Performance of the Afferent Limb of Rapid Response Systems in Managing Deteriorating Patients: A Systematic Review

Introduction The clinical components of the rapid response system (RRS) are the afferent limb, to ensure identification of in-hospital patients who deteriorate and activation of a response, and the efferent limb, to provide the response. This review aims to evaluate the factors that influence the performance of the afferent limb in managing deteriorating ward patients and their effects on patient outcomes. Methods A systematic review was performed for the years 1995–2017 by employing five electronic databases. Articles were included assessing the ability of the ward staffs to monitor, recognize, and escalate care to patient deterioration. The findings were summarized using a narrative approach. Results Thirty-one studies met the inclusion criteria. The analysis revealed major themes enclosing several factors affecting management of patients having sudden deterioration. The monitoring and recognition process was conditioned by the lack of recording of physiological parameters, the influence of facilitators, including staff education and training, and barriers, including human and environmental factors, and poor compliance with the calling criteria. The escalation of care process highlighted the influence of cultural barriers and personal judgment on RRS activation. Mainly, delayed team calls were factors strongly associated with the increased risk of unplanned admissions to the intensive care unit and length of stay, hospital length of stay and mortality, and 30-day mortality. Conclusions A combination of factors affects the timely identification and response to sudden deterioration by general ward staffs, leading to suboptimal care of patients, delayed or failed activation of RRS teams, and increased risks of worsening outcomes. The research efforts and clinical involvement to improve the governance of the factors limiting the performance of the afferent limb may ensure proper management of hospitalized patients showing physiological deterioration.


Rationale
3 Describe the rationale for the review in the context of what is already known. 4 Objectives 4 Provide an explicit statement of the questions being addressed with reference to participants, interventions, comparisons, outcomes, and study design (PICOS).

Protocol and registration 5
Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, provide registration information including registration number.
6 Appendix (Table A) Eligibility criteria 6 Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered, language, publication status) used as criteria for eligibility, giving rationale. Describe the method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators.

9
Data items 11 List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made.

9
Risk of bias in individual studies 12 Describe methods used for assessing the risk of bias of individual studies (including specification of whether this was done at the study or outcome level) and how this information is to be used in any data synthesis. Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta-regression), if done, indicating which were pre-specified. N/a

Study selection 17
Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally with a flow diagram.
8 Figure 2 Study characteristics 18 For each study, to present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) and to provide the citations.

Sample
Adult patients and ward physicians and nurses. General wards of the acute hospital.

Phenomenon of Interest
Factors that influence, by promoting or preventing, the performance of the afferent limb of the rapid response system (RRS) in managing deteriorating patients in general wards. Primary peer-reviewed research articles in the English language, the only full text, published between January 1995 and December 2017 were included. The year 1995 was chosen for the Australian study [Reference 1] that first outlined the concept of the RRS as a team of critical care clinicians responding to deteriorating patients outside the intensive care unit.

Design
The designs of the included studies were randomized controlled trial, quasi-experimental study, before-and-after study, retrospective observational study, prospective observational study, crosssectional survey, post-hoc analysis, qualitative study, and mixed methods study.

Evaluation
Selected studies were grouped into three domains and common areas among studies were structured into themes related to the review purpose. Themes on monitoring deteriorating patients comprised lack of recording, poor documentation of respiratory rate, and influence of facilitator and barriers (effects of RRS implementation, effects of educational programs, and effects of standardized measurements and interfering factors). Themes on recognizing deteriorating patients comprised compliance with the calling criteria and impact of communication between ward clinicians. Themes on escalating care to deteriorating patients comprised influence of cultural barriers and personal judgment on response activation, delayed team calls, and effects of delays on clinical outcomes.
Research type Research types were qualitative, quantitative, and mixed methods.
SPIDER tool (Cooke et al., 2012) is an adaptation of the PICO components to make them more suitable for qualitative and qualitative research [Reference 29]. S5 S1 AND S2 AND S3 AND S4 4,968