Failure of bedside hospital clinical staff to follow established treatment protocols has been identified as a common factor in patients having an adverse event during their hospitalisation. Post hoc analysis1
of the data from the Australian Quality and Health Care Study (AQHCS)2
found that ‘that misapplication of, or failure to apply a rule; or use of a bad or inadequate rule’ and ‘violation of a protocol or rule’ together occurred in 13.6% of the adverse events identified in the AQHCS. These two iterative categories of adverse event causation were associated with death or permanent disability in 26% and 28% respectively of adverse events identified in the AQHCS. Of most concern, the authors rated the degree of preventability of these two causation categories at 90% and 80% respectively based on the actual adverse events in the AQHCS. Likewise, a number of smaller mostly retrospective single institution studies have found various associations between failure to follow established treatment protocols and guidelines for clinically deteriorating patients and increased mortality.3–7
One strategy to counter the problem of in-hospital adverse events has been the use of the rapid response system (RRS) to manage clinically deteriorating patients. In essence a RRS has two essential components: first an afferent arm that is a system of rules that determine the criteria for activation of the rapid response team; and second, the efferent arm which is the system of response once the activation criteria are breached. Varying types of RRS are now common in many European, North American and Australasian hospitals.8
In its simplest form a RRS is merely a rule or protocol that requires the bedside clinical staff to comply with the critical requirement of activating the RRS for it to be of benefit.10
In the Medical Emergency Response Intervention Trial (MERIT).11
there was a significant rate of failure to activate such a system in the control and intervention hospitals that may have contributed to the equivocal results of the study. Specifically, in the 11 control hospitals over the 6-month study there were 246 cardiac arrests. In 44% of these arrests the bedside staff did not activate an emergency response despite the observations fulfilling the response criteria for an emergency team call. Similarly, of the 12 hospitals assigned to the RRS intervention, there was still a failure rate of 30% to activate the RRS in the 250 cardiac arrests that occurred.
Anecdotally, failure to activate the RRS has been thought to be associated with inadequate education about recognition of clinically deteriorating patients or insufficient knowledge of the RRS. In support of this is a post hoc analysis of the MERIT data12
that indicates an inverse relationship between the frequency of emergency response team calls (in the control and intervention hospitals) and the primary outcome measures of cardiac arrest, critical unit admission and hospital mortality. Similarly, Santamaria et al13
reported data from one of the intervention hospitals of the MERIT study 5 years after the study suggesting that an intervention like a RRS takes years not months to derive benefits. Theoretically then, the rate of RRS activation should be high in a system where it has been in place for many years and the clinical staff have adequate training.
In 2007 the Quality and Safety Unit, Southern Health, Melbourne identified 11 sentinel cases in which significant patient harm occurred in association with the failure of bedside staff to call the medical emergency team. This was despite the fact that our organisation had a mature policy and procedure in place for the activation of the RRS that has been well established with an organisational commitment to its use.14
Attempts to rationalise and pattern-match the underlying features of these incidents using clinical reviews and root cause analyses were unsuccessful. There appeared to be no obvious cause in terms of poor staff training, lack of motivation or understanding of the patients' clinical states.16
While previous studies17–21
have documented the incidence of failure of bedside clinical staff to activate an emergency response team, to our knowledge no study has investigated the reasons why staff do not activate the RRS. As such, we undertook a multi-method examination to determine the incidence of clinical staff failing to call the RRS and the human and sociological factors that may be involved.