Kathryn E Roberts1, Christopher P Bonafide, Christine Weirich Paine, Breah Paciotti, Kathleen M Tibbetts, Ron Keren, Frances K Barg, John H Holmes. 1. Kathryn E. Roberts is a clinical nurse specialist in the Department of Nursing, The Children's Hospital of Philadelphia, Pennsylvania. Christopher P. Bonafide is an assistant professor of pediatrics in the Division of General Pediatrics at The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. Christine Weirich Paine is a senior clinical research assistant in the Division of General Pediatrics, The Children's Hospital of Philadelphia. Breah Paciotti is a senior research coordinator in the Mixed Methods Research Lab, University of Pennsylvania. Kathleen M. Tibbetts was a graduate research assistant in the Division of General Pediatrics, The Children's Hospital of Philadelphia at the time of this work and is now a senior research associate at GfK Healthcare, Blue Bell, Pennsylvania. Ron Keren is a professor of pediatrics and epidemiology at the Perelman School of Medicine at the University of Pennsylvania and an attending physician in the Division of General Pediatrics and chief quality officer at The Children's Hospital of Philadelphia. Frances K. Barg is an associate professor of family medicine and community health at the Perelman School of Medicine and an associate professor in the Department of Anthropology in the School of Arts and Sciences at the University of Pennsylvania. John H. Holmes is an associate professor of medical informatics in epidemiology, chair of the Graduate Group in Epidemiology and Biostatistics, and associate director of the Institute for Biomedical Informatics at the University of Pennsylvania Perelman School of Medicine.
Abstract
BACKGROUND: Rapid response systems (RRSs) aim to identify and rescue hospitalized patients whose condition is deteriorating before respiratory or cardiac arrest occurs. Previous studies of RRS implementation have shown variable effectiveness, which may be attributable in part to barriers preventing staff from activating the system. OBJECTIVE: To proactively identify barriers to calling for urgent assistance that exist despite recent implementation of a comprehensive RRS in a children's hospital. METHODS: Qualitative study using open-ended, semistructured interviews of 27 nurses and 30 physicians caring for patients in general medical and surgical care areas. RESULTS: The following themes emerged: (1) Self-efficacy in recognizing deteriorating conditions and activating the medical emergency team (MET) were considered strong determinants of whether care would be appropriately escalated for children in a deteriorating condition. (2) Intraprofessional and interprofessional hierarchies were sometimes challenging to navigate and led to delays in care for patients whose condition was deteriorating. (3) Expectations of adverse interpersonal or clinical outcomes from MET activations and intensive care unit transfers could strongly shape escalation-of-care behavior (eg, reluctance among subspecialty attending physicians to transfer patients to the intensive care unit for fear of inappropriate management). CONCLUSIONS: The results of this study provide an in-depth description of the barriers that may limit RRS effectiveness. By recognizing and addressing these barriers, hospital leaders may be able to improve the RRS safety culture and thus enhance the impact of the RRS on rates of cardiac arrest, respiratory arrest, and mortality outside the intensive care unit.
BACKGROUND: Rapid response systems (RRSs) aim to identify and rescue hospitalized patients whose condition is deteriorating before respiratory or cardiac arrest occurs. Previous studies of RRS implementation have shown variable effectiveness, which may be attributable in part to barriers preventing staff from activating the system. OBJECTIVE: To proactively identify barriers to calling for urgent assistance that exist despite recent implementation of a comprehensive RRS in a children's hospital. METHODS: Qualitative study using open-ended, semistructured interviews of 27 nurses and 30 physicians caring for patients in general medical and surgical care areas. RESULTS: The following themes emerged: (1) Self-efficacy in recognizing deteriorating conditions and activating the medical emergency team (MET) were considered strong determinants of whether care would be appropriately escalated for children in a deteriorating condition. (2) Intraprofessional and interprofessional hierarchies were sometimes challenging to navigate and led to delays in care for patients whose condition was deteriorating. (3) Expectations of adverse interpersonal or clinical outcomes from MET activations and intensive care unit transfers could strongly shape escalation-of-care behavior (eg, reluctance among subspecialty attending physicians to transfer patients to the intensive care unit for fear of inappropriate management). CONCLUSIONS: The results of this study provide an in-depth description of the barriers that may limit RRS effectiveness. By recognizing and addressing these barriers, hospital leaders may be able to improve the RRS safety culture and thus enhance the impact of the RRS on rates of cardiac arrest, respiratory arrest, and mortality outside the intensive care unit.