Impact of Non-Technical Skills on Performance and Effectiveness of a Rapid Response System

Abstract

Background The Rapid Response System (RRS) is a globally recognised hospital safety service that recognises and escalates inpatient clinical deterioration for management by a Rapid Response Team (RRT). Successful use of Non-Technical Skills (NTS) during RRT calls may facilitate and expedite resolution of clinical deteriorations. Improving clinicians’ use of NTS typically involves dedicated training which requires considerable time and financial resources, which are commonly not available. Therefore, this research was undertaken, aiming to promote use of NTS during RRT calls using a pragmatic approach with minimal resource requirements. Methods This research, presented herein as a PhD-by-publication, investigated the re-design of an existing RRS on the use of NTS during RRT calls. The re-design had three components: 1) shift-by-shift meetings of the RRT; 2) RRT role badges; and 3) a structured “hand-off” transition-of-care process at the end of calls. A literature review was undertaken on NTS in context of an RRS to inform development of the redesign. Prior to implementation of the re-design (Phase 1), RRT Members and Users (ward staff that called the RRT) were surveyed regarding their experiences of RRT calls, and analysis of an RRS performance indicator: repeat RRT calls to the same patient during an admission, was conducted. Following introduction of the RRS re-design (Phase 2), the survey of RRT Members and Users was repeated, and an interrupted time series analysis was performed to determine the effect of the redesign on the proportion of RRT attended patients going on to have repeat calls. Results Potentially preventable repeat calls (i.e. following an initial call that ended despite an ongoing breach of RRT calling triggers) were associated with increased risk of in-hospital mortality (odds ratio 4.80 [95% confidence interval (CI) 2.96 – 7.81)], by comparison to not having repeat RRT calls. The RRS re-design was associated with improvements in both RRT Members’ and Users’ perceptions of NTS use during RRT calls. There were significant reductions in the proportion of RRT Members and Users reporting inter-personnel conflicts during calls following introduction of the re-design (26% less [95%CI -41% – -11%] and 14% less [95%CI -21% – -7%], respectively). However, there was little evidence of a significant difference in the proportion of RRT-attended patients (per month) going on to have repeat calls (6% fewer [95%CI -15.1% – 3.1%]) or in the mean number of calls per admission for these patients (-0.07 calls [95%CI -0.23 – 0.08]). Conclusions This program of research showed that a pragmatic NTS-based re-design of an existing RRS was associated with statistically significant reductions in RRT Members’ and Users’ perceptions of conflicts during RRT calls; however, this did not extend to a significant reduction in repeat RRT calls. Conflict between staff can exacerbate and/or be symptomatic of burnout. The results suggest that the RRS re-design had some beneficial effects on the working relationship between RRT Members and Users, which is promising as the well-being and resilience of clinicians is vital for sustainability of effective healthcare delivery. This research provides an important precedent for other resource-limited hospitals by demonstrating that a low-cost quality improvement initiative could be implemented for an existing RRS. The RRS redesign has broad applicability, and potential for future iterative refinement.