Su relación con las Divinidades y sus Creencias.

factors that are known to be important to achieving sustainability. To date, no such research has been conducted to examine RRT sustainability and the related organizational factors, or the contexts and processes that facilitate or inhibit achieving sustainability of this innovation.

Rapid Response Teams

RRTs are teams that have been implemented as a way for organizations to quickly respond to patients on acute care units who show signs or symptoms of acute clinical

deterioration or when a pre-determined objective (such as a heart rate less than 40/minute) or subjective (such as nurse is worried) RRT calling criteria are met. An RRT can be initiated by staff members, patients or family members, depending on organizational policy. RRTs are one type of rapid response system (RRS) in hospitals. A RRS is a coordinated and organizational- wide approach to care for patients in crisis by getting the right resources and services to the patient as quickly as possible to prevent adverse patient outcomes. The RRS provides a means for detecting a patient event (by using predetermined objective and subjective criteria), which then trigger an organizational response. The response to the trigger involves calling the RRT or other specialized resources (e.g., a cardiac arrest or stroke team) to resolve the crisis (DeVita et al., 2006). Other types of RRS include medical emergency teams and critical care outreach teams (http://psnet.ahrq.gov).

When RRTs were first introduced, they were touted as having the potential to improve patient outcomes, specifically decreasing cardiac arrest rates outside of Intensive Care Units (ICUs), unanticipated ICU admissions, and hospital mortality rates (Cretikos et al., 2006; Garretson et al., 2006). Some researchers have reported improvements in patient outcomes following RRT calls (Bellomo, Goldsmith, Uchino, et al., 2004; Butner, 2011; Randhawa, Turner, Woronick, & duVal, 2010). Bellomo et al. (2004) conducted a prospective controlled study using a pre-post design to examine the effect of medical emergency teams on postoperative morbidity and mortality rates. Outcome measures included the percentage of patients affected by adverse

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events, the incidence of in-hospital deaths and individual adverse events, and the mean duration of hospital stay. In the 4-month “before” period, outcome measures were studied under the normal operating conditions of the hospital. After a period during which initial education of the RRT was provided to nursing and medical staff , the RRT was implemented. A “run-in” period was observed to identify and manage logistical problems, followed by a 4-month intervention period during which an RRT operated in the hospital. Patients who were admitted to the hospital and who underwent major surgery (i.e., any operation associated with a hospital stay longer than 48 hours) were included in the study. Bellomo et al. (2004) found a significant reduction in adverse events (acute myocardial infarction, pulmonary embolism, acute pulmonary edema, respiratory failure, severe sepsis, stroke, and acute renal failure) for patients who underwent major surgery (p < .0001). A significant reduction in hospital stay (p = .0092) was also observed. Because the study was conducted in one institution (i.e., a 400-bed teaching hospital in Australia), the generalizability of findings is limited. The improvements in adverse outcomes observed could also have been a function of other quality improvements initiatives that were conducted during the time of the study. It could also have been a function of RRT program-related training enhancing nurses’ existing knowledge and skills to identify patients with problems that

potentially resulted in interventions to treat problems, thus reducing the need for RRT calling. Because the study was limited to surgical patients, the potential impact of RRTs on other patient populations could not be demonstrated.

In an integrative review of 12 studies on RRTs, Butner (2011) found that 30% of studies reported a reduction in mortality or overall inpatient deaths, 40% of studies reported reduction in non-ICU arrests, and 60% reduction in overall cardiac arrests. There are, however, some

limitations to the study. Butner included studies that examined patient outcomes as well as studies that examined the effectiveness and/or receptiveness of RRTs. These studies were also conducted mostly in single institutions which limits the generalizability of their findings. The use of a pre-post study design in the majority of these studies also increases threats to internal validity

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because the changes that were observed after the intervention may have been due to changes in the participants rather than due to the intervention (i.e., maturation) (Brink & Wood, 1998).

The impact of RRTs stretches, however, beyond patient outcomes. Many have reported that RRTs improve the quality and safety of care (Berwick, Calkins, McCannon, & Hackbarth, 2006; Sarani et al., 2009; Williams, Newman, Jones, & Woodard, 2011) through the early detection of medical errors, the prevention of avoidable adverse events, and providing treatment for errors that might occur (Braithwaite et al., 2004; Chen et al., 2009; Iyengar et al., 2009; Stolldorf, 2009). Williams et al. (2011) conducted focus group interviews with staff nurses, nurse clinicians, and supervisors/educators from medical and cardiac care units in a 156-bed

community hospital. Fourteen nurses participated in the study. Content analysis was used to identify themes in the data until data saturation was achieved. Three broad categories (the individual nurse, the team, and the system) were identified. The researchers reported that the use of RRTs as a learning tool enhanced nurses’ skills and knowledge about patient care and provided support for new graduate nurses to learn their new roles. The teamwork that occurred during RRT calls also enhanced the collaboration between RRT members and nurses. The

trustworthiness of the study findings is limited because it was conducted in a single institution and no triangulation of data of methods or sources, peer debriefing, and member-checking were reported. Steps were taken to enhance the rigor of data collection and interpretation and included: to reduce investigator bias, an external research team member conducted the focus group

interviews; and to reduce self-selection, a broad range of nurses (different units and different work shifts) were included in the interviews.

Nurse satisfaction has also been reported to improve following RRT implementation. Metcalf, Scott, Ridgway, and Gibson (2008) conducted a survey of nurses on an orthopaedic unit of a large community hospital in North Carolina to determine the impact of RRTs on nurses’ satisfaction. An 11-question 5-point scale was scored using face symbols to indicate strongly disagree to strongly agree. The survey was piloted for readability before administering it to 55

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staff members on the unit. A total of forty-two nurses (who did or did not previously call an RRT) responded to the survey (response rate of 69%). However, to determine nurses’ attitude toward the RRT, only the surveys of nurses who had called the RRT at least once were included in the analysis. A total score for each item in the survey was calculated by multiplying the maximum score for each question (i.e., five) with the number of surveys returned. The total point option for each item was 200. From the results a favorable rate of 80% was calculated (score equal to or greater than 168) and a very favorable rate was set at 90% (score equal to or greater than 189). Nurse satisfaction (84.5%), learning new skills and assessments from RRT

interventions with patients (88.5), and RRTs enhancing nurses’ comfort of practice as a nurse (96%) scored favorably. Piloting the survey before administering it to the rest of the staff on the unit enhanced the readability of the survey. The validity and reliability of the survey instrument were not established and rigorous statistical analysis is absent. The generalizability of the findings is also limited because the study was conducted in one type of unit (orthopaedic) in one type of hospital (community). Nurses on this unit might have been less skilled or less

experienced than nurses on other units. The rigor of the study could have been enhanced by surveying staff from other units where RRTs responded to calls. Also, surveying staff from units where RRTs did not respond to calls and staff members who had not previously activated the RRT would have allowed for a comparison of results across units and groups of staff members who have and have not previously activated RRTs to ensure that the results of the study was related to RRTs and not other causes.

Other unintended benefits from RRT implementation include the breaking down of system barriers in the delivery of care and the enhancement of nurses’ knowledge and skills. For example, Williams et al. (2011) found that nurses used the RRT to circumvent unit or system barriers in an effort to provide safe, timely care to patients. Nurses also perceived that RRTs improved their knowledge and skills, helped them to overcome deficits in knowledge and experience, and empowered them to call for help when it was needed. Thus, the potential for

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unintended benefits and improvements in organizational outcomes such as patient safety and timeliness of care may make the implementation and sustainability of RRTs a worthwhile endeavor for hospitals.

However, the evidence of improvement in patient outcomes following RRT

implementation remains inconclusive (Bristow et al., 2000; Buist et al., 2002; Chan, et al., 2010; DeVita et al. 2004; Hillman et al., 2005; Kellett, 2009; Kenward, Castle, Hodgetts, & Shaikh, 2004). Two studies underscore the lack of evidence of improved patient outcomes. First, in the only experimental design study (the gold standard in research designs), Hillman et al. (2005) randomized twenty-three hospitals, eleven to continue functioning as usual and twelve to

implement a rapid response system. Despite standardized implementation strategies and training, the researchers found no significant changes in the incidence of cardiac arrest rates, unplanned ICU admissions, or unexpected deaths following RRT implementation. A possible explanation for the insignificant study findings may be the difficulty in standardizing RRT implementation across the study hospitals. However, compared to baseline data, there was a significant reduction in unexpected cardiac arrest (p = .003) and death (p = .01) in both control and study hospitals, suggesting that Code Blue teams may have operated as informal RRTs in the control hospitals. That is, the Code Blue teams in the control hospitals functioned similarly to the RRTs in the other hospitals in the study by responding to both patients experiencing a cardiac and/or respiratory arrest and patients with signs and symptoms of acute deterioration. Differences in team composition and calling criteria, the scope of RRT member functions, and the personalities of those serving on the team may have also influenced the use of the RRTs in the different experimental hospitals which may have impacted patient outcomes.

Second, in a systematic review and meta-analysis of RRT literature (N=18), Chan, Jain, Nallmothu, Berg, and Sasson (2010) reported that RRT implementation resulted in a 33.8% reduction in cardiac arrest rates outside the ICUs, but not a reduction in hospital mortality rates. These findings suggest that, despite reductions in cardiac arrest rates of patients outside of the

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ICUs, overall patient mortality rates in hospitals have not improved. Therefore, the effectiveness of RRTs to improve patient mortality rates remains unsupported. The majority of hospitals in the sample were academic medical centers, physicians served on the RRT in 81.3% of the hospitals, and activation criteria were similar across studies. Thus, variances in hospital type, team composition, and activation criteria across studies were reduced, limiting their impact on the findings.

Differences in findings between the aforementioned studies likely related to differences in the design of studies and the dependent variable (patient outcomes) that were examined. The rigor of the research method (e.g., a meta-analysis versus an integrative review) may also account for differences in the outcomes reported. Inconsistencies in patient outcomes between studies may also be related to variations in RRT composition, activation criteria used to call the RRT, strategies and comprehensiveness of RRT-related education and training, and the underuse of RRTs in hospitals (Winters et al., 2007). How these variations impact patient outcomes has not been examined. Therefore, it is unclear what potential role variations in RRT composition activation criteria, RRT-related education and training, and the underuse of RRTs variables may play on subsequent patient outcomes. Furthermore, the personal interaction (positive or negative) that occurs during RRT calls between team members and end-users of the team (i.e. staff

members on patient care units) may impact future calling (Astroth, Woith, Stapleton, Degitz, & Jenkins, 2013; Donaldson et al., 2009) and the degree to which RRTs effect patient outcomes.

The inability of RRTs to conclusively improve patient outcomes may also bring about the underuse and delayed use of RRTs (Schmid-Mazzoccoli, Hoffman, Wolf, Happ, & DeVita, 2008). Downey et al. (2008) conducted a two-year retrospective analysis of two cohorts of 100 patients—those with acute changes in conscious state or arrhythmias—for whom the RRT was activated. The purpose of the study was to determine the characteristics and outcomes of patients who experienced an RRT call during their hospital stay. The two groups of patients were similar in the following characteristics: demographics (age, gender); the presence of comorbidities like

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ischemic heart disease and congestive heart failure; and acute underlying causes of RRT calls like sepsis and hypovolemia. No significant differences were found in delayed calls—defined as calls with documentation that patients met RRT calling criteria at least 30 minutes prior to the

activation of the RRT call—between the two groups in terms of delayed calls. However, when the two cohorts were pooled, 29% of calls were delayed. Patients with delayed calls had a significant reduced 30-day survival rate compared with patients without delayed calls (p = .02). Unfortunately, the study was conducted in a single academic institution and was limited to two medical conditions as the reason for the RRT, which limits the generalizability of their findings. However, the study does demonstrate the impact of delayed calls on patient outcomes.

Other studies have also reported delays in RRT calls. Schmid-Mazzoccoli, Hoffman, Wolf, Happ, and Devita (2008), reviewed a convenience sample of 108 RRT calls that were made over a 2-year period in five medical and five surgical units of a university hospital. Nurse

characteristics (such as education and experience), patient characteristics (age, gender, days in hospital prior to RRT event, and reason for RRT call), and organizational characteristics (admission site, type of unit, and number of patients the nurse was assigned) were examined. These researchers found that 44% of RRT calls were delayed and a significant relationship between delayed calls and work shift (i.e., more delayed calls on night shift) (p = 0.02) existed.

Wynn, Engelke, and Swanson (2009) examined the relationship between nurse

educational preparation, years of experience, degree of engagement with patients (i.e., knowing the patient well enough to be able to identify subtle changes in their clinical status), and the RRT call status. Several tools were developed to measure nurse educational preparation, years of experience, and RRT call status. One pre-existing tool (Manifestations of Early Recognition Scale [MER]) was adapted and used to measure nurse engagement. (Reported reliability of the MER was a Cronbach alpha of .87) These researchers reported that 73% of RRT calls were delayed by 2-8 hours. Although the purpose of the study was clear, it lacked clear conceptual and operational definitions and the internal consistency of the instruments used to measure nurse

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educational preparation, years of experience, and RRT call status was not reported. In both aforementioned studies research questions were well defined. However, these studies were limited to academic medical centers and specific patient populations, thus the generalizability of their findings to other hospitals and patient populations are limited. Reasons for delayed calls were not reported. It is possible that some of these calls were delayed simply because the patient’s healthcare team was intervening (such as giving medications and inserting intravenous catheters for fluid administration) and decided to call the RRT only when initial interventions failed to correct the problem. Thus, the researchers could have included delayed calls without any intervention as well as delayed calls that included interventions by the healthcare team.

Reasons for delayed calls and lack of RRT utilization are gleaned from the literature that informed this study. Only a few studies have examined factors that contribute to the successful implementation and use of RRTs. Jones, Bellomo, & DeVita (2009) found that nurses were more likely to use the RRT if they had been educated on the principles, theory, and purpose of RRTs, and if medical and nursing staff (including RRT members) encouraged them to call the RRT. Donaldson, Foley, Shapiro, Spetz, and Scott (2009) conducted a large evaluation mixed-methods study to understand the impact of RRTs in hospitals. Nine multihospital organizations (hereafter called grantees) that had received Robert Wood Johnson Foundation (RWJF) grants to advance the implementation of RRTs were included in the study. The nine grantees were asked to “nominate” hospitals that participated in RRT implementation projects and, using their own criteria, to indicate whether hospitals represented “early and robust” or “delayed” adopters of RRTs. One “robust adopter” and one “reluctant adopter” hospital were randomly selected from each of the nine grantee hospitals (n=18). The researchers collected quantitative data on

organizational characteristics and patient outcomes from the 9 grantees hospitals (details on how the data was collected are not reported) and nurses (n=56, from 18 hospitals in 13 states) who had activated at least one RRT call were invited by nurse leaders to participate in the study to gain their perspective on RRTs. The researchers reported that nurses’ confidence in the RRT,

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leadership support, initial and ongoing training, feedback to staff about the use of RRTs, and clear, consistent communication were important for RRT implementation. Although the generalizability of the study is limited, transcript validation, inter-coder reliability, member checking, and peer review were employed to enhance the reliability and validity. These findings suggest that some organizational contexts and processes are important for RRT implementation and sustainability. Organizational leaders must therefore pay attention to contextual and process elements during implementation and sustainability activities.

Although research on RRTs suggests that certain organizational conditions are necessary for the implementation of RRTs, studies on the sustainability of RRTs following their initial implementation are lacking. Therefore, little is known about whether RRT sustainability is achieved in U.S. hospitals or how hospitals can facilitate RRT sustainability. As a result, hospital leaders lack studies that inform the implementation of RRTs to achieve sustainability, the desired outcomes may not be achieved.

Sustainability

Several different terms have been used in the literature to refer to the sustainability of innovations in organizations or communities. They include continuation (Bradley et al., 2005; Scheirer, 1990), durability (Glaser, 1981), institutionalization (Commins & Elias, 1991; Goodsen, Smith, Evans, Meyer, & Gottlieb, 2001; Goodman & Steckler, 1989; Kalafat & Ryerson, 1999), routinization (Yin, 1979), and sustainability (Altman, 1995; Bossert, 1990; Bowman, Sobo, Asch, & Gifford, 2008; Casey, Payne, Eime, & Brown, 2009; Johnson et al., 2004; Mancini & Marek, 2004; O’Loughlin et al., 1998; Shediac-Rizkallah & Bone, 1998). In a recent review of 125 studies of sustainability, Stirman et al. (2012) found the terms

institutionalization (n=6) and sustainability (n=77) to be used most frequently. Their findings mirror those of Johnson et al. (2004), who also found these terms to be most frequently used and

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suggested that the two terms encompass all the elements of the other terms used. These terms have also been used synonymously to refer to the continuation of innovations in organizations