Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong, Australia; Illawarra Health Medical Research Institute, University of Wollongong, Australia.
Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong, Australia; Illawarra Health Medical Research Institute, University of Wollongong, Australia; Susan Wakil School of Nursing and Midwifery, University of Sydney, Australia; George Institute for Global Health.
Aust Crit Care. 2023 Sep;36(5):743-753. doi: 10.1016/j.aucc.2022.10.006. Epub 2022 Dec 7.
Failure to recognise and respond to clinical deterioration is a major cause of high mortality events in emergency department (ED) patients. Whilst there is substantial evidence that rapid response teams reduce hospital mortality, unplanned intensive care admissions, and cardiac arrests on in-patient settings, the use of rapid response teams in the ED is variable with poor integration of care between emergency and specialty/intensive care teams.
The aim of this study was to evaluate uptake and impact of a rapid response system on recognising and responding to deteriorating patients in the ED and identify implementation factors and strategies to optimise future implementation success.
A dual-methods design was used to evaluate an ED Clinical Emergency Response System (EDCERS) protocol implemented at a regional Australian ED in June 2019. A documentation audit was conducted on patients eligible for the EDCERS during the first 3 months of implementation. Quantitative data from documentation audit were used to measure uptake and impact of the protocol on escalation and response to patient deterioration. Facilitators and barriers to the EDCERS uptake were identified via key stakeholder engagement and consultation. An implementation plan was developed using the Behaviour Change Wheel for future implementation.
The EDCERS was activated in 42 (53.1%) of 79 eligible patients. The specialty care team were more likely to respond when the EDCERS was activated than when there was no activation ([n = 40, 50.6%] v [n = 26, 32.9%], p = 0.01). Six facilitators and nine barriers to protocol uptake were identified. Twenty behaviour change techniques were selected and informed the development of a theory-informed implementation plan.
Implementation of the EDCERS protocol resulted in high response rates from specialty and intensive care staff. However, overall uptake of the protocol by emergency staff was poor. This study highlights the importance of understanding facilitators and barriers to uptake prior to implementing a new intervention.
未能识别和应对临床恶化是急诊科（ED）患者死亡率高的主要原因。虽然有大量证据表明快速反应团队可以降低医院死亡率、非计划性重症监护病房入院率和住院患者的心脏骤停率，但快速反应团队在急诊科的使用情况存在差异，急诊和专科/重症监护团队之间的护理整合不佳。
本研究旨在评估快速反应系统在识别和应对急诊科恶化患者方面的采用情况和影响，并确定实施因素和策略，以优化未来实施的成功。
采用双重方法设计来评估 2019 年 6 月在澳大利亚一家地区性急诊科实施的 ED 临床应急响应系统（EDCERS）方案。在实施的头 3 个月内，对符合 EDCERS 条件的患者进行了文件审核。从文件审核中获得的定量数据用于衡量该方案对患者恶化的升级和响应的采用情况和影响。通过主要利益相关者的参与和协商，确定了 EDCERS 采用的促进因素和障碍。使用行为改变车轮为未来的实施制定了实施计划。
在 79 名符合条件的患者中，有 42 名（53.1%）患者激活了 EDCERS。当 EDCERS 被激活时，专科护理团队比没有激活时更有可能做出反应（[n=40，50.6%]比[n=26，32.9%]，p=0.01）。确定了 6 个促进因素和 9 个采用障碍。选择了 20 项行为改变技术，并为制定基于理论的实施计划提供了信息。
EDCERS 方案的实施导致专科和重症监护人员的反应率很高。然而，急诊人员对该方案的总体采用率很低。本研究强调了在实施新干预措施之前了解采用障碍的重要性。
