Practice variability in management of patient deterioration and fit with predefined procedures

Abstract

Background Management of deterioration in patients on a general ward is a complex key safety and quality challenge in hospitals. Rapid Response Systems (RRS) have been implemented to improve the management of deterioration; however, the impact on improving patient safety has stagnated. To increase the understanding of the management of patient deterioration, insights into practice variability and fit with predefined procedures could be helpful. Aim The objective of this study is to describe practice variability in management of patient deterioration and rapid response team (RRT) activation by nurses and physicians in everyday practice and to compare this to predefined procedures, as described in protocols and guidelines for the detection of patient deterioration and RRT activation. Method A retrospective qualitative study was performed in a general hospital in the Netherlands. Practice variability is described based on written reports in patient files and RRT activations, and compared with predefined procedures, using the Functional Resonance Analysis Method (FRAM). Results In 40 cases, practice variability is shown in the use of vital parameters, worry, patient input, consultations with the ward physician and medical specialist, choices of treatment interventions, re-assessment, RRT activation and follow-up. Comparison with predefined procedures shows that the process in everyday practice is more complex and consists of more activities and aspects than the process in predefined procedures. Conclusion Everyday practice shows a lot of variability in the management of patient deterioration and RRT activation and a lack of fit with predefined procedures. Recommendations Future research should focus on identifying core activities to perform well in the management of patient deterioration and RRT activation for different patients and to give professionals the ability to succeed under variable conditions. The re-design and re-implementation of predefined procedures are needed to create documents that convey unambiguous statements about clinical actions and their timings.