Siri Lerstøl Olsen

Modern hospital care is both advanced and complicated with multiple opportunities for medical errors including serious adverse events. Rapid Response Systems (RRSs) have been implemented in hospitals globally to prevent serious adverse events, such as cardiopulmonary arrest or death through systematic patient monitoring, early detection of deterioration (afferent limb), and timely response by competent personnel (efferent limb). An RRS also has two governance limbs, for ensuring resources (administrative limb) and follow up on quality (quality limb). Although RRSs have been found to be effective in many hospitals, patients still experience omission events; lack of monitoring, delayed or missing recognition of deterioration, and delayed or lack of response to deterioration. The concept of the RRS constitutes the conceptual framework of this thesis. The overall aim of this PhD project was to increase the knowledge of how to prevent omission events in hospitals through succeeding with an RRS.

This thesis uses a sequential mixed-methods design consisting of two qualitative studies and one quantitative study, and an integrated synthesis of their findings. The first study, a systematic review, included 21 qualitative papers that presented perceptions of healthcare professionals from different parts of the world, regarding facilitators and barriers of a hospital RRS. The second and third studies were both conducted in a Norwegian university hospital. In the second study, focus group interviews were conducted in two wards in the context of RRS simulation training, and separately in the intensive care unit to add the perspective of the efferent limb. Qualitative analyses were performed to provide an understanding of how healthcare professionals manage the complexities of an RRS in daily practice as well as identifying its challenges. In the third study a mortality review of diseased patients in two wards of a Department of Gastrointestinal Surgery were conducted. Quantitative analyses were performed to compare results from three time periods before- and after the implementation (2012) and further development (2016) of an RRS. Mortality rates for patients admitted to the study wards in the period of 2010–2019 are presented. Finally, this thesis presents a qualitative synthesis integrating the results of the three studies, addressing a thesis research question of how hospital organisations with an RRS can better prevent omission events.

Paper I highlights the importance of the administrative and quality improvement limbs. When these limbs were poorly connected to the operative limbs it led to unclear protocols, poor logistics, inconsistent education of healthcare professionals, and a lack of resources, including staff and beds. Furthermore, this paper emphasises the complexity of operating the afferent limb, ensuring regular monitoring, using scoring systems as intended in addition to managing a variety of documentation systems in busy hospital wards. Moreover, the paper reveals how the collaboration between the afferent and efferent limbs is vulnerable. Criticism and disrespectful behaviour down the hierarchy was frequently reported. This paper provides an international overview of barriers and facilitators of an RRS and influenced the aim, design, and research questions of Studies 2 and 3.

Paper II reports how healthcare professionals value combining a scoring system with clinical competence to discover deterioration. However, their ability to recognise deterioration was variable. Structured communication supported escalation when a patient was deteriorating, whereas variability in knowledge regarding the RRS and documentation routines impeded timely detection and escalation. Competing tasks, crowded units, and fear of criticism when calling the efferent limb from the intensive care unit disrupted collaboration. This paper illuminates the value of simulation training to probe a hospital RRS and as an arena to improve consistent use of the RRS and interprofessional collaboration. These findings contributed to the development of the aim and design of Study 3.

Paper III reports how patient demographics did not change during the three time periods studied in the mortality review. After implementation and development of the RRS, there was a significant increase in documented vital signs, earlier documentation of limitations of medical treatment, an increase in reviews by healthcare professionals from the intensive care unit, without an increase in transfers to the intensive care unit, and a decrease in the number of patients experiencing omission events. This was associated with a significant decrease in in-hospital mortality, as well as 30-day mortality rates. The integrated synthesis of the three studies underlines the need for hospital organisations to take overall responsibility for adequate resourcing. This includes competent personnel, necessary equipment, and comprehensive and user-friendly technological solutions for monitoring and documentation. Furthermore, the RRS protocol needs to be customised to the organisation. The trigger criteria and the structure of the efferent limb must be wisely chosen, and a clear RRS protocol is essential. Finally, hospital organisations need to ensure continuous follow up of quality and improvement. The chosen RRS structure, how it is used by healthcare professionals, and defined outcome measures should be continuously evaluated, and results fed back to healthcare professionals. Identified challenges need to be acknowledged and addressed.

Through studying the perceptions of healthcare personnel internationally and nationally, performing a mortality review and integrating the findings from the three studies, this thesis contributes to increased knowledge on how to prevent omission events in hospitals through succeeding with an RRS. This thesis demonstrates that leadership, taking the overall responsibility in the hospital organisation is essential to ensure adequate resources, including the alignment of workload and staffing, and providing user-friendly monitoring and documentation systems. Developing an environment where healthcare personnel can build competence in clinical evaluation and interprofessional collaboration is fundamental. Furthermore, a conscious choice of RRS structure, including trigger criteria, and efferent limb structures, described in a clear RRS protocols is needed. Continuous quality follow-up enabling improvements and adjustments of the RRS is warranted to prevent omission events, and thus minimise the occurrence of serious adverse events.

Siri Lerstøl Olsen is an ED physician at Stavanger University Hospital. She defended her thesis November 10 2023.

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