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A7659 - Cracking the Escalation Riddle: Root-Causes for the Rapid Response Team Activation Afferent Limb Failures. A Prospective, Semi-Qualitative Study
Author Block: M. G. Kashiouris1, J. Tormey2, S. Lubin2, N. Appelbaum3, P. Mazmanian3, S. Pedram1, C. N. Sessler1; 1Pulmonary and Critical Care, Virginia Commonwealth University, Richmond, VA, United States, 2Rapid Response System, Virginia Commonwealth University, Richmond, VA, United States, 3Office of Assessment and Evaluation Studies, Virginia Commonwealth University, Richmond, VA, United States.
Rationale: Rapid Response System (RRS) escalation failures, also known as Afferent Limb Failures (ALFs) are recognized systematic dysfunctions, which result in delays, or failure to rescue critically ill patients outside the intensive care unit. A thorough exploration of the ALF phenomenon has been challenging because of the multiple types of bias among other factors. In the MERIT trial, ALF was prevalent in approximately 50% of the patients who experienced cardiac arrest and who had prior met the activation criteria. Traditional intervention trials would have been unacceptable if a large proportion of the enrolled patients at risk received no, or delayed “treatment.” The present study set out to explore the riddle of delayed, or lack of escalation to the RRS.
Methods: In this prospective, semi-qualitative study we employed a real-time algorithm to identify patients who met the RRS activation criteria, by utilizing an electronic dashboard of the Early Warning Score (EWS) vital sign trigger criteria combined. Subsequently, we identified the patients’ nurses and conducted a structured algorithmic script interview, which explored several domains including behavioral, educational, environmental (physical and electronic), cultural and heuristics.
Results: We enrolled 144 patients, with nurses who did not activate RRS, despite the clear criteria. Most of the nurses knew that the patient met the RRS triggers (94.0%). A small percentage (6%) did not know that their patient met the RRS triggers; none of those nurses considered activating the RRS. Among the nurses who knew the triggers, 83.7% considered calling - but did not call, and 16.3% did not consider - and did not call. The majority of the nurses who considered calling - but did not call reported that they had enough support (62.1%), followed by that they had paged the and waited for response (17.2%), and the belief that the RRS was not the appropriate team for the patient’s active problem (10.3%). The average reported waiting time for the team to respond was 15.8 minutes. Approximately 7% of the nurses who considered calling, but did not call, reported intimidation by the physician staff as the reason for not activating the RRS.
Conclusion: Our study shows that the phenomenon of escalation failure is common, complex and multifactorial. It includes lack of education, systems failures, false-reassurances by non-critical care teams and cultural norms. Interestingly, the phenomenon of healthcare bullying did not appear not to be uncommon, even in the setting of clinically deteriorating patients.