physiologic instability criteria in the setting of either a poor baseline prognosis or a documented goals of care conversation) or 3) potentially preventable (remaining cases). RESULTS: Of 544 arrests between 09/2015 and 11/2023, 339 (61%) were deemed predictable by consensus, with 235 (42% of all IHCAs) considered potentially preventable. Potentially preventable arrests disproportionately occurred on nights and weekends (70% vs 55%, p = 0.002) and were more frequently respiratory than cardiac in etiology (33% vs 15%, p < 0.001). Despite similar rates of ROSC across groups (67-70%), survival to discharge was highest in arrests deemed unpredictable (31%), followed by potentially preventable (21%), and then those deemed predictable but unpreventable which had the lowest survival rate (16%, p = 0.007). CONCLUSIONS: Our IHCA debriefing procedures are a feasible and sustainable means of determining the predictability and potential preventability of ward cardiac arrests. This approach may be useful for improving quality benchmarks and care processes around pre-arrest clinical activities.

Systems of Care Delivery and Optimization in the Postoperative Care Wards.

A third of all patients are at risk for a serious adverse event, including death, in the first month after undergoing a major surgery. Most of these events will occur within 24 hours of the operation but are unlikely to occur in the operating room or postanesthesia care unit. Most opioid-induced respiratory depression events in the postoperative period resulted in death (55%) or anoxic brain injury (22%). A future state of mature artificial intelligence and machine learning will improve situational awareness of acute clinical deterioration, minimize alert fatigue, and facilitate early intervention to minimize poor outcomes.

Triggers for medical emergency team activation after non-cardiac surgery.

Deterioration after major surgery is common, with many patients experiencing a medical emergency team (MET) activation. Understanding the triggers for MET calls may help design interventions to prevent deterioration. We aimed to identify triggers for MET activation in non-cardiac surgical patients. A retrospective cohort study of adult patients who experienced a postoperative MET call at a single tertiary hospital was undertaken. The trigger and timing of each MET call and patient characteristics were collected.Four hundred and one MET calls occurred after 23,258 surgical procedures, a rate of 1.7% of all non-cardiac surgical procedures, accounting for 11.7% of all MET calls over the study period. Hypotension (41.4%) was the most common trigger, followed by tachycardia (18.5%), altered conscious state (11.0%), hypoxia (10.0%), tachypnoea (5.7%), 'other' (5.7%), clinical concern (4.0%), increased work of breathing (1.5%) and bradypnoea (0.7%). Cardiac and/or respiratory arrest triggered 1.2% of MET activations. Eighty-six percent of patients had a single MET call, 10.2% had two, 1.8% had three and one patient (0.3%) had four. The median interval between post-anaesthetic care unit (PACU) discharge and MET call was 14.7 h (95% confidence interval 4.2 to 28.9 h). MET calls resulted in intensive care unit (ICU) admission in 40 patients (10%), while 82% remained on the ward, 4% had a MET call shortly after ICU discharge and returned there, 2% returned to theatre, and 2% went to a high dependency unit.Hypotension was the most common trigger for MET calls after non-cardiac surgery. Deterioration frequently occurred within 24 h of PACU discharge. Future research should focus on prevention of hypotension and tachycardia after surgery.

Predictive value of a tiered escalation response system: A case control study.

OBJECTIVE: Rapid response systems designed to detect and respond to clinical deterioration often incorporate a multitiered, escalation response. We sought to determine the 'predictive strength' of commonly used triggers, and tiers of escalation, for predicting a rapid response team (RRT) call, unanticipated intensive care unit admission, or cardiac arrest (events). DESIGN: This was a nested, matched case-control study. SETTING: The study setting involved a tertiary referral hospital. PARTICIPANTS: Cases experienced an event, and controls were matched patients without an event. OUTCOME MEASURES: Sensitivity and specificity and area under the receiver operating characteristic curve (AUC) were measured. Logistic regression determined the set of triggers with the highest AUC. RESULTS: There were 321 cases and 321 controls. Nurse triggers occurred in 62%, medical review triggers in 34%, and RRT triggers 20%. Positive predictive value of nurse triggers was 59%, that of medical review triggers was 75%, and that of RRT triggers was 88%. These values were no different when modifications to triggers were considered. The AUC was 0.61 for nurses, 0.67 for medical review, and 0.65 for RRT triggers. With modelling, the AUC was 0.63 for the lowest tier, 0.71 for next highest, and 0.73 for the highest tier. CONCLUSION: For a three-tiered system, at the lowest tier, specificity of triggers decreases, sensitivity increases, but the discriminatory power is poor. Thus, there is little to be gained by using a rapid response system with more than two tiers. Modifications to triggers reduced the potential number of escalations and did not affect tier discriminatory value.

Frontline Nurses' clinical judgment in recognizing, understanding, and responding to patient deterioration: A qualitative study.

BACKGROUND: Early warning systems and rapid response teams have been widely implemented in hospitals worldwide to facilitate early recognition and response to patient deterioration. Unfortunately, evidence suggests that these interventions have made little impact on unexpected cardiac or respiratory arrest, hospital mortality, unplanned admission to intensive care units, or hospital length of stay. These programs depend on nurses recognizing at risk patients and initiating a timely response. Although physiologic abnormalities commonly precede serious adverse events, nurses often fail to recognize or respond effectively. Clinical judgment is a critical component in the effective response to deterioration, yet little is known about factors that influence nurses' clinical judgment in these situations. Noticing, interpreting, and responding are aspects of clinical judgment and are essential to preventing further patient deterioration and serious adverse events. OBJECTIVE: To describe medical-surgical nurses' perceptions of factors that influenced their clinical judgment in situations of patient deterioration. DESIGN: A qualitative descriptive design using individual, semi-structured interviews. Tanner's Clinical Judgment Model served as the framework for interview questions and data analysis. PARTICIPANTS: A purposive sample of 20 medical-surgical registered nurses were recruited from 10 adult medical-surgical units at an academic medical center hospital in the United States. METHODS: Telephone interviews occurred between March and July 2018. A directed approach to content analysis was used to code the transcribed data and identify themes. RESULTS: Eight themes related to each aspect of clinical judgment emerged from the analysis: Knowing the patient, Experience matters, Lots of small points where the system can fail, Making sense of the data, Something doesn't go together, Caught in the middle, Culture of teamwork, and Increased nursing workload. An overarching theme was Nurses' keen sense of responsibility. Findings revealed that factors within the nurse, the patient, and the work environment influence each component of noticing, interpreting, and initiating an effective response to deteriorating patients. CONCLUSIONS: Findings have implications for health care systems regarding interventions to support timely recognition and response to deterioration. Nurses' clinical judgment and factors that influence each aspect (noticing, interpreting, and responding) should be a key consideration in organizational efforts to improve the overall response to patient deterioration. Research is needed to enhance understanding of the contextual factors that impact nurses' clinical judgment to inform interventions to support timely recognition and response.

Structural Elements and Requirements in Forming Prehospital Health Response Teams in Response to Chemical, Biological, Radiation, and Nuclear Incidents (CBRN), a Comparative Review Study.

One of the important indicators of increasing the capacity of the health system and the chances of survival of patients and injured immediately after chemical, biological, radiation and nuclear (CBRN) accidents is rapid access to medical services. Establishing prehospital health response teams is one of the main strategies to improve the capacity and ability to respond to unusual events. The aim of this study was to investigate the factors influencing the formation of rapid response teams in the field of health in response to chemical, biological, radiation and nuclear accidents (CBRN EDMRT). In this study, the comparative review method was used. The study period was from November 1, 2021 to March 2022. Forming and deploying rapid health response teams based on an extensive multi-step search and keywords in multiple databases such as PubMed, CINHAL, Blackwell, Iranmedex, SID, Cochrane Database of Systematic Reviews, Google Scholar, Scopus Also, the websites of the Ministry of Health and the responsible organizations in different countries and the proposed structure were done by international institutions and sites. After accessing the resources and documents, the process of analysis and comparison of different team structures was performed. After the initial search, the structure and required elements of their teams were extracted. According to published articles and texts, 10 teams from the International Atomic Energy Agency (IAEA), the US Centers for Disease Control and Prevention (CDC), the US Department of Homeland Security, and the North Atlantic Treaty Organization (NATO), Australia, the British Public Health Organization, and the Japanese Red Cross were compared. Team requirements, population distribution, type of accident, level of team activity and training, equipment required by the team after the accident, according to which, each country/organization should consider the above factors to design and establish the structure of CBRN EDMRT to take. A study should be conducted to design a comprehensive and evidence-based structure.

Rapid Response Systems at a Long-Term Acute Care Hospital.

Rapid Response Systems (RRS) improve patient outcomes at large medical centers. Little is known about how RRS are used in other medical settings. The purpose of this exploratory study was to describe RRS events at a long-term acute care hospital (LTACH). We conducted a retrospective review of 71 RRS event records at an urban 50-bed Midwestern LTACH. Measures included demographic data, triggering mechanisms, contextual factors, mechanism factors, and clinical outcomes. Of patients who experienced a RRS event, median age was 71 (62, 80) years; 52.1% were female; most (n = 49, 69%) were "full code." Most (n = 41, 58%) events occurred during the daytime. The most common trigger was "mental status changes/unresponsiveness." Registered nurses were the most frequent activator (n = 19, 26.8%) and responders (n = 63, 60.6%). Median duration of RRS events was 14 (6, 25) minutes. Most patients stabilized and their condition improved (n = 54, 76.1%). RRS can be expanded and modified to the LTACH population.

Construct and clinical verification of a nurse-led rapid response systems and activation criteria.

BACKGROUND: Effective team leadership and good activation criteria can effectively initiate rapid response system (RRS) to reduce hospital mortality and improve quality of life. The first reaction time of nurses plays an important role in the rescue process. To construct a nurse-led (nurse-led RRS) and activation criteria and then to conduct a pragmatic evaluation of the nurse-led RRS. METHODS: We used literature review and the Delphi method to construct a nurse-led RRS and activation criteria based on the theory of "rapid response system planning." Then, we conducted a quasi-experimental study to verify the nurse-led RRS. The control group patients were admitted from August to October 2020 and performed traditional rescue procedures. The intervention group patients were admitted from August to October 2021 and implemented nurse-led RRS. The primary outcome was success rate of rescue. SETTING: Emergency department, Gansu Province, China. RESULTS: The nurse-led RRS and activation criteria include 4 level 1 indicators, 14 level 2 indicators, and 88 level 3 indicators. There were 203 patients who met the inclusion criteria to verify the nurse-led RRS. The results showed that success rate of rescue in intervention group (86.55%) was significantly higher than that in control group (66.5%), the rate of cardiac arrest in intervention group (33.61%) was significantly lower than that in control group (72.62%), the effective rescue time of intervention group (46.98 ± 12.01 min) was shorter than that of control group (58.67 ± 13.73 min), and the difference was statistically significant (P < 0.05). The rate of unplanned ICU admissions in intervention group (42.85%) was lower than that in control group (44.04%), but the difference was not statistically significant (P > 0.05). CONCLUSIONS: The nurse-led RRS and activation criteria can improve the success rate of rescue, reduce the rate of cardiac arrest, shorten the effective time of rescue, effectively improve the rescue efficiency of patients.

Association of Time to Rapid Response Team Activation With Patient Outcomes Using a Range of Physiologic Deterioration Thresholds.

Clinical deterioration of hospitalized patients is common and can lead to critical illness and death. Rapid response teams (RRTs) assess and treat high-risk patients with signs of clinical deterioration to prevent further worsening and subsequent adverse outcomes. Whether activation of the RRT early in the course of clinical deterioration impacts outcomes, however, remains unclear. We sought to characterize the relationship between increasing time to RRT activation after physiologic deterioration and short-term patient outcomes. DESIGN: Retrospective multicenter cohort study. SETTING: Three academic hospitals in Pennsylvania. PATIENTS: We included the RRT activation of a hospitalization for non-ICU inpatients greater than or equal to 18 years old. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary exposure was time to RRT activation after physiologic deterioration. We selected four Cardiac Arrest Risk Triage (CART) score thresholds a priori from which to measure time to RRT activation (CART score ≥ 12, ≥ 16, ≥ 20, and ≥ 24). The primary outcome was 7-day mortality-death or discharge to hospice care within 7 days of RRT activation. For each CART threshold, we modeled the association of time to RRT activation duration with 7-day mortality using multivariable fractional polynomial regression. Increased time from clinical decompensation to RRT activation was associated with higher risk of 7-day mortality. This relationship was nonlinear, with odds of mortality increasing rapidly as time to RRT activation increased from 0 to 4 hours and then plateauing. This pattern was observed across several thresholds of physiologic derangement. CONCLUSIONS: Increasing time to RRT activation was associated in a nonlinear fashion with increased 7-day mortality. This relationship appeared most marked when using a CART score greater than 20 threshold from which to measure time to RRT activation. We suggest that these empirical findings could be used to inform RRT delay definitions in further studies to determine the clinical impact of interventions focused on timely RRT activation.

Use of mobile medical teams to fill critical gaps in health service delivery in complex humanitarian settings, 2017-2020: a case study of South Sudan.

The vulnerable populations in the protracted humanitarian crisis in South Sudan are faced with constrained access to health services and frequent disease outbreaks. Here, we describe the experiences of emergency mobile medical teams (eMMT) assembled by the World Health Organization (WHO) South Sudan to respond to public health emergencies. Interventions: the eMMTs, multidisciplinary teams based at national, state and county levels, are rapidly deployed to conduct rapid assessments, outbreak investigations, and initiate public health response during acute emergencies. The eMMTs were deployed to locations affected by flooding, conflicts, famine, and disease outbreaks. We reviewed records of deployment reports, outreach and campaign registers, and analyzed the key achievements of the eMMTs for 2017 through 2020. Achievements: the eMMTs investigated disease outbreaks including cholera, measles, Rift Valley fever and coronavirus disease (COVID-19) in 13 counties, conducted mobile outreaches in emergency locations in 38 counties (320,988 consultations conducted), trained 550 healthcare workers including rapid response teams, and supported reactive measles vaccination campaigns in seven counties [148,726, (72-125%) under-5-year-old children vaccinated] and reactive oral cholera vaccination campaigns in four counties (355,790 vaccinated). The eMMT is relevant in humanitarian settings and can reduce excess morbidity and mortality and fill gaps that routine health facilities and health partners could not bridge. However, the scope of the services offered needs to be broadened to include mental and psychosocial care and a strategy for ensuring continuity of vaccination services and management of chronic conditions after the mobile outreach is instituted.

Contextual factors influencing patients' experiences of acute deterioration and medical emergency team (MET) encounter: A grounded theory study.

AIM: This paper explores the personal, social and structural factors that influence patients' experiences of acute deterioration and medical emergency team (MET) encounter. BACKGROUND: Patient experience is recognized as a means of assessing healthcare delivery with a positive experience being linked to high-quality healthcare, improved patient safety and reduced length of stay. The experience of acute deterioration is unique, extensive and complex. However, little is known about this experience from the patient's perspective. DESIGN: Constructivist grounded theory, informed by Kathy Charmaz, was used to explore the personal, social and structural factors that influence patients' experiences of acute deterioration and MET encounter. METHODS: Using a semi-structured interview guide, in-depth individual interviews were conducted with 27 patients from three healthcare services in Victoria, Australia. Data were collected over a 12-month period from 2018 to 2019. Interview data were analysed using grounded theory processes. FINDINGS: Contextual factors exert a powerful influence on patients' experiences of acute deterioration and MET encounter. The most significant factors identified include patients' expectations and illness perception, relationship with healthcare professionals during MET call and past experiences of acute illness. The expectations and perceptions patients had about their disease can condition their overall experience. Healthcare professional-patient interactions can significantly impact quality of care, patient experience and recovery. Patients' experiences of illness and healthcare can impact a person's future health-seeking behaviour and health status. CONCLUSION: Patients' actions and processes about their experiences of acute deterioration and MET encounter are the result of the complex interface of contextual factors. IMPACT: The findings from this study have highlighted the need for revised protocols for screening and management of patients who experience acute deterioration.

Association of Social Determinants of Health With Rapid Response Events: A Retrospective Cohort Trial in a Large Pediatric Academic Hospital System.

Background: Social determinants of health (SDH) are known to impact hospital and intensive care unit (ICU) outcomes. Little is known about the association between SDH and pediatric rapid response (RR) events and understanding this impact will help guide future interventions aimed to eliminate health disparities in the inpatient setting. Objectives: The primary objective of this study is to describe the association between SDH and RR utilization (number of RR events, time to RR event, shift of event and caller). The secondary objective is to determine if SDH can predict hospital length of stay (LOS), ICU transfer, critical deterioration (CD), and mortality. Methods: A retrospective cohort study was conducted. We reviewed all RR events from 2016 to 2019 at a large, academic, pediatric hospital system including a level 1 trauma center and two satellite community campuses. All hospitalized patients up to age 25 who had a RR event during their index hospitalization were included. Exposure variables included age, gender, race/ethnicity, language, income, insurance status, chronic disease status, and repeat RR event. The primary outcome variables were hospital LOS, ICU transfer, CD, and mortality. The odds of mortality, CD events and ICU transfer were assessed using unadjusted and multivariable logistic regression. Associations with hospital LOS were assessed with unadjusted and multivariable quantile regression. Results: Four thousand five hundred and sixty-eight RR events occurred from 3,690 unique admissions and 3301 unique patients, and the cohort was reduced to the index admission. The cohort was largely representative of the population served by the hospital system and varied according to race and ethnicity. There was no variation by race/ethnicity in the number of RR events or the shift in which RR events occurred. Attending physicians initiated RR calls more for event for non-Hispanic patients of mixed or other race (31.6% of events), and fellows and residents were more likely to be the callers for Hispanic patients (29.7% of events, p = 0.002). Families who are non-English speaking are also less likely to activate the RR system (12% of total RR events, p = 0.048). LOS was longest for patients speaking languages other than Spanish or English and CD was more common in patients with government insurance. In adjusted logistic regression, Hispanic patients had 2.5 times the odds of mortality (95% CI: 1.43-4.53, p = 0.002) compared with non-Hispanic white patients. Conclusion: Disparities exist in access to and within the inpatient management of pediatric patients. Our results suggest that interventions to address disparities should focus on Hispanic patients and non-English speaking patients to improve inpatient health equity. More research is needed to understand and address the mortality outcomes in Hispanic children compared to other groups.

European standard internal telephone number 2222 for in-hospital emergency calls: A national survey in all French military training hospitals.

Background: In 2016, three European scientific societies called for standardization to the "2222" as a European unique phone number in case of in-hospital emergencies. This study describes the management of in-hospital emergency calls in all French military training hospitals and aims to detail their original transition, for the first time in France, to the "2222". Methods: An electronic standardized questionnaire was emailed to heads of rapid response teams in the eight French military training hospitals. Results: All participants answered the questionnaire (100%). The eight French military training hospitals had a specific procedure for management of in-hospital emergencies. Six hospitals already used a unique phone number for in-hospital emergencies, but none of them were using the 2222 in March 2019. Two hospitals still used several phone numbers for in-hospital emergencies, mainly due to historical and local arrangements. Rapid response teams included at least a physician and a nurse. There was a discussion to switch to "2222" as the unique phone number for in-hospital emergencies in two hospitals. In both, the discussions involved hospital executive officers, medical teams, rapid response teams and technical teams leading to a step-by-step transition. Finally, in October 2019, these two hospitals launched the "2222" procedure for in-hospital emergencies. Conclusion: This study found a large disparity in the eight French military training hospitals, concerning in-hospital emergency protocols. Two French military training hospitals launched the "2222" procedure for the first time in France. Further efforts are still needed to continue to promote the use of the 2222 as a European unique phone number for in-hospital emergencies.

Design for resilient performance: Concept and principles.

Resilient performance in socio-technical systems is usually described as stemming from people's self-organization and spur-of-the-moment actions and decisions. However, this is not exclusive with work system design ahead of time, with the deliberate intention of influencing resilient performance. This paper proposes a concept and principles of Design for Resilient Performance (DfRP), making explicit contributions that had been concealed and fragmented in the literature. Based on a literature review of influential human factors studies, 23 design principles were identified and set a basis for a Delphi study with 27 experts from nine countries. After three Delphi rounds, consensus was obtained and the DfRP concept was defined as well as seven design principles, namely: (i) there must be functional models of the system; (ii) make variations in performance visible; (iii) use the type of standardization that best fits the nature of the function; (iv) design slack resources and strategies; (v) design for acceptable performance even under degraded conditions; (vi) design must involve leveraging diverse perspectives; and (vii) design to support continuous learning at the individual and organisational level. The applicability of the principles is demonstrated through an exploratory case study of the rapid response team in a hospital. The principles of DfRP are contributions of prescriptive nature, which might give rise to more resilient socio-technical systems.

Proactive rounding: Perspectives and experiences of nurses and midwives working in a large metropolitan hospital.

BACKGROUND: Rounding by the Rapid Response team (RRT) is an integral part of safety and quality care of the deteriorating patient. Rounding enables Intensive Care Units (ICU) liaison nurses to proactively identify deteriorating patients in the general wards and minimize the time spent by general nursing staff to call for assistance. OBJECTIVE: The study examined nurses' and midwives' experiences of proactive rounding by a RRT/ICU Liaison service, including the impact on workflow and patient care as well as enablers and barriers to utilization of the service. METHOD: A mixed method approach was used: an online survey and semi-structured interviews with nurses and midwives in an acute care setting. RESULTS: 52 respondents completed the online survey and 6 participated in a semi-structured interviews. The majority of survey respondents found the service useful and indicated that rounding by the ICU Liaison service improves patient care. Participants also believed that pro-active rounding increases staff confidence and builds rapport when utilizing the ICU Liaison service. Barriers to use of the service included the lack of out of normal business hours support and obtaining prompt support. CONCLUSION: Proactive rounding was perceived by nurses and midwives to be beneficial for both themselves and patients, and ensured that deteriorating patients were identified.

Rapid response teams-how and who? A protocol for a randomised clinical trial evaluating the composition of the efferent limb of the rapid response system.

BACKGROUND: Many patients experiencing deterioration have documented deviation of vital signs prior to the deterioration event. Increasing focus on these patients led to the rapid response systems and their configuration with afferent and efferent limbs. The two most prevalent team constellations in the efferent limb are the medical emergency team (MET), usually led by a doctor, and the critical care outreach team (CCOT), usually led by a nurse. The two constellations have not previously been examined in a comparative clinical trial. METHODS: This is a single centre non-inferiority randomised controlled trial of MET vs CCOT. All patients will be randomised at the time of the call. The intervention group will be the critical care outreach team. The primary outcome is mortality at 30 days and the occurrence of serious adverse events. All patients will be followed for 90 days. We aim to detect or reject a change of 7% in mortality whilst accepting a type I error of 5 and type II error of 20, using a sample size of maximum of 2000 individual patients. DISCUSSION: There is evidence supporting a benefit for the patient when using rapid response systems; however, earlier randomised studies are marked by cross-contamination and selection bias. Previous studies have primarily examined the effect of RRS on hospital cardiac arrests (IHCA) and mortality. Our study will be examining the effect on intensive care unit admissions as well as the ICHA and mortality. CONCLUSION: This study may highlight potential benefits of specific configurations of rapid response systems and their impact on safety outcomes.

Paediatric cardiac rapid response systems: a survey of multicentre practices.

INTRODUCTION: While the efficacy and guidelines for implementation of rapid response systems are well established, limited information exists about rapid response paradigms for paediatric cardiac patients despite their unique pathophysiology. METHODS: With endorsement from the Paediatric Cardiac Intensive Care Society, we designed and implemented a web-based survey of paediatric cardiac and multidisciplinary ICU medical directors in the United States of America and Canada to better understand paediatric cardiac rapid response practices. RESULTS: Sixty-five (52%) of 125 centres responded. Seventy-one per cent of centres had ∼300 non-ICU beds and 71% had dedicated cardiac ICUs. To respond to cardiac patients, dedicated cardiac rapid response teams were utilised in 29% of all centres (39% and 5% in centres with and without dedicated cardiac ICUs, respectively) [p = 0.006]. Early warning scores were utilised in 62% of centres. Only 31% reported that rapid response teams received specialised training. Transfers to ICU were higher for cardiac (73%) compared to generalised rapid response events (54%). The monitoring and reassessment of patients not transferred to ICU after the rapid response was variable. Cardiac and respiratory arrests outside the ICU were infrequent. Only 29% of centres formally appraise critical deterioration events (need for ventilation and/or inotropes post-rapid response) and 34% perform post-event debriefs. CONCLUSION: Paediatric cardiac rapid response practices are variable and dedicated paediatric cardiac rapid response systems are infrequent in the United States of America and Canada. Opportunity exists to delineate best practices for paediatric cardiac rapid response and standardise practices for activation, training, patient monitoring post-rapid response events, and outcomes evaluation.

Addressing Operational Challenges Faced by COVID-19 Public Health Rapid Response Teams in Non-United States Settings.

The coronavirus disease 2019 (COVID-19) global response underscores the need for a multidisciplinary approach that integrates and coordinates various public health systems-surveillance, laboratory, and health-care systems/networks, among others-as part of a larger emergency response system. Multidisciplinary public health rapid response teams (RRTs) are one mechanism used within a larger COVID-19 outbreak response strategy. As COVID-19 RRTs are deployed, countries are facing operational challenges in optimizing their RRT's impact, while ensuring the safety of their RRT responders. From March to May 2020, United States Centers for Disease Control and Prevention received requests from 12 countries for technical assistance related to COVID-19 RRTs and emergency operations support. Challenges included: (1) an insufficient number of RRT responders available for COVID-19 deployments; (2) limited capacity to monitor RRT responders' health, safety, and resiliency; (3) difficulty converting critical in-person RRT operational processes to remote information technology platforms; and (4) stigmatization of RRT responders hindering COVID-19 interventions. Although geographically and socioeconomically diverse, these 12 countries experienced similar RRT operational challenges, indicating potential applicability to other countries. As the response has highlighted the critical need for immediate and effective implementation measures, addressing these challenges is essential to ensuring an impactful and sustainable COVID-19 response strategy globally.