Performance of the Afferent Limb of Rapid Response Systems in Managing Deteriorating Patients: A Systematic Review

Abstract

Introduction The clinical components of the rapid response system (RRS) are the afferent limb, to ensure identification of in-hospital patients who deteriorate and activation of a response, and the efferent limb, to provide the response. This review aims to evaluate the factors that influence the performance of the afferent limb in managing deteriorating ward patients and their effects on patient outcomes. Methods A systematic review was performed for the years 1995–2017 by employing five electronic databases. Articles were included assessing the ability of the ward staffs to monitor, recognize, and escalate care to patient deterioration. The findings were summarized using a narrative approach. Results Thirty-one studies met the inclusion criteria. The analysis revealed major themes enclosing several factors affecting management of patients having sudden deterioration. The monitoring and recognition process was conditioned by the lack of recording of physiological parameters, the influence of facilitators, including staff education and training, and barriers, including human and environmental factors, and poor compliance with the calling criteria. The escalation of care process highlighted the influence of cultural barriers and personal judgment on RRS activation. Mainly, delayed team calls were factors strongly associated with the increased risk of unplanned admissions to the intensive care unit and length of stay, hospital length of stay and mortality, and 30-day mortality. Conclusions A combination of factors affects the timely identification and response to sudden deterioration by general ward staffs, leading to suboptimal care of patients, delayed or failed activation of RRS teams, and increased risks of worsening outcomes. The research efforts and clinical involvement to improve the governance of the factors limiting the performance of the afferent limb may ensure proper management of hospitalized patients showing physiological deterioration.

Perfil De Crianças E Adolescentes Que Apresentaram Deterioração Clínica Em Um Contexto Hospitalar Pediátrico Do Município De Feira De Santana – Ba

“…Um escore de alerta que permite a identificação precoce da deterioração clínica pediátrica, atrelado à sistematização da assistência, torna o trabalho da equipe mais dinâmico e eficiente, atendendo às necessidades do paciente com qualidade e segurança (PEREIRA; MANSUR; IONEMOTO, 2016). Os escores de alerta precoce não substituem o julgamento e a habilidade clínica do profissional, mas podem ajudar a sistematizar e auxiliar a avaliação (DIFONZO, 2019). Sendo assim, o uso de escores de alerta objetiva melhorar a prática assistencial e a escolha de cuidados adequados a crianças em iminência de deterioração clínica (KONISHI et al, 2019).…”

Increased time from physiological derangement to critical care admission associates with mortality

“…Focussing solely on the efferent pathway ignores an important process of detection, escalation, response, and decision. Barriers to prompt recognition and escalation include a lack of timely or complete observations, poor communication, delayed response by CCOTs, or lack of senior decision maker [ 35 ], during which time the patient may suffer further deterioration [ 20 ]. We advocate for a whole-systems approach to improving both the afferent and efferent response to deterioration [ 36 ], and merely increasing critical care bed capacity will not necessarily address the challenges.…”

The transcultural adaptation and validation of the Chinese version of the Attitudes Toward Recognizing Early and Noticeable Deterioration scale

“…Even with physiological tracking and trigger tools in hospitals, patient deterioration often remains undetected or missed, resulting in adverse outcomes ( Credland et al, 2018 ). Several studies have shown that infrequent and incomplete vital sign measurements and charting ( Redfern et al, 2019 ), insufficient knowledge of normal vital sign values ( Difonzo, 2019 ), inadequate knowledge of some vital signs ( Difonzo, 2019 ), inadequate supervision of nursing staff performing vital sign monitoring ( Downey et al, 2022 ), excessive workload ( Dall'Ora et al, 2021 ), and prioritization of vital sign readings over clinical judgment ( Massey et al, 2017 ) are several risk factors that contribute to the failure of ward nurses to identify deteriorating patients. It was found that as the operation of vital signs was relatively simple and vital signs became a daily task in nursing, nurses did not pay enough attention to them, learned less about them, and even failed to record the values of vital signs truthfully, such as writing respiratory rate as a normal range value just by normal oxygen saturation ( Weenk et al, 2019 ; Nicolò et al, 2020 ).…”