Assessment of Barriers, Perceptions, and Improvement Strategies Related to Rapid Response Team (RRT) Activation: A Comparative Study in an Oncology Setting

1. INTRODUCTION

Rapid Response Teams (RRTs) are multidisciplinary clinical teams to provide immediate assessment with concomitant management of patients showing signs of acute physiological deterioration; and they are comprised of trained professionals, including critical care nurses, respiratory therapists, and physicians. Rapid Response Teams (RRTs) are being used in hospitals throughout the world now as part of patient safety systems. They are teams who have been expected to intervene early over the deterioration of patients that is yet to become a life-threatening condition, such as transfer to the critical care unit or death [1]. However, things do not always evolve positively. In many cases, vital signs (such as abnormal blood pressure or breathing rate) will appear hours before cardiac arrest takes place, but are not addressed in time. Each year, about 290,000 in-hospital cardiac arrests occur in the USA [2, 3]; however, a good portion of these events go unreported. Failure to identify later signs and RRT activation as late as possible may contribute to a prolonged hospitalization and poor patient outcomes [4, 5].

To try to solve this gap, Rapid Response Systems (RRS) have been introduced in hospitals, which are based on four important elements: identification of deterioration (afferent limb); deployment of assistance (efferent limb); continuing enhancement; and administrative support, such as appropriate staff and equipment [6]. The National Early Warning Score Instrument (NEWS) tool is often also used during the first step to help nurses or physicians detect early risk and call in the RRT when it's needed [7, 8]. Not all calls are appropriate - up to 30% of RRT activations were for something that was not an emergency. Others are connected with comfort care or are not in a critical condition, resulting in the challenge of the work of the teams taking care of critically ill patients [3, 9].

The situation is complicated even more in an oncology setting. Cancer patients are predisposed to a situation where the condition progresses rapidly, and the decisions related to the care of cancer patients need to be extremely accurate! Mis-evaluation of escalation may have serious consequences. In such situations, fear of taking wrong decisions, decisional inadequacy, or apathy pertaining to the activation principles can be a limiting factor in the utilization of RRT. There are other issues, like a lack of communication or too much hierarchy in the clinical team [4, 10]. Staff often undergo training but might be afraid to be blamed or be able to go beyond their authority and, consequently, fail to act in time.

RRTs have been extensively researched in the non-oncology ward environment; however, there is little research on them in oncology centres. Therefore, general RRT models may not be totally appropriate for immunocompromised patients and patients with advanced disease [11]. Solutions that are effective in other departments may not work in oncology.

Accordingly, the following research questions were intended to be answered in this study: (1) What are the barriers and inhibiting factors that delay the activation of the Rapid Response Team (RRT) in the oncology settings? and (2) What are the differences in the perception of general staff and members of the RRT?

This paper discusses the perceptions of RRT system staff in the cancer care environment, how the teams are limited in terms of system use, and possibilities for improvement. Based on the participants' feedback, an attempt is made to offer thoughts on how RRT could be improved in terms of effectiveness.

2. METHODS

3. RESULTS

The demographic statistics are described in Table 1, which depicts the demographic profile of the participants: general staff (342) and RRT members (28). The female staff percentage of general staff was 57%, whereas the male staff percentage was 43%, whereas the RRT staff had a 50-50 balance of staff between male and female staff. Almost all general staff (99%) were from a clinical background, and only 1% were non-clinical. The largest number (61) in the RRT group was made up of staff nurses, followed by respiratory therapists (21) and critical care physicians (18). Regarding age, the largest segment (94%) was between the ages of 20 and 50 years, and RRT staff (89%) between the ages of 20 and 40 years. Concerning professional experience, the most frequent category of all staff (56%) and RRT staff (71%) was 6 to 15 years of service, with a smaller proportion of members having more than 15 years of service (21% and 13%, respectively).

The barriers and inhibiting factors in the activation process of the Rapid Response Team (RRT) by the staff from SQCCCRC are presented in Table 2 based on responses from 342 staff members. Among the identified barriers, lack of knowledge about recognition of when to activate RRT was the most commonly experienced barrier, especially in cases of slow or progressive clinical deterioration, and was identified by 27% of staff (n=92). Lack of consistent education on RRT and the perceived need to “justify” the decision to activate both penned a 22% response from participants (n = 75). Less commonly reported barriers were interdisciplinary hierarchy or chain of command (9%, n = 31); lack of perceived barriers (6%, n = 21); and increased workload of ICU or medical-surgical nurse (3%, n = 10). Other minimal causes were limited nursing experience (3% of the sample, n=10), never having called the RRT (3%, n=10), and isolated comments of negative experience with RRTs (1%, n=3).

Two of the most frequent inhibiting factors preventing the staff from activating the RRT, even when needed, were the lack of knowledge and inability to calculate the early warning score, which was among 15% of the staff (n = 51). This was followed by the need for mobilizing the RRT by the physicians (14%, n = 48) and team leaders (12%, n = 41). Additional factors that had close to the same occurrence were lack of knowledge about vital signs (11%, n = 38), inadequacy in knowledge associated with activating criteria (10%, n = 34), and a failure to detect the change in patient condition (9%, n = 31). Other important concerns were also mentioned, and they included fear of being reprimanded or blamed by the RRT (4% (n = 14), the negative or no response (5% (n = 17), as well as lack of policy awareness (6% (n = 21). Problems that were described rarely were a lack of a paging system (1%, n = 3) and multiple factors in general (1%, n = 3). These outcomes identify an uneducated and unstructured environment, which contributes to the delay and insufficient activation of the RRT.

Table 3 gives a narrative comparison of the top three frequently reported barriers to Rapid Response Team (RRT) activation - uncertainty about activation, perceived need to justify activation, and lack of RRT training - by gender, level of experience, and age among general staff at SQCCCRC (n=342). The results show that levels of concern differed according to staff demographics, and the test of statistical significance was the chi-square test.

The three barriers were noted more often by females than by males. The difference between the uncertainty about reporting activation was not statistically significant (29.2% vs. 23.8%; kh2 = 0.88, p = 0.348). Females, however, were significantly more likely to report a need to justify activation (23.1% vs. 20.4%; kh2 = 4.95, p = 0.026) and not offering routine RRT training (24.1% vs. 19.0%; kh2 = 5.78, p = 0.016). This raises the possibility of gender differences in confidence or self-assertion in RRT protocol initiation.

Employees with lower experience (0-5 years) suggested all three barriers at higher levels than the other experienced employees, with employees who had more than 15 years of experience suggesting all three barriers at a higher level. For instance, close to a third of early-career staff reported having uncertainty about activation when compared with a smaller proportion of the most experienced group. All three differences that related to the level of experience were statistically significant: uncertainty (kh2 = 7.85, p = 0.020), justification (kh2 = 6.94, p = 0.031), and lack of education (kh2 = 5.62, p = 0.034). These outcomes suggest a very real need for some specific support/training for less experienced professionals. Barriers reported more often by younger workers (20-50 years) than older workers (above 51 years) came to light with age-related differences. The younger group was less certain about activation (27.4% vs. 19.0%), although this was not statistically significant (kh2 = 3.41, p = 0.065). However, differences associated with justification of activation (21.8% vs. 23.8%) and lack of RRT education (21.8% vs. 23.8%) were statistically significant (kh2 = 4.99, p = 0.025 and kh2 = 4.76, p = 0.029, respectively), reinforcing the observation that younger staff might need more detailed communication and reinforcement of RRT procedures and policies.

Overall, the results show that younger, less experienced, and female staff are more likely to experience a barrier against or fellowship with RRT activation. This is why it is vital to have ongoing education, better communication about what needs to be activated, and strategies within organizations to ensure that all employees feel empowered to react effectively in an emergency.

The breakdown of the most common inhibiting factors for RRT activation in SQCCCRC at the gender, years of experience, and age level is presented in Table 4. Specifically, it focuses on three main barriers: reliance on physicians to trigger the RRT, misinterpretation of vital signs, and inability to calculate the Early Warning Score (EWS). Frequencies and percentages for each of the factors and the results of the chi-square (kh2) tests on the significance of the subgroups are shown in the table.

In terms of gender, these inhibiting factors were reported similarly for males and females in the staff. For example, 12.2% of male employees and 15.4% of female employees reported reliance on physicians to be activated in RRT. Similarly, 10.2% of males and 11.8% of females mentioned misinterpretation of vital signs, and 12.2% of males, when compared with 16.9% of females mentioned inability to calculate the EWS. None of these differences proved to be statistically significant because of p-values greater than 0.05 (p = 0.368, p = 0.579, and p = 0.267, respectively) at which gender had no significant effect on these inhibiting behaviors.

Contrarily, years of experience revealed a greater association with RRT activation barriers. Staff with 0-5 years of experience were found to be more likely to report reliance on physicians (20.0%) than those with 6-15 years (13.0%) and more than 15 years of experience (11.1%). This difference was calculated to be statistically significant (kh2 = 7.85, p = 0.019), which may indicate that less experienced staff may feel less sure-footed or empowered to make RRT calls on their own. Similarly, the inability to calculate the EWS was more common among newer staff (26.7%) compared with more experienced counterparts (13.0% for 6-15 years and 8.3% for >15 years), and this difference was also statistically significant [kh2 = 8.41, p = 0.015]. However, misinterpretation of vital signs (although more common among less experienced staff, 16.0%) did not differ significantly between the experience groups (kh2 = 4.22, p = 0.121).

Staff aged 20-50 years reported inhibiting factors a little bit more than those aged above 51 years. For instance, the use of physicians was stated by 14.0% of younger staffers compared to 14.3% of older staffers. Only one statistically significant difference was seen about physician dependence (kh2 = 4.11, p = 0.042), and the other indicators of misidentification of vital signs (i.e., misdiagnosis of hypotension) and inability to calculate EWS were not significantly different between age groups (p = > 0.05).

Table 5 describes the operational and setting issues RRT staff face during activation events. DNR-Related Issues and Inappropriate Handovers. These were the most reported activation-related issues (14% each, n = 4). These were followed by a lack of required tools or resources during activation (12%, n = 3) and communication issues between the physicians and the RRT (10%, n = 3). Overcrowded patient rooms with the presence of family (10%, n = 3), consultation about non-RRT related cases (8%, n = 2), inaccessibility of ward staff (8%, n = 2), and requests to perform non-RTT related tasks such as insertion of lines (8%, n = 2) were also reported. Less frequent problems included inappropriate responses of Code Blue (6%), not recognizing early deterioration (4%), and other responses that were selected (no issues, or all of the above) (2% each).

As for team member issues, the most common issue of concern was the concurrent responsibility of ICU patients during activation of RRT, which was reported by 34% of RRT staff (n = 10). This was followed by covering staff shortages (23%, n = 6) and time pressure associated with dealing with the deteriorating cases in the ICU (11%, n = 3). Other challenges included poor coordination of teams (11%, n = 3), being used outside the intended scope of the RRT (9%, n = 3), and a lack of physical space to perform RRT operations (7%, n = 2). A small proportion of the respondents (2%, n = 1) reported emotional and psychological stress and a lack of physician preparedness in the wards.

Table 6 gives suggestions for improving RRT activation and effectiveness at SQCCCRC from general staff and RRT members. Out of the general staff, educational intervention sessions on RRT (22%, n = 75), routine generation of early warning scores (17%, n = 58), and frequent RRT simulation (15%, n = 51) were the most frequent proposed interventions. Other suggestions included awareness campaigns (14%), visual reminders of RRT criteria or procedures (10%), and encouragement of independent decision-making (9%). Less commonly recommended but of note included re-emphasising RRT policy (7%, n = 24); learning from experience through unit-based discussions (3%, n = 10); promotion of a non-punitive culture (3%, n = 10), and meetings with junior doctors regarding deterioration recognition (1%, n = 3). Only a few respondents (3 or 1%) recommended implementing all improvements within one year.

Meanwhile, RRT members focused on making structural and operational improvements. The highest-ranked recommendation was for better team coordination (36% n = 10), followed by better communication and handover procedures (29% n = 8) and improved personnel levels during RRT calls (18% n = 5). Additional recommendations were better availability of equipment (13%, n=4), complete handovers by ICU physicians (2%, n=1), and readiness of RRT bag (2%, n=1). These findings suggest the need for the use of a combination of training, process support, and logistical preparedness to enhance the quality and timeliness of RRT interventions.

4. DISCUSSION

This study evaluated perceptions, barriers, and improvement strategies associated with the activation process of the Rapid Response Team (RRT) in an oncology facility. Insights from both general staff and members of RRT published mixed experiences with respect to how training and communication norms affect activation behaviors. Even though most of the participants had clinical training and experience in the middle of their careers, many of the general staff indicated difficulty deciding when RRT activation was warranted, especially when deterioration was not obvious or rapid. These trends are consistent with past research in acute care settings [1-3]. Awareness of the existence of RRT alone is not enough without the clarity of the criteria for activation, and reflects poor integration of the frameworks of rapid response into clinical decision-making [4-6].

One of the most reported barriers was the perceived need to justify the activation of RRT. This requirement may be due to the hierarchical structures and vague expectations within clinical teams. Junior or newly employed staff may not want to switch on the RRT out of fear of being criticized or negatively judged by senior colleagues, and this may cause delay in timely intervention [10, 11]. Fear of wrong decision-making and going beyond perceived authority also adds to hesitation.

Training gaps were also strong. Many staff described having little familiarity with early warning scores and trends of vital signs and no access to reliable and ongoing updates on RRT protocols. Tools like NEWS were often commented upon, and it was noted that some staff found calculation of scores, or understanding of triggering criteria, difficult. Prior studies have stressed the importance of early warning systems if they are to be effective, including ongoing organizational training and reinforcement [6-8].

Dependence on the physicians or team leaders to take the initiative to RRT activation was another theme repeatedly. This reliance could not come from negligence but could have a basis through unclear delineation of roles or negative experiences in the past. Hesitation represents uncertainty about responsibility and is associated with fear of exceeding the professional boundaries, which is consistent with the literature on interprofessional communication and teamwork dynamics [13, 14].

Younger and less experienced staff were more likely to report these challenges. Respondents with less experience often had uncertainty and fear of being judged, and confidence in recognizing patient deterioration. These findings are consistent with prior studies suggesting that novices in the professions will display limited instances of clinical autonomy and escalation behavior due to lack of experience and organizational support [11, 14]. Younger staff also pointed out gaps with respect to policy awareness and EWS training and highlighted gaps in orientation and mentorship.

These findings suggest that challenges are more than just those associated with training. New nurses may not be confident and not supported well enough to make decisions for escalation, and this may lead them to fear being criticized or going wrong. Empowerment frameworks propose that inclusion in planning, simulation-based training, and opportunities for feedback may contribute to confidence and promote the use of RRT as patient conditions get worse.

RRT members experienced unique activation challenges such as a lack of suitable equipment, poor communication during handover, and the absence of clear DNR documentation. Such logistical and process-related issues have been widely documented as contributing factors to delayed response time [4, 16]. In addition, systemic pressures such as ICU workload, staff shortages, and emotional burnout, especially balancing the ICU job with emergency response, were emphasized [14, 15].

General staff often suggested more simulations, visual cues, educational programs, and regular awareness programs to enhance RRT activation. Quality improvement models such as FOCUS-PDSA have been shown to be effective in improving escalation skills and avoiding clinical errors [18-20]. Staff perceived that such training would make them less apprehensive and normalize RRT activation.

In contrast, members of RRT focused on improving areas at the system level, such as improving handover processes, regular replenishment of emergency kits, and better team communication. Adequate ICU support through activations was also mentioned [20-25]. These difficulties are associated with the efferent limb of the fast response system, where inefficiencies account for possible delays and miscommunication [1, 9].

The oncology care environment exaggerates these difficulties. Symptoms associated with oncology patients are often vague or are linked to the treatments being received, so it can be hard to determine the difference between expected changes and critical deterioration [20-25]. Emotional stress linked to caring for complex or end-stage cases makes decisions on escalations even more complex. Despite the urgency and unique demands of oncology environments, the field of RRT research is sparse in this area [3], a gap that highlights the need for specific research and interventions in this area.

5. STUDY LIMITATION

Key limitations are the single-center design, making generalization to other oncology or general hospital settings. One of the problems relating to the use of self-reported surveys is the potential for response bias, especially with respect to the perception of challenges and staff behaviour. As the nature of the study is cross-sectional, this allowed zero conjecture between characteristics of staff and activation patterns. Although the sample size was sufficient, the subgroup of RRT was relatively small (n = 28), which may have limited the validity of subgroup comparisons. The general staff Response rate did not go to 50%; this would imply possible non-response bias and that certain perspectives are underrepresented. These factors should be kept in mind when interpreting the results or applying them to other situations.

6. RECOMMENDATIONS AND PRACTICAL IMPLICATION

In light of the findings, oncology institutions are encouraged to strengthen training efforts - specifically pertaining to the issue of when to activate the RRT, how to interpret early warning scores, and making clinical calls during the early signs of decline. A higher frequency of simulations, as well as mixed role practice, may help give junior or less experienced staff a greater sense of preparedness, as well as adjustment to hesitancy. Hospital policies may also need to be modified to better support staff autonomy and reduce the effects of hierarchy that often is a reason for delay. On the tech side, configuring automatic EWS tools and having visual reminders all across clinical areas might aid in faster decision-making and visually consistent awareness. Communication needs attention too--the use of standard formats when getting information to the handovers can be a way to avoid confusion. For RRT members, staffing and ICU pressures were an overarching concern, and improving staffing during activations could make a big difference in how fast and effectively the team was able to respond. Management should take a look at the current model of staffing of the RRT to minimize conflict between work in the ICU and RRT activations, to ensure that the team can respond rapidly and without divided responsibility. A simple digital tool could also be created for the RRT to be activated uniformly and for the calculation of the Early Warning Score to be automatically determined. Using an SBAR-based format (Situation, Background, Assessment, Recommendation) would help to increase communication and reduce uncertainty during the activation.

CONCLUSION

This study provides a closer look at some of the multi-layered issues that contribute to the decision about how and when to activate a Rapid Response Team in oncology care. Educational shortfalls, unclear protocols, and the effects of team hierarchy stood out as major reasons why escalation may be delayed. Of particular interest, staff who were younger, female, or less experienced were more likely to report these challenges. On the other end, input from RRT members provided insight into the larger operational issues that include resource gaps and workflow burden during emergencies. Addressing these concerns will require some combination of specific training, cultural changes that foster staff confidence, and structural changes at the system level - particularly in specialized environments, as in cancer centers, where quick decisions are vital. The result of having many people in the RRT who have to juggle ICU duties while on activations also demonstrates the need for management to enhance the structure of the rapid response system.

REFERENCES