Background: Systemic and structural issues of rapid response system (RRS) models can hinder implementation. This study sought to understand the ways in which acute care clinicians (physicians and nurses) experience and negotiate care for deteriorating patients within the RRS. Methods: Physicians and nurses working within an Australian academic health centre within a jurisdictional-based model of clinical governance participated in focus group interviews. Verbatim transcripts were analysed using thematic content analysis. Results: Thirty-four participants (21 physicians and 13 registered nurses [RNs]) participated in six focus groups over five weeks in 2014. Implementing the RRS in daily practice was a process of informal communication and negotiation in spite of standardised protocols. Themes highlighted several systems or organisational-level barriers to an effective RRS, including (1) responsibility is inversely proportional to clinical experience; (2) actions around system flexibility contribute to deviation from protocol; (3) misdistribution of resources leads to perceptions of inadequate staffing levels inhibiting full optimisation of the RRS; and (4) poor communication and documentation of RRS increases clinician workloads. Conclusion: Implementing a RRS is complex and multifactorial, influenced by various inter- and intra-professional factors, staffing models and organisational culture. The RRS is not a static model; it is both reflexive and iterative, perpetually transforming to meet healthcare consumer and provider demands and local unit contexts and needs. Requiring more than just a strong initial implementation phase, new models of care such as a RRS demand good governance processes, ongoing support and regular evaluation and refinement. Cultural, organizational and professional factors, as well as systems-based processes, require consideration if RRSs are to achieve their intended outcomes in dynamic healthcare settings

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Background: Clinical deterioration and adverse events in hospitals is an increasing cause for concern. Rapid response systems have been widely implemented to identify deteriorating patients. Aim: We aimed to examine the literature highlighting major historical trends leading to widespread adoption of rapid response systems, focussing on Australian issues and identifying future focus areas. Method: Integrative literature review including published and grey literature Results: Seventy-eight sources including journal articles and Australian government materials resulted. Pertinent themes were the increasing acuity and aging of the population, importance of hospital cultures, the emerging role of the consumer, and proliferation, evolution and standardisation of rapid response systems. Discussion: Translating evidence to usual care practice is challenging and is strongly driven by local factors and political imperatives. Conclusion: Rapid response systems are complex interventions requiring consideration of contextual factors at all levels. Appropriate resources, skilled workforce and positive workplace cultures are needed for these systems to reach their full potential.

Rapid response systems: where we have come from and where we need to go?Internationally, health care systems are being held accountable for the outcomes of hospitalized patients. Lavoie and colleagues define a deteriorating patient as 'an evolving, predictable and symptomatic process of worsening physiology towards critical illness' (Lavoie, Pepin, & Alderson, 2016). Rapid response systems (RRS) have evolved over the past 25 years to enable the early detection and management of the deteriorating patient in non-critical care units. The premise of these models is that patient deterioration in the hospital ward is generally preceded by several hours of altered physiological processes, as measured by the patient's vital signs. Rapid response systems are built around trigger or calling criteria, which are typically significant deviations in vital signs and other measurements made in all patients. These triggers, such as hypotension and tachycardia, are common antecedents to adverse events.Breaches of patient parameters set to these criteria lead to activation of a team with specified skills, knowledge and experience. Despite the widespread adoption of RRS there is a vast heterogeneity in models including workforce composition, initiation criteria as well as variability in patient outcomes (Tirkkonen, Tamminen, & Skrifvars, 2017). Some stud- | PATIENTSPatients in acute care organisations are commonly older and presenting with multiple and more complex conditions. Increasing the role of patients and families in shared decision making can increase the clarity of treatment goals. This decision making is now extending to their ability to engage the rapid response system through the power to activate calls themselves (Albutt, O'Hara, Conner, Fletcher, & Lawton, 2016). | PROVIDERS | SYSTEMIncreasing the importance of culture and organisational systems are being recognized as crucial for promoting both the safety and quality of health care (Smith & McSweeney, 2017). Understanding the barriers and facilitators to implementing RRS is crucial. Ensuring role clarification, education and support for clinicians working within RRS can improve patient outcomes. | CONCLUSIONThe complexity of health care is growing and the need to implement systems to safeguard patients is increasing. Many local practice and cultural factors likely influence the efficacy of the RRS. The nurse's 2 | EDITORIAL role is crucial in any model of RRS in both the afferent and efferent limbs and should be an important focus of nursing managers. The RRS is a conceptually compelling model but the devil is in the detail of implementation to ensure intervention fidelity and robust patient outcomes. More attention to model implementation, attention to the nurses' role, robust strategies for quality improvement and exploring person -centered models are important strategies for future development.