Hospital Clinical Deterioration:Sing Clinical an Responding to In-Hospital and Integrative Review

This article isThis article by protected copyright. All rights reserved. 10.1111/jocn.13839 doi: differences to lead between the of this version cite thisarticle and asVersion Record.Please copyediting, pagination been throughthe andproofreadingtypesetting, process,may which This article acceptedhas been for publication andundergone fullpeer review buthasnot hasbeenThere no sourceoffundingor contributionsfor the developmentofthis paper. (0)1865Ph +44 482736 [email protected] Brookes LifeOxford Faculty and Sciences University, UK ofHealth OxfordInstitute Director, Nursing of and Allied HealthResearch Debra Prof Jackson, PhD (0)2Ph +61 4832 9514 [email protected] BoxHealth, PO Broadway, NSWFaculty 123, of 2007 Professor of Nursing, University of Technology Sydney Doug PhD Prof Elliott, (0)8Ph +61 0813 6151 [email protected] Research,SirCentre for CharlesGairdner Hospital,Nursing Nedlands 6009 University Sydney/Murdoch of Technology University PhD Candidate/Nurse Researcher Emily Allen, BSc Authors: of interprofessional practice issues Recogni Title: :Review type Article ID:0000-0001-5252-5325) (Orcid JACKSON DEBRA PROF. ID:0000-0002-6081-5442) (Orcid ELLIOTT DOUG PROF. ID :0000-0003-0381-5160) (Orcid ALLEN EMILY MS. Accepted Article

sing and responding to in-hospital clinical deterioration:sing clinical an responding to in-hospital and integrative review

This article isThis article by protected copyright. All rights reserved. Accepted deterioration. toclinical and response recognition effective or inhibit facilitate that ofICP issues understanding and meaningful in-depth a more todevelop necessary is research organisation-wide interpretive Further ICP framework. an presented using has been issues practice interprofessional organisation-wide exploring for approach A unique Conclusions (facilitating). relationships interprofessional and (facilitating), services careoutreach critical hierarchies (inhibiting), reporting professional highlighted: were issues practice interprofessional three notable themes deterioration. clinical to andresponding recognising in learning opportunities needs of clinical Communication accountability, development professional four the with aligned Fivemain themes Results framework. (ICP) practice collaborative interprofessional usingan RRS ofanorganisation-wide the context ly narrative were findings Study guidelines. recommended using was performed methods of appraisal Quality identified. were full textpapers eligible Library) Cochrane Central, ProQuest CINAHL, (PubMed, databases bibliographic electronic four search systematically to words key using was conducted This review Methods Article review An integrative Design respon and recognise effectively influences or similar, model, this of implementation model offers a theoretical While expertise. of levels withvarying disciplines fromdifferent professionals health multiple involves and sometimes complex is escalation care of Theprocess worldwide. organisations healthcare acute in practice interprofessional a routine as isembedded patients, ward medical-surgical general inadult deterioration, clinical to andresponse Recognition Background model (RRS) System Response Rapid a theoretical using deterioration, clinical to response and recognition effective orinhibit facilitate that issues practice interprofessional organisation-wide regarding evidence current synthesise and appraise To identify, Objectives Aims and ABSTRACT a formalised structured approach to escalate patient care patient escalate to approach structured formalised Organisational culture : Organisational d to clinical deterioration. deterioration. to clinical IC P competency domains and a learning continuum of of continuum a learning and domains P competency , Team-based practices, and Interprofessional Interprofessional and practices, Team-based , Role perceptions and professional professional and perceptions Role RRS -wide interprofessional practices to practices interprofessional -wide coded, themed and conceptualized in conceptualized and themed coded,

, it is unclear how the unclear how is it . Within these these Within

. Twenty-nine Twenty-nine RRS This article isThis article by protected copyright. All rights reserved. standards healthcare safety, Keywords systems have been implemented in practice (Jones inpractice implemented been systems have organisation-wide Various 2012). Healthcare in Quality and on Safety Commission (Australian processes decision-making in engaged and informed and carers families, patients, keeping while actions appropriate take and care to escalate professionals health facilitates and deterioration, clinical to and response recognition early and promotes supports that system organisation-wide forma ofa evidence toprovide required are hospitals care acute example, 2008). Organisations ofHealthcare Accreditation on Commission 2007; Joint Agency Safety Patient (National worldwide hospitals acute care in standards and safety quality for benchmark accreditation accepted an become has patients Early recognition INTRODUCTION criteria for ward staff to activate a MET (Lee MET a activate staffto ward for criteria settrigger provided balance) fluid pressure, blood rate, respiration (e.g. parameters clinical deterioration clinical to response timely and recognition early promote to strategy safety patient proactive (MET) ‘ the in be found can element limb efferent the and RRS of Origins system: elements fourkey identifies model This todate. found been has 2006) organisation-wide

Accepted Article community? clinical global wider the to add paper this does What Clinical deterioration, communication, interprofessional collaborative practice, patient patient practice, collaborative interprofessional communication, deterioration, Clinical   

’ concept (Lee concept A system understood. are poorly on org careenvironments, acute complex busy within implementation, of RRS The effects and applied in routine inroutine practice. and applied of recommende implications future for, and prepare understand, better to makers and policy researchers Further in strategies. improvement safety patient local of ordevelopment methods research future guide to be may used and been presented, has deterioration clinical the afferent limb, the efferent limb, administration, and quality and administration, limb, the efferent limb, afferent the . anisation Based on principles of ‘early recognition’ and ‘timely response’ ‘timely and recognition’ of‘early principles Based on - wide approach for exploring effective ICP in recognition and response to to andresponse inrecognition ICP effective for exploring approach wide an - depth, RRS depth, model, known as a ‘Rapid Response System (RRS) structure’ (RRS) System Response a ‘Rapid as known model, d response to clinical deterioration in adult general medical-surgical ward ward medical-surgical general adult in deterioration clinical to d response 1995), which was implemented over 20 years ago as a standardised a standardised as ago 20 years over implemented was which 1995), al. et - wide ICP in recognising and responding to clinical deterioration deterioration clinical to andresponding inrecognising ICP wide , rapid response system responsesystem rapid - wide investigation into ICP would help clinicians, helpclinicians, would ICP into investigation wide

d healthcare standards that are to be implemented be implemented are that to standards d healthcare

et al. et 1995) To et al. these standards, in Australia for inAustralia standards, e these achiev

2015) . A MET comprises a group of clinicians clinicians of a group comprises A MET

, yet Medical Emergency Team Team Emergency Medical only one theoretical theoretical one only in .

an organisation-wide organisation-wide an lly established established , predetermined predetermined , (DeVita et al. et

; This article isThis article by protected copyright. All rights reserved. Acceptedal. et (McQuillan outcomes patient worse with ICU transfers to unplanned and invasive interventions subsequent deterioration, clinical further of chance to rescue’ ‘failure failure’ or of phenomena practice describe to data outcome patient and parameters clinical (Jones support and supervisory patients (Boniatti seeking oradvice decision-making al. et (McQuillan care lead to suboptimal focused (Jones nursing be tendto studies These scrutiny. widespread also received have practices afferent limb escalation care ofdeterioration, recognition ofpractices, documentation monitoring (e.g. intermittent care occurs patient bedside of practice routine and deterioration clinical limb,where afferent forthe response acritical provides limb efferent the Importantly, 2012). Healthcare in Quality and on Safety Commission (Australian locally adapted are again, 2013) which ‘individualised’ unclear et al. specialist-led bemedical should 2013) &Bryden event (McNeill isleadingthe RT skills care critical with a clinician when effective tobe likely more are deterioration to responses that except composition, staffing regarding guide recommendations to evidence little currently There is organisations. 2010) Investigators MET dose (DeVita Teams (CCOT) Outreach limb Efferent Article manner. appropriate and a timely in deterioration clinical to respond and recognise care’ large- (Maharaj approaches methodological inconsistent used have that outcome studies patient RT comparing in challenges highlights variations due to slight be thismay 2015). While (Maharaj 29 only latter and the 2013), & Bryden (McNeill studies 42 eligible identified outcomes, patient similar examined reviews of these both Interestingly, arrests cardiopulmonary that 2013) &Bryden (McNeill strategy improvement safety patient orcost-effective sustainable reliable, asa implementation to support evidence high-level for need still is there care hospitals by acute worldwide adopted have been efferentlimb RRS or concept MET the to (RT), similar teams response emergency Even though and (ICU); care units tointensive transfers unplanned preventing interventions; invasive) (potentially deterioration further prevent and condition clinical patients’ skills thenecessary provide who care expertise critical with RT 2009; Howell 2009; (National Advisory group on the Safety of Patients in England 2013, p. 4), i.e. to effectively to effectively i.e. 4), 2013,p. England in Safety ofPatients onthe group Advisory (National scale data sets, ‘quantitative targets…sh ‘quantitative datasets, scale (RR 0.87, 95 %CI 0.81-0.95, p<0.001) p<0.001) 95%CI0.81-0.95, 0.87, (RR mortality in-hospital reduce significantly could . ’ Other variations in RT composition occur between organisations according to according organisations between occur composition in RT variations Other clinical needs (Endacott needs clinical th e necessity for cardiopulmonary resuscitation. resuscitation. cardiopulmonary for e necessity RT et al. predetermined clinical parameters and recommended responses (Psirides responses and recommended parameters clinical predetermined are also commonly termed Rapid Response Teams (RRT) or Critical Care Care or Critical (RRT) Teams Response Rapid termed commonly also are et al. 2009; Odell 2012), or nurse specialist-led (Mitchell specialist-led nurse 2012), or (RR 0.65, 95 %CI 0.61-0.70, p<0.001) p<0.001) 95%CI 0.61-0.70, (RR 0.65, (Trinkle & Flabouris 2011). These system failures can increase the the can increase failures These system 2011). &Flabouris (Trinkle , depending on local policy and resources available available resources and policy local on depending 2009). Other afferent limb studies used predetermined predetermined used studies limb afferent 2009). Other al. et et al. et et al. et (Al et al. et et al. -Qahtani et 2009) or identify failures in patient management, which which management, in patient failures or identify 2009) et al. 2006) and often vary in staff composition (ANZICS-CORE (ANZICS-CORE composition staff varyin often and 2006) 2007); and when there is a lack of underlying knowledge knowledge underlying of a lack is when there and 2007); to 1998). For example, when health professionals delay delay professionals health when example, For 1998). align with relevant policies protocols and resources and resources protocols policies relevant with align 2015) et al. et ould never displace the primary goal of better better goalof primary the never displace ould . in suggested meta-analysis a recent Although, . 2014), 2014), or inadequate 2013), primary care team-led (Moldenhauer team-led care 2013), primary While outcome studies can provide important important can provide studies outcome While eligibility and selection criteria, it also it also criteria, selection and eligibility

by the bedside to stabilise a stabilise to the bedside 1998). 1998). (Maharaj etal. limiting unnecessary unnecessary limiting 2014; Pirret 2014; ly 2015). 2015). al. et ye ). communicate a a communicate Like the efferent limb, efferent the Like t the former former t the et al. to ‘ afferent limb afferent limb . Whether RT Whether individual individual RT et al. et 2015) is 2015)

et al.

and ,

This article isThis article by protected copyright. All rights reserved. for inclusion. a consensus to reach allauthors between process an iterative et al. (Moher recommendations statement on PRISMA based articles full-text eligible used toidentify process selection and the search Figure1 illustrates RRS. of a elements four of the any between issue practice interprofessional if selected were articles Therefore, model (DeVita RRS organisation-wide an of context the in issues explored these that reviews systematic or studies relevant specifically any not did identify search initial issue practice interprofessional of evidence with articles peer-reviewed to retrieve used 1) was Table (in strategy The search SEARCH METHOD inform to evidence existing in gaps determine and 3) framework, ICP an using issues practice recurrent and unique andsynthesise explore 2) evidence, current to: were keyobjectives Three issues. al. deterioration toclinical response and recognition effective or inhibit facilitate that issues practice interprofessional organisation-wide for literature AIMS deterioratio explor to framework conceptual a provided continuum, alearning by domains, overarched competency 2011). (IECEP care patient and team-based communication, and responsibilities, domains competency four key in development professional ongoing supports and promotes that culture learning isanorganisation-wide there where occur to likely 2011 (IECEP)) Panel Expert Collaborative Education Interprofessional 2010; HealthOrganisation (World care patient-focused optimal and provide cultures safety organisational tostrengthen processes healthcare fragmented and silos mitigate professional to are likely (ICP) practices collaborative interprofessional effective that proposed been It has deterioration clinical to responding and recognising of practices system’ investigations in- more for a need is there organisations, healthcare acute between improvement for service differing andneeds and RRS RTcomposition, practices, variable view ofsuch In disparate. remains but growing evidence is limb efferent and afferent and issparse, elements quality and administration regarding evidence Overall, unclear. remains however elements organisation-wide ofan elements two How these (DeVita RRS use of the optimise to feedback forsystem-wide data ongoing andprovide collect processes improvement areavailable resources necessary the ensure and to ofthe RRS sustainability of elements andquality administrative of exploration studies limb efferent and afferent to In contrast

Accepted diverse of these understanding holistic aunique developing for thecontext provided 2006) Article An integrative review was undertaken (Whittemore & Knafl 2005) to explore current explore to 2005) &Knafl (Whittemore undertaken was review An integrative 2009) e ICP issues that facilitated or inhibited effective recognition and respon and recognition effective orinhibited facilitated that issues ICP .

n. RRS The procedure for confirming accuracy and relevance of selected articles followed followed articles selected of and relevance accuracy confirming for The procedure

has been stark. Administration has a governance responsibility to support tosupport responsibility agovernance has Administration stark. has been et al. et (McCallin 2001; McNeill & Bryden 2013) into effective interprofessional interprofessional into effective 2013) &Bryden McNeill 2001; (McCallin 2006). 2006). s in recognising and responding responding and in recognising 1) identify and appraise the quality the appraise and identify RRS interrelate with afferent and efferent limb limb efferent and afferent with interrelate .

A theoretical RRS model (DeVita model RRS theoretical A to .

fu clinical deterioration clinical s ture research. research. ture : were described within or within were described values and ethics, roles roles and ethics, values . Effective I Effective , depth and breadth o breadth and depth while quality quality ; while se et al. et to clinical clinical to Th CP depth ‘whole ‘whole depth ese four ese four are more are 2006) . An . et et f

This article isThis article by protected copyright. All rights reserved. the address to strategies incorporated Most studies al. (Mackintosh or more 10 strategies on information provided four papers Only 15 all strategies. address to details sufficient provided papers 21qualitative None ofthe of 15. score trustworthiness a total as presented and combined were met’ or ‘partially ‘met’ ofstrategies The number (U). level, unclear ofafourth addition the with above, to similarly coded and extracted were for criterion each 1986; Houghton Sandelowski 1985; Guba (Lincoln & (n=4) and confirmability (n=3), (n=3),dependability transferability n=5), strategies, number of 3) (Table weaknesses and strengths additional revealed of trustworthiness analyses in-depth further addressed, were CASP criteria most While 2013) 2010; Shapiro two papers in lacking also Detail was 1986; Houghton 1986; Sandelowski 1985, &Guba (Lincoln findings qualitative of interpretation reader and transparency for necessary is which 71%), (15/21; the papers of overtwo-thirds in lacking were relationships onparticipant and influences bias researcher Bunkenborg (Athifa criteria all met foursufficiently only although (92%), papers 21 qualitative of the by each met partially or eithermet were CASP criteria All Qualitative of Findings review. from the omitted were process theappraisal during quality ofpoor Papers deemed (Bennett papers survey-based to appraise used was 4) Table in (shown checklist a37-item and *); 3 (see Table methods for qualitative criteria appraisal recommended provided 2014) checklist (CASP Program Skills Assessment The Critical inbothappraisals. included (Beebe approaches both used paper mixed-method one based, were survey- papers nine approach, qualitative useda 21 papers In review, this Knafl 2005). (Whittemore frame sampling onthe depends usually ofmethods appraisal quality standards, Due divers to QUALITY APPRAISAL STUDY OF METHODS 2014). re offered both which study, larger scale froma findings based on papers were Two 2). (Table studies mixed-methods three and eightsurvey-based, 18qualitative, this review: search the database from retrieved papers full-text eligible A deterioration). facilitat that issues practice interprofessional (i.e. outcomes and professionals); (i.e.health population settings); ward surgical general-medical adult in RRS organisation-wide (i.e. context to according eligibility for assessed and were retrieved articles 67full-text abstracts, of and screening titles duplicate 6 revealed databases bibliographic of four A search current insights insights current

Accepted20 Article 13; Mackintosh , and another the data analysis process (Wood process analysis data the and another et al. sources often used in an integrative review, and a lack of recommended recommended of a and lack review, integrative an in used often e sources et al. et further seven relevant papers were identified by hand searching references of of references searching by hand identified were papers relevant seven further 2013; Leach & Mayo 2013). Importantly, details of strategies used to address address usedto of strategies details Importantly, 2013). Mayo & Leach 2013; in 2010), one study design did not clearly address study aims (Astroth aims study address clearly not did design one study 2010), to the phenomena of interest (Mackintosh of interest phenomena the to et al. et 2014; Massey 2014; e Appr or inhibit effective recognition and response to clinical toclinical response and recognition effective or inhibit aisal aisal on the ethical approaches used (Donohue & Endacott Endacott & (Donohue used approaches ethical the et al. et 2014), while the remaining scored eight or less. less. or eight scored remaining the while 2014), . Using four key criteria: credibility (n=total (n=total criteria: credibility key four Using 37 ‘transferability’ ‘transferability’ et al. et al. et 2011; Williams al. et papers of of interest papers 2009) 2013), details of relevant strategies strategies relevant of details 2013), .

In total et al. et al. .

, 2012) and was therefore was therefore and 2012) 2012; Mackintosh 2012; criterion (86%), although although (86%), criterion 29 papers were included in wereincluded 29 papers et al. et . After removal of of removal After et al. et unique 2012; Astroth 2012; et al. et 2011; et al. et and and 2013) 2011). 2011). et al. et al. .

& This article isThis article by protected copyright. All rights reserved. surveys (Plowright improvement quality aslocal exempted withthree ineverystudy, noted was approval Ethics (Jones frame sampling et al. Sarani (Plowright size calculations forsample clear justification provided Three studies validity. or reliability of instrument evidence convincing any none provided to distribution, testing prior 2014; Stevens (Pusateri instrument the of or administration de previously ofa version modified a locally used which one, except aims specificstudy address al. 2006; Sarani (Plowright information very limited provided although three developed they were andhow instrument, survey ofthe a description provided nineAll papers Appraisal Survey-Based of Findings audit. external Houghton 1985; Guba & (Lincoln process entire research the of records accurate maintaining by criteria, andconfirmability dependability addressing (Astroth datacoding and decision-making tracking for trails onaudit commented twopapers Only analysis. informfurther or findings validate to strategy a if was this was unclear (Leach participants with findings sharing et al. (Endacott issues contextual identify refine and criteria credibility and confirmability toaddress strategy asa checking of member the use described papers Seven 2011). Silverman 2000; Pope & (Mays findings or study interpretation collection, (Massey outset at the biases and assumptions values, personal ofidentifying importance the recognised beliefs’ of own ‘bracketing mentioned one study While process. research of the as part conducted was researcher reflexivity how described explicitly bias. researcher address used to onstrategies information insufficient Furthermore, lacking. therefore were overall trustworthiness addre to used on strategies details Important criteria. confirmability and dependability boththe 27%addressed only while (53/105), papers allqualitative across addressed Mackintosh 2013; & Mayo 2013; Leach (Williams allstrategies five addressed only 2006; Sarani (Jones procedures consenting participant on comment explicitly 2006; Salamonson Accepted(Beebe veloped tool Article 2006; 2006; Sarani 2014) et al. et 2014), neither explained how these were captured nor applied in context of data ofdata incontext applied nor were captured howthese explained neither al. 2014), et et al. et ; 2009; Stevens e conducted further interviews (Chellel interviews further one conducted et al. et al. 2013; Massey 2013; this et al. et al. et 2009) and two of those did not include individual survey items (Plowright items survey individual include not did ofthose and two 2009) 2009; Pusateri 2009; . trustworthiness analyses supported CASP appraisal findings where there was was there where findings appraisal CASP supported analyses trustworthiness et al. et Four confirmed study findings were shared with participants to further further to participants with were shared findings study confirmed Four 2014) 2006) (Table 4). Each study developed a new local survey tool to tool survey new local a developed study Each 4). (Table 2006) al. et et al. et et al. et 2009; 2009; Pusateri 2006; Salamonson . et al. While all studies reported that the newly developed surveys had pre- surveys developed newly the that reported all studies While 2012). Only four referenced other work to inform the development thedevelopment work toinform other fourreferenced 2012). Only 2006; Sarani et al. et (Jones ofsample the representativeness fourdescribed 2014), 2011; Stevens 2011; al. et 2014). Transparent audit trails are an important strategy for strategy important arean trails audit Transparent 2014). et al. et al. et al. et et al. et et al. et 2006; Stevens al. et 2011; Stevens 2011; 2014). Over half of the credibility strategies were strategies credibility of the Over half 2014). 2011; McIntyre 2011; al. et 2009; 2009; Rotella 2010; Shapiro 2010; et al. et 2011; Mackintosh 2011; 2007; Mackintosh

et et al. (Astroth al. et al. et et al. et 2014). 2014).

2006) et al. et et al. et et al. 2013). No papers considered an an considered papers 2013). No etal. et al. 2014), and the population population and the 2014), et al. 2014; Stevens 2006; Salamonson 2006; . 2010; Leach & Mayo 2013), it it 2013), Mayo & Leach 2010; et al. et et al. While others described described others While 2014) 2013), and another and another 2013), 2006; Plowright

et al. et In addition, no papers papers no addition, In 2012; Rotella 2012; 2012; Astroth . 2012; Mackintosh 2012; Of note, five did not did five note, 2014) al. et et al. et et al. et 2006; 2006; et al. et et al. et al. et ss

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, This article isThis article by protected copyright. All rights reserved. 2. Figure and 6, and 5 Tables in codes refer to (V1)) (e.g. inparentheses noted codes Paragraph model. RRS organisation-wide ofa theoretical context the in issues ICP resulting 2 conceptualises bridged were These fourthemes deterioration. to clinical responding and in recognising based practices Team- and, 4) needs clinical of Communication 3) accountability, and professional perceptions culture Organisational 1) domain: competency ICP each with aligned themes main Four RESULTS elements four all between, and issueswithin, practice interprofessional regarding evidence of and distribution organisation-wide d conceptualise and synthesised were 6). Findings (Table domain competency each within themed and grouped coded, were issues ICP inhibiting or facilitating 2011) (IECEP continuum development professional overarching by an bridged practices; team-based communication, rolesandresponsibilities, ethics, and values ICP: of domains competency four the using analysed 5)and (Table extracted were findings Study ANAL forinclusion. appropriate considered also therefore, were and deterioration clinical to responding and recognising in of practices perceptions professional health important some revealed questions of survey uniqueness the reliability, or validity demonstrated (Bennett interpretation and bias e.g. participant achieving rigour of context the in limitations has inherent enquiry survey-based studies, qualitative to Similar forinclusion. appropriate considered therefore and were deterioration, clinical to and responding recognising in practices interprofessional of phenomena the al. Houghton 2000; Pope & Mays 1986; & Guba (Lincoln issue this improve help to can strategies trustworthiness recommended of consideration careful although achieve, to can bechallenging ofqualitati thenature to Due weaknesses. and strengths further highlighted and methods qualitative met in were criteria Most CASP Eligibility and Study Appraisal of Quality Summary surveys. completed partially versus complete for definitions orprovided error, of non-response foranalysis approaches None explained 2006; Pusateri McIntyre (Jones data missing handling for steps threenoted Only methods. analysis of data forreplication information sufficient provided papers no Importantly,

Accepted Article2013) se varied and diverse qualitative approaches are essential for exploring the sociocultural sociocultural the exploring for are essential approaches qualitative diverse and varied YSIS AND INTERPRETATION OF STUDY FINDINGS by . et al. et Despite some of the limitations identified from quality appraisal of study methods study of appraisal from quality identified limitations of the some Despite an

. overarching theme of ‘ of theme overarching 2012; Rotella et al.

RRS 2011), and one explained response rate calculations (Rotella rate calculations response explained andone 2011), model (DeVita model et al. et et al. et (Jones verified was entry howdata described 2014), two Interprofessional learning opportunities learning Interprofessional et al. 2006) (Figure 2) to determine the depth, breadth breadth depth, the determine to 2) (Figure 2006) et al. et in -depth analyses of trustworthiness of trustworthiness analyses -depth

2006; Pusateri 2006; et al. in the context of an of context in the 2011) . Unique and recurrent andrecurrent Unique ve et al. . ’ While few surveys few While (Table 6) (Table research rigour research et al. et 2011; 2011; 2014) , . 2) Role Role 2) Figure Figure , . et

This article isThis article by protected copyright. All rights reserved. staff (R3). limb afferent by services of utilisation events advoca safety providing patient limb Efferent (R2) activation limb to,efferent prior or of, instead response afferent limb an and wards; to general back care fromcritical discharged when needs care ongoing complex with major frombecoming events minor prevent making, decision- clinical accelerated which expertise, clinical and knowledge care critical important The elements. limb efferent and afferent throughout escalation care effective facilitating of terms in value most the provide to appeared roles service outreach Importantly, (R1). deterioration toclinical response and recognition effective facilitate to required characteristics key role elements quality and administration from leadership, and clear commitment Senior level Facilitating deterioration. clinical response to and recognition effective inhibit or facilitate to considered were which issues, accountability of characteristics key described (86%) papers Twenty-five accountability professional and Role perceptions (V2) deterioration toclinical and response recognition effective inhibited and practice with existing conflicted sometimes issues hierarchical and policy organisational local that awith perception aligned Thispractice signs. vital abnormal to over responding other duties prioritised staff or medical nursing where reported also was breaches protocol normalising of culture practice A escalation. care delaysin and practices variable caused which strategies, response formal of and alack ongoing improvement; lack of a perceived concept; RRS ofthe understanding limited was there where reflected were cultures organisational Inhibiting Inhibiting (V1). orientation hospital stories and success criteria activation limb efferent ofresponsibilities, roles, discussions open through facilitated further was understanding organisation-wide A shared deterioration. toclinical and respond recognise effectively to signs of vital value of core the understanding te w culture organisational A facilitating Facilitating deterioration. clinical or inhibit facilitated which values, practice professional papers ( review Eight culture Organisational

Accepted Article shared a having while care, problem-focused and patient- with environment aching . Clarity of RT role and staff composition was important for effective care escalation and care escalation foreffective important was composition staff and ofRTrole Clarity RT ed services were, similarly, considered an invaluable expert resource for resource expert invaluable an considered similarly, were, services unnecessary delays, and addressed deficiencies in ward practices to prevent prevent to practices ward in deficiencies and addressed delays, unnecessary 27 identified %) identified cy , while preventing minor events from becoming major adverse adverse major becoming from events minor preventing , while . Outreach services also provided a safety net for patients patients netfor safety a also provided services Outreach as RRS described as having shared values of a collegial a collegial of values shared as having described -wide ICP issues concerning organisational culture culture organisational ICP issuesconcerning -wide ed effective recognition and response to to response and recognition effective

RRS roles and, and, roles . pro

se . fessional fessional

roles provided provided roles at , were

This article isThis article by protected copyright. All rights reserved. (R9). utilisation RT engage in staff to medical from reluctance with described, previously issues accountability and autonomy limbservices efferent activating without issue, the to address roles own their in enough confident staff felt and ward (e.g. neurology) specialty clinical specific when occurred incare escalation delays potential Other (R8). appropriate considered planwas management current or the enough, sick considered not was the patient if escalation a patient manage staff to care. fragment concerns of further caused which was activated, to challenge a perceived was staff medical limb) (afferent for influence efferent limb An inhibiting junior’ ‘too themselves they considered because limb efferent the to care patient escalate not did member one staff care. patient over taking or interfering perceived been may have which management, patient involved staff became outreach when care patient leading from disengage sometimes also would staff Medical was. leader clinical main the of who perceptions mixed with described, were RT events during roles leadership responsibilities regarding individual uncertainty and tension interprofessional was there boundaries professional and blurred clarity of role a With lack during bedside patient’s the and leave todisengage observed were nurses why be reasons These may participate. intimidatin as described was acuity patient of increasing Demands event. an during support provide ongoing limb efferent felt nurses ward (afferent limb) managing already when events RT attend to responsibility additional and demands workload increased from of burden a felt sense RTstaff limb Efferent (R5). mix and skill staff in variations by ongoing influenced also were management patient appropriate and responsibilities Professional needs. complex care with patients for accept responsibility to resistance were teams medical between ofcare division and demands workload Increased responsibilities. clinical and collection data additional given were clinicians when workload in increase a perceived was there Asaresult priorities. inmanagerial changes with feedback curtailed system and available werenot for resources funding and support when occurred elements quality and administration for issues Inhibiting Inhibiting (R4). deterioration clinical recognising for observers nurses ward also supported assistants nursing Unqualified patients. ward unwell acutely for caring when of responsibility easing burden and workload of nursing redistribution escalation limb care afferent facilitating and initiating rolein pivotal a for providing were recognised nurses Ward e assum Accepted as perceived was RT responses during crowding bedside nurses, for overwhelming Article Use Use of accountability for patient management with limited clinical autonomy once the RT the RT once autonomy clinical limited with management for patient accountability g, efferent limb limb efferent and uncertainty of role responsibilities caused reluctance for ward nurses to fully to fully nurses ward for caused reluctance responsibilities ofrole uncertainty and . They perceived the efferent limbRT efferent the perceived They to activate the RT (R7) RT activate the to ’ RT events (R6). (R6). RT events s increasing clinical needs, potentially inhibiting or delaying care care ordelaying inhibiting potentially needs, clinical s increasing RT services was also considered a failure by (afferent limb) medical medical limb) (afferent by a failure was alsoconsidered services An other inhibiting role perception was described where described was perception role inhibiting other considered to create a ‘pass the buck’ culture with culture buck’ the a‘pass tocreate considered RT .

staff had unrealistic expectations of them to of them expectations unrealistic staff had a patient’s as a supportive resource for enabling enabling for resource supportive as a ed

heavy patient caseload patient a heavy and compartmentalis and . . Shared (medical and nursing) andnursing) (medical Shared Th is may be be is may clinical needs were within a a within were needs clinical re inforced by the by inforced as ‘backup’ as ‘backup’ ed ; patient patient while while as

supported when escalating patient care although, senior nurses were considered more likely to to likely more were considered senior nurses although, care patient escalating when supported . articulate) or specify to but unable wrong something is knowing (e.g. concerns intuitive or subjective any reinforcing for important considered also was signs) vital data (e.g. Objective care. escalating when medical response conveying on importance escalation care limb afferent facilitated that medical staff and nursing between identified practices communication and inter-professional intra- unique There were (C4). careunits critical units care and critical (e.g.wards areas clinical and medical) and nursing (i.e. staff between ward expertise. This article isThis article by protected copyright. All rights reserved. communicati characteristic key Another (C3). needs immediate clinical of delivery verbal toguide used handover technique (SBAR) Recommendation Assessment, Background, Situation, the and measurements; sign forvital system (EWS) of communication RRS-wide facilitate to considered werealso tools practice clinical structured Formal an becould improved what and well, worked of what understanding a shared and communication interprofessional feedba Constructive (C1). feedback data performance formative as aswell deterioration, provid They communication. interprofessional system-wide facilitate to considered were also records collaboration interprofessional and improved processes communication hierarchical escalation care timely facilitate t model a formal as viewed was concept RRS the perspective organisation-wide From an Facilitating deterioration. clinical to response and recognition careand, of escalation or inhibit facilitated that and methods attitudes practices, professional comprised all papers across theme supported widely The most of clinicalneeds Communication (R10). elsewhere support seeking while care escalation wi familiarity lacked and authority criteria escalation toalter responsibility contacted notbe could consultants clinical awaited staff ward while delays occurred decisions, collaborative making for available not immediately was support When interprofessional

Accepted (C2). doctors than care patient improving for beneficial and useful more leader efferent limb Article ), accelerate medical review processes, and expedit review processes, medical accelerate ), ed staff with easily accessible patient information and real-time alerts of clinical of clinical alerts and real-time information patient accessible easily with staff This level of communication was considered to limit interprofessional conflict conflict interprofessional limit to wasconsidered of levelcommunication This ng and prioritising patients and prioritising a patient to address patient’s needs patient’s address to ck d facilitate event, RT a following limbleaders, efferent from a patient’s clinical clinical patient’s a of ’ s increasing needs. Examples included the Early Warning Scoring Scoring Warning theEarly included Examples needs. s increasing outreach roles, which facilitated care escalation, was escalation, care facilitated which roles, outreach , which importantly circumvented time-intensive traditional traditional time-intensive circumvented importantly which th . Nurses appreciated having their concerns acknowledged or acknowledged concerns their having appreciated Nurses In these circumstances medical staff hold overriding overriding hold staff medical circumstances these In

patient’s patient’s ed , ’ effective communication of communication effective clinical needs using their critical care knowledge and knowledge care critical their using needs clinical although after-hours after-hours although urgency to increase the likelihood of obtaining a ofobtaining likelihood the increase to urgency in the future. Of note, nurses found feedback from feedback found nurses note, Of future. the in clinical issues, which caused further delays in delays further caused which issues, clinical more timely referrals and transfers to to and transfers referrals timely e more

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Accepted judgement’ clinical based on medicine Article intra-disciplinary decision-making process decision-making intra-disciplinary , usually kept at a patient at a kept usually clinical needs. EWS were sometimes used to confirm deterioration rather rather deterioration toconfirm used weresometimes EWS needs. clinical he wa n patient monitoring responsibilities were divided between roles, there between roles, divided were responsibilities monitoring patient n e ‘highly hierarchical andprotocol hierarchical ‘highly rd clinicians were more likely to seek advice from other ward staff staff other ward from advice to likely seek more were clinicians rd issue of formal structured clinical practice tools, EWS and SBAR were were SBAR and EWS tools, practice clinical structured formal . . With a sense of professional duty to comply with embedded embedded with to comply duty sense ofprofessional a With

’ . s For example, when medical staff ordered tests or prescribed orprescribed orderedtests medical staff when For example, clinical diagnosis, issue or management plan (C5, C6). C6). (C5, plan management or issue diagnosis, clinical optimal handover of a patient’s clinical needs toon needs clinical ofapatient’s handover optimal ’s bedside (Kitto f patient’s clinical needs clinical a patient’s et al. et , also occurred when computer terminals were in were in terminals computer when occurred also of changes in a patient’s clinical priorities clinical a patient’s in of changes es 2014, p. 342), with a perception that nurses nurses that a perception with 342), 2014, p. to escalate patient care. Nurse decision- Nurse care. patient escalate to ed -

based’, and medical as ‘autonomous as medical and based’, breaching traditional medical or medical traditional breaching was also an inhibiting inhibiting also an was ’ clarifying clarifying -call -call . ; or

. team-based practices, and for building and developing ICP competency skills (T7). (T7). skills ICP competency developing and building for and practices, team-based limb efferent in Frequent changes (T6). available not serviceswere support additional and with familiar less were they of patients a cohort larger for cared doctors junior when staff after-hours for concern aparticular This was care expertise. critical lacking despite decision-maker, medical asenior from support without patients manage occasionally to doctors ward limb) (afferent junior of expectation a perceived There was (T5) unwell acutely becoming from patient a preventing than rather unwell, acutely was a when patient approach, as areactive occur likelyto more considered was collaboration Interprofessional conflict. to interprofessional and lead engagement, to inhibit likely also were of support and lack performance professional individual of recognition Poor ICP. staff in engage effectively to challenges were there staff) ward senior clinical (e.g. of key stakeholders consultation This article isThis article by protected copyright. All rights reserved. W Inhibiting (T4) criticism negative of concern without patient-focused and dialogue, have to willing non-interfering, enabling, encouraging, friendly, polite, as: described were values and team-building relationship interprofessional of Examples cl their from away support limb provide efferent required to was of them one if existing workload activation efferent limb or escalation care forfurther need the prevented occasionally which doctors, ward junior with collaborated offer They wardstaff. with trust and familiarity fostering by practices collaborative facilitated further services Outreach (T2). deterioration further prevent to decision-making clinical and solving shared problem along with collaborative; be to likely more were practices escalation clinicians, limb afferent and efferent between existed rapport professional a When support. collaborative and theircollegial for appreciated also widely were services andoutreach RT efferent limb expertise, clinical essential as providing As well (T1). deterioration clinical to andresponding in recognising ICP promote to was considered noted previously, discussions structured a formal of understanding organisation-wide A shared Facilitating dynamics ofteam and principles values building withrelationship aligned closely were papers(69%), 20 review from ICP issues, Team-based practices Team-based inical area (T3). (T3). inical area Acceptedhe Article n administrative decisions were made to plan and implement practice changes without changes without practice and implement plan to made were decisions administrative .

ed educational and empathic support for ward nurses and nurses for ward support empathic and educational RT . members and ward staff posed inhibiting challenges for for challenges inhibiting posed staff ward and members Outreach nurses also supported each other to manage an an manage to other each alsosupported nurses Outreach .

RRS , facilitated by open byopen facilitated , This article isThis article by protected copyright. All rights reserved. ( deterioration clinical ofin casespreventable Accepted(Tirkkonen outcomes patient unsatisfactory lead to to arelikely communication and poor activation, RT limb efferent escalation, limb efferent t to escalation care delayin or hesitation future to to lead likely more was feedback negative C11) (C10, protocol according to needs clinical increasing patients escalating and communicating for issue ICP an inhibiting as recognised widely most were hierarchies reporting nursing medical and orembedded, Traditional, 2. Figure and 6 5 Tables shownin ICP issues and themes identify inparentheses listed Codes below. discussed (enabling) services (inhibiting) hierarchies reporting and inter-professional intra- emerged: issues practice interprofessional notable Three 2). (Figure ofa RRS elements four the across identified were issues practice sociocultural interrelated andunique of recurrent broad range 6) (Table theme one overarching under grouped were ICP Fourthemes limb efferent of effectiveness the or element, limb efferent of the perceptions monitoring), patient identified elements RRS of relationships organisation-wide examine tospecifically werefound studies no While DISCUSSION (L3). responses RT during provided consistently was not limbleaders efferent from feedback constructive Article created challenges education to sustain resources lacked services often outreach Although, opportunities. learning experiential traditional removing and making, deskill they that perception the was services andoutreach RT limb efferent for issue learning interprofessional An inhibiting Inhibiting L2). (L1, staff inward skills clinical care acute develop and further patients, unwell acutely manage how to professionals health lessexperienced teach to perceived werewidely which responses limb efferent and deterioration, limbclinical afferent during occurred opportunities wh data performance of feedback and discussion enabling by forstakeholders key opportunities learning interprofessional facilitate to considered were meetings Multidisciplinary Facilitating (45 papers review thirteen in identified learning, interprofessional for collaborative Opportunities opportunities learning Interprofessional ich motivated ongoing engagement in the RRS concept. Other, more informal learning learning moreinformal Other, concept. inthe RRS engagement ongoing motivated ich , were distinctly clinical or practice-based. orpractice-based. clinical distinctly %), were RT on patient outcomes. outcomes. patient on or in ICP issue more focused studies. These studies tended to focus on afferent limb practices (e.g. limbpractices onafferent focus to tended These studies studies. more focused RT , while seeking advice from other ward clinicians ward other from advice seeking while , , to and interprofessional relationships (enabling). These practice issues are issues These practice (enabling). relationships and interprofessional e improv s in recognising and responding to clinical deterioration, evidence was evidence deterioration, clinical to andresponding recognising in ed junior medical ward staff staff b ward medical junior acute care skills outside of critical care areas. In addition, addition, In areas. care of critical outside skills care acute et al. et Inquest into the death of Vanessa Anderson Vanessa of death the into Inquest . A breach of traditional hierarchy reporting with with reporting hierarchy of traditional breach A 2014), including catastrophic adverse events adverse catastrophic 2014), including of frequently changing ward staff, which which staff, ward changing frequently y

taking over difficult clinical decision- clinical difficult over taking . Importantly, delays in care in delays Importantly, . Within these themes themes these Within , critical care outreach outreach care critical 2008). 2008). he , a ,

This article isThis article by protected copyright. All rights reserved. 2013). & Flabouris (Chalwin skills decision-making and awareness situational communication, leadership, improve (Hollnagel environments healthcare changing inconstantly resilience organisational build to recommendations 2001) (Firth-Cozens rates lowincident with organisations reliability high in prevalent are which to identif and approaches; qualitative and quantitative both using practices, of organisation-wide relationships interprofessional c framework ICP An been discovered. yet not have that be some also There may inhibitive. some some facilitative, deterioration, to clinical responding and in recognising issues ICP various identified This review 2009). (Zwarenstein investigation further and warrants lacking isconsiderably collaboration interprofessional improve that strategies successful recommend to evidence Current , 2011) (IECEP competencies RRS promot and staff, withward trust reported widely were rapport clinician and values practice team-based Shared T4). (T2, practice effective of facilitator an important as highlighted also were relationships Positive interprofessional (R6). workloads 2001)(R7) (Firth-Cozens ICP can inhibit or boundaries clarity ofrole a that lack consider also should standards practice recommended deterioration clinical to response and recognition effective promote that ICP into insights meaningful more provide would data, outcome patient with combined in orethical feasible not perhaps but bebeneficial would research system-wide large-scale future organisations, healthcare acute in be implemented to teamscontinue safety patient proactive structured uniquely of types various While outcomes. improving on effectiveness their support to perspective a system-wide (Wood at riskof deterioration tea assessment limb) (afferent 2012) &Pittard (Marsh careareas critical of outside expertise care critical of extending intended purpose withtheir consistent was patients in ward deterioration of clinical to concerns responding when approach wide o services, elements efferent limb and afferent the throughout care escalation timely and communication interprofessional facilitating while hierarchies, reporting embedded overcome to perceived was widely and C4,T3) domains (R2, competency A professionals. health between formiscommunication opportunity minimise or reduce that strategies wide system- effective identifying for of urgency level a highlights and 2009), Health Organisation (World communication in healthcare of priorities research significance the Thisissue reinforces -depth inquiry into the implications of patient safety teams on embedded practice cultures practice embedded on teams safety of patient implications the into inquiry -depth Accepted Article noteworthy particularly . Thisreflect . An . analytic lens of system-wide ICP also aligns with recent quality and safety safety and quality recent with aligns also ICP system-wide of lens analytic Examples were provided by outreach roles, again, where they fostered familiarity and and familiarity fostered they where again, roles, outreach providedby were Examples ut reach services provided a more proactive interprofessional collaborative system- collaborative interprofessional a proactive more provided reach services ed an the fundamental relationship-centred, process-oriented properties of ICP of properties process-oriented relationship-centred, fundamental the be used to guide further further guide to used be et al. RRS which promote effective decision-making (Eljiz decision-making effective promote which et al. 2015) where non-technical skills are increasingly promoted to promoted increasingly are skills where non-technical 2015) ms role ed patients of identification early with services, as outreach , such , 2009; 2009; Pirret when staff feel burdened with excessive excessive burdened with feel staff when collaborative interprofessional relationships throughout throughout relationships interprofessional collaborative provided by outreach services, bridged three ICP ICP bridged three services, outreach by provided facilitating practices that promote safe patient care, care, safe patient promote that practices y facilitating , and . While there appears to be benefits in proactive proactive in benefits tobe appears there While in -depth system-wide research into the into research system-wide -depth et al. et . When compared to efferent limb RT RT limb efferent to When compared 2015), there is still a lack lack a is still there 2015), . Alternatively, it is proposed that more more that proposed is it Alternatively,

. Organisations or Organisations in -hospital patient patient -hospital et al. et of 2010) evidence from from evidence et al. et , which which .

, This article isThis article by protected copyright. All rights reserved. (Miller contexts learning simulated to ICP concept of the applying of benefits have described Studies is unclear. learning interprofessional facilitate prac clinical routine in are utilised opportunities these how Although, activation. and RT deterioration, of clinical meetings, episodes multidisciplinary assuch review this (IECEP 2011) deterioration clinical to andresponse recognition effective facilitate to health professionals between mutually occur should practices clinical collaborative and learning Interprofessional Practice toClinical Relevance and Education deterioration. clinical respond and recognise effectively to care patient optimal thatpromote cultures ICP of positive understanding organisation-wide shared a todevelop administrators and clinicians for researchers, appropriate therefore seem It would 1986). &Guba (Lincoln issues practice interprofessional a effectiveness, ofRRS view tangible positivist, more a provides data outcome patient While limited. and is fragmented deterioration clinical to and response recognition ICP in organisation-wide (Tsasis care saferpatient and better towards cultures practice healthcare and align adapt effectively and can collectively professionals healthcare how understand better to necessary it is this, Despite 2001). (Firth-Cozens challenging is environments clinical busy changing constantly and complex in research Organisation-wide Research RECOMMENDATIONS analysis. forfurther retained therefore, and was issues practice interprofessional important report to considered was review inthis included study each 2005), Knafl & (Whittemore process isacomplex studies qualitative from multiple 2000) &Pope (Mays considered be carefully rigour should achiev to challenging be can rigour study appraisal, quality following were identified trustworthiness in limitations 1. While Table usedin strategy search by the literature identified papers not inother reported been have issues practice thatinterprofessional also possible is review. It for this ofevidence strength limited which identified, not were studies relevant Specifically thistopic. for literature the in reviewing transparency has enabled disciplines clinical within or issues elements RRS onspecific focusing than rather issues, practice interprofessional amore building for foundations some early and response recognition for effective standards recommended apply and to implement responsibilities and roles with professionals health i.e. RRS, of a elements human essential the exploring lens for analytic an as framework A limitations and Review strengths

Accepted Article ICP of an application unique the was review integrative ofthis strength methodological in qualitative research (Sandelowski 1986) (Sandelowski research qualitative e in . Examples of existing interprofessional learning opportunities were identified in in were identified opportunities learning interprofessional ofexisting Examples n interpretive approach could reveal the less tangible multiple realities of realities multiple tangible the less reveal could approach interpretive . In addition, the use of a clear review strategy and established appraisal tools tools appraisal established and strategy review clear of a the use In addition, to clinical deterioration clinical to in -depth understanding of organisation-wide organisation-wide of understanding -depth , and recommended strategies to enhance enhance to strategies and recommended et al. et al. 2013), and in health professional professional and inhealth 2013), .

2012). Current knowledge of of knowledge Current 2012). Even though synthesis of evidence evidence of synthesis though Even . This approach has provided provided approach has This tice to to This article isThis article by protected copyright. All rights reserved. AR, Foxwell, W, J, Runiciman, D, Travaglia, Greenfield, Nugus,P, M, J, Westbrook, Braithwaite, L, Schulz, Zorzi, M, Guimaraes, R, Castilho, R, Coelho, B, Viana, M,Ribeiro, N, Azzolini, M, Boniatti, Al REFERENCES strategies. improvement safety and quality moreeffective todevelop makers policy researchersand clinicians, deterioration se and respon recognition foreffective issues of ICP understanding a in-depth more of effectiveness quality. depthand strength, lacks the evidence but were identified ICP issues Various ICP framework. an issuesusing practice interprofessional has present This review CONCLUSION models RRS with in organisations practices effective facilitate to be used could framework ICP of an application ICP enable to shared values and ground tofindcommon clinicians for essential is whyit whichis cultures, practice collaborative andpoor silos healthcare perpetuate to arelikely attitudes and perceptions professional in Thesedifferences least. the medical and the intervention towards attitude a favourable more indicated administration (Braithwaite benefits perceived staff, towards administrative and health allied nursing, medical, between attitudes, in differences significant found Australia system in health astate-wide across ICP ataimed improving intervention action research four-year recent (Darlow programs undergraduate Bennett, C, Khangura, S, Brehaut, JC, Graham, ID, Moher, D, Potter, BK & M. Grimshaw, J2011, Grimshaw, BK&M. D,Potter, Moher, ID, JC,Graham, S,Brehaut, Khangura, C, Bennett, teamwork andself-percieved 'Observed 2012, C K&O'Leary-Kelley, P,Bawel-Brinkley, Beebe, 2012, Healthcare in Quality and Safety on Commission Australian M, Watt, K,Stuart, T, O'Brien, K,Leen, Laurie, TA, Hay,B, L,Williams, J,Brearley, M, Finn, Athifa, of exploration 'Qualitative 2013, SH Jenkins, Degitz,RJ& SJ, Stapleton, WM, Woith, KS, Astroth, resourcing Teamcomposition, Response 2010, 'Rapid Investigators dose MET ANZICS-CORE

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RRS .

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26 , 8: - Resuscitation 30. Australian Critical Care Critical Australian

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3379- , 19:

3, , 320:

World Health Organisation 2010, HealthOrganisation World 2009, HealthOrganisation World academic inadult systems response of rapid K 'Use 2009, B &Dracup, Ide, SR, KA,Ranji, Wood, complex- care:a tointegrated challenges the 2012, 'Reframing S &Owen, JM P,Evans, Tsasis, and failure limb afferent ResponseSystem Rapid A2011,'Documenting & Flabouris, Trinkle, RM Williams, DJ, Newman, A, Jones, C & Woodard, B 2011, 'Nurses' perceptions of how rapid of rapid how perceptions B 2011, 'Nurses' Jones, C&Woodard, A, DJ,Newman, Williams, methodology', updated review: 2005, 'The integrative K R&Knafl, Whittemore, and arrest teams 'Cardiac S2014, Hoppu, J& Tenhunen, KT, J,Olkkola, Nurmi, J, Tirkkonen, change culture M 'Long-term 2014, Howell, A& D,Tess, I, Hsu, Lennes, A, J,Johansson, Stevens, 2011, D Silverman, Shapiro, SE, Donaldson, NE & Scott, MB 2010, 'Rapid response systems seen through the of eyes the seen through systems response 'Rapid MB 2010, NE &Scott, Donaldson, SE, Shapiro, JS2009, &Myers, AA MK,Chalian, J,Fitzpatrick, MR,Phillips, Bergey, S, Sonnad, Sarani, B, Sandelowski, M 1986, 'The problem of rigor in qualitative research', research', rigorinqualitative of problem 'The M1986, Sandelowski, nurses' the floor: from 'Voices P2006, Davidson, B & Everett, B, Y, van Heere, Salamonson, junior by ofcare escalation influencing 2014, 'Factors D Jones, J& Ferguson, W, Yu, JA, Rotella, medical ona nurse staff ofnon-ICU the role 2011,'The Kiely,SC MM& Prior, ME, Pusateri, Psirides, A, Hill, J & Hurford, S 2013, 'A review of rapid response team activation parameters in parameters activation team response of rapid review 'A S2013, J & Hurford, Hill, A, Psirides, This article isThis article by protected copyright. All rights reserved. Accepted Article P, C,Seymour, MacLellan, D, King, L, Dennington, S, S,Buras-Rees, C,Fraser,J,Smith, Plowright, teamcomprised risk at ofapatient 'Theeffectiveness 2015, LM &Kazula, SF AM,Takerei, Pirret, wardpatients: in deterioration detecting in role D 'Nurses’ 2009, C M,Victor, & Oliver, Odell, 2007, Agency Safety Patient National 2013, England in ofPatients on the Safety group Advisory National for safer care safer for medical centers', perspective', systems adaptive outcomes', patient associated Collaborative Practice Collaborative 3, and system', nurse,team the affect repsonse teams Advanced Nursing Scandinavica Anaesthesiologica survey', postal cross-sectional anationwide inFinland: teams medical emergency implementation', system response rapid related to UK. London, Ltd, Publications 4th edn, Sage the nurse', the nurse', 6. center', medical academic inan safety and patient education on emergency team ofa medical impact ofthe perceptions RN and 'Resident Science 138- team', emergency medical of the perceptions medical officers', 22- understanding', and perceptions team: emergency New Zealand hospitals', hospitals', New Zealand Times a network', within care outreach ofcritical 'Perceptions A2006, G&Brindle, Scott, Nursing Care Critical study', after and before A nurses: experienced ward of predominantly review', literature systematic patients inhospitalised deterioration London, UK. inEngland patients of thesafety toact: Improving commitement

265- 9. 43.

, 102: , 8: 72.

American Journal ofNursing Journal American 3, Interpreting qualitative data: a guide to the principles of qualitative research qualitative of principles tothe guide a data: qualitative Interpreting

29, , WHO, Geneva. Geneva. , WHO,

-37. -37. 36- Joint Commission Journal on Quality and Patient Safe Patient and onQuality Journal Commission Joint Anaesthesia and Intensive Care and Intensive Anaesthesia , 52: 40. , 31: , WHO, Geneva. Geneva. WHO,

5, Resuscitation

546-53. 546-53. Global priorities for patient safety research: better knowledge knowledge better research: patient safety for priorities Global Framework for Action on Interprofessional Education & Education onInterprofessional Action for Framework 3,

133-40. 133-40. Recognising and responding appropriately to early signs of of signs toearly appropriately and responding Recognising Journal of Advanced Nursing Advanced of Journal Resuscitation International Journal of Integrated Care ofIntegrated Journal International , , 58:

, NPSA, UK. UK. NPSA, , 4, , ,

84: 420- , 110:

8, , 7.

82: 1040- Intensive & Critical Nursing Care &Critical Intensive

, 42:

7, 28 Critical Medicine Care Critical

American Journal ofNursing Journal American 810- Medical Education Medical

- Journal of Nursing Care Quality Care ofNursing Journal 4. 34.

723- 4. , 65:

A promise to learn - - tolearn A promise Advances in Nursing Nursing in Advances 9.

, Department of Health, of Health, Department , 10,

1992-2006. 1992-2006. , ty, , 48: Intensive and Intensive , 12: , Journal of Journal 37: 35: 12,

1-11. 1-11. 9,

12, , 22:

1211- , 111: 472- a

3091- Acta Acta , 3, Nurs Nurs 26: 82.

This article isThis article by protected copyright. All rights reserved. Accepted Article Strategy Search Table 1Literature effects of collaboration: 'Interprofessional S 2009, J & Reeves, M,Goldman, Zwarenstein, Year sources Electronic Item Restrictions search terms Additional MeSHterms cri Exclusion criteria Inclusion teria (review)', outcomes healthcare and practice onprofessional interventions practice-based

range

Cochrane Database of Systematic Reviews Reviews Systematic of Database Cochrane Rapidresponse system, rapidresponse team, medical emergency team, Practice cultur Interdisciplinary, multidisciplinary, multiprofessional, interprofessional, Professional role, nurses Commentaries, editorials, conference abstracts without publications Studies reportingpatient outcomes only e.g. in Studies examiningresponse teams orrapidresponse systems in Roles and responsibilities ofhealth professionals withinbet or Interprofessional practice behaviours associated with care and Interprofessional relations within between or elements of a Peer reviewedarticles ofstudies of adult medical/surgical inpatients in 1995 (Medical Emergency Team concept) Dec to 2014 PubMed, CINAHL (Cumulative Index for Nursing and Allied Health), Details English language, humans Deteriorating patient, acutely ill patient, acute patient, patient rescue, adult critical care outreach interpersonal communication nurse arrest/mortality, unplanned End lifeof or Emergency departments, trauma settings, emergency retrieval services mental health clinical specialties e.g.sepsis, stroke, oncology, cardiology, pharmacy, more element of aRapid Response System management wardof patients at riskof deterioration, or acute care hospital wards that described: ProQuest Central, Cochrane Library patient

- physician relations, communication, interdisciplinary

e, safety culture, organisational culture, workplace culture palliative care

role, doctorsrole, interprofessional relations,

critical care

admissions

- hospital cardiopulmonary

e.g. ICU RRS,

ween one or

pecific

This article isThis article by protected copyright. All rights reserved. 2010 Endacott Donohue & 2000 Cioffi 2006 Chellel 2005 Chaboyer 2013 al. Bunkenborg 2012 Benin 2012 Beebe 2008 McClearn Baker 2011 Athifa 2013 Astroth Year First Author ofStudyMethods Table 2Summary

Accepted Article

et al. et al. et al. et al. et al.

etal. etal.

Qualitative; semi Design Qualitative; semi Qualitative; Qualitative; Qualitative; open Mixed method; Qualitative; semi Qualitative; Qualitative; semi Qualitative; interviews further in interviews, structured interviews structured interviews structured focus groups before interviews ended survey RRT member observations, unstructured structured and interviews structured interviews structured interviews unstructured interviews structured and semi observations structured

after - - depth

semi

------15 nurses ward Setting Study population 20 outreach nurses, 60 other 1 university hospital, Australia 10 nurses ward 1 university hospital, Denmark 13 nurses 1 university hospital, US 18 nurses, 12 home team 1 teachingmedical centre, US 5 RRT doctors, 3ward nurses, 8 hospitals, UK 56 nurses, 3students, 27 3 teachinghospitals, Australia 66 nurses pre intervention, 65 1 community hospital, US 1 district hospital, UK 11 nurses, ward 3CCO staff 2 hospitals, 32 registered nurses 2 and acute 5 general hospitals, 3 unknown manager, 3nurse supervisors, practitioners, 1 assistant 10nurses, RRT 2 respiratory managers doctors, 8 alliedhealth, 6 nurses post intervention UK nurses, doctors, anaesthetists) (dieticians, physiotherapists, 3 RRT respiratory technicians RRT physicians, 4RRTnurses, physicians, 8 administrators, 4

Australia

A A

Observedand self Impact ofCCO Nurses perceptions Barriers/facilitators focusStudy Wardnurse and Experiences of Outreach Wardnurses Nursing practices of Impact andvalue of members teamwork of RRT perceived care and organisation of services on delivery implementation and post of CCO services pre activateto RRT to perceptions of CCO staff assistance emergency nurses calling illpatients ward managing critically contribution to ICU liaison nurse perceptions of the in bedside monitoring attitudes experiences and RRT a - nurses decisions hospital patients

staff

This article isThis article by protected copyright. All rights reserved. 2011 Pusateri 2006 Plowright McIntyre 2012 Massey 2014 2014 al. Mackintosh 2012 al. Mackintosh 2013 Leach 2010 Leach 2014 Kitto 2006 Jones 2007 Endacott Year First Author

Accepted Article

et al. et et al. et al. et al. al. et al. et al. etal.

et al.

et et

Design Qualitative; in 2012 See Mackintosh Ethnographic Qualitative; semi Qualitative; semi Multiple case Survey; Likert Mixed methods; Survey design; Survey; closed Survey design; observations interviews and structured interviews structured group interviews, focus semi document audit, Likert interviews structured depth semi answers free questions with agreement scale Likert interviewsand observations case study; comparative groups study; focus scale type agreement

- - text text structured

- - type type

- - -

Setting Study population 15 nurses ward See Mackintosh 2012 2 tertiary hospitals, UK 35 doctors, 11 ward nurses, 4 1 tertiary university hospital, 17 (ward staff nurses RRT 6 hospitals, acute US 14 bedside nurses, 16 RRT 4 hospitals, Australia 27 doctors, 62 nurses 1 teachinghospital, Australia 351 nurses ward (RR 100%) 1 regionalhospital, Australia 11 nurses, 14 doctors, 17 131 nurses ward (RR 7 hospitals, UK 400 nurses, 120 medical staff, 1 university hospital, Australia 208 nurses97%) (RR 1 publicteaching hospital, supervisors therapists, 18 nurse nurses, 2 respiratory patientcases 158 other(RR 52%) Australia leads and managers health care assistants, 6safety US heads) administrators, department nurses, ward doctors, A

34%)

How How Reasonswhy Value ofMET and Cues used to focusStudy Perceptions ofMET Views ofoutreach Nurse perceptions Experiences and Rules ofrescue Process of patient Perceived and with RRT patients inhospitals activate the RRS members donot activation barriers to deterioration patient communicate identify, assess and patients deteriorating ward caring for and and actions duringa escalation services and care consultant ICUof nurse utilising aMET accessing and perceptions of behaviours in RRS and practice collective norms the c strategies within and safety rescue trajectories effectiveness of RRT observed are pathway nurse

s rescue

staff

This article isThis article by protected copyright. All rights reserved. CCO 2009 Wood 2011 Williams 2014 Stevens 2012 Shearer 2010 Shapiro 2009 Sarani 2006 al. Salamonson 2014 Rotella Year First Author rate, rate, RRT

Accepted Article –

critical care outreach, ICU etal. et al. et al. et al. et al. et al. et al. –

rapid response team, RRS

Survey; Likert Design Qualitative; Qualitative; Cross Mixed method; Qualitative part of Survey; web Survey agreement scale interviews telephone structured groups structured focus scale type agreement survey; Likert interviews audit, structured prospective point prevalence, focus groups semi methods study; larger mixed based scale type agreement - -

sectional structured

semi - - -

– -

intensive care, MET -

–

rapidresponse system 50 junior medical officers (RR 661 bedacademic medical Setting Study population 15 academic medical 15 department directors from 1 community hospital, US 13 nurses ward 1 university hospital, US 5months:At 111 doctors (RR 2months:At 60 doctors (RR 4 tertiary hospitals, Australia 44 nurses, ward 29 ward 18 hospitals, 13 USstates 56 nurses 1 university 414 nurses ward (RR 83%), 103 1 regionalhospital, Australia 92 nurses ward (RR73%) 1 teachinghospital, Australia doctors, 10 other e.g. ICU ward doctors (RR 67%) 100%) centre, US US ICU, emergency, patient safety 70%) 38%) outreach A

A – hospital, US

medical emergencymedical team, RR

centres,

A A

Delayedor non Nurses experiences Perceived effect of Satisfaction and Self focusStudy Practices, Nurses shared Self activated RRS calls of activating an RRT safety MET on patient METof perceived benefits escalation influencing MET call structures of RRS characteristics and use experiences ofRRT implementation post RRS months and 5 years behaviours 2 factors and sociological - -

reported factors reported

–

response

care

This article isThis article by protected copyright. All rights reserved. Accepted2012 Shearer 2010 Shapiro 2014 Massey 2014 Mackintosh 2012 Mackintosh 2013 Leach 2010 Leach 2014 Kitto 2007 Endacott 2010 Donohue 2000 Cioffi 2006 Chellel 2005 ArticleChaboyer 2013 Bunkenborg 2012 Benin 2010 Beebe 2008 Baker 2011 Athifa 2013 Astroth Author First Appraisal ofQualitative Table 3Summary

et al. et

Appraisal Question* Appraisal - et al. et et al. et al. et et al. et et al. et McClearn McClearn et al. et et al. et et al. et et al. et et al. al. et et al. et et al. et et al. et

et al. et al.

et al.

et al. et

1 Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

2 Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

3 Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

N 4 Y Y Y Y Y P P P P P P P P P P P P P

5 Y Y Y Y Y Y Y Y Y Y Y Y P P P P P P P

6 Y Y Y Y Y Y Y Y Y Y Y Y P P P P P P P

N N N N N N N N N N N N N N 7 Y P P P P

N N 8 Y Y Y Y Y Y Y Y Y Y Y Y Y P P P P

9 Y Y Y Y Y Y Y Y Y P P P P P P P P P P

10 Y Y Y Y Y Y Y Y Y Y Y Y Y Y P P P P P

11 Y Y Y Y Y Y Y Y Y P P P P P P P P P P

12 11 10 12 12 5 7 6 2 4 5 4 7 7 6 4 8 5 5 7

et al.

addressed? (Total of15) (Total addressed? questions CASP to Additional research? is the How valuable offindings? statement clear Is therea rigorous? sufficiently analysis Was the consideration? into been taken issues Have ethical addressed? been participants and researcher between Has therelationship issue? the research addressed that a inway collected data Was the appropriate? strategy recruitment Was the of the theaims address to designappropriate Was the continuing? Is itworth appropriate? methodology Was qualitative research? ofthe aims of the clear statement a Was there

Programme, 2014 (Table 3) Y Y

Y Y

: How many trustworthiness strategies were were strategies trustworthiness many : How Y P

Y P

N P

research? Y P

N P

Y P

P P

5 7

This article isThis article by protected copyright. All rights reserved. All respondents accounted for AcceptedResponse rate reported / clearly defined RESULTS Funding reported Subjectconsent procedures reported HREC ETHICALQUALITY Financial incentives offered/provided Type andnumber of contacts provided Mode of administration Who ADMINISTRATION OFTOOL Description of representativeness ofsample Sample sizecalculation rationale/justification Description of population andsample frame Description of representativeness ofsample Sample sizecalculation rationale/justification Description of population andsample frame Description of representativeness ofsample Sample sizecalculation rationale/justification RESEARCHTOOL DEVELOPMENT Description of population andsample frame Description of representativeness ofsample Sample sizecalculation SAMPLESELECTION Methods for handling item missing data provided Definitions for complete vs partial completions Methodfor calculating Methodfor analysis of nonresponse error provided ArticleMethods for verifyingdata entry Description of methods usedfor data analysis DATA ANALYSIS Use of acodebook Dates of data collection Location of data collection Methods sufficiently describedfor replication METHODS Survey design; TITLE, ABSTRACT, INTRODUCTION Appraisal ofSurvey-based Table 4Summary provided approachedpotential participants approval

explicit purpose/aim; background

response rate provided

rationale/justification

First Author/Year ND ND ND N N N N N N N N N N N N N N N N N N N Y Y Y P P Y Y Y P

Beebe 2012

ND ND ND N N N N N N N N N Y Y Y Y P P P Y Y Y Y Y Y Y Y Y Y Y Y

Jones 2006

ND ND ND N N N N N N N N N N N N N N N N N N N Y Y P Y Y Y Y Y Y

McIntyre 2012

ND ND ND N N N N N N N N N N N N N N N N N N Y Y P Y P Y Y Y Y Y

Plowright 2006

ND ND N N N N N N N N N N N N Y Y Y Y P Y P Y Y Y P Y Y Y Y Y Y

Pusateri 2013

ND ND ND Y/N N N N N N N N N N N N N N Y Y Y P P Y Y Y Y P P P Y Y

Rotella 2014

ND ND ND N N N N N N N N N N N N N N N N N N N N N Y Y Y P Y P Y

Salamonson 2006

ND ND N N N N N N N N Y Y Y Y P Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Sarani 2009

ND ND N N N N N N P Y Y Y P Y P Y Y Y Y Y Y Y P Y Y P Y Y P Y Y

Stevens 2014

This article isThis article by protected copyright. All rights reserved. Accepted Article Ref: Bennett Generalisability ofresults discussed Limitations of the study stated (bias) Strengths of the study stated Results DISCUSSION Results address objectives Results clearly presented Information on hownon respondents provided (complete andpartial summarised referencing study objectives

etal, 2011

- respondents differ from

according to eligibility)

N N Y Y Y Y Y

N Y Y Y Y Y Y

N N Y Y Y Y Y

N N N Y P Y Y

N N Y Y P P Y

N Y Y Y Y Y Y

N N Y Y Y Y Y

N N Y Y Y P Y

N N N Y Y Y Y

et al. Mackintosh 2014 Massey 2014 Rotella 2014 Stevens 2014 First Author Year

et al. et al. et al.

Efferent Limb Nursing Afferent limb Medical Afferent limb Medical RRSElement Professions Medical, Afferent managers HCAs, nursing,

limb

CCOT perceivedas supportive byjunior docto HCA provided backup for ward RN EWS mediated between nursing and medical boundaries Understanding of core value in signs vital monitoring for Leadership andsupport for appropriate Unconcern of criticism (T4) Uncertainty about diagnosis or management plan; Familiarity andacceptance increases utilisation (C6) RRS considereda necessity for improving patientcare (R3) deterioration (R4) (C3) clinical deterioration (V1) response to initial treatment(C6) unfamiliarity with patients’

Facilitat

clinical problem; no patient ing

in detecting

activation (R1) rs (T3)

Key Findings

Seni Poor engagement of key stakeholders (T5) Hierarchical division of labour/selective vital sign Junior doctors reprimanded without legitimate reason for Specific clinical concerns not implicitly supported by EWS; Intraprofessional jurisdictional disputes of Normalisation of protocol breaches (V2) MET not recognised as early intervention strategy (V2) Previous negative experiences (C11) Nurses report along the traditional hierarchy (C10) Lack ofrole clarity (R7) Reluctance to wake seniora escalate to care (C11) Suboptimal handover from the home team to on Difficultyescalat Over confidence tomanage patientwithout support (R9) Patientnot sickenough or clearly dying andmanagement RRS not consideredto improve ability manageto monitoring (C12) escalation (C11) blurredEWS professional care (R8) accountability/responsibility caused fragmentation of doctors (C8) unavailable (R10) plan consideredappropriate (R8) deteriorating patient(R8) or doctors concerned about CCOT

ing care when registrar or consultant

Inhibiti

responsibilities (C9) ng

increased

- call call

Astroth 2013 et al. Bunkenborg 2013 Leach 2013 Kitto 2014 First Author Year

et al. et al. et al.

RRSElement Professions Efferent limb Medical, Efferent limb Medical, Afferent limb Nursing Afferent limb Nursing management nursing, nursing

Unit cultures of teamworkwillingness and (T2, T4) Support andencouragement from nursing unit Collaborative decision Nurses placed RRT members non Collaborative teamwork (T2) Clarity of RRT role/structure (R3) nurseRRT resources/skills/expertise (R2) Administrative leadership to organise andmanage change Shared mission to innovate and pursue safety and quality RRS used asformal toolby nursing and junior medical to Nurses felt empowered to communicate concerns and Improvedcommunication and collaboration across

and leadersand (C5) (C5) escalate care when concerns acknowledgedby doctor obtained vital beforesigns contacting doctor; likely to dialogue’ around patient needs (T3, T4) (R1) T1) improvement with acollegial teaching environment (V1, obtain expertise toaddress patientneeds (T1) initiate responsea for help (C5) hierarchical boundaries (C1)

importance on clear communication; -

intimidating and ‘willinghave to

- making(T2) Facilitat

ing

colleagues

Key Findings Calling home team doctor Uncertainty of expectations during event (R6) Poor knowledge ofpolicy (V2) Collaborative communication more likely occurto when Nurses concerns not taken seriously (C11) Patients Lack of clarity incommunicating patients needs (C8) Frequently changing Negative experiences/reprimand (C11) Poor communication, not patientfocused (C8) Medical staff conveyeda sense offailure if RRTan had to Ambiguous leadership duringefferent limb response (R7) RRS escalation criteria deskilledjunior with doctors less Previous negative experiences andstories reprimandof Utilisation of (nursing Non Medical responsibility alter to escalation criteria (R10) vital signs abnormal (T5) (C9) be (R8) called exposure to difficult decision making (C11) pathways (C10) hierarchies; discipline specific decision communication (C8) pro - activation ofRRS caused bybreakdown in

fessional power inmedical domain (L3)

’

condition

needed tobe severe to get responsea R and medical) traditional reporting RT members (T6) Inhibiti

first first (C10)

experiences (L3) -

making

Accepted Article

et al. Mackintosh 2012 al. McIntyre 2012 Shearer 2012 First Author Year

et al. et

Efferent Limb Medical, nursing RRSElement Professions Outreach Nursing services Afferent limb Medical, managers HCAs, nursing,

EWS facilitatedescala Audit and feedback for staff engagement (C2) Electronicsystems provided access to timely patientdata, CCOT mediated between wardstaff andcritical Senior level commitment/leadership (R1) Teach how to manage (69%) andident Accelerated medical review (71%) (C4) Helpedprioritise patients’ clinical issues after MET/ICU Collegial support with chosen approach of care escalation; Wardstaff appreciated R occupational boundaries (C3) inbuilt prompts and formative feedback data (C1) from ICU (R2, C4) prevented delays, and safety net for patients discharged patients on ward (T2) (R2) major (90%); reduced serious adverse events (83%) discharge (82%); preventeda minor problem becoming no concern of hostile response (C5, T2) and follow

- up (L2)

tion of care across hierarchical and

Facilitat R

T members ing

’

guidance, education ify (56%) sick

care,

Key Findings Electronicsystems Challenges to escalate care without objective signs (C5) Lack of administrative su CCOT introduced compartmentalisation and Lack of formalisedresponse strategy (V2) Utilisation of outreach services instead of MET (C10) Junior staffwithout clinical expertise expected to manage Concern of negative or hostile response (medical and Poor communicatio Medical staff delay Escalation delayedwhen issue iswithin clinical discipline Staff consideredthemselves junior too to activate RRS Communication style ofRRT members, fear of appearing (C7) face communication, not available atpatient bedside priorities (R5) fragmentation of care (R8) patient(T7) nursing) for efferent limb activation (C11) nursing (C8) control (R9) homeof team,ward or staff felt the situation wasunder (R7) dumb or being reprimanded(C11)

review patient on ward(R10) – n of prioritisation by medical to

restricted access, replace Inhibiti pport with shiftingmanagerial

face to

Accepted Article

Pusateri 2011 al. Williams 2011 Beebe 2012 Benin 2012 First Author Year

et al. et al. et al. et

RRSElement Professions Efferent limb Efferent limb Efferent limb Medical, Efferent limb Nursing Efferent limb Nursing R nursing RT members

Collaborative teamwork anddecision eliminatedRRT time intensive process of reporting along Perceived role ofRT as advocates forpatients safety (R3) nurseRRT support and expertise T2) (R2, Members R Effective leadership (67%); familiarity with each other’s R Collegial support between ward andRRT nurses (T2) Use of situation, background, Field Observations: Responses facilitated interprofessional learning (L2) Empowerment ofnurses andincreased morale (C5) Improvedmodel tofacilitate timely escalation of care (C1) Enabledredistribution of workload wardfor CCOT providededucation, support and IPtraining (L2) R R traditional hierarchy (C1) solving skills (83%) (T2) job responsibilities (78%) (R1) (SBAR) (C3) on T perceived as patienta safetynet (93%) (R3) T Member Survey: - call call doctors (R4)

use effect

ive decision

Facilitat

assessment, recommendation - making andproblem ing

- making (T2)

nurses and

Key Findings

Not feelingvalued as a member of the MET (29%); W Lack of constructive feedback(33%), and coaching from Poor recognition ofindividual performance (37%); Perceived lackof continuous improvement(52%) (V2) R Fragmented Ambiguous leadership duringRRT events (R7) Inconsistent engagement, or disengagement, bybedside Field Observations: RRS model negated traditional teaching approaches (L3) Reduced autonomy for trainee doctors (R8) Tensio RRT members feltburdened with additional workload Medical and nurse reporting hierarchies (C10) inconsistentlyEWS used to request he R ard doctors unavailable or reluctance activateto RRT; T reluctance to participate fully (11%) (R6) MET; feelingintimidated duringMET (18%) caused uncertain (22%) or uncomfortable (20%) with (C11) negative responses to ward nurses from RRT members leaderRT (30%) (L3) unresolvedIP conflicts (33%) (T5) nurses (R6) (R6) deterioration not formalised byEWS (C9) with useof SBAR as handovera tool; signs of Member Survey:

ns between nurses, doctors andRRT (R7)

interprofessional

Inhibiti

communication (C8) ng

lp; poor adherence

role in

Accepted Article

Wood 2009 al. Donohue 2010 Leach 2010 Shapiro 2010 Athifa 2011 First Author Year

et al. etal. et al. et al. et

RRSElement Professions Afferent limb, Nursing Efferent limb Nursing Outreach Nursing Efferent limb Management Afferent limb Nursing efferentlimb services

Feedback of outcome data, follow Nurse role pivotal tocareescalation (R4) Open discussions of roles, activation criteria and success CCO provided calm andreassurance fo Use of CCO considered importantan resource for initiating clear nurseRRT augmented, reinforced and supported the Nurse decision nurseRRT provided critical care skills andknowledge nurseRRT Supportive working relationshipswith RRTmembers (T2) Positive feedback(C2) R An important resource to educate staff on complex Friendly, non Improvedcommunication processes R stories (V1) concerns, intuition, visual observation (C2, C5) action plans (R2) bedside nurse (T2) consultation (C10) patients (L2) procedures uncommon to general wards for post disciplinary team members, ward staff and ICU(C4) T perceived as invaluablean expertresource (R3)

objective data/ collegial support, autonomy andexpertise (T3) - intrusive interfering or attributes (T2, T4)

making facilitated byprotocol and

EWS to communicate andreinforce

Facilitat ing - up surveys (C2)

between multi r ward staff (T2)

- - ICU

Key Findings

Reluctance from medical staff to activate Bedside crowding perceivedas intimidating (R6) Lack of administrative support/funding for resources and infrequentlyEWS use Medical staff sometimes delayedescalation to manage Disengagementof medical staff when CCO become Collaboration more likely when the patient is acutely Nurses felt their voiceswereheard, not respected or Decision Lack of clarity inarticulating Concerns ofreprimand for activating efferentlimb R nurseRRT concerns ofleaving own patientcaseload (R6) Uncertainty when activate to or RRT call codeblue (R7) No CCOS available Physician discouragement caused hesitation toactivate positions (R5) used confirmto deterioration rather than asse patientthemselves (R9) involved(R7) unwell (T5) acceptedby doctors (C11) (C10)call (C8) (C11) intervention study) (T7) (20%) (C12)

- makingoccurred within nursing hierarchy before

after d tolook for trends indata; E - Inhibiti hours (services discontinued post

care escalation requirements

R RT; negative

ss itss (C9) WS R T

Accepted Article

Plowright 2006 et al. Salamonson 2006 al. Endacott 2007 al. McClearn Baker 2008 Sarani 2009 First Author Year

et al. et et et

Medical, nursing RRSElement Professions Medical, Outreach Medical, Afferent limb Efferent limb Nursing Efferent limb Medical, nursing services health nursing, allied nursing

Positive Providedimmediate attention Clear communication of situational urgency for patient(C5) Imparted critic Providedencouragement maketo timely andappropriate Improvedrelationships and communication between Reduced ICUreferrals and instilled confidence inICU staff (Mean Positive perceptions ofMET (RN4.4:Dr 3.9) (T2) Feedback from MET Wardstaff rapport with RRS members (T2) Utilisation improved with medical M ultidisciplinary team of of critical care referrals (85%) (R2) medicalto experts interventions in ward staff (L2) decisions (T4) nurses and doctors (C4) transferto patients backto ward (R2) and feedback (L1) Likert effects ofservices onpatient care and facilitation - score: 1strongly disagree to5 strongly agree) al al care expertise and developed confidence -

34%RR; backup support

–

(RN 3.5, Dr 2.7) (C2)

18%(R3)

meetings Facilitat

41%RR; early ing

–

acceptance (C6) opportunity for learning

33%RR; access

Key Findings

Negative perceptions of the MET attitude (11%) (C11) Division patient of care between medical teams; staffing Delays intreatment created On Local policy andhierarchical issues prevented appropriate Challenged to improve and sustain skills in context of Negative perception of MET educational on experiences - staff) (R5) demands, skill mix,medical rotations, inexperienced issues (casual/locum/part changeto management (R10) responses (V2) deskillingjunior of doctors (L3) ongoing staff rotations and turnover; perceived (L3) (RN 2.5, Dr 3) and resuscitation skills (RN 2.1, Dr 2.6) feedback for inappropriate activation (C11) call doctorscall lack familiarity with patients and authority

Inhibiti interprofessional - time, shortages, multiple ng

friction (T5)

Accepted Article

medical emergencymedical team, ( T )

– Cioffi 2000 al. Chaboyer 2005 Chellel 2006 Jones 2006 al. First Author Year

critical care outreach

et al. et al. et

Outreach RRSElement Professions services Nursing Outreach Medical, Efferent limb Nursing Outreach Efferent limb Nursing services services health nursing, allied RN (

team

–

registered nurse,

)

, EWS

Primary use ofsubjective data/use ofintuition was Debriefingpost MET (C2)call Supported wardstaff when advancedcritical care skills Improvedcommunication and transfers between ward and Advocated for ward staff Communicatedeffectively andwere listened toby doctors; Facilitated timely escalation processes anddecision MET considered to teach how to better manage sick MET allowed nurses toseek help when worried (97%) (C5) Prevented a minor eventbecoming major (90%) (R3) Polite attitude ofservice (97%) (T4) High Improvedtimeliness responses of (98%) and transfer to – supported by objective data/vital signs (C5) required for ward patient (T3, L2) ICU (C4) agent, promoter good of will and diplomacy (R2) mediator, and negotiator of teams; pressures (C4, T4) investigations; liaised, coordinated and relievedwork developed action plans; initiated ad expertise and critical care skills for ward patients (R2) making to addresspatient needs; providedclinical (L2) patients (71%); METnot perceivedas deskilling critical care (93%) (C4)

early warningscore, HCA - level awareness of RRS services (98%) (T1)

RRS

–

rapid response system

Facilitat -

acted as advisor, counsellor,

–

unqualified healthcare assistant, ing

considered a change ditional , RRT –

rapidresponse team

(95%)

Key Findings

Feelings ofnervousness or anxiety, self Collaboration with other ward staffbefore calling MET Lack ofrole clarity; interference Wardstaff felt unsupported by senior clinical decision Extra demands ofincreasing pat Medical resistance to ownership, responsibility and Coveredup deficiencies innursing and medical practices Fear of criticism for activating MET (10%) (C11) Nurses would wardcall doctor before MET (72%) ICU whether MET wascall appropriate (C11) (C10) (R7) makers (T7) ward staff (R6) accountability (R5) on ward (R2) available (81%) (C10) although, would activate MET if ward doctor not

–

intensive care unit,

Inhibiti

IP –

interprofessional, ng /taking over patientcare ient acuity overwhelmed

- doubt/questioning

MET - –

V2 INHIBITING V1 ENABLING Values and Ethics Values and 3, 4,8,3, 11, 13, 23 noncompliant practices values Organisational – –

Variable or Shared practice Culture 4, 6,20 4,

R6 R6 R5 INHIBITING R4 R3 R2 R1 ENABLING R10 R10 R9 R8 R7 resources 25, 22, 27, 28 leadership 2, 5,9,2, 23 specialty services professional boundaries patient caseloads Role Role Perceptions and Professional – – – – – – – – – – Roles and Responsibilities and Roles Patients needs within ward clinical Limited benefits of efferent limb Lack of role clarity and blurred Increasing clinical acuity and Lack of organisational support and Ward nurses Efferent limb teams Outreach service roles Senior level commitment with clear

Unsupported clinical decision

1,2, 4, 6, 11, 12

2, 9,19 2,

11,20, 23, 27 3,6, 11, 13 Accountability

4, 12,20 4, 8, 12,13,8, 15, 17, 20, 27

ENABLING

1, 6,1, 3, 6,12,3, 13, 17,19, 28

4,6,10, 11, 14, 18, 19, 13, 17, 14, 24, 26

Interprofessional Learning Opportunities

heavy

makin

Recognising and Responding to Clinical Deterioration Clinical Deterioration to Responding and Recognising g C12 C12 C11 C10 C9 C8 C7 INHIBITING C6 C5 C4 C3 C2 C1 ENABLING responsibilities hie hierarchies Scoring system 9,13,7, 18 26, 23, 29 27, 25, 28 19 13, leaders records – – – – – – – – – – – – Inconsistent application of Early Warning Ambiguous/cir Restrictions of electronic records Medical specific practice issues Nursing specific practice issues Outreach professional expertise Formal structured clinical practice tools Constructive feedback from efferent limb Formal conceptual model with electronic rarchies breached Communication

Division of patient monitoring Negative experiences when embedded Concerns of breaching traditional reporting

10,11, 17, 20, 21,29 5, 11,12,5, 14

3,5,8, 10, 11, 18, 26, 29 Communication 4 4, 7,11,4, 19

cuitous IP communication 2

- of Clinical Needs 9,14, 15, 17, 20, 18, 23, 24, 26, 29

1, 2,20 5, 7 4,10, 11, 16, 22, 11 -

9,11, 12, 19,

4, 11, 2,6, 5,

T7 T6 T5 INHIBITING T4 T3 T2 T1 ENABLING 2, 6,8,16,2, 22, 23, 25, 27 decision staff and support System concept understanding of ResponseRapid – – – – – – –

Lack of support for clinical Frequently changing efferent limb Poor administrative engagement Positive professional team values Outreach services support Professional rapport Shared organisation 6 Team

- making

Teamwork - 4,7, 18, 13, 23 based Practices

5, 6,25 5, 9, 16,27 9,

- 6 wide -

9,13, 16 14, 4, 6,17,4, 28

- 21

Accepted ArticleDomain ICP

Values and Ethics Values and

Roles and Responsibilities and Roles L2 L1 L3 INHIBITING – – –

Clinical deterioration and efferent limb events Multidisciplinary meetings Efferent limb and outreach services

Communication 4,5, 12, 21, 22

8, 10 8, - 12,16,

22,26, 28

Teamwork

T5 C7 V2 Inhibiting L1 T1 C1 V1 Facilitating R5 Inhibiting R1 Facilitating – – – – – – – – –

Multidisciplinary meetings Poor administrative and support engagement organisationShared Restrictions ofelectronic records Formal conceptual modelwith electronic records Lack andresources ofsupport levelSenior commitment withclear leadership T7 C12 C11 C10 R10 R9 R8 Inhibiting T4 T3 C6 C5 R4 Facilitating Variable/noncompliant practices practiceShared values This article isThis article by protected copyright. All rights reserved. Issues Practice Collaborative Interprofessional System-wide Response Rapid 2 Figure – – – – – – – – A

– – – – Positive team professional values Outreach support services Lack fordecision ofsupport clinical

Medical specific practice issues Nursing Patients limbof efferent Limited services benefits Ward nurses

DMINISTRATION Div Negative whenexperiences embedded hierarchies breached Concerns traditionalhierarchiesof breaching reporting Unsupported clinicalUnsupported decision

Accepted Article

R isionpatient monitoringresponsibilities of

APID APID

’ specific issues practice

needs within needs wardclinical specialty R ESPONSE 4, 1 - 2, 20 wide understanding of wide understanding 4,6, 20 A

ND ND 20

Q YSTEM 11,20, UALITY 4, 6, 17, 28 3, 11 4, 8, A

23, - 5,7 making - 1, 2,20 1, FFERENT WIDE WIDE

27 11,13 2, 6 - I

SSUES - making 11, 11, -

8,16, 22,8,16,23, 25, 27 , 23, 12, 12, 19, I RRS 2, 5,9, 2, 23 SSUES

L 1, 3, 6, 11, 6, 11, 13 3,

IMB IMB

2, concept 23, 9, 16,27 9,

13,18, 23 5, 11,12,14 5, 4, 6,11,4, 12 2, 9,19 2,

26,29

I 4 SSUES

5, 6, 25 6, 5,

3, 5,3, 10,11,18,26, 298, 2 - 9, 14,9, 15,

17, 17, 18, 20,23

Rapid Response structureRapidSystem Response ,24,26 , 29,

(DeVita Facilitating L3 C9 C8 R7 R6 Inhibiting L2 T2 C4 C3 C2 R2 et al, – – – – – – – – – – –

Efferent limb outre Efferent and Clinical limbevents deteriorationefferent and Professional rapport Inconsistent applicationE of Ambiguous/circuitous IP communication Outreach clinical expertise Formal structuredclinical practice tools Constructive feedback fromefferent limb leaders Lack of role clarityLack blurredprofessional ofrole boundaries and clinicalIncreasing patientcaseloads acuity and Outreach service roles 2006)

A FFERENT 6 - 9, 13,14, 9, 16 4, 6 4, ach services , 10,11, 4, 10,11,16, 4, 22, 25, 27, 28 – arly

L T C R V Coding References E T6 Inhibiting R3 Facilitating - 2 FFERENT FFERENT 14,18, – – – – – 1 W

– –

Interprofessional learning Teamwork and team Communication Roles and values and ethics

Lack ofcontinuity in Efferent limbEfferent teams arning 4, 5,12,4, 21, 22 19, correspond withTable 5

4, 11, 4, 13 E 25,28, 27, L

2, FFERENT S IMB coring system 5, 6, responsibilities

, 19, 7, I 8, 108, 8, 12, 8, 12, 13, SSUES

9,13,18

- 10,11, 12, 16, 22, 26,28 L

IMB IMB

16, 17, 1, efferent limb staff

3,6, 12,13, 17,20, 27 - 6,

I 4,7, 19 11, basedcare 20,21,29 SSUES 13,14,

17, 24, 17,

17,

and 6

19,28