A practical approach to establishing a critical care outreach service: An expert panel research design

BackgroundFor over two decades, nurse-led critical care outreach services have improved the recognition, response, and management of deteriorating patients in general hospital wards, yet variation in terms, design, implementation, and evaluation of such services continue. For those establishing a critical care outreach service, these factors make the literature difficult to interpret and translate to the real-world setting.AimThe aim of this study was to provide a practical approach to establishing a critical care outreach service in the hospital setting.MethodAn international expert panel of clinicians, managers, and academics with experience in implementing, developing, operationalising, educating, and evaluating critical care outreach services collaborated to synthesise evidence, experience, and clinical judgment to develop a practical approach for those establishing a critical care outreach service. A rapid review of the literature identified publications relevant to the study. A modified Delphi technique was used to achieve expert panel consensus particularly in areas where insufficient published literature or ambiguities existed.FindingsThere were 502 publications sourced from the rapid review, of which 104 were relevant and reviewed. Using the modified Delphi technique, the expert panel identified five key components needed to establish a critical care outreach service: (i) approaches to service delivery, (ii) education and training, (iii) organisational engagement, (iv) clinical governance, and (v) monitoring and evaluation.ConclusionAn expert panel research design successfully synthesised evidence, experience, and clinical judgement to provide a practical approach for those establishing a critical care outreach service. This method of research will likely be valuable in other areas of practice where terms are used interchangeably, and the literature is diverse and lacking a single approach to practice.     

A review of rapid response team activation parameters in New Zealand hospitals

Objective

To review current systems for recognising and responding to clinically deteriorating patients in all New Zealand public hospitals.

Design

A cross-sectional study of recognition and response systems in all New Zealand public hospitals was conducted in October 2011. Copies of all current vital sign charts and/or relevant policies were requested. These were examined for vital sign based recognition and response systems. The charts or policies were also used to determine the type of system in use and the vital sign parameters and trigger thresholds that provoke a call to the rapid response team.

Setting

All New Zealand District Health Boards (DHBs).

Main outcome measures

Physiological parameters used to trigger rapid response, the weighting of any early warning score assigned to them, type of system used, values of physiological derangement that trigger maximal system response.

Results

All DHBs use aggregate scoring systems to assess deterioration and respond. A total of 9 different physiological parameters were scored with most charts (21%) scoring 6 different parameters. All scored respiratory rate, heart rate, systolic blood pressure and conscious level. 86% scored oliguria, 14% polyuria, 33% oxygen saturation and 24% oxygen administration. All systems used either aggregate scores or a single extreme parameter to elicit a maximal system response. The extremes of physiological derangement to which scores were assigned varied greatly with bradypnoea having the greatest range for what was considered grossly abnormal.

Conclusion

A large variance exists in the criteria used to detect deteriorating patients within New Zealand hospitals. Standardising both the vital signs chart and escalation criteria is likely to be of significant benefit in the early detection of and response to patient deterioration.     

Clinicians’ attitudes towards escalation and management of deteriorating patients: A cross-sectional study

BackgroundInternationally, rapid response systems have been implemented to recognise and categorise hospital patients at risk of deterioration. Whilst rapid response systems have been implemented with a varying amount of success, there remains ongoing concern about the lack of improvement in the escalation, and management of the deteriorating patient. It also remains unclear why some clinicians fail to escalate concerns for the deteriorating patient.ObjectiveThe objective of this study was to explore clinicians’ attitudes towards the escalation, and management of the deteriorating patient.MethodsA cross-sectional online survey of conveniently sampled clinicians from the acute care sector in a regional health district in Australia was conducted. The Clinicians’ Attitudes towards Responding and Escalating care of Deteriorating patients scale, was used to explore attitudes towards the escalation and management of the deteriorating patient.ResultsSurvey responses were received from medical officers (n = 43), nurses (n = 677), allied health clinicians (n = 60), and students (n = 57). Years of experience was significantly associated with more confidence responding to deteriorating patients (p < .001) and significantly less fears about escalating care (p < .001). Nurses (M = 4.16, SD = .57) and students (M = 4.11, SD = .55) in general had significantly greater positive beliefs that the rapid response system would support them to respond to the deteriorating patient than allied health (M = 3.67, SD = .64) and medical (M = 3.87, SD = .54) clinicians, whilst nurses and medical clinicians had significantly less fear about escalating care and greater confidence in responding to deteriorating patients than allied health clinicians and healthcare students (p < .001).ConclusionNurses and medical officers have less fear to escalate care and greater confidence responding to the deteriorating patient than allied health clinicians and students. Whilst the majority of participants had positive perceptions towards the rapid response system, those with less experience lacked the confidence to escalate care and respond to the deteriorating patient.     

The impact of implementing a rapid response system: A comparison of cardiopulmonary arrests and mortality among four teaching hospitals in Australia

Aims

To compare clinical outcomes between a teaching hospital with a mature rapid response system (RRS), with three similar teaching hospitals without a RRS in Sydney, Australia.

Methods

For the period 2002–2009, we compared a teaching hospital with a mature RRS, with three similar teaching hospitals without a RRS. Two non-RRS hospitals began implementing the system in 2009 and a third in January 2010. We compared the rates of in-hospital cardiopulmonary arrest (IHCA), IHCA-related mortality, overall hospital mortality and 1-year post discharge mortality after IHCA between the RRS hospital and the non-RRS hospitals based on three separate analyses: (1) pooled analysis during 2002–2008; (2) before–after difference between 2008 and 2009; (3) after implementation in 2009.

Results

During the 2002–2008 period, the mature RRS hospital had a greater than 50% lower IHCA rate, a 40% lower IHCA-related mortality, and 6% lower overall hospital mortality. Compared to 2008, in their first year of RRS (2009) two hospitals achieved a 22% reduction in IHCA rate, a 22% reduction in IHCA-related mortality and an 11% reduction in overall hospital mortality. During the same time, the mature RRS hospital showed no significant change in those outcomes but, in 2009, it still achieved a crude 20% lower IHCA rate, and a 14% lower overall hospital mortality rate. There was no significant difference in 1-year post-discharge mortality for survivors of IHCA over the study period.

Conclusions

Implementation of a RRS was associated with a significant reduction in IHCA, IHCA-related mortality and overall hospital mortality.     

Proactive rounding by the rapid response team reduces inpatient cardiac arrests

Objective

Rapid response teams (RRTs) are frequently employed to respond to deteriorating inpatients. Proactive rounding (PR) consists of the RRT nurse rounding through the inpatient wards identifying high risk patients and intervening preemptively. At our institution, PR began in July of 2007. Our objective was to determine the effect of PR by the RRT at our institution on non-ICU cardiac arrests, code deaths, RRT interventions, and transfers to a higher level of care. Also, to report ICU transfer survival and survival to discharge rates after the start of PR.

Design

Retrospective review of a prospectively collected database.

Setting

A tertiary, academic, level 1 trauma center with 696 beds and a rapid response system.

Patients

1253 Non-ICU cardiac arrests from 2005 through June of 2012.

Interventions

None.

Measurements and main results

The total study period included 223,267 inpatient admissions (70,129 pre-PR and 153,138 post-PR) and 1,250,814 patient days (391,088 pre-PR and 859,726 post-PR). The quarterly code rate before PR was 66 and the code rate after the institution of PR was 30 (difference = 36.8, 95% CI 25.6–48.0, p < .001). Quarterly code deaths decreased from 29 to 7 (difference = 21.95, 95% CI 16.3–27.6, p < .001). This decrease in floor codes and code deaths was still present after adjusting for inpatient admission and inpatient days. Average quarterly RRT interventions increased from 141 in the pre-PR period to 690 in the post-PR period (difference = 549, 95% CI 360–738, p < .001). Average quarterly transfers to HLC went up from 38 pre-PR to 164 post-PR (difference = 126, 95% CI 79–172, p < .001).

Conclusions

The institution of proactive rounding at a tertiary care, academic, level 1 trauma center results in reduced floor codes and code deaths as well as increased RRT interventions and transfers to a higher level of care.     

The impact of rapid response systems on mortality and cardiac arrests – A literature review

BackgroundRapid response systems were created to improve recognition of and response to deterioration of general ward patients.AimThis literature review aimed to evaluate the evidence on whether rapid response systems decrease in-hospital mortality and non-intensive care unit cardiac arrests.MethodSix databases (MEDLINE, Cochrane Central Register of Controlled Trials, Cumulative Index of Nursing and Allied Health Literature, SCOPUS, Web of Science and PubMed) were systematically searched for primary studies published between 1st January 2014 and 31st October 2017, recruiting general ward patients, where the intervention involved introducing/maintaining a rapid response system, the comparison referred to a hospital setting without a rapid response system and the outcomes included mortality and cardiac arrests.ResultsFifteen studies met eligibility criteria: one stepped wedge cluster randomised controlled trial, one concurrent cohort controlled study and thirteen historically controlled studies. Thirteen studies investigated mortality of which seven reported statistically significant findings in favour of rapid response systems. Thirteen studies investigated cardiac arrests, of which eight reported statistically significant findings in favour of rapid response systems.ConclusionEvidence suggests that when the process of introducing/maintaining a rapid response system is successful and under certain favourable conditions, rapid response systems significantly decrease mortality and cardiac arrests.     

Evaluation of a patient and family activated escalation system: Ryan's Rule

IntroductionPatients experience physiological changes in the hours preceding adverse medical events, and patients or their family can be the first to identify ominous signs of clinical deterioration that have gone undetected by health professionals. Patient and family activated escalation systems provide consumers access to a referral system that can address their concerns. In Queensland, this escalation system is called Ryan's Rule and once activated, triggers an independent clinical review. This study aimed to access clinicians' and activators' experiences to develop an understanding of the incidence, contributing factors, and outcomes surrounding Ryan's Rule activations.MethodThe study involved a retrospective chart review of Ryan's Rule (n = 57) activations in a regional hospital, over a 24-month period.ResultsOn average, there were 2.4 activations a month. There are three major findings: first, communication issues were central to more than half the activations, 35% of cases required no clinical intervention, with communication alone sufficient to achieve resolution. Second, this initiative was valued with 65% of activators stating that they would be comfortable calling again and having access to the escalation process was reassuring and improved communication between clinicians and patients. While clinicians doubted the appropriateness of activators use of the escalation tool, 15% of patients were transferred to receive a higher level of care. Lastly, clinicians labelled activations as a ‘complaints’ as opposed to a ‘concern’ and reasoned that a ‘complaint’ did not justify a full review of the consumer's perspective for the activation.ConclusionConsumers who activated a Ryan's Rule were satisfied and valued the process. It provides a reassuring safety net, empowering them to speak up and initiate a clinical review. Clear communication among clinicians and between clinicians and consumers is essential. Clinicians are hesitant to fully embrace Ryan's Rule, and this discordance contributes to the failure to fully evaluate reasons for call activation.     

The use of altered rapid response calling criteria in a tertiary referral facility

PurposeThe purpose of this study was to examine the current utilisation of altered rapid response calling criteria (ARRCCs) at a tertiary hospital.MethodsA retrospective review of all acute care admissions across 17 months was undertaken using the hospital administration system and electronic medical record to identify patients with ARRCCs. In patients with altered criteria, the type of alteration, frequency of rapid response calls, cardiac arrest, intensive care admission, and death in the hospital were identified. Comparisons were made using standard statistical methods.ResultsThe total hospital admissions numbered 45 912, with ARRCCs used in 768 (1.7%). Patients with an ARRCC during hospital admission were older (68.5 [55.5, 79.0] vs 59.0 [43.0, 72.0] years, p < 0.001) and had a significantly longer length of hospital stay (6.9 [3.0, 16.3] vs 2 [1, 5] days, p < 0.001).Compared with the total group of patient admissions, patients with ARRCCs more frequently triggered a rapid response team (9.0% vs 14.2%, χ²(1, n = 46 680) = 23.87, p < 0.001), more frequently suffered a cardiac arrest (0.2 vs 0.9%, χ²(1, n = 46 678) = 20.34, p < 0.001), more frequently died in the hospital (p < 0.001), and were less frequently discharged home (χ²(1, n = 46 680) = 43.91, p < 0.001).ConclusionPatients with an ARRCC stayed longer in the hospital and were at increased risk of cardiac arrest and death during hospitalisation. Further exploration of the role of ARRCCs in facilitating individualised care to meet the needs and treatment goals of each patient in the acute hospital setting is required.     

Barriers to activation of the rapid response system

Background

The rapid response system (RRS) has been widely implemented in the US. Despite efforts to encourage activation of the RRS, adherence to activation criteria remains suboptimal. Barriers to adherence to RRS activation criteria remains poorly understood.

Objective

To identify barriers associated to activation of the RRS system by clinical staff.

Methods

Physicians and nurses on the medical and surgical wards of a New York City community hospital were surveyed to identify barriers to six criteria for activation of the RRS. A paper questionnaire was disseminated. We assessed familiarity with, agreement with, and recognition of perceived benefit of the RRS calling criteria using a Likert scale. Self-reported adherence to RRS activation was also measured on a Likert scale. Logistic regression was used to assess the association between the barriers and the six RRS criteria.

Results

Sixty eight physicians and 16 nurses completed the survey; response rates were 59% and 35%, respectively. Self-reported adherence rate was ≤25% for the six criteria. We observed that as the familiarity with, agreement with, and perceived benefit of activating the RRS increases, the self-reported adherence also increases.

Conclusions

Adherence to activation of RRT based on the six criteria measured is low. As familiarity with, agreement with, and perceived benefit of the RRS activating criteria rise, self-reported adherence rates increase, with familiarity having the greatest impact. These results can be used to develop tailored interventions to increase adherence to RRT activation in health care institutions.     

Timing of palliative care team referrals for inpatients receiving rapid response services: A retrospective pilot study in a US hospital

Background/objectivesResearch indicates up to one-third of rapid response team calls relate to end-of-life symptoms. The CriSTAL criteria were developed as a screening tool to identify high risk of death within three months. The primary purpose of this pilot study was to investigate the timing of palliative care referrals in patients receiving rapid response team services, and patients’ CriSTAL criteria score on admission. The potential feasibility of using the CriSTAL tool to stimulate earlier Palliative Care Team (PCT) referral served as an underlying goal, and investigation of a relationship between specific CriSTAL criteria and the prediction of in-hospital death was a secondary objective.DesignA retrospective chart review of rapid response calls made in 2015 was used to identify patient risk of death on admission based on the CriSTAL criteria. The presence and timing of PCT referral as well as patient survival status to hospital discharge were documented for comparison.Setting/participantsA sample of 183 charts from 584 inpatients involved in over 600 RRT events recorded in 2015. The study was undertaken in a 676-bed teaching hospital in the Midwestern U.S.Methods/resultsNinety-one patients died during the hospital stay while 92 patients from the 493 individuals who survived were randomly selected for full analysis. Applying CriSTAL criteria to the 141 individuals aged 50 years or older indicated that frailty (OR = 1.43, 95%CI 1.08–1.89, p = 0.012), being a male (OR = 3.14; 95%CI 1.40–7.05, p = 0.006), and the presence of two or more comorbidities (OR = 3.71, 95%CI 1.67–8.24, p = 0.001) were the most significant predictors of in-hospital death after adjusting for age. A CriSTAL score of 6 was the optimal cut-off for high-risk of in-hospital death. Palliative care consultations within the high-risk population occurred for 45.2% of the deceased and 40.4% of the survivors. Consultation often occurred within two days of the RRT event and many patients (46.8%) died within one day of the consultation.ConclusionA positive relationship was found between the CriSTAL score, palliative care referral, and in-hospital mortality in patients who received RRT services. The study indicates a need for earlier PCT referral, showcases the potential to identify high risk of in-hospital death upon admission and supports the feasibility of using the CriSTAL criteria tool to encourage earlier PCT referrals.     

Family initiated escalation of care for the deteriorating patient in hospital: Family centred care or just “box ticking”

Family centred care is a shared belief that a child's emotional and developmental needs are best met when the health system involves the family in planning, delivery and evaluation of care. The important role that families contribute to health care outcomes is emphasised throughout the National Safety and Quality Healthcare Service (NSQHS) Standards. An emerging component is the family's contribution to Rapid Response Systems (RRS) through the early detection of patient clinical deterioration. This initiative has been driven, in part, by a number of high profile paediatric cases where it was identified that healthcare providers did not appropriately respond to families’ concerns, resulting in patient deaths. This paper draws together the synergies between family centred care concepts, the NSQHS Standards, and the progress made to date in developing a family initiated process for escalating care with specific reference to paediatric acute care.A number of programs have been developed to guide implementation of family escalation of care. Measures of effectiveness of implementation have mainly focused on policy and process without first understanding barriers or facilitators through engagement with stakeholders and environmental assessment. Two recent reviews have not identified any rigorous attempts to evaluate implementation and only 11 reports are cited across these reviews to date. Evaluation of effectiveness of this complex intervention should take into account process measures of fidelity, dose and reach. There is also a need to assess the impact on families, particularly within a diverse cultural mix. An agreed definition for a paediatric RRS patient outcome measure is essential in evaluating the impact on patient safety and quality. Without this systematic evidence informed knowledge translation approach, then it would appear that progress in implementing family initiated deterioration of condition processes is more about meeting the NSQHS Standards – ticking the box – than genuine engagement with families.     

Duration and management of sepsis-associated hypotension at rapid response team call-outs to patients subsequently admitted to the intensive care unit: A case series

BackgroundSepsis-related hypotension in hospital patients is a common reason for rapid response team (RRT) attendance and transfer to intensive care, but little is known about the duration and management of hypotension during these RRT call-outs.ObjectivesWe aimed to describe the duration and management of hypotension during RRT call-outs to patients with sepsis-related hypotension who required transfer to intensive care.MethodsRRT call-outs during 2018 for hypotension with transfer to intensive care were identified from a prospectively maintained database of RRT call-outs at a single tertiary hospital. From these, the records of a random sample of 60 cases were reviewed, and those attributed to sepsis and without missing data were described. Hypotension was defined as systolic blood pressure < 90 mmHg.ResultsThere were 117 RRT call-outs for hypotension with transfer to intensive care, and of the 60 cases randomly chosen for further review, 41 were deemed sepsis related and were not missing data. The average age of the patients was 62 years, and 18 (44%) were already receiving antibiotics. The median time to arrival in the intensive care unit was 47 minutes. Patients were hypotensive for approximately two-thirds of their RRT time, despite 88% receiving some initial resuscitative treatments (fluids and/or vasopressors). Thirty-two (78%) were treated with intravenous fluids, and 20 (49%), with vasopressors. Patients spent 3 [2-4] days in intensive care, and 7 (17%) died in hospital.ConclusionsPatients with sepsis-related hypotension requiring an RRT call and transfer to intensive care remain hypotensive for a substantial duration of the call. This concept of adequacy of resuscitation after rapid response calls needs further exploration in a larger study.     

The epidemiology of rapid response team activation amongst patients undergoing major gastrointestinal surgery

BackgroundClinical deterioration requiring rapid response team (RRT) review is associated with increased morbidity amongst hospitalised patients. The frequency of and association with RRT calls in patients undergoing major gastrointestinal surgery is unknown. Understanding the epidemiology of RRT calls might identify areas for quality improvement in this cohort.ObjectivesThe objective of this study is to identify perioperative risks and outcome associations with RRT review following major gastrointestinal surgery.MethodsWe conducted a retrospective cohort study using electronic databases at a large Australian university hospital. We included adult patients admitted for major gastrointestinal surgery between 1 January 2015 and 31 March 2018.ResultsOf 7158 patients, 514 (7.4%) required RRT activation postoperatively. After adjustment, variables associated with RRT activation included the following: hemiplegia/paraplegia (odds ratio [OR]: 8.0, 95% confidence interval [CI]: 2.3 to 27.8, p = 0.001), heart failure (OR: 6.9, 95% CI: 3.3 to 14.6, p < 0.001), peripheral vascular disease (OR: 5.3, 95% CI: 2.7 to 10.4, p < 0.001), peptic ulcer disease (OR: 4.2, 95% CI: 2.2 to 8.0, p < 0.001), chronic obstructive pulmonary disease (OR: 4.0, 95% CI: 2.2 to 7.2, p < 0.001), and emergency admission status (OR: 2.6, 95% CI: 2.1 to 3.3, p < 0.001). Following the index operation, 46% of first RRT activations occurred within 24 h of surgery and 61% had occurred within 48 h. The most common triggers for RRT activation were tachycardia, hypotension, and tachypnoea. Postoperative RRT activation was associated with in-hospital mortality (OR: 6.7, 95% CI: 3.8 to 11.8, p < 0.001), critical care admission (incidence rate ratio: 8.18, 95% CI: 5.23 to 12.77, p < 0.001), and longer median length of hospital stay (12 days vs. 2 days, p < 0.001) compared to no RRT activation.ConclusionAfter major gastrointestinal surgery, one in 14 patients had an RRT activation, almost half within 24 h of surgery. Such activation was independently associated with increased morbidity and mortality. Identified associations may guide more pre-emptive management for those at an increased risk of RRT activation.     

Prognostic value of the calling criteria in patients receiving a medical emergency team review

Aim

To describe the reasons for medical emergency team (MET) activation, and to verify the association of the MET score with 30-day mortality.

Methods

This retrospective observational study took place in a 794-bed university-affiliated hospital. The population included all adult admissions reviewed by the MET during the period between January 2007 and June 2008. MET score was defined as the sum of each of the physiological triggers, and score zero was considered the calls made due to concern about the patient, without any physiological alteration.

Results

During the period of the study, 1051 calls were generated for 901 patients. Respiratory distress and hypotension accounted for most of MET calls. The triggers that showed an independent association with mortality were threatened airway, systolic blood pressure <90 mmHg, decrease in Glasgow Coma Scale score ≥2 points and respiratory frequency >36 breaths/min. Logistic regression analysis revealed MET score, age, medical patient, documented do not resuscitate orders and MET decision to transfer to the intensive care unit to be significant predictors of 30-day mortality.

Conclusions

MET score presents a strong association with 30-day mortality in patients seen on the ward.     

Electrocardiogram interpretation during nurse triage improves the performance of the triage system in patients with cardiovascular symptoms – A prospective observational study

BackgroundAn immediate ECG on arrival of a patient with cardiovascular symptoms in the ED may anticipate the need for life-saving intervention. The aim was to evaluate whether ECG interpretation during nurse triage can improve triage system performance in patients with cardiovascular symptoms.MethodsAll patients who required an assessment for cardiovascular symptoms were considered for this observational study. During triage assessment, the nurses assessed the patient's level of urgency applying the MTS, then again after this evaluation (confirming or modifying the level of urgency based on personal clinical experience) and after interpretation of the patient’s ECG. The main study outcome was the diagnosis of an acute cardiovascular event.ResultsOf the 1211 patients in the study, 10.5% presented the main study outcome. ECG interpretation in triage exhibited a nurse–physician agreement of 92.9% (p<0.001). increased patient priority in 7.5% of cases and reduced it in 39.6%. The discriminatory ability of the triage system had an area under the ROC of 0.712 and 0.845 after ECG interpretation. ECG interpretation improved the baseline assessment of priority, with an NRI of 60.1% (p<0.001).ConclusionsECG interpretation in triage can be a simple and safe tool that improves the assessment of patient priority.     

The role of the intensive care nurse in the medical emergency team: A constructivist grounded theory study

BackgroundIntensive care nurses are essential members of rapid response systems (RRSs) with little qualitative data available to capture what intensive care nurses do as they navigate their way around the complexity of a medical emergency call.ObjectiveThe study aims to describe and explain the role of the intensive care nurse within the medical emergency team (MET) of a tertiary-level hospital to develop an understanding of the intensive care nurse role, the way it is enacted, and their responsibilities within the team.MethodA constructivist grounded theory research approach collected qualitative data from intensive care nurses who had experience attending MET calls. Data were collected through participant observation (16 MET calls), followed by 12 semistructured interviews.FindingsA substantive theory was developed that ‘keeping patient's safe’ is a fundamental role of the intensive care nurse within the MET. This is derived from four key concepts: Systematic framework for decision making, Figuring it out, Directing care, and Patient safety. Each of these concepts was developed from categories that describe the role of the intensive care unit nurse on the MET. They include performing assessments and interventions, figuring it out, critical thinking, prioritising care, directing care, being supportive, and ensuring patient safety.ConclusionThis study provides new insights into and an understanding of the ways intensive care nurses work within the MET, making a significant contribution to our existing understanding of the role.     

Use of the pre-medical emergency team tier of rapid response systems: A scoping Review

ObjectiveThe aim of this review was to explore use of the pre-Medical Emergency Team (pre-MET) tier of Rapid Response Systems to recognise and respond to adult ward patients experiencing early clinical deterioration.MethodsA scoping review of studies published in English reporting on use of a pre-MET tier in adult ward patients was conducted. Three databases were searched (Medline, CINAHL, EMBASE) for studies published between January 1995 and September 2020. Two researchers independently performed screening and quality assessments. Findings were synthesised thematically. Reporting of the review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews.ResultsSix of 1669 studies were included in this review. All were single-site studies of single-parameter Rapid Response Systems in Australian hospitals. Five were quantitative studies; one had a qualitative design. Studies fulfilled 50–100% of quality criteria. Two themes were constructed: Afferent processes – Recognising and escalating pre-MET events; and Efferent processes – Pre-MET reviews and associated interventions. There was disparity between clinical practice and pre-MET escalation protocols, and reports of nurse-initiated management of early deterioration. Prospective methods and exploration of multidisciplinary perspectives were notable research gaps.ConclusionUse of the pre-MET tier of Rapid Response Systems is under-researched. Further research is needed to understand barriers and facilitators influencing use of pre-MET strategies to address patient deterioration.