Dukes Kimberly, Bunch Jacinda L, Chan Paul S, Guetterman Timothy C, Lehrich Jessica L, Trumpower Brad, Harrod Molly, Krein Sarah L, Kellenberg Joan E, Reisinger Heather Schacht, Kronick Steven L, Iwashyna Theodore J, Nallamothu Brahmajee K, Girotra Saket
Institute of Clinical and Translational Science, University of Iowa, Iowa City.
College of Nursing, University of Iowa, Iowa City.
JAMA Intern Med. 2019 Oct 1;179(10):1398-1405. doi: 10.1001/jamainternmed.2019.2420.
Rapid response teams (RRTs) are foundational to hospital response to deteriorating conditions of patients. However, little is known about differences in RRT organization and function across top-performing and non-top-performing hospitals for in-hospital cardiac arrest (IHCA) care.
To evaluate differences in design and implementation of RRTs at top-performing and non-top-performing sites for survival of IHCA, which is known to be associated with hospital performance on IHCA incidence.
DESIGN, SETTING, AND PARTICIPANTS: A qualitative analysis was performed of data from semistructured interviews of 158 hospital staff members (nurses, physicians, administrators, and staff) during site visits to 9 hospitals participating in the Get With The Guidelines-Resuscitation program and consistently ranked in the top, middle, and bottom quartiles for IHCA survival during 2012-2014. Site visits were conducted from April 19, 2016, to July 27, 2017. Data analysis was completed in January 2019.
Semistructured in-depth interviews were performed and thematic analysis was conducted on strategies for IHCA prevention, including RRT roles and responsibilities.
Of the 158 participants, 72 were nurses (45.6%), 27 physicians (17.1%), 27 clinical staff (17.1%), and 32 administrators (20.3%). Between 12 and 30 people at each hospital participated in interviews. Differences in RRTs at top-performing and non-top-performing sites were found in the following 4 domains: team design and composition, RRT engagement in surveillance of at-risk patients, empowerment of bedside nurses to activate the RRT, and collaboration with bedside nurses during and after a rapid response. At top-performing hospitals, RRTs were typically staffed with dedicated team members without competing clinical responsibilities, who provided expertise to bedside nurses in managing patients who were at risk for deterioration, and collaborated with nurses during and after a rapid response. Bedside nurses were empowered to activate RRTs based on their judgment and experience without fear of reprisal from physicians or hospital staff. In contrast, RRT members at non-top-performing hospitals had competing clinical responsibilities and were generally less engaged with bedside nurses. Nurses at non-top-performing hospitals reported concerns about potential consequences from activating the RRT.
This qualitative study's findings suggest that top-performing hospitals feature RRTs with dedicated staff without competing clinical responsibilities, that work collaboratively with bedside nurses, and that can be activated without fear of reprisal. These findings provide unique insights into RRTs at hospitals with better IHCA outcomes.
快速反应小组（RRTs）是医院应对患者病情恶化的基础。然而，对于在院内心脏骤停（IHCA）护理方面表现出色和表现不佳的医院，RRT的组织和功能差异知之甚少。
评估在表现出色和表现不佳的医院中，RRT在设计和实施方面的差异，以提高IHCA的生存率，已知这与医院在IHCA发生率方面的表现相关。
设计、地点和参与者：对参与“遵循指南-复苏”计划的9家医院的158名医院工作人员（护士、医生、管理人员和其他工作人员）进行半结构化访谈的数据进行了定性分析。这些医院在2012 - 2014年期间在IHCA生存率方面一直排名在前四分之一、中间四分之一和后四分之一。现场访问于2016年4月19日至2017年7月27日进行。数据分析于2019年1月完成。
进行了半结构化深入访谈，并对IHCA预防策略进行了主题分析，包括RRT的角色和职责。
158名参与者中，72名是护士（45.6%），27名医生（17.1%），27名临床工作人员（17.1%），32名管理人员（20.3%）。每家医院有12至30人参与访谈。在表现出色和表现不佳的医院中，RRT在以下4个方面存在差异：团队设计和组成、RRT对高危患者的监测参与度、床边护士启动RRT的自主权以及在快速反应期间和之后与床边护士的协作。在表现出色的医院，RRT通常配备专门的团队成员，他们没有相互冲突的临床职责，为床边护士管理病情恶化风险患者提供专业知识，并在快速反应期间和之后与护士协作。床边护士有权根据自己的判断和经验启动RRT，而不用担心受到医生或医院工作人员的报复。相比之下，表现不佳的医院中，RRT成员有相互冲突的临床职责，并且通常与床边护士的互动较少。表现不佳的医院的护士报告了对启动RRT可能产生的后果的担忧。
这项定性研究的结果表明，表现出色的医院的RRT具有专门的工作人员，没有相互冲突的临床职责，与床边护士协作良好，并且可以在不用担心报复的情况下启动。这些发现为IHCA结果较好的医院的RRT提供了独特的见解。
