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Understanding how rapid response systems may improve safety for the acutely ill patient: learning from the frontline
  1. Nicola Mackintosh,
  2. Helen Rainey,
  3. 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

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.

  • Hospital rapid response team
  • physician–patient relations
  • nurse–patient relations
  • quality improvement
  • qualitative research
  • interprofessional communication
  • social sciences
  • transitions in care
  • health services research
  • teamwork
  • qualitative research
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Introduction

Prompt detection and response to the acutely ill hospitalised patient is an ongoing national and international patient safety concern. A number of deaths from acute/general hospitals are related to ‘deterioration not recognised or not acted upon’.1 2 Cases of ‘failure to rescue’ have been linked with difficulties asking for advice, relaying and interpreting information across occupational, professional and hierarchical boundaries.3 A ‘rapid response system’ (RRS) may offer a safety net for patients on the ward who are at risk of becoming acutely unwell. There are several elements to a RRS: education, monitoring, event detection and calling for help, crisis response, patient safety/process improvement, and a governance/administrative structure.4 5 Tools such as an early warning system (EWS) have been introduced to aid event detection, whereas the UK-based critical care outreach team (CCOT) has been set up to facilitate timely and appropriate response. A number of studies have demonstrated benefit from the introduction of these interventions.6 7

However, at present the heterogeneity of safety tools, implementation strategies and social contexts make it difficult to recommend specific models for practice.8–10 In this paper, we explore the RRS used in the management of escalation in two large tertiary care hospitals in the UK. Locating the application in two sites will further understanding of ‘what works in what circumstances’ and why. By situating the research within the everyday practice of medical ward work we aim to illuminate the different contextual processes which contribute to patients' rescue trajectories and clarify the benefits and limitations of particular safety strategies within a pathway of care for the acutely ill patient. These findings are part of a wider study exploring the management of escalation of care for acutely ill patients within medicine and maternity, which includes one of the author's (NM) doctoral studies exploring the nature of ‘rescue work’.

Methods

For an expanded version of the methods see online appendix 1.

Setting

The study was carried out in the medical directorate of two tertiary UK NHS teaching hospitals. The Acute Medicine service of each hospital admits 15 000–20 000 patients annually. The pseudonyms, Eastward and Westward, are used to maintain anonymity of sites.

Safety strategies

Five strategies were in use across the two hospitals (table 1). At Westward, an EWS, escalation protocol, communication protocol and CCOT were in operation, while at Eastward, there was an EWS and two of the medical wards were piloting an intelligent assessment technology (IAT).

Table 1

Description of the safety strategies and utilisation at the two study sites

Data collection and analysis

Data collection and analysis were guided by ethnography as a qualitative methodology.14 Data were collected by one of the authors (NM) between January and December 2009 and involved over 150 h of observations of interactions among multi-professional healthcare staff and patient management processes of one of the acute medical wards in each of the hospitals. Observations also included periods of shadowing a purposive sample of medical staff and the CCOT at Westward, covering the selected wards together with others within the medical directorate of the hospitals. In addition, the same author attended committee meetings (18) and stakeholder meetings (15), the focus of which was the care of acutely ill patients, and collected documentary evidence (audit data, protocols).

Observations were supplemented by semi-structured, face-to-face, individual interviews (35) with doctors (14), ward and critical care nurses (11), healthcare assistants (HCAs) (4) and safety leads and managers (6) (for topic guide see online appendix 2). Participants were recruited with the aim of acquiring a broad sample across occupational and professional groups. All interviews were recorded and transcribed.

All the authors were involved in data interpretation and analysis. This study team included two social scientists with clinical backgrounds and one healthcare professional on secondment to the research centre. Ethical approval was obtained (ref. 08/H0808/178). Consent was given before attending ward rounds and meetings, undertaking interviews and collecting hospital documents. Anonymity and confidentiality were assured to participants. Data were inductively and deductively coded using NVivo v8 and organised thematically.15 The team (NM, JS and HR) discussed and iteratively reviewed the coding framework and emerging themes at regular team meetings. Our analysis used theme building and structuring methods from the framework approach but was also informed by relevant theoretical frameworks such as ‘technology-in-practice’.16 17 Comparative data analysis focused on contextual similarities and differences between the sites and relationships between these and implementation of the individual strategies. Early findings were presented to stakeholders at both sites to test validity and enable further refinement.

Results

Five main themes emerged from the analysis: routine monitoring practice, formalising understandings of deterioration, summoning help, response behaviour and contextual influences. For the purpose of this paper, these themes have been organised into the overarching themes of benefits and challenges, unintended consequences, factors influencing implementation, and gaps in the pathway.

Benefits and challenges

Table 2 presents data to illustrate how the themes map against the benefits and challenges of the two sites' safety systems. The EWS had been used at both sites for over 2 years. Hospital audit data suggested that early warning scores were used by HCAs and nurses as part of their daily monitoring practice (Eastward and Westward observation audit results, unpublished data, 2009). The EWS across both sites functioned as a risk assessment tool and structured attention to those observations which were included in calculation of the score. An added value of the IAT at Eastward, as opposed to the EWS in operation across the rest of the hospital, was the requirement that HCAs had to enter vital signs into a handheld device and respond to inbuilt safety prompts (when partial data or ‘unlikely observations’ were entered). This, together with the tracking of vital signs against named nurses or HCAs and the flagging of overdue observations, was perceived to have increased the completeness of recordings and improved compliance to protocol.

Table 2

Benefits and challenges of safety systems at Eastward and Westward

The IAT provided access to real-time electronic data and generated information about the quality of recording observations, for example, adherence to protocol. ‘Lateness’ values for 6 hourly observations included any recorded over 8 h while for 1 hourly observations, anything over 1.5 h was termed as a ‘breach’. Electronic data suggested that after implementation of the IAT, adherence to protocol generally improved, but remained variable, with late observations on the ward ranging from 30% to 70%. Despite this, the display of patients' risk scores provided at a glance by the IAT was reported by HCAs and nursing staff to enable sharing of understandings, planning and managing their workload. The IAT on the two pilot wards at Eastward enabled doctors to review observation data remotely alongside other information such as patient records, x-rays, and blood results, facilitating understanding of deterioration.

At both sites, the scores provided staff with the license to escalate care across hierarchical and occupational boundaries. Following the re-launch of the EWS and introduction of an escalation protocol at Westward, the scores were observed to be part of the verbal and written vernacular at an organisational level, routinely integrated into handovers and documentation. The scores and protocol were observed to structure discussions regarding acutely ill patients among HCAs, nurses, doctors and physiotherapists. Observation and interview data additionally illustrated how the CCOT at Westward helped to overcome delays due to occupational divisions and hierarchies.

In contrast, while HCAs and nursing staff from the pilot ward at Eastward demonstrated awareness of the scores incorporated within the IAT, observations of medical staff working across the directorate illustrated how scores were not routinely utilised on other wards as part of the assessment or handover practice. This was substantiated by interview data. Utilisation of different EWSs across the hospital and the absence of a Trust-wide escalation protocol appeared to contribute to problems with utilisation and application of these scores in practice.

Westward's escalation protocol included a recommendation to use a modified ‘situation-background-assessment-recommendation’ (SBAR) communication tool. The tool was not witnessed in action despite being perceived by nursing and medical staff as useful for formalising interprofessional commitment and responsibilities. However, in the interviews, some junior nurses reported that they had used the structured template and found it facilitated handover in emergency situations. Lack of adherence to this standard was confirmed by hospital audit data (Westward observation audit results, unpublished data, 2009) and appeared to reflect difficulties monitoring compliance and concerns among senior nurses regarding the unnecessary formality of the tool's script.

Both the escalation protocol and the CCOT at Westward promoted uniformity and standardisation with regards to response to the acutely ill patient. The CCOT enabled error recoveries and provided educational support, a resource for nursing and medical staff, and ‘an extra pair of hands’. The team additionally bridged the gap between ward staff and critical care, and mediated communication and decision making at the interface between the two.

At Eastward, hospital audit results of consecutive admissions from the wards to general intensive care between December 2007 and March 2008 had demonstrated variability of response to seriously ill patients across the hospital (Eastward audit of acute pre-ICU care, unpublished data, 2008). Observations across the directorate illustrated instances of delayed escalation of care across hierarchical and professional boundaries (nurse to doctor, junior to senior doctor). A number of nursing staff, medical staff and managers reported that the variance in response reflected the lack of a ‘planned’ hospital-wide pathway for acutely ill patients.

Unintended consequences

Table 3 provides quotations to illustrate mapping of the themes against unintended consequences of introduction of the tools and safety strategies. Managers, nursing and medical staff perceived that the EWS and IAT increased reliability of clinical practice by reducing variance in the recording of observations and addition of weighted values to form a risk score (the IAT additionally offered automatic scoring). This appeared to legitimise the delegation of taking observations to HCAs, despite the fact that this introduced further boundaries and a new division of labour.

Table 3

Unintended consequences of introducing safety systems

Intuitive-experiential knowledge was acknowledged by a number of senior nursing and medical staff to be a valid element in detecting early deterioration. However, junior nurses and HCAs reported and were observed to base their view of what constituted a crisis event on markers such as blood pressure and respiratory rates, which were included in the aggregated score. Other important indicators, such as tacit signs (eg, increasing restlessness) and blood results which were not included in the score, and markers such as urine output which were not mandatory, were given less importance leading to observed and reported instances of delay in recognition and triggering.

At Eastward the handheld device which directed HCAs to follow a routine every time they recorded their observations at times appeared to promote inattention to other significant signs of deterioration (eg, a report of chest tightness was ignored). Although recordings of respiratory rates were reported to have increased at Westward and on the pilot ward at Eastward, concerns regarding the accuracy of some of the recorded respiratory rates were reported by senior nursing and medical staff at both hospitals.

At Westward, it was acknowledged formally (via the protocol) and informally by nursing and medical staff that the scores were an adjunct to clinical judgement. Despite this, without the ‘objective’ authority of either the score itself or a worsening trend in scoring, when junior nursing staff tried to escalate care using alternative indicators such as a tacit sign, a patient's or family member's concern, or an ‘intuitive’ sense that the patient's condition was deteriorating, they struggled at times to summon a response.

At Westward, concerns were also expressed by a number of nursing and medical staff that the CCOT reduced exposure of ward nurses and doctors to the trajectory of deterioration and had introduced further compartmentalisation and fragmentation of care.

At Eastward, replacement of paper records with electronic charting meant that vital signs, electronic flags and scores were not accessible until staff logged in and retrieved the charts. Access to the data was contingent on availability of computers on wheels, a problem during ward rounds and busy times (during the study period, two to three were in operation on a ward for 28 patients). The paper charts were also removed from the patient so markers from visual cues of potential deterioration were separated from the patient.

Factors influencing implementation

Table 4 maps the theme of contextual influences to those factors influencing implementation.

Table 4

Contextual influences

One of the key facilitating factors was senior-level commitment to patient safety. At Westward, patient safety leads championed a policy of zero tolerance for hospital cardiac arrests. The hospital had invested resources in establishing a comprehensive, hospital-wide RRS supported by an interprofessional training programme focusing on utilisation of the tools and the CCOT. With mandatory regulation and audit, compliance rates improved. A 6-monthly hospital audit of ward observations, use of the EWS and adherence to protocol was reported to a central safety committee. Data included cardiac arrest data, CCOT activity, review of escalations and the hospital standardised mortality ratio. Data demonstrated where cardiac arrests were occurring, triggers prior to the arrest and patient outcomes. Rapid cycle reviews of care pathways of those patients admitted to critical care generated additional insight into other risk factors, for example, lack of fluid balance. Regular review of these data by the safety committee was observed to generate new local knowledge about the management of the acutely ill patient and to drive clinical behaviour change. Audit data were fed back to the wards regularly, prompting the development of action plans.

At Eastward, the IAT enabled collection of ward data for benchmarking purposes for the two wards involved in the pilot. Data regarding observations and workload (eg, total number of observations taken including score), compliance (eg, completeness of observations, number of late observations) and escalations (eg, compliance to escalation protocol) were initially reviewed by the directorate team and fed back to the individual two wards for performance purposes. However, over time, managerial priorities shifted and interest in utilisation of the data for quality improvement purposes tailed off.

Gaps in the pathway

Lastly, we mapped the safety strategies onto a pathway of care for the acutely ill patient (see figure 1).

Figure 1

Mapping strategies to an acute care pathway.

Although the pathway is displayed as a linear trajectory, in reality it took the form more of a recursive cycle since at various points, effective recognition and rescue involved continuous monitoring, review and response. The mapping showed that the majority of the strategies are designed to facilitate processes at the start of the pathway, suggesting a need for additional data and understanding about response behaviour, particularly team decisions downstream. Observation and interview data revealed that difficulties with referral (both routinely and during emergency situations) across medical boundaries occurred frequently at both hospitals (eg, poor handover practices, delayed response). While the CCOT helped facilitate escalation across hierarchical boundaries during emergency situations, junior doctors from both hospitals reported problems accessing specialist advice (eg, referrals to cardiology, surgery): ‘there was a delay to treatment onset because a registrar's mindset was antagonistic and negative … boundaries can make a huge difference (consultant, 9, Westward); ‘When we weren't so clued up on making referrals there were some really horrible ones, people would shout at you, tell you they were busy’ (junior doctor, 9, Eastward).

Observations of out of hours work also demonstrated instances of poor continuity of medical care, with reviews of ‘Do not attempt resuscitation’ status delegated to on-call teams and confusion regarding plans for escalation of care:

‘out of hours it's hard to get a decision because the doctors feel they don't know the patient and the full situation, and some of the more junior ones are quite worried about making a decision. A gentleman over the weekend became unwell and the doctors were confused about which bleep they should contact, it was difficult to get the person we needed. We ended up with a medical registrar for someone who needed palliative care; she made the decision to make him not for resuscitation’ (nurse, 5, Westward).

A further concern was that performance management of detection of and initiation of escalation of care (where the EWS, escalation policy and IAT strategies were principally directed) focused scrutiny largely on nursing care and opened up opportunities for selective blame of particular professional groups rather than fostering a culture of team responsibility for problems with rescue. While data on completeness of observations and scoring provided proxy measures of quality, few data were captured illustrating subsequent decision making and outcomes, particularly when patients were noted to have scored highly over a number of days. The ‘everyday’ process of ward medical team response to early stages of deterioration and follow-up reviews largely escaped scrutiny, both in terms of capturing rates of response and outcomes.

Discussion

These safety strategies helped improve uniformity in monitoring, detection and ‘calling for help’ practice. The tools elevated the importance of early rescue work for HCAs, provided a standard safety net by shaping perceptions of deterioration, and legitimised calls for help. Our findings add to previous research which illustrates how nurses use protocols to legitimise their experiential knowledge,18 and EWS to ‘package’ referrals to medical staff.19 The Royal College of Physicians has recommended the establishment of a national EWS which would facilitate standardisation of practice across UK hospitals.20 Our study also supports some of the benefits of CCOT previously identified, notably structuring relations between the ward and critical care staff, mediating decision making at the interface between the two and promoting uniformity and standardisation in response to the acutely ill patient.21 22

Supporting the importance of organisational context in implementation research,23 24 we found the wider organisational culture of the hospital and level of senior lead commitment influenced utilisation. Integration of these strategies within a hospital-wide service model (including a comprehensive training programme) helped uptake. Compliance was greatly increased by the authority provided by the protocol and by the inbuilt safety prompts of the IAT. Lastly, regular review and feedback of local data regarding compliance to standards had a performative role. Our findings support the importance of a governance/administrative structure, to organise resources, and a process improvement approach for a RRS in order to support care provision of acutely ill hospitalised patients.8

The IAT opened up opportunities for staff outside the ward to ‘watch over’ patients at risk. However, vital sign data were ‘disconnected’ from the patient and access to data was contingent on the availability of computers on wheels (a problem during busy periods). Fears have been expressed that staff may become over reliant on EWS.7 We found that with the normalisation of EWS comes the risk that interpretations of crisis events become shaped by the safety tools. EWS are not accurate in identifying patients with established critical illness.7 The prompts for the IAT served to ‘design-out’ the dialogue between HCAs and nurses which had implications for risk assessment, given that these were based on the inbuilt EWS. The standardisation and rationality underpinning both the IAT and EWS reinforced certain markers as ‘valid’ while marginalising the importance of intuitive sensemaking and patient and/or family concerns which have been found to be useful in early detection of deterioration.25 26 Further research on the IAT is warranted to explore its potential impact on work routines and responsibilities.

Delays in recognition and response to acute illness have been partly attributed to difficulties escalating across occupational, professional and hierarchical boundaries. Westward's modified SBAR communication tool was not witnessed in action during escalation episodes. Westward's audit data also suggested some resistance to utilisation of this protocol, which raises questions about its perceived value as an heuristic for handover in emergency situations.27 Additional research is needed into SBAR implementation.

Our findings contribute to the evidence base that the mandate provided by protocols and the ‘packaging’ of objective data by the EWS provide a means of overcoming hierarchies.7 18 21 However, we additionally noted that there were boundaries between senior and junior staff, in both nursing and medicine, regarding the limits of responsibility and power and the norms of conformity and improvisation in implementation of the EWS, IAT and escalation protocol. These boundaries reinforced existing power relations and acted as disciplinary mechanisms. While standardisation of practice clearly has its benefits, it also comes at a cost that these tools attenuate lower level staff's authority and ability to persuade staff higher up in the organisation of the credibility of their knowledge. Educational efforts to develop junior staff's assessment, clinical reasoning and communication skills are likely to be hampered by these underlying power dynamics.

What our study adds to the literature is an understanding of the complex nature of the escalation work that HCAs, junior nurses and doctors engage with and the contributory role safety strategies play in the pathway of care for acutely ill patients. What is still lacking are data and understanding about the nature and timeliness of ‘downstream’ response behaviour, including escalation across the nursing/medical boundary and within and across medical teams, and ‘Do not attempt resuscitation’ decision making. We need to move away from viewing these strategies as ‘solutions’, and towards an approach which not only focuses on gaining the most out of each tool or system, but also addresses potential problems that still lie ‘under the radar’, such as handover and referral across medical teams,28 particularly with patients that score highly over long periods. Attempts must be made to capture how utilisation of vital signs and EWS influence subsequent multi-professional decision making and interventions. The IAT may offer an opportunity to capture some of this work as access to real-time data facilitates prospective review of patients with high early warning scores. It is important for us to remember that tools and technologies are ‘the beginning, not the end of, the quality journey’.29

Conclusion

Our study supports previous research identifying how safety strategies provide a formal mechanism to aid recognition of, calling for help for, and response to acutely ill patients. What our ethnographic study has added is a nuanced understanding of facilitating factors for successful implementation of these strategies, plus associated challenges and unaddressed gaps in the pathway of care for the seriously ill patient. Our findings highlight the importance of organisational structures and constraints, including issues of legitimacy and power which need to be addressed. Quality improvement strategies for seriously ill patients also need to expand their focus beyond measuring compliance with standards set by safety strategies to care processes ‘downstream’.

Acknowledgments

The research team would like to thank all the staff of the two study hospitals who contributed to the research, and members of the PSSQ team and key researchers to the Innovations Programme for their helpful comments on earlier drafts of the paper.

References

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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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