Clinician Perspectives of Barriers to Effective Implementation of a Rapid Response System in an Academic Health Centre: A Focus Group Study

Abstract

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

Succeeding with rapid response systems – a never-ending process: A systematic review of how health-care professionals perceive facilitators and barriers within the limbs of the RRS

“…34,35 Cooperation and patient flow were facilitated by incorporating RRT events into the handover processes and daily use of early warning scores (EWS) in unit rounds. 22,28 Inconsistent education Low priority of education regarding the RRS and management of deteriorating patients 14,25,30 was a barrier while training was a facilitator, 25,27,36 with an emphasis on joint training sessions between ward staff and the RRT 35 and the use of simulation-based training. 25 Training in the use of EWS as early as in university was described as a facilitator.…”

“…36 Physicians worrying the system could deskill junior physicians was a barrier, 33,37 while viewing RRT calls as learning opportunities was a facilitator. 37,38 Lack of equipment, personnel and integration with other hospital systems HCP described that the RRS increased workload, 14,28,35,37,38 and staff shortages were seen as a barrier. 21,27À29,31,38 An example was too few RRT respondents: " There is one [Registrar] in the whole hospital and there could be six [rapid response] calls at once, and how can they possibly get to six?"…”

“…29 Nurses described applying an informal triage when wards were busy, allowing them to focus on sicker patients and reduce monitoring of other patients. 35 Not wanting to disturb a busy ICU-nurse or physician, 28,29 or knowing the ICU was (continued on next page) 30 HCP describe lacking a system to determine how and when additional resources could be provided. 35 Other barriers were not having hospital-wide systems for end-of-life-care decisions and planning, 27,38 pain management and palliative care services.…”

“…39 Delays of vital-signs entry into the electronic health records could delay the detection of clinical deterioration. 31 Barriers were described in HCPs use of documentation systems, 22,27,28,32 for example: charts had incomplete dataset and incorrectly calculated EWS, 14,22 deliberately not documenting vitals in the electronic management system when wards were busy, seeing this as only a bureaucratic task 35 and documenting altered call-criteria for patients on loose notes. 28 The introduction of a chart with ranges rather than exact numbers resulted in double documentation or nurses having to estimate numbers when speaking with physicians 32 posing as barrier.…”

“…The customization by physicians of call-criteria for individual patients, was viewed as both a facilitator and a barrier. 19,22,28,32 One publication described how this practice had resulted in both inappropriate changes to avoid alarms and reluctance to change criteria resulting in unnecessary activation. 28 The value of knowing the patient Continuity of care and knowing the patient were perceived as important for the detection of subtle changes.…”