| Astroth et al. [48] |
To identify barriers and facilitators to nurses’ decisions regarding activation of RRTs |
US, community hospital |
NS |
Sample: Convenience sampling; registered nurses (n = 15) Data collection: Individual semi-structured interviews Data analysis: Concept thematic analysis |
Facilitators:
Barriers:
Condescension in tone of RRT members Fear of appearing ‘dumb’ to RRT members especially among less experienced nurses Belief that nurses should call attending physicians first Experienced nurses confident of managing deterioration themselves Unstandardized RRT education and no follow-up or reinforcement Unclear about hospital’s RRT policy and their role in the process
|
High |
| Bagshaw et al. [49] |
To evaluate nurses’ beliefs and behaviors about the MET system. |
Canada, teaching hospital |
3 |
Sample: Convenience sampling; registered nurses & licensed practical nurses working in general acute units (n = 293) (Response rate: 93.9%) Data collection: Cross-sectional survey with open-ended questions Survey tool adopted from Jones et al. [37] Data analysis: Descriptive statistics; content analysis for open-ended comments |
75.9% of respondents would call attending physician before activating the MET and 10.1% would not activate the MET if unable to contact & notify the attending physician about a change in patient’s condition 15.4% of respondents indicated reluctance to activate the MET because of fear of criticism 48% indicated they would activate MET for a patient they were worried about, but has otherwise normal vital signs Comments:
Conflicting opinions among healthcare professionals about how to manage patients once the MET had been activated Anecdotes of criticism and concern about how the MET was activated and the role of the unit nurse during MET activation
|
Medium |
| Benin et al. [50] |
To qualitatively describe the experiences of and attitudes held by nurses, physicians, administrators and staff regarding RRT |
US, teaching hospital |
3 |
Sample: Purposive sampling; registered nurses (n = 18), administrators (n = 8), senior physicians (n = 6), house officers (n = 6), RRT physicians (n = 4), RRT nurses (n = 4), RRT respiratory therapists (n = 3) Data collection: Individual semi-structured interviews Data analysis: Thematic & constant comparative analysis following grounded theory approach |
Nurses viewed RRT as a solution to pre-existing problems e.g. not getting a satisfactory outcome/response from house staff RRS activation enables real-time redistribution of workload for nurses and physicians. It also reduces neglect of non-acutely ill patients during emergencies Some primary team physicians discouraged the nurse from calling an RRT regardless of the severity of the situation. They felt that they are better suited in caring the patient Perception by physicians that a call to RRT implied a failure on the part of physician and detriment to education of house officers due to inadequate exposure to decision-making process Some participants feel that RRS activation could result in errors, disjointed care and delay due to lack of continuity as RRT members were unfamiliar with patient’s medical history and condition Need to have clear RRS protocols stating individual role and responsibilities |
High |
| Braaten [51] |
Using cognitive work analysis to describe factors within a hospital system that shaped medical-surgical nurses’ RRT activation behavior |
US, acute care hospital |
7 |
Sample: Purposive sampling; nurses (n = 12) Data collection: Individual semi-structured interview using cognitive work analysis framework & document review of RRT policy and protocols Data analysis: Content analysis |
RRT activation requires justification especially for subtle/gradual clinical changes which can lead to delay activation, i.e. increasing monitoring, waiting for bigger change to occur, waiting for higher level consult, or trying available interventions Justification requires increase competencies e.g. deciding the need for increased observation, apply clinical reasoning, reliance on one’s experience, junior nurse consulting experienced nurse while experienced nurse consulting a peer prior to activation and articulate the reasons for RRT call Scarcity of staff/staffing level to closely observe or perform physical assessment for patients with subtle changes Activation criteria were seen as nonspecific to diff medical condition RRT as last resort when there is no response from physician or no patient improvement Expectation that nurses should first try to ‘handle’ the situation Limitations of electronic monitoring equipment |
Medium |
| Butcher et al. [52] |
To determine whether resident physicians perceive education benefit from collaboration with RRT and the impact of RRT on their clinical autonomy |
US, acute tertiary hospitals |
7 |
Sample: Convenience sampling; physicians (n = 236) (Response rate: 72%) Data collection: Cross-sectional survey Survey tool developed and piloted Data analysis: Descriptive statistics |
78% of the residents agreed that working with the RRT is a valuable educational experience 76% of the residents disagreed that RRT decreased their clinical autonomy The majority of resident physicians perceive educational benefit from interaction with the RRT, though this benefit is greater for less experienced residents |
Medium |
| Cioffi [53] |
To explore the experiences of nurses calling the MET to ward patients who require early medical interventions |
Australia, acute tertiary hospital |
NS |
Sample: Purposive sampling; registered nurses (n = 32) with ≥5 years of nursing experience Data collection: Individual unstructured interviews Data analysis: Thematic analysis |
A gut feeling, knowing the patient and past experiences with similar patients were involved in the recognition of deterioration Nurses’ decision to call the MET was made in conditions of uncertainty: mainly being unsure if the patient met the MET criteria, questioned themselves whether they were doing the ‘right thing’ calling the MET, do not know what will be expected of them when the MET arrives Less experienced nurses sought the opinions of more experienced nurses while experience nurses conferred with their peers. Decision to call the MET was also influenced by the ability of staff to support the patient or primary team physicians to support the deteriorating patient and effectiveness of team’s management RRS activation were made more frequently during night shift and on weekends as they were fewer physicians on duty to offer medical help to deteriorating ward patients and to reduce neglect of other non-acutely ill patients during emergencies |
Medium |
| Cioffi [54] |
To investigate nurses’ use of past experiences in the decision-making process to call the MET |
Australia, acute tertiary hospital |
NS |
Sample: Purposive sampling; registered nurses (n = 32) with ≥5 years of nursing experience Data collection: Individual unstructured interviews Data analysis: Thematic analysis |
63% of the nurses described using their past experiences in the decision-making process to call the MET. However, 37% of them did not overtly refer to past experiences in their accounts of calling the MET Nurses most commonly described recognizing a similarity between the present patient’s condition/situation and a group of patients they had cared for with this presenting condition/situation. The use of experience in this manner was often related to a group of patients who were exhibiting a nonspecific state of unwell or ‘just not being right’ |
High |
| Cretikos et al. [55] |
To measure the process of the implementation of the MET system and to identify factors associated with the level of MET utilization |
Australia, acute tertiary hospitals (n = 12) |
½ |
Sample: Convenience sampling; nurses at initial point (n = 708) (Response rate: 41%), nurses at follow-up point (n = 781) (Response rate: 47%), Data collection: Longitudinal survey with open-ended questions Initial survey: 4 month post implementation Follow-up survey: 6 month post implementation Survey tool developed and piloted Data analysis: Descriptive statistics, correlational analysis; content analysis for open-ended comments |
Nurses who had attended MET education session had a significantly greater intention to call the MET (87.0% vs. 72.9%, P < 0.001), significantly more positive attitude to the MET than those who had not attended (91.5% vs. 78.5%, P < 0.001) and correctly identified more of the MET activation criteria than those who had not attended a session (5 versus 4 out of 6, P < 0.001) Nurses who were more senior indicated a significantly greater intention to call the MET than more junior nurses (P < 0.001) This measure of MET system utilization varied significantly across the 12 hospitals (P = 0.002), and was significantly associated with knowledge of the activation criteria (P = 0.048), understanding the purpose of the MET system (P = 0.01), perceptions of the hospital’s readiness for a change in the way care was provided (P = 0.004), and an overall positive attitude to the MET system (P = 0.003) Negative comments typically expressed concern about the appropriateness of activating the MET system in certain specialist areas of hospital; rude and condescending behavior/ attitude of MET team towards staff who had called the team |
Medium |
| Davies et al. [56] |
To identify and assess the types and prevalence of barriers associated to the activation of the RRS by clinical staff |
US, community hospital |
NS |
Sample: Convenience sampling; physicians (n = 68), registered nurses (n = 16) from medical & surgical wards (Respond rate: 59% for physicians and 35% for nurses) Data collection: Cross-sectional survey Survey tool adapted from 2 previously validated surveys Data analysis: Descriptive statistics, logistic regression |
Self-reported adherence rate was ≤25% for the 6 activation criteria Respondents were most familiar with mental status change criteria (76.2%) and least familiar with ‘Not looking right’ (65.5%) 65% of respondents felt that they had not been trained to an adequate level on RRS despite the existence of education and in-service training (lectures, posters & orientation sessions) to reinforce on the RRS system As familiarity with, agreement with, and perceived benefit of activating the RRS increases, the self-reported adherence to the activation criteria also increases significantly (0.001 < P < 0.05) |
Medium |
| Donohue and Endacott [57] |
To examine ward nurses and critical care outreach team perceptions of the management of patients who deteriorate in acute wards |
UK, acute tertiary hospital |
NS |
Sample: Purposive sampling; nurses (n = 11) & outreach team members (n = 3) Data collection: Individual semi-structured interviews using critical incident techniques Data analysis: Thematic analysis |
The outreach team was perceived by ward staff as calming and reassuring to the team and patient, and providing support, knowledge and skills When assessing the patient visually, nurses compared the patient’s condition across time MEWS was unreliable especially when used on chronically ill patients Some nurses indicated the need to ensure they have convincing evidence of patient’s condition prior to contacting the outreach team Medical help is sought through a clear hierarchy where the call went from the RN to the junior physician, who then contacted the outreach team or after notifying more senior medical help. In some instances, junior physicians were often reluctant to seek more senior advice which frustrates nurses |
Medium |
| Douglas et al. [21] |
To explore and compare nursing and medical staff's perceptions of Medical Emergency Response Team (MERT) use |
Australia, tertiary hospital |
NS |
Sample: Convenience sampling; registered nurses (n = 434), medical staff (n = 190) (Response rate: 29.8%) Data collection: Cross-sectional survey with open-ended questions Survey tool adopted from Australian Commission on Safety and Quality in Health care Data analysis: Descriptive statistics, fisher exact tests, using analysis of covariance, adjusting for years of clinical experience Constructivist methodology for analysis of open-ended text |
RNs held a stronger belief than medical staff in disagreeing that MERT reduced their skills in managing sick patients (P = 0.04) >70% of staff would contact the patient’s treating physician before activating the MERT, but found more prevalent among medical staff (P < 0.01) 55.7% of RNs and 55.8% medical staff were uncertain or disagreed that they would activate the MERT for a patient using the ‘worried’ criteria if the patient’s vital signs were normal. 34.2% of medical respondents and 20% of RNs agreed they would not trigger a MERT if a patient met the activation criteria but did not look unwell 17.1% of RNs and 7.9% medical staff were reluctant to activate the MERT because they feared criticism for unnecessary activations RNs perceived greater support from ward nurses (P < 0.01) and senior nurses (P < 0.01) to activate MERT than medical staffs Open-ended text comments:
|
Medium |
| Green and Allison [58] |
To explore nursing and medical staff’s perceptions, attitudes, perceived understanding of a clinical marker referral tool implemented to assist in early identification and referral of unstable patients in the general wards |
Australia, tertiary hospital |
<½ |
Sample: Convenience sampling; nurses & junior medical staff (n = 168) (Response rate: 42.3%), residents/registrars (n = 7) (Response rate: 8.2%), ICU registrars (n = 3) (Response rate: 33.3%) Data collection: Cross-sectional survey with open-ended questions Survey tool developed and piloted Data analysis: Descriptive statistics content analysis for open-ended question |
Respondents were generally positive to the clinical marker project/tool, offering clear guidelines for staff to respond to patient’s clinical condition, and contact the medical staff and the ICU liaison team as appropriate. Only 49.2% of ward medical staff agreed that the clinical markers identified patients at risk of further deterioration, whereas 28.8% indicated that they were unsure Some ward medical and nursing staff had reservations with the clinical markers chosen (some of the criteria could be normal parameters in some cases) 74% of nurses and 85.6% of ward medical staff requested further education about clinical marker project |
Medium |
| Jenkins et al. [59] |
To explore the non-ICU nurses’ perceptions of facilitators and barriers to RRT activation |
US, community hospital |
9 |
Sample: Convenience sampling; non-ICU nurses (n = 50) Data collection: Cross-sectional survey Survey tool developed and content validated Data analysis: Descriptive statistics, bivariate correlations |
Bivariate correlation analysis showed that older (r = 0.330, P = 0.02) and more experienced nurses (r = 0.350, P = 0.014) were more likely to call RRTs. 92% indicated receiving strong support from nursing leaders and colleagues in activating the RRT and 95% indicated they could rely on their peers to help them with other duties during the call. 18% believed that they would not be treated with respect and 14–16% expected that the responding ICU nurse would complain, be condescending, or would think the call was unnecessary 14% were unfamiliar with RRT protocols and 12% were unfamiliar with their role during the call 50% believed inadequate continuing RRT education: 40% noted that they had not participated in RRT education for >12 months, and 42% indicated that they had never received any education on RRT |
Medium |
| Jones et al. [37] |
To assess whether nurses value the MET service and to determine whether barriers to calling MET exist |
Australia, acute tertiary hospital |
4 |
Sample: Convenience sampling; ward nurses (n = 351) (response rate 100%) Data collection: Cross-sectional survey using personal interview approach Survey tool developed and piloted Data analysis: Descriptive statistics |
Nurses value and appreciate the potential benefit of MET Major barrier to calling MET appears to be allegiance to the traditional approach of initially calling parent medical unit doctors 72% of nurses indicated that they would call the covering doctor before the MET for a sick ward patient 56% suggested that they would make a MET call for a patient they were worried about even if patient’s vital signs were normal |
Medium |
| Kitto et al. [38] |
To examine medical and nursing staff members’ experiences of the RRS and to explore social, professional and cultural factors that mediate RRS usage |
Australia, mixed settings (n = 4) |
NS |
Sample: Criterion & maximum variation sampling; nurses (n = 62), doctors (n = 27) Data collection: Exploratory case study approach using multiple case analysis using Focus group discussions (n = 10) Data analysis: Conventional content analysis & complementary directed content analysis |
RRS seen as nursing ‘work-around’ strategy Junior nurses seek the guidance & experiential knowledge of senior nurses when deciding whether or not to activate RRS Doctors have the authority to modify RRS criteria Instances where missed RRS calls: ward staff accessed local support without activating the system; intimidated by the potential negative repercussion by the RRT for ‘incorrect’ call Reasons for not activating RRS: RRS activation was potentially a show of incompetence by junior physicians and from a senior physicians’ point of view as deskilling of junior physicians, potentially taking out their decision-making opportunities and taking away essential learning opportunities to make difficult decisions |
Medium |
| Leach et al. [60] |
To investigate how RNs rescue patients in hospitals where RRTs are in place and to understand the processes involved in making the decision to call the RRT |
US, acute hospitals (n = 6) |
NS |
Sample: Purposive sampling; bedside RNs (n = 14), RRT RNs (n = 16), RRT respiratory therapists (n = 2), nurses supervisors (n = 18) Data collection: Individual semi-structured interviews Data analysis: Thematic & constant comparative analysis following grounded theory approach |
Bedside RNs use their knowledge of the RRT trigger protocol, knowledge of subjective cues, interpretation of data and clinical experience to make a thought decision to call the RRT After which, some RNs would sought consultation with other RNs to get support and affirmation that there was a need for help before enacting the decision to call the RRT RRT RNs and bedside RNs support one another in a synergistic way to prevent adverse patient events during the rescuing process, whereby RRT RNs enables immediate access to resources and applied their expertise with critically ill patients, while bedside RNs brought patient information to the situation In some cases, traditional hierarchies and relationships with physicians and supervisors impede some components of RN decision-making during rescuing |
Medium |
| Massey et al. [61] |
To explore nurses’ experiences of using and activating a MET, and to understand facilitators and barriers to nurses’ use of the MET |
Australia, teaching hospital |
NS |
Sample: Consecutive sampling; registered nurses (n = 15) from 5 medical wards Data collection: Individual semi-structured interviews Data analysis: Inductive thematic analysis |
Nurses appear to prefer to access help or support from among their team (consult their peers or more senior nurses) and ‘use the home team’ rather than the MET as a last resort, i.e. when the patient suffered from a cardiac arrest Nurses would decide if patient could ‘hang on a few more minutes’ Resisting and hesitating calling a MET due to the fear of ‘being reprimanded’, ‘scared of the MET’, ‘looking like an idiot’ or ‘being told off’; previous experience of being reprimanded by members of MET during previous call. Fear of reprisals for incorrect activation was related to clinical inexperience and uncertainty whether a RRT was warranted |
High |
| Pantazpoulos et al. [62] |
To evaluate the relationship between nurse demographics and correct identification of clinical situations warranting specific nursing actions, including MET activation |
Greece, tertiary hospital |
NS |
Sample: Random sampling; medical-surgical nurses (n = 94) (Response rate of 62%) Data collection: Cross-sectional survey Survey tool developed and content validated Data analysis: Descriptive statistics, Mann-Whitney test, Pearson’s chi-square test and fisher’s exact test |
Participants who had graduated from a four-year educational program could identify more accurately clinical situations that necessitated MET activation (P = 0.031) and achieved a significantly higher score in theoretical knowledge questions (M = 4.0, SD = 1.7 vs M = 1.7, SD = 1.3, P = 0.002). Contribution of working experience is limited. Nurses with only a few years of service time recognize patient’s life-threatening situations and act in the same way as experienced nurses (88.9% vs. 52.6%, P = 0.008) |
Medium |
| Pattison and Eastham [63] |
To explore referrals to CCOT, the associate factors around patient management and survival to discharge, and the qualitative exploration of CCOT referral characteristics |
UK, specialist hospital |
NS |
Sample: 407 episodes of CCOT referrals from 20 ward areas; Theoretical sampling of nurses (n = 7) & doctors (n = 2) Data collection: Phase 1: Medical record reviews Phase 2: Loosely structured interviews Data analysis: Phase 1: Descriptive statistics Phase 2: Thematic and constant comparative analysis following grounded theory approach |
Junior nurses made fewer referrals (18/407 = 4.4%) in comparison with senior nurses (202/407 = 49.6%). Indications for referral: culmination of factors including blood results, MEWS, patients’ verbalization of unwell, patients’ appearances; reliance on gut instinct and intuition especially among senior nurses which developed with time and experience; familiarity of patients from continuous care; experience and theoretical knowledge Facilitating factors for referral: confidence to make referral decision; awareness of the significance of early referrals; outreach’s approachable style and non-critical attitude; ease of accessibility and prompt responses from outreach to expedite acute care; support from doctors to call CCOT Barriers to referral (delayed referral): misjudgment of their ability to handle patients’ condition due to over-confidence; ward busyness; slight sense of intimidation as CCOT viewed superior in knowledge; CCOT could result in increased workload which was difficult to manage with other patient workloads; source of conflict due to differing medical opinion and communication breakdown Consequences of referral: Allows for easier liaise for ward nurses with doctors regarding care; junior doctors would back away slightly from their role in the care of patient |
Medium |
| Radeschi et al. [64] |
To identify the attitudes and barriers to MET utilization among both ward nurses and physicians and to investigate whether these attitudes and barriers are influenced by participation in a specific educational program of MET |
Italy, mixed settings (n = 10) |
NS |
Sample: Convenience sampling; nurses (1278), physicians (n = 534) (Response rate: 79.6%) Data collection: Cross-sectional survey Survey tool modified from Jones et al. Data analysis: Descriptive statistics, chi-square test, logistic regression adjusting for profession |
Only 54% respondents agreed that the METal course significantly improved their skills in managing unstable patients in the ward Major barrier to MET activation: nurses referral to the covering physician instead of the MET for deteriorating patient (62%), although significantly lesser among the more experienced (OR = 0.69 [95% CI:0.47–0.99, 0.05 > P > 0.01]) or a METal certification (OR = 0.6 [95% CI: 0.46–0.79, P < 0.001]) Other important barriers: reluctance to call the MET in a patient fulfilling the calling criteria (21%), although was less likely to occur in physicians vs. nurses (OR = 0.65 [95% CI: 0.5–0.85, 0.01 > P > 0.001]) Only 5% of respondents were reluctant to call the MET because of the fear of being criticized for not caring for their patients well and 12% due to having an inappropriate call (12%). Physicians more likely to perceive using of MET increase their workload when caring for sick patients (OR = 1.72 [95% CI: 1.2–2.49], 0.01 > P > 0.001) |
High |
| Robert [65] |
To explore the experiences of staff nurses using intuition in the process of activating RRT for patients being cared for in medical-surgical and telemetry units. |
US, acute hospital |
5 |
Sample: Theoretical and zig zag sampling; registered nurses (n = 32) Data collection: Individual semi-structured interviews using grounded theory Data analysis: Thematic & constant comparative analysis following grounded theory approach |
The decision to call the RRT is rooted in a combination of nurse’s personal knowledge of a patient, patient assessment and intuitive knowledge. Nursing intuition is rooted in the recognition of patterns among a complex combination of factual information and subjective inferences collected from the patient Having collected and interpreted the assessment data, the decision to activate the RRT is moderated by emotional (e.g. concern, worry, anxiety, stress, repeatedly returning to check the patient’s conditions) and physiological reactions (e.g. adrenalin, knot in stomach), collaboration with others (e.g. more experienced nurses to obtain advice about whether or not to activate the RRT), education, and historical experience (particularly the number of previous times the nurse has activated the RRT) |
High |
| Salamonson et al. [66] |
To explore nurses’ satisfaction with the MET, perceived benefits and suggestions for improvement, and to examine the characteristics of nurses who were more likely to activate the MET |
Australia, acute hospital |
NS |
Sample: Convenience sampling; medical-surgical nurses (n = 73) (Response rate: 79%) Data collection: Cross-sectional survey with open-ended questions Survey tool developed and content validated Data analysis: Descriptive statistics; content analysis for open-ended text |
A positive significant relationship was found between years of nursing experience and MET activation (P = 0.018). Nurses who were less experienced (0–5 years) were less likely to have activated the MET than nurses who were more experienced (≥11 years) Suggestions for improvement: more education on medical emergencies for both ward and MET staff, a more positive attitude of the MET staff when summoned for ‘borderline’ cases (11% of participants) |
Medium |
| Sarani et al. [67] |
To assess the perceptions of physicians and registered nurses about the effects of a MET on patient safety and their own educational experiences |
US, acute tertiary hospital |
1 |
Sample: Convenience sampling; medical-surgical nurses (n = 414) (Response rate: 83%), Physicians from internal medicine & general surgery (n = 103) (Response rate: 67%) Data collection: Cross-sectional survey Survey tool reviewed Data analysis: Descriptive statistics, Mann–WhitneyU test, Kruskal–Wallis, multivariate regression |
Both residents and RNs agreed that the MET improved patient safety, although RNs held this belief more strongly than the residents (residents = 4.0, RNs = 4.4, P < 0.01) Residents neither agreed nor disagreed that the MET decreased their skills and educational opportunities in critical care and resuscitation, whereas, RNs disagreed with this assertion (skills: residents = 2.7, RNs = 2.1, P < 0.01; education: residents = 2.9, RNs = 2.4, P < 0.01) |
Medium |
| Schiid-Mazzoccoli et al. [68] |
To compare differences in nurse, patient and organizational characteristics in medical and surgical patients requiring a MET activation |
US, tertiary hospital |
15–17 |
Sample: Convenience sampling; 108 MET activations (51 medical patients & 57 surgical patients) Data collection: Medical record reviews Data analysis: Descriptive statistics, logistic regression model |
Of 108 event, 44% were delayed and delayed events occurred more often during the night shift (P = 0.012) There is a significant difference in MET activation associated with patient and unit type mismatch (P = 0.005) Shift and patient-unit-match were significant predictors of delays There was a 3.25 greater likelihood of delayed RRS activation occurring on night shifts (95% CI:1.34–7.9, P = 0.009) Although not statistically significant, there was a trend for more delays when more patients were assigned (4:1 = 21% vs. 6:1 = 43%, P = 0.609) |
High |
| Shapiro et al. [40] |
To described the impact of RRTs on staff nurses’ practice, perspectives, experiences and challenges when RRTs are used. |
US, mixed settings (n = 18) |
NS |
Sample: Nominated sampling; nurses (n = 56) Data collection: Focus group discussions using semi-structured guide (n = 18) Data analysis: Modified thematic & constant comparison analysis |
Three reasons for activation: (1) patient exhibited signs and symptoms significantly different from baseline; (2) gut feeling; (3) nurses convinced that the patient needed immediate evaluation but was unable to get the treating physician to respond Presence of RRT allowed primary nurse to care for other patients and families when the team was responding to the crisis Nurses from robust-adopter hospitals expressed receiving clear communication regarding RRS activation and had numerous reinforcements on RRS. They had no hesitation to call the RRT and had no fear of repercussions if the call was ultimately deemed unnecessary Nurses in reluctant-adopter hospitals (nurses hesitated to activate RRT) expressed receiving mixed messages regarding RRS activation protocol and difficulty in differentiating between situations that warrants a call to the RRT versus code blue team Some physicians insisted that nurses follow the usual chain of command no matter what. They also expressed unclear individual roles and responsibilities during a rapid response |
High |
| Shearer et al. [39] |
To determine the incidence of clinical staff failing to call the RRS and the socio-cultural barriers to failure to activate the RRS |
Australia, mixed settings (n = 4) |
3–13 |
Sample: 570 observation charts; 363 760 patient cases; purposive sampling of 91 junior physicians, nursing staff, MET members & ICU teams Data collection: Phase 1: Two part medical record reviews to determine the incidence of abnormal simple bedside observations & activation of RRS Phase 2: individual structured interviews Data analysis: Phase 1: Descriptive statistics Phase 2: Thematic analysis |
42% did not receive an appropriate clinical response from staff (missed RRS call) despite 69.2% recognizing their patient met physiological criteria for activating RRS, and being ‘quite’, or ‘very’ concerned about their patient Actions performed prior to activating RRS: awaiting further review by medical staff (51.8%); specific treatment or investigation delay activation (50.6%); involved ICU outreach (33.7%); involved senior nursing staff (12%) Main barriers: feel that they should be able to manage patients by themselves (54.2%) Insufficient ‘face validity’ in the sensitivity and specificity of RRS activation criteria: primary team was experienced and felt RRS activation was not required (16.9%); poor communication /prioritization of medical team (15.7%) |
High |
| Stewart et al. [69] |
To evaluate the impact of the implementation of the MEWS on the early identification of patients at risk for clinical deterioration and factors that influence how nurses use MEWS as a framework in the decision-making process for RRS activation |
US, acute care hospital |
1 year |
Sample: 39 RRS activations in pre-MEWS period & 55 RRS activations in post-MEWS period; purposive sampling of registered nurses (n = 11) Data collection: Phase 1: Medical record reviews 12 months before and 12 months after implementation of the MEWS scoring system Phase 2: Focus group using semi-structured guide (n = 5) Data analysis: Phase 1: Descriptive statistics Phase 2: Content analysis |
While the MEWS was considered a valuable tool to enhance interdisciplinary communication about a patient’s condition, participants do not rely exclusively on the MEWS score to prescribe an intervention The MEWS score prompts them to gather additional clinical data from a prioritized physical and behavioral assessment of the patient Participants cited that the MEWS does not assign a numeric value to nurse ‘worry or concern’ so the nursing assessments are not factored into the aggregated score Participants expressed confidence in activating the RRS if they believed it was necessary without fear of being ridiculed or reprimanded by physicians or RRT members Nursing administrators were regarded by participants as supporters of nurses’ decisions to activate the RRS Perceived barriers to utilization of MEWS system: the inability of nurses to tailor the MEWS alarm settings and limits to accommodate patients whose vital signs measurements normally fell outside predetermined threshold |
High |
| Tirkkonen et al. [70] |
Using the Ustein template to study documentation of vitals before a MET call, with special reference to patients having automated patient monitoring in general ward and to identify factors associated with delayed MET activation |
Finland, tertiary hospital |
<1 |
Sample: 569 MET reviews to 458 general ward patients Data collection: Medical record reviews Data analysis: Descriptive statistics, multivariate logistic regression |
Documentation of vital signs before MET activation was suboptimal. Particularly, documentation of respiratory rate was alarming low (75% monitored bed vs. 17% non-monitored beds) When adjusted to the documentation frequency of vitals, failure and delayed activations occurred more among monitored ward patients (monitored bed 81% vs. non-monitored bed 53%, P < 0.0001) Delayed and failure of ward staff to call MET immediately when patient meets the calling criteria is associated with increased hospital mortality (OR 95% CI 1.02–2.72, P < 0.041) |
High |
| Williams et al. [71] |
To describe nurses’ experiences and perceptions of RRT |
US, community hospital |
4 |
Sample: Convenience sampling; registered nurses (n = 14) from 3 medical and cardiac care units Data collection: Focus group discussions using semi-structure guide (n = 6) Data analysis: content analysis |
Individual nurse use intuition/‘gut feeling’ to activate the RRT However, at times they are hesitant to call RRT as RRT members could not assimilate nurses’ concerns of a patient’s condition RRS as working around people and processes (system barriers): RRT as a relief for nurses and safeguard for patients when support was needed; work around time of delays in care of having to page physicians and getting call back for orders Presence of resistance from some physicians for nurses to call the RRT for their patients Negative reactions from RRT made nurses reluctant to call an RRT |
High |
| Wynn et al. [72] |
To examine nurse characteristics and nursing action related to RRT calls |
US, acute tertiary medical center |
1 |
Sample: Convenience sampling; registered nurses (n = 97) (Response rate: 70%) Data collection: Cross-sectional survey Survey tool developed Data analysis: Descriptive statistics, chi-square test, independent samples t test, Pearson correlation and logistic regression |
Top 3 reasons for calling RRT: (1) ‘sudden change in patient’s condition’ (78%), (2) ‘steady decline in patient condition’ (56%), (3) ‘inadequate response from the physician’ (35%). Education and experience are the most important predictors of independent calling Independent callers were 4.95 times more likely to have a bachelor degree in nursing (95% CI; 1.43–17.16, P = 0.01), and 3.72 times more likely to have more than 3 years of nursing experience (95% CI: 1.07–12.92, P = 0.04), than nurses who called at the request of another nurse or physician, after adjusting for the effects of other independent variables |
Medium |
