Rapid Response Team Activation Research Articles

Improved intensive patient prognosis by earlier activation of rapid response teams and timely response

Background: The prognosis of hospitalised patients requiring ICU admission depends on the time since onset of clinical deterioration. The objective of this study was to assess differences between hospital-ward patients admitted to the intensive care unit (ICU) with persistent clinical deterioration measured by a patient at risk (PR) score and those admitted at an earlier stage of deterioration. Methods: Retrospective analysis was conducted of patients admitted to the ICU from hospital wards between January and July 2013. During this period, a protocol was in place to assess the PR on hospital wards. We gathered data on demographic characteristics, clinical risk scores, PAR scores and trigger criteria. A delayed alert was defined as a PAR score >2, or ≥2 warning signs in systemic blood pressure or peripheral pulse oximetry saturation assessments between 8 and 24 h before ICU admission. Delayed alerts and other variables were compared using Student’s t, Mann Whitney U or X2 tests, as appropriate, with p<0.05 considered significant. Results: During the study, there were 80 admissions of 69 patients (Mean age: 67.91 years, standard deviation: 13.85). Alerts were most frequently circulatory (33.7%) or respiratory (30%) related, and made by physicians on duty (85.2%). In the 33 delayed alerts, patients had higher APACHE II and SAPS II scores and incidence of multiple organ dysfunction syndrome (MODS), and tended to have longer ICU admission; while other variables were similar. Conclusions: Patients admitted to the ICU after late assessment of their clinical status using a PR score have higher APACHE and SAPS scores and MODS rate and possibly longer ICU stays. Scoring systems may promote timely assessment and treatment on hospital wards.

Factors Influencing Registered Nurses' Decision to Activate an Adult Rapid Response Team in a Community Hospital.

One factor impacting patient outcomes in the acutely deteriorating patient is a delay by nursing staff to activate a rapid response team (RRT); however, a gap in knowledge exists concerning factors influencing activation of an RRT by nursing staff working in adult areas outside the medical-surgical and telemetry setting. The purpose of this study was to examine beliefs and behaviors that influence registered nurses' decision to activate an adult rapid response team in a community hospital that includes 3 specialties: medical-surgical and telemetry, peripartum, and psychiatric areas. One hundred sixty-three nurses were surveyed using a 17-item Likert-style instrument to assess registered nurses' beliefs and attitudes on and barriers to utilizing an RRT. The survey was analyzed yielding 3 factors: RRT barriers, RRT positive/intent to activate, and patient management beliefs. Barriers cited by other research to activate RRT including criticism by the team and perception that the RRT increases workload or reduces skills were not found to be influential considerations. A significant difference was found among the 3 specialty groups related to RRT positive/intent to activate (F2,159 = 6.09, P = .003) and patient management beliefs (F2,159 = 5.87, P = .003). A strong negative correlation was found between years of experience as an RN and RRT barriers (ρ161 = -0.250). Organizations should examine RRT activation delays particularly in the area of calls to covering physicians prior to RRT activations. Differences between specialty groups highlight the need for education across specialties on the recognition of the acutely deteriorating patient. The findings indicate that the inexperienced nurse requires support from experienced colleagues and temporary adjustments to workload during situations of acute deterioration of a patient.

Communication and general concern criterion prior to activation of the rapid response team: a grounded theory.

Objective Patients commonly show signs and symptoms of deterioration for hours or days before cardiorespiratory arrest. Rapid response teams (RRT) were created to improve recognition and response to patient deterioration in these situations. Activation criteria include vital signs or 'general concern' by a clinician or family member. The general concern criterion for RRT activation accounts for nearly one-third of all RRT activity, and although it is well established that communication deficits between staff can contribute to poorer outcomes for patients, there is little evidence pertaining to communication and its effects on the general concern RRT activation. Thus, the aim of the present study was to develop a substantive grounded theory related to the communication process between clinicians that preceded the activation of an RRT when general concern criterion was used. Methods Qualitative grounded theory involved collection of three types of data details namely personal notes from participants in focus groups with white board notes from discussions and audio recordings of the focus groups sessions. Focus groups were conducted with participants exploring issues associated with clinician communication and how it related to the activation of an RRT using the general concern criterion. Results The three main phases of coding (i.e. open, axial and selective coding) analysis identified 322 separate open codes. The strongest theme contributed to a theory of ineffective communication and decreased psychological safety, namely that 'In the absence of effective communication there is a subsequent increase in anxiety, fear or concern that can be directly attributed to the activation of an RRT using the 'general concern' criterion'. The RRT filled cultural and process deficiencies in the compliance with an escalation protocol. Issues such as 'not for resuscitation documentation' and 'inability to establish communication with and between medical or nursing personnel' rated highly and contributed to the debate. Conclusions This study highlighted that in the surveillance and management of the deteriorating patient and in the absence of effective communication there is a subsequent increase in anxiety, fear or concern that can be directly attributed to the activation of an RRT for the 'general concern' calling criteria. What is known about the topic? Deficiencies in collaboration and communication between healthcare professionals (HCPs) increase the stress and anxiety of healthcare staff and correspond to poorer outcomes for patients. The RRT can be activated as a 'general concern RRT' without observation of physiological derangements if staff are concerned about a patient's condition, allowing for assistance from a skilled critical care team at the patient's bedside. There are limited data on how poor communication affects the frequency of activation of general concern RRTs. What does this paper add? This study shows that poor communication between health professionals increases staff levels of anxiety and concern. In addition, the RRT system is being used to fill deficiencies in many other hospital processes, including end-of-life discussions. The deficiencies in hospital processes contribute to poor communication and increased levels of concern with this study demonstrating a direct link between a clinician's level of anxiety/concern and the 'general concern' activation category for the RRT system. What are the implications for practitioners? The present study highlights the importance of effective communication strategies between HCPs to improve patient safety and quality of care. The study also highlights the expanding role of the RRT in hospitals, which has implications for hospital policy makers with regard to future funding and resource allocation. Finally, many of the concerns raised in the present study by the focus groups have been addressed by recent measures introduced through the Australian Commission on Safety and Quality in Health Care (e.g. rapid detection and response observation charts and Introduction, Situation, Background, Assessment and Recommendation [ISBAR] style of communication) with these measures supported by the findings of the present study.

Perceptions of interactions between staff members calling, and those responding to, rapid response team activations for patient deterioration.

Objectives The aim of the present study was to investigate experiences of staff interactions and non-technical skills (NTS) at rapid response team (RRT) calls, and their association with repeat RRT calls. Methods Mixed-methods surveys were conducted of RRT members and staff who activate the RRT (RRT users) for their perceptions and attitudes regarding the use of NTS during RRT calls. Responses within the survey were recorded as Likert items, ranked data and free comments. The latter were coded into nodes relating to one of four NTS domains: leadership, communication, cooperation and planning. Results Two hundred and ninety-seven (32%) RRT users and 79 (73.8%) RRT members provided responses. Of the RRT user respondents, 76.5% had activated the RRT at some point. Deficits in NTS at RRT calls were revealed, with 36.9% of users not feeling involved during RRT calls and 24.7% of members perceiving that users were disinterested. Unresolved user clinical concerns, or persistence of RRT calling criteria, were reasons cited by 37.6% and 23%, respectively, of RRT users for reactivating an RRT to the same patient. Despite recollections of conflict at previous RRT calls, 92% of users would still reactivate the RRT. The most common theme in the free comments related to deficiencies in cooperation (52.9%), communication (28.6%) and leadership (14.3%). Conclusions This survey of RRT users and members revealed problems with RRT users' and members' interactions at the time of an RRT call. Both users and members considered NTS to be important, but lacking. These findings support NTS training for RRT members and users. What is known about the topic? Previous surveying has related experiences of criticism and conflict between clinical staff at RRT activations. This leads to reluctance to call the RRT when indicated, with risks to patient safety, especially if subsequent RRT activation is necessary. Training in NTS has improved clinician interactions in simulated emergencies, but the exact role of NTS during RRT calls has not yet been established. What does this paper add? The present survey examined experienced clinicians' perceptions of the use of NTS at RRT calls and the effect on subsequent calling. A key finding was a disparity between perceptions of how RRT members interact with those activating the RRT (RRT users) and their performance of NTS. This was reflected with unresolved RRT user clinical concern at the time of a call. In turn, this affected RRT users' attitudes and intentions to reactivate the RRT. Formal handover was considered desirable by both RRT users and members. What are the implications for practitioners? The interface between the RRT and those who call the RRT is crucial. This survey shows that RRT users desire to be included in the management of the deteriorating patient and have their concerns addressed before completion of RRT attendance. Failure to do so results in repeat activations to the same patient, with the potential for adverse patient outcomes. Training to include NTS, especially around handover, for RRT members may address this issue and should be explored further.

Nurses' documentation of physiological observations in three acute care settings.

To explore nurses' documentation of physiological observations in acute care; emergency department, medical and surgical units. In Australia, physiological observations include respiratory rate, oxygen saturation, heart rate, blood pressure, temperature and level of consciousness. There is a clear relationship between abnormal physiological observations and adverse events. Nurses have highest level of responsibility for accurate measurement, interpretation and documentation of physiological observations. A descriptive exploratory design was used and the study data were collected using a prospective point prevalence approach between 25 July 2012-22 August 2012. The study was conducted in the emergency department, two 30-bed medical units and one 30-bed surgical unit of a 578 bed public health service in Melbourne, Australia. All adult patients aged ≥18 years present during data collection periods were eligible for inclusion. Patients in the emergency department resuscitation area were excluded. Patient characteristics and physiological observations for the preceding 24 hours in ward patients or eight hours in emergency department patients were collected. One hundred and seventy-eight patients were included; 38 emergency department patients, 84 medical patients and 56 surgical patients. The median age was 72·5 years and 43·8% were males. The most frequently documented physiological observations were respiratory rate, oxygen saturation, heart rate and systolic blood pressure. The least frequently recorded physiological observations were temperature and conscious state. One or more abnormal physiological parameters was documented in 79·8% (n = 142) patients; evidence of reporting abnormalities was documented in 19·7% of patients (n = 28/142). When controlled for length of stay, physiological observations were more frequently documented in the emergency department. There was variability in the number of parameters documented and frequency of physiological observations documented by nurses. Physiological abnormalities that do not necessarily fulfil rapid response team activation criteria are common in acute care patients and provide nurses with an opportunity for early recognition of deteriorating patients.

Predictive factors of in-hospital mortality in very old patients following rapid response team activation

The number of very old patients (80 years old) with chronic illness and functional impairment requiring major medical attention is increasing. Rapid Response Teams (RRT) were implemented to improve the recognition and response to deteriorating ward patients. However, the characteristics and outcomes of very old patients assisted by RRT during hospitalization are not well described.

Hospital mortality predictive factors following rapid response team activation in very old patients

The number of very old (≥80 years) patients with chronic illness and functional impairment requiring major medical attention is increasing, with great chances of adverse events during hospitalization. Rapid Response Teams (RRT) were implemented to improve the recognition and response to deteriorating ward patients; however, the characteristics and outcomes of very old patients assisted by RRT during hospitalization are not well described.

143 Vital Signs as Predictors of Rapid Response Team Activations Within Twelve Hours of Admission From the Emergency Department

Rapid-response teams (RRTs) are interdisciplinary groups created to rapidly assess and treat patients with unexpected clinical deterioration in non-intensive care unit (ICU) beds. It has been suggested that emergency department (ED) disposition should take into consideration vital signs (VS) at the time of hospital admission. We aimed to predict which patients will have RRT activation within 12 hours of admission based on their ED VS. We conducted a case-control study of patients presenting from January 2009 to December 2013 to a tertiary ED who subsequently had RRT activation within 12 hours of admission. The records of patients 18 years and older admitted to a non-ICU setting were reviewed to obtain VS at the time of ED departure. Each of the 474 RRT activation cases was matched to a control by age, sex, and ED diagnosis. Controls presented to the ED during the same time period, were admitted, but did not have RRT activation. VS were evaluated using cut points (lowest 10%, middle 80% and highest 10%) based on the distribution of VS for all 948 patients and were compared between cases and controls using conditional logistic regression. Vital signs have a bimodal distribution, where the lowest and the highest extremes are concerning. Cutoff comparison between cases and controls is shown in Table 1. Patients with RRT activations were more likely to have a heart rate > 111 bpm (OR 2.76; CI 1.65-4.60), have a sBP 157 mmHg (OR 1.82; 1.19-2.80), have a respiratory rate >24 (OR 4.15; CI 2.44-7.07) and have an oxygen saturation <93% (OR 2.29; CI 1.43-3.67) at the time of ED departure. After matching for age, sex, and ED diagnosis, abnormal VS at the time of ED departure are predictive of RRT activation within 12 hours of admission. However, an ideal set of VS cut points to trigger a change in ED disposition remain unclear.

209 Trends in Rapid Response Team Activations Within 24 Hours of Admission: A Follow-Up Study

209 Trends in Rapid Response Team Activations Within 24 Hours of Admission: A Follow-Up Study

Rapidly Increasing Rapid Response Team Activation Rates

Rapidly Increasing Rapid Response Team Activation Rates

Obstructive sleep apnea and adverse outcomes in surgical and nonsurgical patients on the wards.

Obstructive sleep apnea (OSA) has been associated with clinical deterioration in postoperative patients and patients hospitalized with pneumonia. Paradoxically, OSA has also been associated with decreased risk of inpatient mortality in these same populations. To investigate the association between OSA and in-hospital mortality in a large cohort of surgical and nonsurgical ward patients. Observational cohort study. A 500-bed academic tertiary care hospital in the United States. A total of 93,676 ward admissions from 53,150 unique adult patients between November 1, 2008 and October 1, 2013. None. OSA diagnoses and comorbidities were identified by International Classification of Diseases, Ninth Revision, Clinical Modification codes. Logistic regression was used to control for patient characteristics, location prior to ward admission, and admission severity of illness. The primary outcome was in-hospital death. Secondary outcomes included rapid response team (RRT) activation, intensive care unit (ICU) transfer, intubation, and cardiac arrest on the wards. OSA was identified in 5,625 (10.6%) patients. Patients with OSA were more likely to be older, male, and obese, and had higher rates of comorbidities. OSA patients had more frequent RRT activations (1.5% vs 1.1%) and ICU transfers (8% vs 7%) than controls (P < 0.001 for both comparisons), but a lower inpatient mortality rate (1.1% vs 1.4%, P < 0.05). OSA was associated with decreased adjusted odds for ICU transfer (odds ratio [OR]: 0.91 [0.84-0.99]), cardiac arrest (OR: 0.72 [0.55-0.95]), and in-hospital mortality (OR: 0.70 [0.58-0.85]). After adjustment for important confounders, OSA was not associated with clinical deterioration on the wards and was associated with significantly decreased in-hospital mortality.

Epidemiology of early Rapid Response Team activation after Emergency Department admission.

Rapid Response Team (RRT) calls can often occur within 24h of hospital admission to a general ward. We seek to determine whether it is possible to identify these patients before there is a significant clinical deterioration. Retrospective case-controlled study comparing patient characteristics, vital signs, and hospital outcomes in patients triggering RRT activation within 24h of ED admission (cases) with matched ED admissions not receiving a RRT call (controls). Over 12 months, there were 154 early RRT calls. Compared with controls, cases had a higher heart rate (HR) at triage (92 vs. 84 beats/min; p=0.008); after 3h in the ED (91 vs. 80 beats/min; p=0.0007); and at ED discharge (91 vs. 81 beats/min; p=0.0005). Respiratory rate (RR) was also higher at triage (21.2 vs. 19.2 breaths/min; p=0.001). On multiple variable analysis, RR at triage and HR before ward transfer predicted early RRT activation: OR 1.07 [95% CI 1.02-1.12] for each 1 breath/min increase in RR; and 1.02 [95% CI 1.002-1.030] for each beat/minute increase in HR, respectively. Study patients required transfer to the intensive care in approximately 20% of cases and also had a greater mortality: (21% vs. 6%; OR 4.65 [95% CI 1.86-11.65]; p=0.0003) compared with controls. Patients that trigger RRT calls within 24h of admission have a fourfold increase in risk of in-hospital mortality. Such patients may be identified by greater tachycardia and tachypnoea in the ED.

Ten clinical indicators suggesting the need for ICU admission after Rapid Response Team review.

Intensive care units (ICUs) were developed for the care of at-risk and critically ill patients requiring artificial life support, intensive post-operative monitoring or complex therapies which are unfeasible to deliver in a ward environment. Admission of patients to the ICU from the operating room and emergency department is often overseen by senior clinicians possessing critical care expertise. In contrast, for patients deteriorating in a general ward environment, assessment and triage is frequently performed by relatively junior medical staff who may not reliably recognise clinical indicators of deterioration indicating that ICU admission may be required [1–6]. In this article we briefly review studies examining ward patient clinical deterioration and discuss the utility of Rapid Response Team (RRT) calling criteria. Admission to ICU after RRT activation is reviewed and 10 clinical indicators suggesting the need for ICU admission are presented.

A novel configuration of a traditional rapid response team decreases non-intensive care unit arrests and overall hospital mortality.

In-hospital cardiopulmonary arrest (CPA) accounts for substantial morbidity and mortality. Rapid response teams (RRTs) are designed to prevent non-intensive care unit (ICU) CPA through early detection and intervention. However, existing evidence has not consistently demonstrated a clear benefit. To explore the effectiveness of a novel RRT program design to decrease non-ICU CPA and overall hospital mortality. This study was conducted from the start of fiscal year 2005 to 2011. In November 2007, our hospitals implemented RRTs as part of a novel resuscitation program. Charge nurses from each inpatient unit underwent training as unit-specific RRT members. Additionally, all inpatient staff received annual training in RRT concepts including surveillance and recognition of deterioration. We compared the incidence of ICU and non-ICU CPA from first complete preimplementation year 2006 to postimplementation years 2007 to 2011. Overall hospital mortality was also reported. The incidence of non-ICU CPA decreased, whereas the incidence of ICU CPA remained unchanged. Overall hospital mortality also decreased (2.12% to 1.74%, P < 0.001). The year-over-year change in RRT activations was inversely related to the change in Code Blue activations for each inpatient unit (r = -0.68, P < 0.001). Our novel RRT program was associated with a decreased incidence of non-ICU CPA and improved hospital mortality.

Intensive care unit admission in patients following rapid response team activation: call factors, patient characteristics and hospital outcomes.

Rapid Response Systems (RRSs) have been widely introduced throughout hospital health systems, yet there is limited research on the characteristics and outcomes of patients admitted to an intensive care unit (ICU) following RRS activation. Using database extraction, this study examined the factors associated with ICU admission and patient outcome in patients receiving RRS activation in a tertiary level hospital between 2009 and 2013. Of 3004 RRS activations, 392 resulted in ICU admissions. Call factors associated with ICU admission and increased hospital mortality included tachypnoea (P <0.001 and P <0.001, respectively), hypoxia (P <0.001 and P <0.001, respectively) and having multiple Medical Emergency Team call triggers breached simultaneously (P <0.001 and P <0.001, respectively). Patients with seizures (P <0.001) and tachycardia (P=0.004) were more likely to survive to hospital discharge. Patient factors associated with ICU admission included young age (P <0.001) and having severe liver disease (P <0.001). Factors associated with increased hospital mortality included delayed RRS activation (P <0.001), increased age (P <0.001) and comorbidities including ischaemic heart disease (P=0.006), congestive heart failure (P <0.001), chronic kidney disease (P <0.001) and severe liver disease (P <0.001). Multiple factors relating to both the nature of the RRS activation call and patient characteristics are associated with ICU admission and hospital mortality post RRS activation. This information may be useful for risk stratification of deteriorating patients and determination of appropriate escalation.

CE: Original research: hospital system barriers to rapid response team activation: a cognitive work analysis.

The goal of rapid response team (RRT) activation in acute care facilities is to decrease mortality from preventable complications, but such efforts have been only moderately successful. Although recent research has shown decreased mortality when RRTs are activated more often, many hospitals have low activation rates. This has been linked to various hospital, team, and nursing factors. Yet there is a dearth of research examining how hospital systems shape nurses' behavior with regard to RRT activation. Making systemic constraints visible and modifying them may be the key to improving RRT activation rates and saving more lives. The purpose of this study was to use cognitive work analysis to describe factors within the hospital system that shape medical-surgical nurses' RRT activation behavior. Cognitive work analysis offers a framework for the study of complex sociotechnical systems. This framework was used as the organizing element of the study. Qualitative descriptive design was used to obtain data to fill the framework's five domains: resources, tasks, strategies, social systems, and worker competency. Data were obtained from interviews with 12 medical-surgical nurses and document review. Directed content analysis was used to place the obtained data into the framework's predefined domains. Many system factors affected participants' decisions to activate or not activate an RRT. Systemic constraints, especially in cases of subtle or gradual clinical changes, included a lack of adequate information, the availability of multiple strategies, the need to justify RRT activation, a scarcity of human resources, and informal hierarchical norms in the hospital culture. The most profound constraint was the need to justify the call. Justification was based on the objective or subjective nature of clinical changes, whether the nurse expected to be able to "handle" these changes, the presence or absence of a physician, and whether there was an expectation of support from the RRT team. The need for justification led to delays in RRT activation. Although it's generally thought that RRTs are activated without hesitation, this study found the opposite was true. All of the aforementioned constraints increase the cognitive processing load on the nurse. The value of the RRT could be increased by modifying these constraints-in particular, by lifting the need to justify calls, improving protocols, and broadening the range of culturally acceptable triggers-and by involving the RRT earlier in patient cases through discussion, consultation, and collaboration.

Evaluating Simulation Education Via Electronic Surveys Immediately Following Live Critical Events: A Pilot Study

Simulation-based medical education has become popular in postgraduate training for medical emergencies; however, the direct impact on learners' clinical performances during live critical events is unknown. Our goal was to evaluate the perceived impact of simulation-based education on pediatric emergencies by auditing pediatric residents immediately after involvement in actual emergency clinical events. Weekly team-based pediatric simulation training for inpatient emergencies was implemented in an academic tertiary care hospital. Immediately after actual pediatric emergency events, each resident involved was audited regarding roles, performed tasks, and perceived effectiveness of earlier simulation-based education. The audit was performed by using a Likert scale. From September 2010 through August 2011, a total of 49 simulation sessions were held. During the same period, 27 pediatric emergency events occurred: 3 code events, 14 rapid response team activations, and 10 emergency transfers to the PICU. Forty-seven survey responses from 20 pediatric residents were obtained after the emergency clinical events. Fifty-three percent of residents felt well prepared, and 45% reported having experienced a similar simulation before the clinical event. A preceding similar simulation experience was perceived as helpful in improving clinical performance. Residents' confidence levels, however, did not differ significantly between those who reported having had a preceding similar simulation and those who had not (median of 4 vs median of 3; P=.16, Wilcoxon rank-sum test). A novel electronic survey was successfully piloted to measure residents' perceptions of simulation education compared with live critical events. Residents perceived that their experiences in earlier similar simulations positively affected their performances during emergencies.

Individualizing and optimizing the use of early warning scores in acute medical care for deteriorating hospitalized patients

AimWhile early warning scores (EWS) have the potential to identify physiological deterioration in an acute care setting, the implementation of EWS in clinical practice has yet to be fully realized. The primary aim of this study is to identify optimal patient-centered rapid response team (RRT) activation rules using electronic medical records (EMR)-derived Markovian models. MethodsThe setting for the observational cohort study included 38,356 adult general floor patients hospitalized in 2011. The national early warning score (NEWS) was used to measure the patient health condition. Chi-square and Kruskal Wallis tests were used to identify statistically significant subpopulations as a function of the admission type (medical or surgical), frailty as measured by the Braden skin score, and history of prior clinical deterioration (RRT, cardiopulmonary arrest, or unscheduled ICU transfer). ResultsStatistical tests identified 12 statistically significant subpopulations which differed clinically, as measured by length of stay and time to re-admission (P<.001). The Chi-square test of independence results showed a dependency structure between subsequent states in the embedded Markov chains (P<.001). The SMDP models identified two sets of subpopulation-specific RRT activation rules for each statistically unique subpopulation. Clinical deterioration experience in prior hospitalizations did not change the RRT activation rules. The thresholds differed as a function of admission type and frailty. ConclusionsEWS were used to identify personalized thresholds for RRT activation for statistically significant Markovian patient subpopulations as a function of frailty and admission type. The full potential of EWS for personalizing acute care delivery is yet to be realized.

Non-Critical-Care Nurses' Perceptions of Facilitators and Barriers to Rapid Response Team Activation.

Rapid response teams can save lives but are only effective when activated. We surveyed 50 nurses for their perceptions of facilitators and barriers to activation. Findings showed that participants need more education on their role and when to activate the rapid response team. Nurses who comprise the team need help building their communication skills. We recommend nursing professional development specialists increase the frequency of offerings and expand the focus on roles, activation criteria, and communication skills.

Lessons learned from conducting qualitative research in a hospital.

To examine unexpected barriers to the conduct of hospital research during a study of nurses' activation of rapid response teams. We interviewed hospital nurses regarding their decisions to activate rapid response teams and encountered unexpected barriers to the conduct of this study in the hospital setting. Experience of conducting qualitative research with bedside nurses in a community hospital. Review of the reports of others who have conducted hospital research. Barriers related to administrative support, environmental distractors, constraints on nurses' time, apparent lack of investment in research by staff and a cumbersome recruitment process are identified. Recommendations on study site selection, timing of research, gaining access to nurses, scheduling and conducting interviews, and transcribing recorded data are made. As evidence is necessary to deliver safe, quality care, it is important that nurses understand and participate in research. This participation involves not only conducting research, but also serving as subjects. Given the importance of bedside nurses' willingness to engage in research, it is crucial to understand factors that impede or assist their participation. We offer several recommendations to nurses conducting research in hospitals, including: ■ Seek hospitals that are supportive of research, yet not over-invested in the process. ■ Build extra time into data collection schedules to maximize flexibility and accommodate work-place demands. ■ Emphasise the relevance and benefits of the research to nurses.