When patients (and families) heighten the alarm: Patient and family unit activated rapid response as a safety strategy for hospitals

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Abstruse

Patients and those shut to them often take an intimate understanding of their condition and can participate in a broad range of clinical processes. During times of deterioration, their concerns might get unheard. Advocacy of family and friends can fulfil an important rubber office and can support patients and healthcare professionals looking afterwards them. If concerns by patients are not heard by the patient'south master team in hospital, patient and family activated rapid response systems allow patients and family members to alert disquisitional care outreach teams direct. These types of systems are stipulated by regulators in Australia and in parts of the USA, and there are examples in the United kingdom congenital effectually the 'Call for Concern' model championed by the Regal Berkshire Hospital. Implementation is not without its problems and requires a deep agreement of barriers and enablers. Empowering patients to escalate directly might help to change safety civilisation and have protective effects for patients and staff. Policy makers are urged to consider standardised regulation to help implementation.

KEYWORDS:

  • patient centred
  • patient safety
  • advancement

Introduction

Partnering with patients and families in intendance and care decisions was founded upon the notion that patients have a legitimate right to exist involved in their own care and intendance decisions. Although patient and family unit roles in promoting patient rubber accept been advocated internationally, the agreement of interventions and strategies to achieve meaningful engagement and successful implementation is poorly understood. Patient and family participation has been studied in bedside handover, ward rounds, medication management, pressure injury prevention and recognition of clinical deterioration.1–vi Other research has focused on patient and family interest in patient safety activities, transitions of care and clinical advice.seven–9 Notably this trunk of bear witness demonstrates that a continuum of participation, from passive to active engagement, exists. Preferences for participation involves a circuitous interplay between factors such as personal characteristics, knowledge, understanding of care, health status and expectations. Importantly, preferences and needs are dynamic and may vary depending on a patient's health status or their family being present. Family member engagement is especially valued by wellness professionals when caring for vulnerable, elderly, critically ill, or cognitively- or hearing-impaired patients. Although research highlights both benefits and challenges associated with patient and family participation, embedding effective strategies remains a frontier to be crossed.

Here, we review the statement for patient and family participation in intendance and care decisions of acutely unwell patients in hospital with a focus on two systems: the office of advancement and the operation of patient and family activated escalation systems.

Advocacy as a driver for patient prophylactic

Advocacy in healthcare is anybody's responsibility. Only in lodge to truly correspond the patient, the advocate is required to know the patient's wishes and needs, and who better to do this than family and friends? Not just do those closest to the patient know them best, simply they are also most invested in ensuring that the patient gets the all-time possible outcome. Family and friends might not exist familiar with hospital and professional culture, hierarchy, alien priorities and professional boundaries that may influence clinical decision making of healthcare workers merely might be still affected by them. The importance of the involvement of family and friends in patient intendance and planning is evidenced in the literature and has been recognised as a crucial resource for protecting vulnerable patient populations in acute healthcare environments in Commonwealth of australia.10–12 The importance of this resource has been additionally highlighted by its absenteeism during the COVID-19 pandemic with restriction of visiting having a detrimental effect on the power of families to fairly advocate for the patient. In improver, the separation of family unit from loved ones in stressful circumstances can have a negative result on the ability of the family to cope.thirteen

What is a patient and family activated rapid response arrangement?

Rapid response systems consist of ii parts: an afferent limb and an efferent limb.fourteen The function of the afferent limb is to monitor patients in hospital using physiological parameters such as vital signs through a tool such as the National Early Warning Score and escalate care to the efferent limb, a critical intendance outreach type of team, where there is concern about signs of deterioration.fifteen

Given these insights into the ability of patients and families to recognise deterioration, a number of initiatives have explored the power of patients to escalate intendance beyond their own clinical team and without the team's mediation. Critically sick and deteriorating patients, withal, are often unable to express concerns, whereas families and friends are much more likely to raise awareness of possible deterioration.sixteen,17

In Commonwealth of australia, the National Safety and Quality Health Service (NSQHS) standards are required for hospital accreditation and include standard 8: Recognising and responding to astute deterioration.18 This standard, updated in 2017, specifies the duty of hospitals to ensure that 'a person's acute deterioration is recognised promptly and appropriate action is taken'. Deterioration is divers as changes in physiology, cognition and mental country.18

Following widely publicised adverse events, when children died after delayed escalation despite parents' concerns, three of the seven Australian states have embedded the intent of this legislation in consumer activated rapid response systems: 'Ryan'south rule' in Queensland, Call for Help(C4H) in Western Australia and Accomplish in New Due south Wales.19,20 Ryan'south dominion stipulates that patients, families and friends can request an urgent independent review if they are not satisfied past the response of the patient'south own care team to their concern.19 Other states (such as Victoria) were unable to navigate the political mural.21 Consequently, hospitals and healthcare facilities accept implemented local policies and procedures to meet accreditation standards independently.

The fragmented approach in Australia presents a number of risks, including a failure of the program to be triggered due to the consumer being unaware of its beingness or how to access it, every bit well as inappropriate use of the organization and a subsequent waste material of resources and time.

In the USA, individual states have enshrined the right of patients to escalate to senior staff in legislation.22 In the United kingdom of great britain and northern ireland, no universally accepted model of care exists for patient and family escalation only the Royal Berkshire Hospital's 'Call for Concern' (C4C) has been adopted past a number of other institutions.16,17

While the evidence is simply just edifice, the International Consensus Conference for Rapid Response Systems recommended in 2018 that the choice for patients and their friends and families to escalate their concerns directly to a critical care outreach team (CCOT) is a quality indicator for the patient-centred care of deteriorating patients.23–25 Involving patients and families in the co-pattern of patient activated rapid response and similar resource can help ensure that their voice is heard and is reflected in the developed resource to ensure their needs are addressed.26

Opportunities and barriers for implementation of patient and family activated rapid response

The contribution that patients and/or families can make to the detection of and response to hospital deterioration is increasingly being recognised. However, calling for help can be challenging for patients and/or relatives. Factors accept been identified that act every bit both barriers and facilitators to existence heard, including personal factors (such as previous experience or knowledge of illness) and personality traits determining how confident patients and families will feel about responding to changes and raising concerns.27 Perceptions of the patient—healthcare professional person'southward office, including the notion that the healthcare professional 'knows best', too contribute to a reluctance to voice concerns and to the adoption of a passive role. In addition, the quality of relationships betwixt patients/families and healthcare professionals can promote or inhibit the ability to speak up. Finally, organisational factors (such as reduced staffing levels / resource) tin human activity every bit further barriers to patient and/or family involvement in the escalation of intendance.28 Given these challenges, there is a need to farther consider the processes and interventions that volition influence patient and relative empowerment in this expanse and help patients and families to move more than confidently towards feeling that they have 'permission to participate'.27,29 Systematic review evidence recommended that, given the paucity of robust enquiry in this area, further inquiry was required that utilised a structured approach and included consumer involvement in the development of an escalation of care intervention.30,31 To further explore these and other contextual factors that may bear upon on their part, and to address some of the identified challenges, a Health Service Executive funded project in Belfast co-designed a patient and family escalation of intendance prototype resource based on the experiences of patients, relatives and healthcare professionals to improve patient and family engagement across Ireland. This aimed to further examine the extent to which patient and/or relative intuition can be used to complement clinician judgement and preferences for involvement equally well as identifying strategies to enhance future implementation.28

The difficulties of implementing a patient and family unit activated rapid response system are illustrated by the implementation of a C4C service post-obit a recent trust merger between Ipswich and Colchester to course East Suffolk and North Essex NHS Foundation Trust: prior to the merger, Ipswich hospital had a well-established patient activated service run by the local CCOT. This patient safety initiative enabled patients to call for assist if they were concerned about a noticeable modify or deterioration in their condition, or if they experienced emotional stress afterward belch from intensive care. The service was well received by patients and their families every bit well every bit clinical staff.

Following the merger, the patient activated service was relaunched with permission from the Royal Berkshire Hospital to rename information technology 'Call for Concern' on both sites.

Understandably, at that place were initial reservations almost the impact of the new service on the clinical team and patients. The CCOT team was concerned nigh how C4C would exist embedded into the CCOT service: would there be an increase in CCOT workload, how would medical and ward-based teams answer to the idea that patients and families could independently activate a phone call to CCOT over their ain intendance, and would the service create a 'them and us' mentality resulting in conflict between the CCOT and ward-based teams.

There were anxieties most inappropriate calls by patients and families who didn't fully sympathise when or when not to actuate the service, and would expectations of the patients be disappointed if a call could non exist responded to immediately, and would patients and families actually use C4C or would they experience anxious that they may be treated differently as a result.

Engagement across the system achieved an understanding that C4C was an additional rubber net with the patient at the centre and not something that would overshadow or undermine other services. Using a collaborative approach and close links with the trust'south communications team, detailed and curtailed communications nearly the service were sent out cross site and presented to senior teams. Information about the comparatively small-scale number of calls generated by existing services was shared with staff. However, the well-nigh powerful bulletin came from the patient and families who reported that the service had positively impacted their experience and that they felt listened to when at their most vulnerable. Today, C4C has now been successfully embedded across the 2 hospitals and continues to have a positive impact on patient and family feel.

Discussion

Patient safety remains a reactive process in many parts of the health service rather than a co-designed, collaborative, proactive process to reduce adventure and meliorate care. Patients and families tin can play a significant function in patient safety, however, navigating the healthcare system and obtaining assistance for concerns regarding deterioration will remain challenging unless greater efforts are fabricated to enable and normalise their involvement in the recognition and escalation of deterioration. Taking an active role, when possible, has shown benefits for patient condom and satisfaction with intendance in other areas.

While sentinel events might exist rare, the effects are devastating for patients, families and affected healthcare professionals. For healthcare providers, patient and family activated rapid response might, therefore, exist a key intervention to create a hospital culture that truly embraces patient/family unit empowerment and partnership in the detection and escalation of deterioration in hospitals. More often than not, poor advice is at the heart of failed escalation.32 Clinical decision making is decumbent to bias, and mistake in a complex system is mutual and should not be routinely labelled as failure.33,34 Patient and family activated rapid response offers a rubber-net of escalation by healthcare professionals but might protect patients and overstretched healthcare professionals alike.

Initiation of a broader policy discussion that provides a platform to develop a coordinated and consistent national approach to patient and family activated rapid response systems is required. In the USA and Australia, patient safety has been driven by accreditation standards for hospitals whereas, in the U.k., standards are being adult and published past the National Institute for Health and Intendance Excellence.35 A standardised approach would utilize the same process in all healthcare facilities in much the same way that nosotros employ a national approach for calling an emergency through 999. For a system similar patient and family activated rapid response to succeed, it is essential to ensure the support and buy-in from decision makers at a local and national level. In this context, the recent launch of a job-and-end-group by NHS England on 'worry and concern' chaired by the deputy chief nursing officer for safety and innovation is encouraging.

Decision

Patient and family unit activated rapid response systems can exist an important tool to raise safety for patients in infirmary in situations where communication breakdown with a patient's primary clinical team has occurred. They might besides positively influence the culture of patient and family involvement and increase confidence in intendance. A consistent national arroyo supported by a coordinated public education program should exist explored.

Acknowledgements

The content of the manuscript was first presented at an international symposium on 'Patient-powered safety' on the 21 May 2021.