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

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Review

Succeeding with rapid response systems a never-ending process: A systematic review of

how health-care professionals perceive facilitators and barriers within the limbs of the RRS

Siri Lerstøl Olsen

^a,b,

*, Eldar Søreide

^c,d

, Ken Hillman

^e,f

, Britt Sætre Hansen

^a,g

aDepartmentofQualityandHealthTechnology,FacultyofHealthSciences,UniversityofStavanger,KjellArholmsGate43,4036Stavanger, Norway

bDivisionofMedicine,DepartmentofEmergencyMedicine,StavangerUniversityHospital,GerdRagnaBlochThorsensGate8,4011Stavanger, Norway

cCriticalCareandAnaesthesiologyResearchGroupStavangerUniversityHospital,GerdRagnaBlochThorsensGate8,4011Stavanger,Norway

dDepartmentofClinicalMedicine,UniversityofBergen,Bergen,Norway

eLiverpoolHospital,UniversityofNewSouthWales(SWSClinicalSchool),c/oIntensiveCareUnitLiverpoolHospitalLiverpool,NSW, 2170Australia

fTheSimpsonCentreforHealthServicesResearch,UniversityofNewSouthWales,InghamInstituteforAppliedMedicalResearch,Australia

gResearchDepartment,StavangerUniversityHospital,GerdRagnaBlochThorsensGate8,4011Stavanger,Norway

Abstract

Background:Meta-analysesshowthathospitalrapidresponsesystems(RRS)areassociatedwithreducedratesofcardiorespiratoryarrestand mortality.However,manyRRSfailtoprovideappropriateoutcomes.ThusanimprovedunderstandingofhowtosucceedwithaRRSiscrucial.By understandingthebarriersandfacilitatorswithinthelimbsofaRRS,thesecanbeaddressed.

Objective:ToexplorethebarriersandfacilitatorswithinthelimbsofaRRSasdescribedbyhealth-careprofessionalsworkingwithinthesystem.

Methods:Theelectronicdatabasessearchedwere:EMBASE,MEDLINE,CINAHL,Epistemonikos,Cochrane,PsychInfoandWebofScience.Search termswererelatedtoRRSandtheirfacilitatorsandbarriers.StudieswereappraisedguidedbytheCASPtool.Twenty-onequalitativestudieswere identifiedandsubjectedtocontentanalysis.

Results:Clearleadership,interprofessionaltrustandcollaborationseemstobecrucialforsucceedingwithaRRS.Clearprotocols,feedback, continuousevaluationandinterprofessionaltrainingwerehighlightedasfacilitators.Reprimandingdownthehierarchy,underestimatingtheimportance ofcall-criteria,alarmfatigueandalackofintegrationwithotherhospitalsystemswereidentifiedasbarriers.

Conclusion:TosucceedwithaRRS,thekeysseemtolieintheadministrativeandqualityimprovementlimbs.Clearleadershipandcontinuousquality improvementprovidethefoundationforthecontinuingcollaborationtomanagedeterioratingpatients.SucceedingwithaRRSisanever-ending process.

Keywords:Rapidresponsesystems,RRS,RRSbarriers,RRSfacilitators,Healthcareprofessionalperceptions,Deterioratingpatients,RRS collaboration,RRSsimulation,SuccedingwithRRS,Continousqualityimprovement

* Correspondingauthorat:DepartmentofQualityandHealthTechnology,FacultyofHealthSciences,UniversityofStavanger,KjellArholmsGate43, 4036Stavanger,Norway.

E-mailaddress:[email protected](S.L.Olsen).

https://doi.org/10.1016/j.resuscitation.2019.08.034

Received22May2019;Receivedinrevisedform15August2019;Accepted24August2019

licenses/by-nc-nd/4.0/).ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

RESUSCITATION144(2019)75 90

Availableonlineatwww.sciencedirect.com

Resuscitation

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Introduction

Theimplementationofrapidresponsesystems(RRS) toimprove patientsafetyisstronglysupportedbyqualityimprovementorganiza- tions such as the Institute of Healthcare Improvement,¹ and is recommendedininternationalguidelines.^{2 4}AsuccessfulRRSmay be defined asahospital-wide system thatensuresobservations, detectionofdeterioration,andtailoredresponsetowardpatients.^5,6 Timeisessential,asdelayedmanagementhasbeenassociatedwith increasemortality.^7,8

Twoprevioussystematicreviews^5,9havefoundmoderate-strength evidencethatimplementationofRRSisassociatedwithreducedrates ofcardiacarrestandmortality.However,becausemanyRRSfailto provideappropriateoutcomes,thereisdebateabouttheireffective- ness,andhowtoevaluatethem.^{10 13}Studiesfocusingprimarilyon outcomesoftenhavelimitedassessmentofthecontext,processesor mechanisms leading tothose outcomes,and thus provide limited explanationsofwhyRRSworkordonotworkinclinicalpractice.¹⁴

ThereisgeneralconsensusaboutwhatconstitutesanRRS(Fig.1), but great variation in how RRS components are constituted and operate.⁹

Thishighlightstheneedtoidentifythefactorsthatcontributetotheir effectivenessindifferentoperationalcontexts.IftheRRSisnotusedas intended,expectingresultsisfutile.Evenifahospitalhasofficially implementedanRRS,compliancewiththesystemmaybelow.^13,15 Culturalbarriersmaypersist,⁵andunderstandingtheseishighlighted asessential.¹⁶

Toimproveourcurrentunderstandingofthefactorsaffectingthe RRS we performed a systematic review based on the following question: “How do healthcare professionals perceive potential facilitatorsandbarrierswithinthelimbsofaRRS?”

Methods

The present systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta- Analyses(PRISMA)statement.¹⁸Abroadsearchstrategywasused toensureinclusionofallrelevantpapers.

Searchprotocolandeligibilitycriteria

InOctober2017wesystematicallysearchedEMBASE,MEDLINE, CINAHL,Epistemonikos,Cochrane,PsychInfo,andWebofScience, fortheperiod2000 2017andupdatedthesearchonMarch20,2019.

The search terms used were: “rapid response team”, “medical emergencyteam”,“criticalcareoutreachteam”,“evaluate”,“imple- ment”,“utilize”,“adopt”,“success”,“fail”,and“barrier”(Appendix1).

Anexpertlibrarianassistedwiththissearch.

Inclusioncriteria

PaperspublishedfromJanuary1,2010 March20,2019.

Originalresearch Peerreviewed

Fig.1–ThestructureofaRapidresponsesystem(RRS),adaptedfromthefindingsofthefirstConsensusConferenceof MedicalEmergencyTeams.¹⁷

ThefourlimbsoftheRRS⁶:

Theafferentlimb:thesystematicprocessofmonitoringpatientsanddetectdeteriorationsupportedbypredefined criteria.

Theefferentlimb:theresponseteamwithexperticeinhandlingdeterioratingpatients.Theteamconfigurationmost commonlyused:MedicalEmergencyTeams(MET),oftenledbyaphysicianfromtheICU,RapidResponseTeams (RRT),inAustraliausedsynonymouswithMET,butinUSoftenledbynurses.CriticalCareOutreachTeams(CCO)most commonlyusedinUK,oftenstaffedbyICUnurses.

Theadministrativelimb:overseesthesystem.Ensurepersonnelandequipmentresources,trainingandeducation.

Thequalityimprovementlimb:collectandreportdata,providefeedbackandtherebyimprovethesystem.

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Allstudydesigns

Languages:English,Norwegian,SwedishandDanish.

RRSwithatleastanafferentandanefferentlimb.

Exclusioncriteria

Inconsensusitwasdecidedtoexcludearticlespublishedbefore 2010,tofocusonthenewestpublications.

ArticlesonpaediatricRRSandsubgroups(example:pulmonary embolismRRT’s,obstetricRRT’s).

Studyselection

We performed an initial screen of publications(3024) to remove duplicates,thenreadalltitlesandabstracts;full-textarticleswere retrievediftheyappearedtomeettheinclusioncriteriaandaddressed thepredefinedreviewquestion.Thefull-textwasalsoretrievedifthe

titleand abstractgaveinsufficient information toallow immediate exclusion.Fourpapersusedmultipledesigns,andonlythequalitative component addressing the review question was included^{19 22} (Fig.2).

Dataextraction

The data extraction process involved familiarization with and comparisonoftheincludedstudies.Thepapersthataddressedour researchquestionusedaqualitativeapproach,soweperformeda qualitativecontentanalysis²³(Table3).Thefindingswereorganized accordingtothefourlimbsoftheRRSmodel(Fig.1)

Qualityandriskofbias

Study quality and riskof bias were evaluated using the Critical AppraisalSkillsProgramme (CASP)tool²⁴(Table1). Twopapers wereexcludedbecauseoflowquality.

Fig.2–PRISMAflowchart.

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Table 1–Critical appraisal: critical appraisal skills programe (CASP) tool.

Valitidy - is it worth continuing?

What are the results? Will the results help locally?

Journal Author, year

CASP 1:

Clear aim statement

CASP 2:

Qualitative methodology appropriate

CASP 3 Appropriate research design to adress aims?

CASP 4:

Appropriate recruitement strategy

CASP 5:

Data collection to address research question

CASP 6:

Consideratation of releationship between researcher and participants

CASP 7:

Ethical considerations

CASP 8:

Rigorous data analysis

CASP 9:

Clear statement of findings

CASP 10: How valuable is the research

Comments

Journal of clinical nursing

Astroth et al., 2012

YES YES Yes YES Yes NO YES Yes YES Valuable findings:

addressing review question.

Cannot use the qualitative part on its own. It supplements the survey.

Excluded Americal

Journal of Critical Care

Bagshaw et al., 2010

YES Used as part of survey

Yes Yes Yes NO NO NO NO Valuable findings:

BMJ Quality and Safety

Benin et al. YES YES YES YES YES NO YES YES YES Valuable findings:

addresing review question.

The Americal Journal of Nursing

Braathen, J., 2015

YES YES YES YES YES NO Yes Yes YES Valuable findings:

Australian critical care

Curry et al., 2017

YES YES YES YES YES NO YES YES YES Valuable findings:

Journal of nursing care quality

Douglas et al., 2016

YES Yes Yes YES YES Not relevant YES No No Valuable findings:

Elliot et al., 2014

International Nursing Review

Jeddian et al.

2017

Journal of Interprofessional Care

Kitto et al., 2015

YES YES YES YES YES NO Yes No Yes Valuable findings:

Americal Journal of Critical Care

Leach LS, and Mayo AM. 2013

Social Science and Medicine

Mackintosh et al., 2014

Mackintosh et al. 2012

YES YES YES YES YES No YES YES YES Valuable findings:

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Table 1(continued)

Valitidy - is it worth continuing?

What are the results? Will the results help locally?

Journal Author, year

CASP 1:

Clear aim statement

CASP 2:

Qualitative methodology appropriate

CASP 3 Appropriate research design to adress aims?

CASP 4:

Appropriate recruitement strategy

CASP 5:

Data collection to address research question

CASP 6:

Consideratation of releationship between researcher and participants

CASP 7:

Ethical considerations

CASP 8:

Rigorous data analysis

CASP 9:

Clear statement of findings

CASP 10: How valuable is the research

Comments

Australian Critical Care

Massey et al., 2014.

YES YES YES YES YES YES YES YES YES Valuable findings:

Journal of Advanced Nursing

McDonnell et al. 2012

YES YES YES YES YES NO YES Yes YES Valuable findings:

Journal of Advanced Nursing

McGaghey et al., 2017

International Journal of Health Policy and Management

Rihari-Thom- as et al., 2017

Advanced Journal of Nursing

Shapiro et al., 2010

YES YES YES YES YES NO NO YES YES Valuable findings:

BMJ quality and safety

Shearer et al., 2012

YES YES YES YES NO NO Yes NO NO Valuable findings:

The quality as a qualitative paper is not suffi- cient. Excluded.

Journal of Clinical Nursing

Smith D, Aitken LM, 2015

YES YES YES YES YES NO YES Yes Yes Valuable findings:

Intensive and Critical Care Nursing

Stafseth et al., 2016

Journal of Nursing Care quality

Stewart et al., 2014

YES YES YES YES YES Yes NO YES YES Valuable findings:

Australian Critical care

Chua et al., 2019

BMC Emergency medicine

Petersen et al., 2017

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Results

We included 21 qualitative papers in thefinal review (Table 2).

Differenttermsusedtodescribetheefferentlimbwerestandardisedin thisreviewasRRT.

Categoriesandthemesthatemergedintheanalysisarepresented inTable3.Findingsconnectedtotheefferentlimbwereintertwined with the afferent limb, thus presented under the headline ‘The connection of the Afferent and Efferent limb’. Key findings are presentedinTable4.

Administrativeandqualityimprovementlimbs

The barrier of disconnected leadership and vague lines of responsibility

Theinfluenceofleadershipandvision

Organizationalleadershipsupport^14,25,26andhavingamission- drivenorganization²⁵weredescribedasessential:“Peoplewhowork inthishospitalarereallyawareofourmissionandtheyarecommitted to carefor our patientsand toour purpose” .²⁵ Conversely, poor governanceassociatedwithalackofprotocolsorequipment,poor logisticsandlackofcommitmentbyseniorstaffandmanagement wereviewedasbarriers.²⁷

Unclearprotocolswithlackofintegrationinhandoverprocesses Confusion around when to call the RRT and their optimal response^{26 33}wasafrequentlyreportedbarrier.Bycontrast,clear

call-criteria,includingtheexpectationthatwhenindoubt,acallshould bemade,wasdescribedasafacilitator.²⁹Normalizationofbreaches ofRRS-protocolduringbusyperiodswerepercievedtounderminethe system.^34,35

CooperationandpatientflowwerefacilitatedbyincorporatingRRT eventsintothehandoverprocessesanddailyuseofearlywarning scores(EWS)inunitrounds.^22,28

Inconsistenteducation

LowpriorityofeducationregardingtheRRSandmanagementof deteriorating patients^14,25,30 was a barrier while training was a facilitator,^25,27,36withanemphasisonjointtrainingsessionsbetween wardstaffandtheRRT³⁵andtheuseofsimulation-basedtraining.²⁵ TrainingintheuseofEWSasearlyasinuniversitywasdescribedasa facilitator.³⁶ Physicians worrying the system could deskill junior physicianswasabarrier,^33,37whileviewingRRTcallsaslearning opportunitieswasafacilitator.^37,38

Lackofequipment,personnelandintegrationwithotherhospital systems

HCPdescribedthattheRRSincreasedworkload,14,28,35,37,38and staffshortageswereseenasabarrier.21,27 29,31,38

Anexamplewas toofewRRTrespondents: “There isone[Registrar]inthewhole hospitalandtherecouldbesix[rapidresponse]callsatonce,andhow can they possibly get to six?”.²⁹ Nurses described applying an informaltriagewhenwardswerebusy,allowingthemtofocuson sickerpatientsandreducemonitoringofotherpatients.³⁵Notwanting todisturbabusyICU-nurseorphysician,^28,29orknowingtheICUwas

Table2–Includedpapers.

Author/

Journal

Year Title Aim/purpose Noof

participants

Location/

hospitalsize

Studydesign RRSmodel

Astrothetal./

Journalof ClinicalNursing

2013 Qualitativeexplo- rationofnurses decisionstoactivaterapidresponse teams

Toidentifybarriers andfacilitatorsto nurses'decisions regardingactiva- tionofrapidre- sponseteams (RRTs)inhospitals.

15medical/surgical nurses

Threemedial/sur- gicalunitsata Midwesterncom- munityhospi- tal.155-beds.

Qualitativedesign;

semi-structuredin- dividualinterviews.

Monitoring:

Callingcriteria,not furtherdescribed.

Response:

RRT(Rapid ResponseTeam),in- cludesICUnurses.

Beninetal./

BMJQuality andSafety

2012 Definingimpactofa rapidresponse team:qualitative studywithnurses, physiciansand hospital administrators

Toqualitativelyde- scribetheexperi- encesofand attitudesheldby nurses,physicians, administratorsand staffregarding RRTs.

49participants:

18registered nurses,8adminis- trators,6primary teamseniorat- tendingphysicians, 6housestaff members,4RRT attendingphysi- cian,4RRTcritical care(SWAT) nurses,3RRT respiratory technicians.

Yale-NewHaven Hospital-academic hospitalinCon- necticut.

944beds.

Qualitativedesign;

semi-structured interviews.

Monitoring:

Triggercriteria,ex- pectingthenurseto callRRTandprimary teamwhenpatientis triggering.Thedeci- sionscouldbemade jointly.

Response:

AdultRRTfrom2005, covering43units.

RRTcomposedof hospitalistphysician,a criticalcare"SWAT"

nurse,andarespira- torytherapist.

BraatenJ./The American Journalof Nursing

2015 Hospitalsystem barrierstorapidre- sponseteamacti- vation:acognitive workanalysis

Tousecognitive workanalysisto describefactors withinahospital systemthatshape medical-surgical nurses'RRTacti- vationbehaviour.

12participants:

medical/surgical nurses.

Medical-surgical unitsinacutecare hospital,Colorado.

500beds,non-for -profit,non-teach- inghospital.

Qualitative design:

1)Documentre- view,(RRTpolicy andprotocols) 2)Individual interviews.

Established2005:

Monitoring:

Callingcriteria Response:

RRT,withstandard- izedpolicy.Notfurther described.

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Table2(continued) Author/

Journal

participants

Location/

hospitalsize

Chuaetal./

Australian IntensiveCare

2019 Acallforbetter doctor-nursecollaboration:Aquali- tativestudyofthe experiencesofju- niordoctorsand nursesinescala- tioncarefordeteri- oratingward patients

Toexploretheex- periencesofjunior doctorsandnurses inescalatingcare forclinicallydeteri- oratingwardpa- tientsinanacute hospitalwithaMET serviceandtoun- derstandthebar- rierssurrounding theescalationof care.

24participants:

14nursesand 10juniordoctors.

1000bedacute tertiarycarepublic hospitalin Singapore.

Qualitativedesign:

Semi-structuredin- dividualinterviews.

From2009:Monitor- ing:Singleparameter MET(MedicalEmer- gencyTeam)criteria.

Includingthe“worried”

criteria.

Response:ICUbased METsystems.Ledby ICUphysician(ICU advancedtraineeor registrarinrespiratory andcriticalcaremed- icineorinternalmedi- cine)supportedby ICUnurseandare- spiratorytherapist.

Availableaccredited intensivistforimmedi- ateconsultation.Pa- tientswithabnormal vitalsignsbutnot reachingtheMETcri- teria:Nursescaniniti- ateanadhocreview byprimaryteam doctors.

Curreyetal./

Australian CriticalCare

2017 Criticalcareclini- cianperceptionsof factorsleadingto MedicalEmergen- cyTeamreview

Toexplorepercep- tionsofintensive careunit(ICU)staff whoattenddeterio- ratingacutecare wardpatientsre- gardingcurrent problems,barriers andpotentialsolu- tionstorecognising andrespondingto clinicaldeteriora- tionthatculminates inaMedicalEmer- gencyTeam review.

207respondentsin 31groupsurveys.

49%ICUnurses, 27,8%ICUeduca- torsorliaison nurses,2,1%ICU medicalregistrars, 11,9%consul- tans,7,7%nurse managers.

Participantsat- tendedthe AustraliaandNew ZealandIntensive CareSocietyRapid ResponseTeam conferenceinMel- bourne2014.

Descriptiveexplor- atorydesign:Group survey,openended questionswithwrit- tenresponses, qualitatively analysed.

Donotdescribethe differentRRSthepar- ticipantsworkwithin.

Referstotheconsen- susofaRRSwithfour limbs."Thesecompo- nentsreflecttheAus- tralianCommissionfor QualityandSafetyin Healthcare (ACSQHC)national standardforrecognis- ingandrespondingto clinicaldeteriorationin acutehealthcare".

Douglasetal./

Journalof NursingCare Quality Qualitativepart ofstudy

2016 NursingandMedi- calPerceptionsofa HospitalRapidRe- sponseSystem -NewProcessBut SameOldGame?

Toexploreand comparenursing andmedicalstaff perceptionsof MERTuseata largetertiaryhospi- talwitha matureRRS.

129participants hadopenended textcontributions- 87registrednurses and87medical staff.

929bed hospital,teaching hospital,Queens- landAustralia

Qualitativedesign:

Openendedques- tionsinsurveyis qualitatively analysed.

Monitoring:

Astandardized observationandre- sponsechart.Single- parametersystem, with2gradedre- sponse-categories, yellow:clinicalreview, orange:MERTreview.

Response:

MERT(medical emergencyresponse team):Criticalcare expertise.

Worksalongsidea codeblueteam.

Elliotetal./BMJ Qualityand Safety

2014 Clinicaluserexpe- riencesofobserva- tionandresponse charts:focusgroup findingsofusinga newformatchart

Toreportinitial clinicaluserexpe- riencesandviews followingimple- mentationoftrack andtriggerchartsin

44focusgroups with218clinical wardstaff.(mostly nurses)Whohad receivedtraining

8trialsites,acute healthcarefacilities inAustralia.

Qualitativedesign;

focus-group interviews.

Monitoring:Astan- dardizedobservation andresponsechart.

Single-parameter system,with2graded response-categories, (continuedonnextpage)

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Journal

participants

Location/

hospitalsize

incorporatinga trackandtrigger system

adultgeneralmed- ical-surgicalwards

andusedchartsfor 2-6weeks.

yellow:clinicalreview, orange:MERTreview.

Response:MERT:

Criticalcareexpertise.

Worksalongsidea codeblueteam.

Jeddianetal./

International Councilof Nurses

2017 Implementationofa criticalcareoutreachservice:a qualitativestudy

Toexplorehospital staffperceptionsof theperceivedchal- lengesandout- comesofthe implementationofa criticalcareoutreachservice

24persons:Focus groupsof21partic- ipants.(2homoge- nousgroupsone withCCOTonewith wardnurses)and 7individualinter- views.

Participants:

6CCOTmembers, 11wardhead nurses,5ward nurses, 2physicians.

Tertiaryteaching hospital,Iran-Te- heran.800beds.

5criticalunits:

54beds.

Qualitativedesign;

Monitoring:

CriteriaPatientcate- gorizedasbeinghigh, moderateandlowrisk byaoutreachnurse.

Response:

CCOT(criticalcare outreachteam):A supplementaryser- viceto13med-surg wards.Consistingof6 nursesfromICU- 24hourservice.Re- sponsibilityremained withtheadmitting physician.

Kittoetal./

Journalof

InterprofessionalCare

2014 Rapidresponse systemsandcol- lective(in)competence:An exploratoryanaly- sisofintraprofes- sionaland interprofessional activationfactors

Toexploretherea- sonswhystaff membersdonot activatetheRRS.

10focusgroups across4hospital settings.Total:27 doctors,67nurses.

Monash Australianhospital system.Infour hospitals.Totalof 2100beds.2sub- urbanhospitals, 1electivecentre, and1largeteach- inghospital

Qualitativedesign;

Monitoring:RRSCall- ingcriteria,notfurther described.

Response:RRSNo specificdescription.

Leach,Mayo/

American Journalof CriticalCare

2013 Rapidresponse teams:Qualitative analysisoftheir effectiveness.

Todescribeeffec- tivenessofrapid responseteamsin alargeteaching hospitalinCalifor- nia.

InvestigatingRRT performanceinthe contextoforgani- sationalsocial processes.

17participants:

hospitalleaders, RRTmembers, bedsidenurses, physicianleaders.

Largepublictertiary careteachinghos- pital,California

Qualitativedesign;

Semi-structuredin- dividual

interviews.

Monitoring:

Callingcriterianotde- scribed

Response:

RRT-nurse-led, includingbedside nurse,respiratory therapist,primary physicianinternand resident.

RRT-Nurseswereex- clusivelyhiredfor RRT,nootheras- signmentthatday.

RespondstoRRT calls,goroundsto identifyRRTpatients, involvedalsoincardi- opulmarrests.

Mackintosh, Humphrey, Sandall/Social Science Medicine

2014 Thehabitusof'rescue'anditssignifi- cancefor implementationof rapidresponse systemsinacute healthcare

Toexploretheso- cialandinstitution- alprocesses associatedwith thepracticeof rescue,andits implicationsforthe implementation andeffectiveness ofRapid Response Systems(RRSs) withinacute healthcare.

35participants.

doctors,ward nursesandcritical carenurses, healthcareassis- tants,safetyleads andmanagers.

TwohospitalsNHS, UK.CalledEast- wardand Westward.

Qualitativedesign:

Inidvidual interviews.

Eastward:

Monitoring:EWS (EarlyWarning Score),twowardspi- lotinganIAT(intelli- gentassessment technology)andPDA (personaldigitalas- sistants)

Response:Patients medicalteam,andon- callteam.

Westward:Monitor- ing:EWS,escalation

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Journal

participants

Location/

hospitalsize

protocol Response:CCOT from2001withcritical carenurseandphys- iotherapist.Operating ondaytime,referring toaMETwithinten- sivecarephysicianif concerned.

Mackintosh, Rainay, Sandall/BMJ Qualityand Safety

2012 Understandinghow rapidresponse systemsmayim- provesafetyforthe acutelyillpatient:

learningfromthe frontline

ToexploretheRRS usedintheman- agementofescala- tionontwolarge hospitals,under- standingwhat worksinwhatcir- cumstances- andwhy.

35participants.In- terviewsofdoctors, wardandcritical carenurses, healthcareassis- tants,safetyleads andmanagers.

TwohospitalsNHS, UK.

Called:Eastward andWestward.

Comparativecase study.Qualitative methodwithobser- vations,interviews anddataanalysis.

Focusinthisre- view:

Thesemi-struc- turedindividual interviews.

Eastward:

Monitoring:

EWS,twowards pilotinganIAT(intelli- gentassessment technology)andPDA (personaldigitalas- sistants)

Response:

Patientsmedicalteam, andon-callteam.

Westward:

Monitoring:

EWS,escalationprotocol

Response:

CCOTfrom2001with criticalcarenurseand physiotherapist.Oper- atingondaytime,re- ferringtoaMETwith intensivecarephysi- cianifconcerned.

Masseyetal./

Australian CriticalCare

2014 Nurses'perceptionsofaccessinga Medical

Emergencyteam:A qualitativestudy

Toexplorenurses' experiencesand perceptionsof usingandactivat- ingaMET,inorder tounderstandthe facilitatorsandbar- rierstonurse'suse oftheMET.

15wardnurses Publicteaching hospitalin Australia, Queensland.

Interpretivequalita- tiveapproach,in depthsemi-struc- turedinterviews.

Monitoring:

Singleparametercall- ingcriteria.

Response:

MET

Aseparatecardiac arrestteam.

McDonnel etal./Journalof Advanced Nursing

2012 Abeforeandafter studyassessingthe impactofanew modelforrecogniz- ingandresponding toearlysignsof deteriorationinan acutehospital

Toevaluatethe impactofanew modelforthede- tectionandman- agementof deterioratingpa- tientsonknowl- edgeand confidenceofnurs- ingstaffinanacute hospital.

15nurses. Districthospitalin England(550beds) -on12wards:allin- patientareas:

medicine,surgery, orthopaedics, gynaecology, strokeservices.

Apartofamixed- methodstudy:

Qualitativedesign:

Semi-structures interviews

Monitoring:

Two-tiertrackand triggersystem-allpa- tientsmonitoredusing twocharts-thenormal chart-andiftriggering- thePARchart(Patient atRiskchart).

Response:

CCOTnotfurther described.

McGeughey etal./Journalof Advanced Nursing

2017 Earlywarningsys- temsandrapidre- sponseto deterioratingpa- tientinhospital:A realistevaluation

TotesttheRapid Responseprogram theoryagainstac- tualpracticecom- ponentsoftheRRS implementedto identifythose mechanismswhich haveanimpacton thesuccessful achievementof

28participantsin individualinterview (seniormanagers, managers,junior doctors,EWSand ALERTchampions.

34participantsin focusgroupinter- views(staffnurses, studentnursesand

NorthernIreland.

2hospitals,2wards ineach:4sites-one high-risk(med)one lowrisk(surg)in eachhospital.

Qualitativedesign;

semi-structuredin- dividualinterviews andfocus-group interviews.(Partof arealistevaluation, alsoreviewingthe litteratureregarding RRS,andadocu- mentanalysis)

Monitoring:

EWS

Responseprotocols andALERTtraining- Response:

Wardphysicians/on callphysicians.

(continuedonnextpage)

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Journal

participants

Location/

hospitalsize

desiredoutcomes inpractice

healthcare assistants Petersenetal./

BMC Emergency Medicine

2017 Barriersandfacili- tatingfactorsrelat- edtouseofearly warningscore amongacutecare nurses:aqualitativestudy

Toidentifybarriers andfacilitatingfac- torsrelatedtothe useoftheEWS escalationprotocol amongnurses.

18nurses:7surgi- caland11medical.

Urbanhospitalin thecapitalregionof Copenhagen, Denmark.700bed

Qualitativedesign;

Monitoring:

EWSimplemented since2012.

Response:

From2007:METcon- stitutedofasenior registrarorstaffspe- cialistinanaesthesia andaspeciallytrained ICUnurse.Allstaff allowedtocallMET regardlessofEWS.

Rihari-Thomas etal./

International Journalof HealthPolicy and Management

2017 ClinicianPerspec- tivesofBarriersto EffectiveImple- mentationofa RapidResponse SysteminanAca- demicHealth Centre:AFocus GroupStudy

Aimedtoexplore andunderstand howdoctorsand nursesexperience thissystem,and howandnegotiate carefordeteriorat- ingpatientswithin theRRSenviron- ment:Objectives1) ascertainfactors thataffectsimple- mentationandon- goingeffectofthe RRS,andascertain clinicianspercep- tionofitsefficacy andutilitywhenthe initialtierofmedical responseisledby thepatientsadmit- tingteam.

34participants:

21physiciansand 13registered nurses

Australia,academ- ichealthcentre.

Qualitativedesign;

RRSinplacefor5 years.

Monitoring:Amulti- tieredvitalsignpa- rametertrackand triggersystem.

Response:Tier1clin- icalreview.(TheUnit RNs-performinga thoroughexam)Tier2:

RRT:inthiscase:The admittingmedical team,andoutof hours-thededicated facilityphysicians.Tier 3activateMETfrom ICU.*Tierparameter criteriacanbemodi- fiedtocreateindivid- ualpatient customisation.

Shapiroetal./

American Journalof Nursing

2010 RapidResponse TeamsSeen throughtheEyesof theNurse-How nurseswhoacti- vatesuchteams feelabouttheex- perienceandwhyit matters

Aimtoreportthe impactofrapidre- sponseteamsas seenthroughthe eyesofthenurse.

56staffnurses from18hospitalsin 13states:USA.

teachingandnon- teaching,different settings(wards)

Qualitativedesign, focusgroups

Monitoring:Objective criteria,andworried.

Response:

18hospitalswithRRT- greatvariationsinre- sponseteams.

*9hospitals-viewed hereas“earlyrobust adopters”(Hospitals wherenurseswere enthusiasticabout RRS)

*9hospitals”reluctant adopters(nursesnot enthusiasticabout RRS)".

SmithDJ, AitkenLM/

Journalof Clinical Nursing.

Qualitativepart ofstudy.

2015 Useofasinglepa- rametertrackand triggerchartandthe perceived barriersandfacili- tatorstoescalation ofadeteriorating wardpatient:

amixedmethods study.

Toexplorethebar- riersandfacilitators percievedbythe nursingstaffrelat- ingtopatient monitoring.

31participants:

11registred nurses,7prereg- istrationnurses, 13healthcareas- sistants.(from 4wards)

Tertiaryreferral hospitalwithincen- tralLondon.

Qualitativedesign, Questionnairewith openendedques- tions:qualitatively analysed(Aspartof amixedmethod study:Alsoin- cludesachartaudit, resultsguidingthe questionaire)

Monitoring:

Singleparameter trackandtrigger.

Threevitalssignsthat couldtriggerre- sponse.

Response:

CCOT(CriticalCare OutreachTeam) Stafsethetal./

Intensiveand

2016 Theexperiencesof nurses

Toexploreexperi- encesofnurses

7nurses. Qualitativedesign;

semi-structured

Monitoring:MEWS (ModifiedEarly

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fullcouldpreventnursesfromactivatingtheRRT.³⁰HCPdescribe lackingasystemtodeterminehowandwhenadditionalresources couldbe provided.³⁵Otherbarrierswerenothavinghospital-wide systems for end-of-life-care decisions and planning,^27,38 pain managementandpalliativecareservices.³⁸

Missingelectronictrackingofvital signsandnon-integrationof monitoringwithotherinfrastructurewasabarrier.²⁷Aswerepoorly designeddocumentation-charts, thesimultaneous use ofmultiple charts^27,32 and different scoring-systems within one hospital.³⁹ Unreliable, outdated,inefficient and poorlymaintained equipment hinderedtheRRS.^21,27

Thevalueofinvolvementandcontinuousfollow-up

TheinvolvementofHCPincontinuousqualityimprovementwas describedasafacilitator.²⁵Theavailabilityoftraining,followedupby localauditsandpositivewrittenresponseswereconsideredimportant componentsto succeedwiththeRRS,^29,34 aswasaprocessfor immediately addressing problems, such as the intimidation of nurses.²⁵Bycontrast,conflictwascreatedbyauditsfocusingsolely onnursingassignmentsandnotonthebehaviouroftheresponding physician.³⁴EWS-auditslosttheireffectwhenstaffdidnotreceive feedback.¹⁴

Theafferentlimb

Thebarrierofunderestimatingcomplexity

Themissinglinkbetweenmeasuringandinterpretingvitalsigns Duetohighworkload,vital-signmeasurementsweremadebythe least-qualified;health-careassistantsandstudents,^14,21,34leadingto anintervalbetweenthemeasurementsandtheirinterpretation.^21,34 Thiswasconsideredtoincreasethedistancebetweennursesand patients^14,21,34 and to reduce vital-sign monitoring to a technical task.¹⁴ Although technology was seen asa solution to facilitate monitoring,thetimespent“doingthevitals”wasalsoseenasan importantopportunitytoobserveandinteractwithpatients.³⁵

Challengesintheuseofobservationanddocumentationsystems HCP perceived track and trigger charts²⁰ and EWS^22,39 as valuable for increasing awareness about deteriorating patients, assisting physicians in prioritizing care^34,39 and to enhance intraprofessional communication.^22,36 Clearly defined documentation-chartsandprotocolsmadestaffmoreconfidentaboutseeking help.^20,32,39Wardstaffreportedusingacombinationofthecall-criteria andtheirclinicaljudgement^14,33,40:“Itshouldbeanin-handsystem, butitshouldn’tbethesystem.¹⁴Itwasafacilitatorwhennursescould Table2(continued)

Author/

Journal

participants

Location/

hospitalsize

CriticalCare Nursing

implementingthe Modifiedearly WarningScoreand a24-houron-call MobileIntensive CareNurse:An exploratorystudy

implementingand usingtheMEWS andamobileinten- sivecarenurse(24/

7-nursingsupport)

OsloUniversity Hospital,Riksho- spitalet,Norway.

focusgroup interviews.

WarningScore),Re- sponse:MICN(Mobile IntensiveCareNurse) -UsingMEWSwas voluntarily.

Stewartetal./

Journalof NursingCare Quality Qualitativepart ofstudy

2014 Evaluationofthe EffectoftheModi- fiedEarlyWarning Systemonthe Nurse-LedActiva- tionoftheRapid ResponseSystem

Toevaluatetheuse ofMEWSasa frameworkinthe decision-making- processforRRS activationby nursing.

11nursesfrom 3medical-surgical units.

Acutecarehospital inPennsylvania, 242beds

Qualitativedesign;

focusgroupinter- views.(Aspartofa mixedmethods study,alsoper- formedmedicalre- cordreview)

Monitoring:

MEWS(ModifiedEar- lyWarningScore)in- troducedin2011.

Response:

Haveanresponse team-notfurther described.

Table3–Categoriesandthemes.

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calltheRRTbasedonclinicalimpressionandconcern²⁹oriftheyfelt theprimaryphysician/on-callphysicianwasnot“doingtheirjob”,was inexperienced,⁴⁰orunavailable.29,33,37,40

The availability of real-time data via technologicalsolutions facilitatedtheRRSbyallowingdoctorstoaccesspatient’svitals fromothersites. However,this technologycouldbeabarrierif accesswascumbersomeinemergencysituations;e.g.havingto log on to a computer.³⁹ Delays of vital-signs entry into the electronic health records could delay the detection of clinical deterioration.³¹

Barriers were described in HCPs use of documentation systems,22,27,28,32forexample:chartshadincompletedatasetand incorrectlycalculatedEWS,^14,22deliberatelynotdocumentingvitalsin theelectronicmanagementsystemwhenwardswerebusy,seeing thisasonlyabureaucratictask³⁵anddocumentingalteredcall-criteria forpatientsonloosenotes.²⁸Theintroductionofachartwithranges ratherthanexactnumbersresultedindoubledocumentationornurses havingtoestimatenumberswhenspeakingwithphysicians³²posing asbarrier.

The customization by physicians of call-criteria for individual patients,wasviewedasbothafacilitatorandabarrier.19,22,28,32

One publication described how this practice had resulted in both inappropriatechanges to avoidalarmsand reluctance tochange criteriaresultinginunnecessaryactivation.²⁸

Thevalueofknowingthepatient

Continuityof careandknowingthepatient wereperceivedas importantforthedetectionofsubtlechanges.²⁰Nursesvaluedclinical intuition to monitor patients and take extra vital-signs when concerned,butresentedbeinginstructedtodoso,withoutagood reason,byjuniorphysicians.³⁵Nothavingtimeto“layeyesonthe patient”wasperceivedasabarrier.³¹HCPworriedfocusingonEWS mightmeanoverlookingcuessuchasbloodresultsandoverallclinical assessment^22,39anddeclineinpatientassessmentskills.^19,32HCP reportedthatindaytime,theypreferredtocalltheprimaryteamrather thantheRRTbecauseoftheirfamiliaritywiththepatient’scondition.⁴⁰

Thecomplexinter-professional“knotworking”process

HCPbelievingthattheRRTbroughtexpertiseandcouldexpedite transfer of patients to higher-level care and improved patient outcomes30 facilitated the RRS. However, the nature of the

detection/decision-makingprocessdifferedbetweennurses(hierar- chicalandprotocol-based)andphysicians(autonomous).19,27,33,34

The process of deciding whether to activate the RRT, were describedbyKittoetal.³³as“knotworking”;nursesandphysicians constantly collaborated vertically (with senior colleagues) and horizontally(betweennurseandphysician)toidentifytheappropriate placefortheRRT.Physicianautonomy couldbeabarriertothis process,19,28,32,34butwhennursescouldobtainhelpwithoutseeking permission,theRRSwasdescribedasempowering.^29,37

HCPdescribedthatcallingtheRRTcouldbeawayofrealigning theworkloadtoensurethatotherpatientswerenotneglected.^29,35,37 Nursesreportedthatknowingtheycouldgethelpfromcolleaguesto careforotherpatientswhileattendingaRRSevent,wasanimportant facilitator.^29,30

Theseverityofclinicalchange

Theperceivedseverityofapatientsclinicalconditioninfluenced thelikelihoodofaRRTactivation,withhighEWS³⁵orabrupt/serious changesbeinganacceptabletriggerforRRTcalls.^31,40Physicians describedtheRRTas“... thego-toteamtoprovideurgentdiagnosis andperiarrestresuscitation ...”BeingabletocalltheRRTwhen concernedwasdescribedasanimportantfacilitator,^22,36butsubtle clinical changes often required navigation around system obstacles.14,31,34,40 Nursesdescribedbeingafraidthepatientwas notsickenoughtorequire thecall^26,30;oftenwaitingfor“ittoget worse”,searchingforsupporttovalidateclinicaldecisions22,26,30,31or usingclosermonitoringtofindanobjectivetriggertojustifyacall.^14,31 Inthesesituations,HCPhighlightedtheimportanceofcommunica- tion,andtheabilitytoarticulatetheexactpatientproblemclearly.⁴⁰

RRSprotocolvs.reality

Confusion and lack of clarity around protocols,^27,31,32 which introduced variationsinresponse behaviour,³⁹was reportedasa barrier.Despitehavingatrackandtriggersystem,escalationoften wentthroughthehierarchyofthesystem.^21,40

Perceptions of the call-criteria influenced their useful- ness.14,19,26,28,30 32,35 Perceivingthemastoosensitive³⁵ ornon- specific^22,31createdalarmfatigue.^19,28,32Nursesbelievingtheycould handlethesituationthemselves,^30,31,35HCPfindingEWSandtheir ownclinicaljudgementconflicting^14,22anddisagreeingwiththeset parameters²⁶werebarriers.Onepublicationdescribedhowitwas Table4–Summarytableofkeyfindings.

RRSlimb Facilitators Barriers

Administrativeandquality improvementlimbs

Leadershipsupport Poorgovernance

Sharedmission Lackofcommitment

Involvementofhealthcareprofessionals Unclearprotocols Continuousqualityimprovement Lackofstaff Interprofessionaltraining Lackofequipment

Poorlydesignedandintegratedmonitoring-anddocumentationsystems

Afferent Knowingthepatient Highworkload

Clearlydefinedprotocols Disconnectionbetweenvital-signmeasurementsandinterpretation Empowerednursesandphysicians Theexistinghierarchy

Challengesinuseofmonitoring-anddocumentationsystems Theconnectionbetweenthe

afferentandefferentlimb

Expertise Reprimandingdownthehierarchy

Patientcenteredteamwork Waitingforthepatienttogetworse

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regardedasacceptablefornursestofalsifyobservationsiftheyfeltthe patientwasokay,toavoidhavingtoexplainwhytheydidnotreactto anabnormalparameter.³²Omissionofmonitoringatnightbecauseof nursesconcernaboutsleepdeprivationwasalsoreported.³⁵ Theconnectionoftheafferentandefferentlimb

Thebarriersinlackoftrustandrespectfulbehaviour

Thelackofinterprofessionaltrustandchallengesofcollaboration MultiplepapersreportedthatwardphysiciansorRRTmembers reprimanded,criticizedorhadanegativeattitudetowardanursewho called the RRT.19,25 27,29 31,33,35,37,40 Nurses’ believed that this behaviourmightbecausedbywardphysiciansfeelingoffailureifthe nurse called the RRT directly: «going over the head of the physician”.25,29,31,37

This,provokedbyphysiciansfearofbeingseen asclinicallyinept^28,40orbeingashamedtoaskforhelp.³⁵

Juniorphysiciansdescribedfearingcriticismbyseniorstafffor activatingtheRRT,27,28,34,40andhadlearnedtheyshouldmanageon theirown.^34,40Wardnurseswerealsoconcernedaboutbeingseenas incompetentbytheRRT.^{26,29 31}PerceivingRRT-callsasafailure disruptedthecollaborationwiththeRRT.²⁵

WardnursesvaluedtheRRT-nurse,regardlessof“theirplacein theRRT” .²⁹Havingadedicatedfull-timeRRT-nurseworkingnextto theward nurses²⁵ ordoingroundson units,³¹weredescribedas facilitators.Nursesalsoreportedalowerthresholdforcallinganurse- ledRRT,thanaphysician-ledRRT.³⁶Onestudyreportedthatanurse- ledRRTsupportedjuniormedicalstaffandfacilitatedcommunication withmoreseniorstaff,³⁹butanotherreportedthatphysiciansfound nurse-ledRRTdifficulttoaccept.³⁸RRT-membersactingasmentors forwardnurses30andprovidingeducationforallwardstaff^34,37,38 facilitatedtheRRS.

Nurses were more inclined to reach out to physicians with whomtheyhadagoodrelationship,andconsideredtobeskilled.³⁵ RRT-callswerefacilitatedbysupportive,professionalandcaring RRT-members,^30,35,36 who confirmed the nurses’findings, and gavepositivefeedback.^29,36 Conversely, differing taskpriorities between the RRT and the ward nurses were described as barriers.³⁸

Familiarity within the RRT and between RRT-members and ward staff was reported to enhance teamwork, especially under time-pressure.²⁵ However, rotation and varied positions of ward physicians made it difficult for the RRT to establish effective relationships.³⁸

Douglasetal.¹⁹statedthattheeffectivenessofanRRTwas

“dependingentirelyonthepeoplewithintheteamonthatparticular day” .Akeyfactorintheeffectivenessoftheefferentlimb, was reported to be the clinical expertise and crisis management skills. An RRT leader that managed to be “an information gathererandwillingtohaveadialogue” ,facilitatedthefunctionof theRRT.²⁵Bycontrast,alackofclearleadershipcouldresultin chaos.²⁶

Whenjuniordoctorswerethefirsttierofresponse,theyreported feelingoutof depthandanxious,²⁸and nursesrarelyfoundtheir contributions helpful.³⁵ The RRS effectiveness was further compromisedifthejuniordoctorsonlyreluctantlyalertedthenext tier(moreseniorspecialist).²⁸

Notknowingthepatient

ItwasconsideredabarriertotheefferentlimbthattheRRTlacked detailedknowledgeofthepatient’smedicalhistory.^28,37,40

Discussion

Inthissystematicreview,weexploredfacilitatorsandbarrierswithin thelimbsoftheRRSasreportedbyHCPworkingwithinthesystem.

Majorfindings

AmajorbarriertosucceedwithaRRSseemstobethedisconnection of the administrative and quality improvement limbs from the operationalafferentandefferentlimbs.Theoperationallimbsoften seem tobe left operatingon their own, dealing with inadequate monitoring and documentation systems,14,21,22,27,28,31,32,39 under- staffing21,27 29,31,38inconsistentRRSeducation^14,25,30andunclear protocols.^27,31,32

Ouranalysisfurtherpresentsthecomplexityofoperatingwithin and between the operational limbs. HCPs interpretation of and confidenceinthecall-criteria14,19,22,28,30 32andalarmfatigue^19,28,32 are barriers tobe taken seriously. Interestingly,thepossibility of customizingthecall-criteriaforanindividualpatientwasdescribedas bothafacilitatorandabarrier,perhapsunderliningthecomplexity of thisprocess.19,22,28,32 Ourfindings implythatit isimportantto incorporateclinicaljudgementasavalidcall-criterionforbothnurses anddoctors.14,19,22,28

Lackofinter-professionaltrustmaybeoneofthecorebarrierfor succeeding with a RRS. HCP rapport being criticized and reprimandedwhentryingtofollowthepatient-centeredintentionof the RRS.19,25 31,33,34,37 The conflicts between nurses and ward physicians regarding alerting the RRT seem to be enhanced in protocolswhereRRTisexpectedtobealerteddirectly,bypassingthe wardphysician.25,29,31,37

InvolvementofthewardphysicianinRRT callsmightreduceconflictandfacilitateRRTactivation.Itmightalso counteractthebarrierofphysiciansfearingthattheRRTwillinterfere with treatment despitebeingunfamiliarwith thepatient`smedical history.^28,37,40

TheRRTstructureinthereviewedpapersvariesgreatly(Table4).

This review highlights the importance of the members` clinical expertise and ability to work together for the patient^25,28 and a belief in inter-professional training and education to improve collaboration.^25,36

Comparisonwithpreviousstudies

Incomplete implementationand sustainability of RRS remains a major issue.^13,41In this review the barriersfor activationof the efferentlimbwerefrequentandinlinewiththefindingdescribedby Chua etal.⁴² Byusing theRRSmodel(Fig. 1)in theanalysing process, we found that root causes for major barriers and facilitators for RRS maylie within theadministrativeand quality improvementlimbs.Theimportanceofleadership,forsuccessful system-wide implementation implies the involvement and align- ment of leaders on all levels.^43,44 Disconnected leadership has beenidentifiedbeasignificantfactorinhealth-careorganizations strugglingtoimprovequality.⁴⁵Jonesetal.⁴⁶emphasisedthatan RRS needs tobe partofthe hospitalsoverall plan.A varietyof approaches is available to assist the process of achieving successful implementation.^47,48 Successful systems engage in qualityimprovementwhichrequirecommitment,focusongoalsas wellasonprocess,usingdatameasurementandfeedback.²

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Regarding activation of the RRT, alarm fatigue is a known barrier.⁴¹Douglasetal.¹⁹foundthatincreasedfamiliarity,agreement, andperceivedbenefitofactivation-criteriaincreasesthefrequencyof RRTactivation. Theongoingdevelopment of avalidated scoring systemsuchasNationalEarlyWarningScore(NEWS),⁴⁹mighthelp toovercomethesebarriers.Thevalueofinvolvingtheprimaryteamin RRT-calls^50,51hasalsobeendemonstrated.

Previousresearchhashighlightedinter-professionalsimulation- basedtrainingasatooltoimprovebothtechnicalandnon-technical skills.⁵² Increased use of this approach might enhance the effectivenessofRRTincaringfordeterioratingpatientsandbreaking downsilosbetweenRRTandwardpersonnel.

Byincreasingtheconfidenceandknowledgeofnursingstaff,training improvestheir abilitytodetectandhandleclinicaldeterioration.⁵³Wehbe- Janeketal.⁵⁴suggestedthatasimulation-basedtrainingprogramcould overcomesystembarriersandaugmenttheuseofRRT.Theilenetal.⁵⁵ demonstratedthatregularin-situsimulationtrainingofapaediatricRRT ledtosustainedimprovement.

ARRSisahospital-wideinterventionwithmanyinterdependent partsandrequiresacomplexchainofeventstooccurinatimely progression.

The health-care system is rapidly developing, continuously educatingandemployingnewstaff,integratingnewtechnologyand providingadvancedcareforpatientswithcomplexconditions.Itis importanttobeawarethat“Anychangeinaworksystemelement interact andproduces changeselsewhere in thework system”.⁵⁶ TechnologicalsolutionstopatientmonitoringthatalertstaffandRRS- personnelofdeterioratingpatients,^{57 60}couldfacilitateafferentlimb, buttheirintegrationshouldbecarefullytestedinclinicalpractice.

WebelieveinincreasedinvolvementofHCPinthecontinuous follow-uponresultsandtheprocesswithinandbetweenthelimbsof RRS. We suggest focus on inter-professional simulation-based trainingtoimprovecommunicationandcollaboration.

Areasforfutureresearch

TofindthekeystosucceedwithaRRS,researchshouldstudythe barriers and facilitators within the administrative and quality improvementlimbs,astheyshouldhavethepowerandbudgetto provideasolidfoundationfortheoperationallimbs.

Continuouslyconnectedandinvolvedadministrativeandquality- improvementlimbsareessentialtoensuretheeffectivenessofthe operationallimbs.^14,25,26Thisworkcannotbecompletedbyasetdate;

itisanever-endingprocess.

Strengthsandlimitations

Thestrengthsofthissystematic reviewareitspresentationofthe perspectivesoftheHCPoperatingtheRRS.Itincludespapersfrom 10 differentnations, more than20 hospital-systems anddifferent professions,levelsofexperienceandRRSstructures,thusprovidinga broadpictureoffacilitatorsofandbarrierstocurrentRRS.Although thereisgreatvariationbetweenhealth-caresystems,weidentified several common facilitators and barriers, which increases the transferabilityoftheanalysis.

Althoughtheliteraturesearchaimedtobebroad,thechoiceof search terms might have failedto identify paperswith important additionalinsights.Becausethestudiesincludedinthereviewwere interview-based,sampledpurposivelyorbyconvenienceandalways voluntary,inclusionbiasmaybeanissue.Asevidentfromthecritical

appraisal(Table2),mostresearchersdonotadequatelyconsider theirrelationshipwiththeparticipants.Thisisaweakness,because the resultsof interviewsare influenced bythemoderator.Ethical considerations were handled differently in the studies, reflecting differentcountriesandregionswithdifferentrulesandregulations.

Conclusion

In this systematicreview,we explored facilitatorsandbarriers, as describedbyHCP,withinalllimbsoftheRRSandtheirinterconnec- tions.ThekeystosucceedwithRRSseemtolieintheadministrative andqualityimprovementlimbs.Clearleadership,theavailabilityof consistent educationandtraining, equipment,personneland clear protocolswereessentialfortheoperationallimbs.Further,wefound thatcontinuousworktomitigatebarriersandimprovethesystemwasof key importance. We suggest increased use of interprofessional simulation-based training toincrease technicalandnon- technical skills,establishinter-professionaltrustandbuildsupportfortheRRS.

Hospitalenvironmentschangecontinuouslywiththeemploymentof new staff, integration of new technology, and provision of more advanced care. Thus, to succeed with aRRS is anever-endingprocess.

Conflict of interests

None.

Acknowledgements

Funding:UniversityofStavangerResearchFund,SaferHealthcare Grant.

ThesearchstrategywasassistedbyanExpertlibrarian,Elisabeth HundstadMolland,UniversityofStavanger,Norway.

TosecurecorrectEnglishspellingandgrammar,themanuscript hasbeenedited,usingOnlineEnglisheditingservices(www.oleng.

com.au),expensescoveredbytheSaferHealthcareGrant.

Appendix A. Supplementary data

Supplementarymaterialrelatedtothisarticlecanbefound,intheonline version,atdoi:https://doi.org/10.1016/j.resuscitation.2019.08.034.

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