Search

An integrative review of the literature specific to leadership within the intensive care unit was planned to guide future research. Four databases were searched. Study selection was based on predetermined inclusion and exclusion criteria and a quality check was done. Data extraction and synthesis involved developing a preliminary thematic coding framework based on a sample of papers. The coding framework and all selected papers were entered into NVivo software. All papers were then coded to the previously identified themes. Themes were summarised and presented with illustrative quotes highlighting key findings. In total, 1102 relevant quotations were coded across the 28 included papers. Four themes pertaining to leadership were described and analysed: (a) leadership dimensions and discourses; (b) leadership experiences; (c) facilitators and/or barriers to leadership; and (d) leadership outcomes. The literature was found to focus on leader behaviours, as well as the leader dimensions of role allocation, clinical and communication skills and traditional hierarchies. Positive behaviours mentioned included good decision-making, staying calm under pressure and being approachable. Leadership experiences (and outcomes) are typically reported to be positive. Personal individual factors seem the biggest enablers and barriers to leadership within the intensive care unit. Training is considered to be a facilitator of leadership within the intensive care unit. This study highlights the current literature on leadership in intensive care medicine and provides a basis for future research on interventions to improve leadership in the intensive care unit.

Rapid response systems have been mandated for the recognition and management of the deteriorating patient. Increasing medical emergency team (MET) dose may be associated with improved outcomes. Large numbers of MET calls may divert resources from the program providing the service unless additional personnel are provided. To describe the implementation and outcomes of a multifaceted rapid response system (RRS) in a teaching hospital, we conducted an observational study. The RRS consisted of the introduction of a MET together with 1) redesign of the ward observation chart with the vital sign variables colour-coded to identify variation from normal; 2) mandated minimum frequency of vital sign measurement; 3) three formal levels of escalation based on the degree of physiological instability as measured by a modified early warning score (MEWS); 4) COMPASS© education and e-learning package with a two-hour face-to-face small group tutorial; 5) practise in escalation and communication using the ISBAR (Identify Situation, Background, Assessment, Response/Recommendation) communication tool. The primary outcome measures were all-cause hospital mortality rate and hospital standardised mortality ratio (HSMR) compared to peer hospitals calculated by the Health Round Table. There were 161,153 separations and 1,994 hospital deaths from July 2008 to December 2012. The MET call rate was 11.3 per 1000 separations in 2012. There was a decline in all-cause hospital mortality from 13.8 to 11 deaths/1000 separations. The HSMR decreased from 95.7 in 2008 to 66 in the second half of 2012 (below the three standard deviation control limit). A low MET dose may be associated with improved hospital mortality when combined with a MEWS and an intervention to improve communication.

We aimed to describe the epidemiology of Rapid Response Team (RRT) activation in New Zealand public hospitals. We undertook a prospective multicentre observational study of RRT activations in 11 hospitals for consecutive 14-day periods during October–December 2014. A standardised case report form was used to collect data on patient demographics, RRT activation criteria and timing, vital signs on RRT arrival, team composition and intervention, treatment limitation and patient outcome at day 30. Three hundred and thirteen patients received 351 RRT calls during the study period. Patients were admitted under a medical specialty in 177 (56.5%) instances. Median duration from hospital admission to first RRT call was two days. Eighty-six percent of RRT calls were to inpatient wards. A total of 43.4% of RRT calls occurred between 0800 and 1700 hours (38% of the day) and 75.5% of RRT calls were activated by ward nurses. A median of three staff attended each call. Common triggers for RRT activation were increased Early Warning Score (56.2%) and staff concern (25.7%). During the RRT call, 2.8% of patients died; 19.8% died by day 30. New ‘Not For Resuscitation’ orders were written in 22.5% of RRT calls. By day 30, 56.2% of patients had been discharged home alive. In conclusion, RRTs in New Zealand are multidisciplinary, mostly nurse-activated and predominantly respond to deteriorating medical (rather than surgical) patients. Most patients remain on the ward. The RRT frequently implements treatment limitations. Given almost one in five patients die within 30 days, over half of whom die within 72 hours of RRT review, surviving the RRT call may provide false reassurance that the patient will subsequently do well.

A third of patients reviewed by rapid response teams (RRT) require end-of-life care. However, little is known about the characteristics and management of these patients following RRT review. This paper presents results of a retrospective, descriptive audit that explored the dying trajectory of adult ward inpatients who died outside of the intensive care unit following RRT review. The study setting was a 430-bed tertiary New Zealand hospital during 2013. RRT, inpatient databases and hospital notes were used to identify 100 consecutive adult inpatients who died subsequent to RRT review. Outcome measures included time from RRT review to death, place of death, pre-existing comorbidities and frequency of medical review. Results demonstrated that patients were old (median 77 years, IQR 63–85years), emergency admissions (n=100) and admitted under a medical specialty (n=71). All but one of the cohort had pre-existing comorbidities (mean 3.2, SD 1.7), almost a third (n=31) had cancer and 51% had 1–4 previous inpatient admissions within the previous 12 months. The mean length of stay prior to RRT review was 4.9 days (SD 5.5) during which patients were frequently reviewed by senior medical staff (mean 6.8 times, SD 6.9, range 0–44). Twenty percent of patients died after their first RRT review with a further 40% receiving treatment limitation/palliation. Fifty-two percent of patients had a pre-existing Do Not Attempt Resuscitation (DNAR) order. Eighty percent of patients died in hospital. Whilst the RRT fulfils an unmet need in decision-making at end of life, there is a need to understand what RRT, instead of ward-based or palliative care teams, offers dying patients.

Relatively few papers have examined specific causes for Medical Emergency Team (MET) review and the assessment and management undertaken by the MET. The aim of our study was to describe the type of patients who require MET review, the reasons such reviews are requested and the subsequent immediate management of these patients. Our prospective single-centre observational study was conducted in a university-affiliated tertiary hospital in New Zealand between October 2012 and September 2013. Each trigger for MET review was assessed separately to allow analysis of the main associated underlying conditions and interventions. Seven hundred and ninety-five MET calls were generated for 630 patients. Mean patient age was 64 years. Sixty percent of all calls involved medical patients. There was a marked diurnal variation in the incidence of MET calls, with MET calls more likely during the daytime and evening compared to the night. The most common triggers for MET calls were an unresponsive or fitting patient (25.2%), tachycardia (24.2%), and an Early Warning Score of 8 or more (22.8%). Neurological causes (30.7%), cardiovascular failure (hypotension, pulmonary oedema) (26.7%), respiratory failure (22.6%), and sepsis (19.2%) were the most common underlying conditions. One of these top four conditions was present in nearly all patients (99.2%). The majority of MET calls were made for a relatively small number of underlying conditions and triggers, supporting the concept of ‘MET syndromes’. The pattern of interventions is predictable from the triggering condition. This may guide education and training of ward staff to improve detection of deteriorating patients and prevent or pre-emptively manage causes of such deterioration prior to MET criteria being reached. The association between time of day and crisis recognition suggests the hospital system does not reliably detect deteriorating patients. This questions the adequacy of monitoring of deteriorating patients on hospital wards.

Rapid response systems (RRS) in hospitals in Australia and New Zealand (ANZ) have been present for more than 20 years but governance of the efferent limb—the rapid response team (RRT)—has not been previously reported in detail. The objectives of this study were to describe current governance arrangements for RRTs within ANZ and contrast those against expected implementation, using the Australian Commission for Safety and Quality in Health Care National Standard 9 (S9) as a benchmark. Assessment focused on S9 subclauses 9.1.1 (governance and oversight), 9.1.2 (RRT implementation), 9.2.3 (data collection and dissemination), 9.2.4 (quality improvement), 9.5.2 (call reviews), 9.6.1 and 9.6.2 (basic and advanced life support [ALS] skill set). We identified public and private hospitals across ANZ from government-maintained registers. Those reasonably expected to have an RRT were contacted and invited to participate. Responses were obtained via an online anonymised questionnaire. Three hundred and forty-two hospitals were contacted, of whom 284 (83.0%) responded. Two hundred and thirty-two hospitals submitted data, and the other 52 declined to participate or did not have an RRT. In hospitals with an intensive care unit (ICU), intensivist attendance at RRT calls occurred less often outside office hours (odds ratio, OR, 0.49, 95% confidence interval, CI, 0.32 to 0.75]). Where intensivists were not on the RRT, consultation with them about calls also occurred less often outside office hours (OR 0.39, 95% CI 0.22 to 0.66). Consultation with patients’ admitting specialists occurred more often during office hours versus out of hours RRT calls and in private versus public hospitals. The presence of ICU staff on the RRT decreased the likelihood of admitting specialists being consulted about RRT calls (OR 0.66, 95% CI 0.47 to 0.93). Most hospitals maintained databases of RRT calls and regularly audited RRT activity (92% and 90% respectively). However, most (63.7%) did not make that information available beyond their hospital or local network. We concluded that the majority of hospitals in the ANZ region had governance mechanisms for their RRT. However, there was a notable lack of consistency, especially around specialist involvement and audit processes. Although some findings from this study are reassuring, there is still potential for improvement. Further development of guidelines and the establishment of a regional RRS database may assist with achieving this.

Rapid Response Teams (RRTs) have been introduced into hospitals worldwide in an effort to improve the outcomes of deteriorating hospitalised patients. Recently, there has been increased awareness of the need to develop systems other than RRTs for deteriorating patients. In May 2016, the 12th International Conference on Rapid Response Systems and Medical Emergency Teams was held in Melbourne. This represented a collaboration between the newly constituted International Society for Rapid Response Systems (iSRRS) and the Australian and New Zealand Intensive Care Society. The conference program included broad ranging presentations related to general clinical deterioration in the acute care setting, as well as deterioration in the emergency department, during pregnancy, in the paediatric setting, and deterioration in mental health status. This article briefly summarises the key features of the conference, links to presentations, and the 18 abstracts of the accepted free papers.

Patients can acutely deteriorate unexpectedly. Junior medical officers (JMOs) are often first to review patients who become unwell. Opportunities to escalate care to a senior colleague may exist prior to the need for a rapid response team review. Little is known about the factors that influence JMO decisions to escalate care. In this study, our objective was to investigate the self-reported factors that influence escalation of care by JMOs in a university-affiliated, tertiary level hospital. We designed a face-to-face questionnaire of JMOs using standardised introduction to minimise interviewer bias. Fifty JMOs participated in the study (a 100% response rate). Most (63.3%) felt that they would be able to identify a clinically deteriorating patient. They would be more likely to escalate care if they were not familiar with the patient's clinical problem. If handover plans were seen to be adequate, JMOs felt it was less necessary to escalate care. Few JMOs (12%) agreed that they limited escalation due to fear of criticism or fear of conflict with senior medical staff. Although 36% agreed that they were concerned about waking seniors overnight, only 6% feared that escalating care overnight would affect their future career prospects. Escalation of care appears to be mostly influenced by the confidence and familiarity of the JMO with the cause of deterioration. JMOs identified clear handover with documented goals of treatment and suggested actions in event of clinical deterioration as the best means by which to improve the process of escalation of care for clinically deteriorating patients.

Rapid Response Systems (RRSs) have been widely introduced throughout hospital health systems, yet there is limited research on the characteristics and outcomes of patients admitted to an intensive care unit (ICU) following RRS activation. Using database extraction, this study examined the factors associated with ICU admission and patient outcome in patients receiving RRS activation in a tertiary level hospital between 2009 and 2013. Of 3004 RRS activations, 392 resulted in ICU admissions. Call factors associated with ICU admission and increased hospital mortality included tachypnoea ( P

Rapid Response Teams (RRT) are specialised teams that review deteriorating ward patients in an attempt to prevent morbidity and mortality. Most studies have assessed the effect of implementing an RRT into a hospital. There is much less literature on the characteristics and outcomes of RRT patients themselves. This article reviews the epidemiology of adult RRT patients in Australia and proposes three models of RRT syndromes. The number of RRT calls varies considerably in Australian hospitals from 1.35 to 71.3/1000 hospital admissions. Common causes of RRT calls include sepsis, atrial fibrillation, seizures and pulmonary oedema. Approximately 20% of patients to whom an RRT has responded have more than one RRT call, and up to one-third have issues around end-of-life care. Calls are least common overnight. Between 10 to 25% of patients are admitted to a critical care area after the call. The in-hospital mortality for RRT patients is approximately 25% overall but only 15% in patients without a limitation of medical therapy. RRT syndromes can be conceptually described by the trigger for the call (e.g. hypotension) or the clinical condition causing the call (e.g. sepsis). Alternatively, the RRT call can be described by the major theme of the call: “end-of-life care”, “requiring critical care” and “stable enough to initially remain on the ward”. Based on these themes, education strategies and quality improvement initiatives may be developed to reduce the incidence of RRT calls, further improving patient outcome.