Risk management of the deteriorating patient in the Acute Care Setting (RACS study) : a single centre case study

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Contemporary acute care health facilities are increasingly recognized as dangerous places for patients due to the high risk of adverse events, many of which are preventable. These events include unplanned admissions to Intensive Care Units, unexpected cardiopulmonary arrests and deaths. The reasons for this are complex, diverse and multifaceted and attributable to patient, provider and health care system factors. Failure to recognise early warnings signs of clinical deterioration on our acute inpatient wards has been widely documented within the literature. This has led to the advent of Rapid Response Systems (RRS) designed for early recognition, escalation and management of the deteriorating general ward patient. Measuring the success of these systems has been difficult, in part due to implementation issues and the underestimated complexity of model workings when placed within the context of the greater healthcare environment. Local resourcing, communication and team cohesion can influence implementation effectiveness, inhibiting RRS from achieving their full potential. Investigating models of health care interventions isolated from contextual factors will result in a failure to successfully implement and sustain interventions to improved health outcomes. Deeper exploration into perspectives of how clinicians operate within these obligatory systems, as well as how the systems themselves impact on clinician work routines and activity is required. Factors influencing daily functioning and activity stability of RRS impact on demand and resourcing in environments that have been found to be resource poor. Using a framework of organisational theory, this thesis examined how individuals perceive organisational structures, processes, relationships and practices, and how these influence their clinical practice and function within the health care system. The study explored, utilising a mixed approach, factors influencing operation of a single centre rapid response system (RRS). The study aims were addressed through collection of data in three discrete phases, interpreting findings not only within the boundaries of the single site, but additionally in the broader interface between professional and regulatory bodies determining practice (the case). This study found that ongoing education and clinical support is essential, especially for medical officers, often left to work independently, with insufficient mentoring and support in the clinical environment. The RRS is potentially unstable in process and easily falls out of control leaving resource poor clinicians struggling to work within the system. Several factors have been identified that are not routinely measured for their negative impact, including patient acuity and team models. Cultural, organisational and technical factors impact on RRS workings. Improvements in RRS should consider the complex interactions that occur within this system as well as workload and staffing issues.
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