Marjon Borgert

34 Chapter 2 To our knowledge, only one study has shown insight in the degree of implementation of the RRS protocol. Shearer et al. explored the causes of the lack of compliance to the RRS protocol using a mixed-method design. 28 In our study, we also give insight in the degree of implementation by describing the level of compliance of the MEWS measurements and the activations of the primary physician and/or RRT. Until now, data on e ectiveness of RRS shows con icting outcomes. 1,2 E ectiveness of any kind of intervention depends on the degree of implementation. The number of RRT activations has been directly linked to a decrease in incidence of AE 16 . However, e ectiveness of RRS depends onmore than only the dose of RRT. 14 A erent limb failure and delayed detection of deteriorating patients is associated with worse clinical outcome. 29 Obviously, e ectiveness also depends on compliance with the protocol, 30 and the degree of monitoring on wards, 20,31 bothofwhichare inmany studies not reported. 3 Todateno trials have linked the reliability of measuring vital signs and MEWS to RRS performance. We show an improvement on protocolized wards, though reasons for the almost complete failure to calculate MEWS on control wards are not clear. Miscalculations of the MEWS 32 , and incomplete ‘routine sets’ of observations in which respiratory rate is often not incorporated, may provide part of the explanation. 19 To which extend these factors and errors in uence individual patient outcome, remains unknown. Despite the intense nature of the implementation process, unfamiliarity with the protocol may still have been present in our study. It is more likely though that there is a knowledge de cit regarding recognition of abnormal vital signs. 33,34 Early admission to the ICU is directly correlated with improved survival. 35 It is imperative that escalation of care and early noti cation of responders is without any delay. In our study, no delay in noti cation of the physician prior a RRT call was found in 51% (29/57) of protocol versus in 50% (2/4) of the patients on control wards. It should however be noted that on control wards delays were di cult to interpret due to omissions in the recording of measurements in vital signs. Therefore, comparisons between both study arms regarding the presence of delay are fraught with di culty. Although this study was not designed to analyze the e ect on clinical outcomes, we did observe an interesting trend in a decrease of AE. Protocol wards and to a lesser extent control wards, showed increased utilization of the RRT, better compliance with the MEWS protocol and a decrease in AE. This may mirror the presence of a dose/response relationship between the dose of RRT calls and improved clinical outcomes found by others. 16 It ispossible that observeddi erencesbetweengroups are in uenceddue to the so called Hawthorne e ect. Since nurses from control wards might have been informed about the intervention. This in our opinion could have led to an underestimation of the observed di erences. The fact that patients assessed by the RRT on protocolized wards