Clinical practices in the escalation of care for the deteriorating patient: a multicentre study

Background: Rapid response systems (RRSs) have been introduced to assist in the effective management of deteriorating patients. Optimal system performance requires adequate staffing levels and compliance with the escalation protocol. Delay and failures in activation of the rapid response team (RRT) are directly correlated to adverse outcomes. The current study analyses clinical practice and adherence to the RRS protocol in the Netherlands in correlation with demographic data from the hospitals. Methods: A multicentre cross-sectional survey using a vignette-based questionnaire was employed. Healthcare providers on the included medical and surgical wards participated. A descriptive analysis was performed on the data from the questionnaires and correlated to RRT activations and nurse-to-patient ratios. Results: The response rate was 31% (n=654). During the day shift, a ratio of 5-8:1 (patient-to-nurse) was reported in 52-60% of the hospitals. During evening shifts, 20-34% reported ratios of more than 8:1, and overnight, at least 84% reported even higher ratios. More than 50% of nurses perceived their workload to be ‘fairly heavy’. In contrast, 55-66% of the registrars perceived their workload to be ‘fairly heavy’ whereas consultants deemed work to be balanced. Upon detection of a deteriorating patient, nurses called the doctor in 88-90% of cases. The RTT was activated in 90% of cases. Conclusion: Compliance with RRS processes is reported to be high. Nurses reported significant workloads and high patient-to-nurse ratios. These ratios are likely to affect the ability to escalate care and provide optimal management for the deteriorating patient.