Marjon Borgert

15 General introduction and outline of the thesis AIM AND OUTLINE OF THIS THESIS This thesis focuses on the implementation of strategies for improving patient safety and quality of care for critically ill patients by encouraging the uptake and implementation of best practices. Part I focuses on improving patient safety for critically ill patients on nursing wards by implementing a rapid response system with support from the ICU. Part II focuses on improving patient safety for critically ill patients in the ICU by implementing evidence- based care bundles. Part I. Improving patient safety for critically ill patients on nursing wards Serious adverse events such as unplanned admission to an ICU, cardiac arrest, and unexpected death are often preceded by changes in vital sign observations. 30,31 In this respect, they are thus predictable. 30,31 However, hospital sta do not always recognize these signs in time, or do not act on them in an adequate or timely fashion. 32 Failure to recognize or respond adequately to the deteriorating patient can lead to a delay in treatment, which can subsequently lead to serious adverse events such as cardiopulmonary resuscitation or even death. 32-34 Rapid response systems (RRSs) are developed to improve care for the deteriorating patient. RRSs have ‘a erent’ (criteria for detecting deterioration) and‘e erent’(responsive) arms. 35 The a erent arm is concerned with recognizing the patient’s condition prior to deterioration using a ‘track-and-trigger system’, such as the modi ed early warning score (MEWS). 36 The e erent arm is designed to trigger response by the rapid response team (RRT). 35 This team generally consists of ICU physicians and ICU nurses, and is designed to respond within 10 minutes for evaluation, triage, and treatment of patients who clinically deteriorate on a nursing ward and to prevent them from su ering a serious adverse event. 37 Part I consists of the following two chapters. Chapter 2 describes the e ects of di erent MEWS implementation strategies on nursing wards. Nursing wards were randomized to measure the MEWS either three times daily or on indication (i.e. if one or more vital signs were abnormal). In this quasi-experiment, we studied the e ects of protocolized measurement (i.e. three times daily) of the MEWS versus measurement on indication. In Chapter 3 , we retrospectively analyse the ‘false arrests’ to determine the ‘level of urgency’ of these false arrests to nd scope for improving e ciency within emergency care.