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BMJ Qual Saf 21:135-144 doi:10.1136/bmjqs-2011-000147
  • Original research

Understanding how rapid response systems may improve safety for the acutely ill patient: learning from the frontline

  1. Jane Sandall
  1. Kings College London, NIHR Kings Patient Safety and Service Quality Research Centre, Strand, London, UK
  1. Correspondence to Nicola Mackintosh, Kings College London, NIHR Kings Patient Safety and Service Quality Research Centre, 138–142 Strand, London WC2R 1HH, UK; nicola.mackintosh{at}kcl.ac.uk
  1. Contributors NM was involved in the conception and the design of the study, collected all data, contributed to the analysis and interpretation of the data and led the writing of this paper. JS was involved in the conception and the design of the study, supervised data collection, and contributed to the analysis of the data and the drafting of the paper. HR contributed to the analysis and interpretation of the data and the drafting of the paper. JS is the guarantor.

  • Accepted 2 September 2011
  • Published Online First 4 October 2011

Abstract

Introduction Rapid response systems (RRSs) have been introduced to facilitate effective ‘rescue’ of seriously ill patients on hospital wards. While research has demonstrated some benefit, uncertainty remains regarding impact on patient outcomes. Little is known about the relationship between social contexts and the application of the RRS.

Design This comparative case study of the RRS within the medical services of two UK hospitals used ethnographic methods over a 12-month period in 2009, including observation (ward work and shadowing medical staff = 150 h), interviews with doctors, ward and critical care nurses, healthcare assistants, safety leads and managers (n=35), documentary review and analysis of routine data. Data were analysed using NVivo software.

Results The RRS reduced variability in recording, recognition and response behaviour. The RRS formalised understandings of deterioration and provided a mandate for escalating care across professional and hierarchical boundaries. However, markers of deterioration not assimilated into risk scores were marginalised and it was harder for staff to escalate care without the ‘objective evidence’ provided by the score. Contextual features (eg, leadership, organisational culture and training) shaped implementation, utilisation and impact of the RRS. Reporting and feedback of audit data enabled learning about ‘selected’ escalation work on the wards. Difficulties with referral upwards and across medical boundaries were reported by junior medical staff.

Conclusion Locating a RRS within a pathway of care for the acutely ill patient illustrates the role of these safety strategies within the social organisation of clinical work. There is a need to broaden the focus of inquiry from detection and initiation of escalation (where the strategies are principally directed) towards team response behaviour and towards those medical response practices which to date have escaped scrutiny and monitoring.

Footnotes

  • Disclaimer This report presents independent research commissioned by the NIHR. The views expressed in this report are those of the author and not necessarily those of the NHS, the NIHR or the Department of Health.

  • Funding The NIHR King's Patient Safety and Service Quality Research Centre (King's PSSQRC) is part of the National Institute for Health Research (NIHR) and is funded by the Department of Health.

  • Competing interests All authors have completed the Unified Competing Interest form (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years, no other relationships or activities that could appear to have influenced the submitted work.

  • Ethics approval Ethics approval was provided by NHS REC (ref. 08/H0808/178).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Confidential data are held on university computers. Working from home is undertaken using King's College Virtual Network; data are therefore held on the university server. Where data are held on memory sticks they are encrypted and password protected.

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