Early warning systems and rapid response to the deteriorating patient in hospital: a realist evaluation

Aim
To identify those contexts and mechanisms that enable or constrain the implementation of Rapid Response Systems on acute general hospital wards to recognise and respond to patient deterioration.
Background

Rapid Response Systems allow deteriorating patients to be recognised using Early Warning Systems, referred early via escalation protocols and managed at the bedside by competent staff.

Design
Realist Evaluation.

Methods
The research design was an embedded multiple case study approach of four wards in two hospitals in Northern Ireland which followed the principles of Realist Evaluation. We used various mixed methods including individual and focus group interviews, observation of nursing practice between June - November 2010 and document analysis of Early Warning Systems audit data between May - October 2010 and hospital acute care training records over 4.5 years from 2003-2008. Data were analysed using NiVivo8 and SPPS.

Results
A cross case analysis highlighted similar patterns of factors which enabled or constrained successful recognition, referral and response to deteriorating patients in practice. Key enabling factors were the use of clinical judgement by experienced nurses and the empowerment of nurses as a result of organisational change associated with implementation of Early Warning System protocols. Key constraining factors were low staffing and inappropriate skill mix levels, rigid implementation of protocols and culturally-embedded suboptimal communication processes.
Conclusion

Successful implementation of Rapid Response Systems was dependent on adopting organisational and cultural changes that facilitated staff empowerment, flexible implementation of protocols and ongoing experiential learning.