Improving the pre-medical emergency team: the case for a behavioural theoretical lens.

There is mounting evidence that the pre-medical emergency team (pre-MET) of rapid response systems is underutilised in clinical practice due to suboptimal structures and processes and resource constraints. In this perspective article, we argue for examining the pre-MET through a 'Behaviour Change Wheel' lens to improve the pre-MET and maximise the associated patient safety benefits. Using pre-MET communication practices as an example, we illustrate the value of the COM-B model, where clinicians' 'capability', 'opportunity', and 'motivation' drive 'behaviour'. Optimising clinicians' behaviours and establishing failsafe rapid response systems is a complex undertaking; however, examining clinicians' behaviours through the COM-B model enables reframing barriers and facilitators to develop multifaceted and coordinated solutions that are behaviourally and theoretically based. The COM-B model is recommended to clinical governance leaders and health services researchers to explore the underlying causes of behaviour and successfully enact change in the design, implementation, and use of the pre-MET to improve patient safety.

Infectious and sepsis presentations to, and hospital admissions from emergency departments in Victoria, Australia.

OBJECTIVE: To investigate the frequency and outcomes of adult infectious and sepsis presentations to, and hospital admissions from, Emergency Departments (EDs) in Victoria, Australia. METHODS: Retrospective cohort study using the Victorian Emergency Minimum Dataset and Victorian Admitted Episodes Dataset. We included adults (age ≥ 18 years) presenting to an ED, or admitted to hospital from ED in Victoria between July 2017 and June 2018. One-year mortality was analysed until June 2019 using the Victorian Death Index, and ICD-10 coding was used to identify cases. RESULTS: Among 1.28 million ED presentations over 1 year, 12.00% and 0.45% were coded with infectious and sepsis diagnoses, respectively. Despite having lower triage categories, patients with infections were more likely to be admitted to hospital (50.4% vs 44.9%), but not directly to ICU (0.8%). Patients coded with sepsis were assigned higher triage categories and required hospital admission much more frequently (96.4% vs 44.9%), including to ICU (15.9% vs 0.8%). Patients presenting with infections and sepsis had increased risk of 1-year mortality (adjusted hazard ratio 1.44 and 4.13, respectively). Of the 648 280 hospital admissions from the ED, infection and sepsis were coded in 23.69% and 2.66%, respectively, and the adjusted odds ratio for 1-year mortality were 1.64 and 4.79, respectively. CONCLUSIONS: Infections and sepsis are common causes of presentation to, and admission from the ED in Victoria. Such patients experience higher mortality than non-infectious patients, even after adjusting for age. There is a need to identify modifiable factors contributing to these outcomes.

Examining emergency departments practices on advance care directives and medical treatment decision making using the victorian emergency minimum dataset.

INTRODUCTION: Existence of Advance Care Planning (ACP) documents including contact details of Medical Treatment Decision Makers (MTDM), are essential patient care records that support Emergency Department (ED) clinicians in implementing treatment concordant with patients' expressed wishes. Based upon previous findings, we conducted a statewide study to evaluate the performance of Victorian public hospital emergency departments on reporting of availability of records for ACP. METHOD: The study is a quantitative retrospective observational comparative design based upon ED tier levels as defined by the Australasian College for Emergency Medicine (ACEM) for the calendar year 2021. RESULTS: Of 1.8 million total Victorian ED attendances, 15,222 patients had an ACP alert status recorded. Of these, 7296 were aged ≥ 65 years (study group). Of the thirty-one public EDs that submitted data, 65 % were accredited and assigned a level of service tier. The presence of ACP alerts positively correlated to location, tier level, age and gender (MANOVA wilk's; p < 0.001, value=.981, F = (12, 15,300), partial ƞ2 = .006, observed power = 1.0 = 95.919). CONCLUSION: The identified rate of ACP reporting is low. Strategies to improve the result include synchronising ACP (generated at different points) electronically, staff education, training and further validation of the data at the sending and receiving agencies.

Dose equivalence for metaraminol and noradrenaline - A retrospective analysis.

BACKGROUND: Noradrenaline and metaraminol are commonly used vasopressors in critically ill patients. However, little is known of their dose equivalence. METHODS: We conducted a single centre retrospective cohort study of all ICU patients who transitioned from metaraminol to noradrenaline infusions between August 26, 2016 and December 31, 2020. Patients receiving additional vasoactive drug infusion were excluded. Dose equivalence was calculated based on the last hour metaraminol dose (in µg/min) and the first hour noradrenaline dose (in µg/min) with the closest matched mean arterial pressure (MAP). Sensitivity analyses were performed on patients with acute kidney injury (AKI), sepsis and mechanical ventilation. RESULTS: We studied 195 patients. The median conversion ratio of metaraminol to noradrenaline was 12.5:1 (IQR 7.5-20.0) for the overall cohort. However, the coefficient of variation was 77% and standard deviation was 11.8. Conversion ratios were unaffected by sepsis or mechanical ventilation but increased (14:1) with AKI. One in five patients had a MAP decrease of >10 mmHg during the transition period from metaraminol to noradrenaline. Post-transition noradrenaline dose (p < 0.001) and AKI (p = 0.045) were independently associated with metaraminol dose. The proportion of variation in noradrenaline dose predicted from metaraminol dose was low (R2 = 0.545). CONCLUSIONS: The median dose equivalence for metaraminol and noradrenaline in this study was 12.5:1. However, there was significant variance in dose equivalence, only half the proportion of variation in noradrenaline infusion dose was predicted by metaraminol dose, and conversion-associated hypotension was common.

Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023.

RATIONALE: Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care hospitals have implemented systems aimed at detecting and responding to such patients. OBJECTIVES: To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients. PANEL DESIGN: The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based Clinical Practice Guidelines. METHODS: We generated actionable questions using the Population, Intervention, Control, and Outcomes (PICO) format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation Approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs). RESULTS: The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among unselected patients. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system. CONCLUSIONS: The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.

Executive Summary: Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU.

RATIONALE: Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care facilities have implemented systems aimed at detecting and responding to such patients. OBJECTIVES: To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients. PANEL DESIGN: The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based clinical practice guidelines. METHODS: We generated actionable questions using the Population, Intervention, Control, and Outcomes format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs). RESULTS: The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among "unselected" patients due to the absence of data regarding the benefit and the potential harms of false positive alarms, the risk of alarm fatigue, and cost. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system (GPS). CONCLUSIONS: The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.

Haemodynamic changes during prone versus supine position in patients with COVID-19 acute respiratory distress syndrome.

BACKGROUND: Prone positioning improves oxygenation in patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19. However, its haemodynamic effects are poorly understood. OBJECTIVES: The objective of this study was to investigate the acute haemodynamic changes associated with prone position in mechanically ventilated patients with COVID-19 ARDS. The primary objective was to describe changes in cardiac index with prone position. The secondary objectives were to describe changes in mean arterial pressure, FiO2, PaO2/FiO2 ratio, and oxygen delivery (DO2) with prone position. METHODS: We performed this cohort-embedded study in an Australian intensive care unit, between September and November 2021. We included adult patients with severe COVID-19 ARDS, requiring mechanical ventilation and prone positioning for respiratory failure. We placed patients in the prone position for 16 h per session. Using pulse contour technology, we collected haemodynamic data every 5 min for 2 h in the supine position and for 2 h in the prone position consecutively. RESULTS: We studied 18 patients. Cardiac index, stroke volume index, and mean arterial pressure increased significantly in the prone position compared to supine position. The mean cardiac index was higher in the prone group than in the supine group by 0.44 L/min/m2 (95% confidence interval, 0.24 to 0.63) (P < 0.001). FiO2 requirement decreased significantly in the prone position (P < 0.001), with a significant increase in PaO2/FiO2 ratio (P < 0.001). DO2 also increased significantly in the prone position, from a median DO2 of 597 mls O2/min (interquartile range, 504 to 931) in the supine position to 743 mls O2/min (interquartile range, 604 to 1075) in the prone position (P < 0.001). CONCLUSION: Prone position increased the cardiac index, mean arterial pressure, and DO2 in invasively ventilated patients with COVID-19 ARDS. These changes may contribute to improved tissue oxygenation and improved outcomes observed in trials of prone positioning.

Frequency of and associations with alterations of medical emergency team calling criteria in a teaching hospital emergency department.

BACKGROUND: Medical emergency team (METs), activated by vital sign-based calling criteria respond to deteriorating patients in the hospital setting. Calling criteria may be altered where clinicians feel this is appropriate. Altered calling criteria (ACC) has not previously been evaluated in the emergency department (ED) setting. OBJECTIVES: The objectives of this study were to (i) describe the frequency of ACC in a teaching hospital ED and the number and type of vital signs that were modified and (ii) associations between ACC in the ED and differences in the baseline patient characteristics and adverse outcomes including subsequent MET activations, unplanned intensive care unit (ICU) admissions and death within 72 h of admission. METHODS: Retrospective observational study of patients presenting to an academic, tertiary hospital ED in Melbourne, Australia between January 1st, 2019 and December 31st, 2019. The primary outcome was frequency and nature of ACC in the ED. Secondary outcomes included differences in baseline patient characteristics, frequency of MET activation, unplanned ICU admission, and mortality in the first 72 h of admission between those with and without ACC in the ED. RESULTS: Amongst 14 159 ED admissions, 725 (5.1%) had ACC, most frequently for increased heart or respiratory rate. ACC was associated with older age and increased comorbidity. Such patients had a higher adjusted risk of MET activation (odds ratio [OR]: 3.14, 95% confidence interval [CI]: 2.50-3.91, p = <0.001), unplanned ICU admission (OR: 1.97, 95% CI: 1.17-3.14, p = 0.016), and death (OR: 3.87, 95% CI: 2.08-6.70, p = 0.020) within 72 h. CONCLUSIONS: ACC occurs commonly in the ED, most frequently for elevated heart and respiratory rates and is associated with worse patient outcomes. In some cases, ACC requires consultant involvement, more frequent vital sign monitoring, expeditious inpatient team review, or ICU referral.

Improving the management of medical emergency team calls due to suspected infections: A before-after study.

Objective: To introduce a management guideline for sepsis-related MET calls to increase lactate and blood culture acquisition, as well as prescription of appropriate antibiotics. Design: Prospective before (Jun-Aug 2018) and after (Oct-Dec 2018) study was designed. Setting: A public university linked hospital in Melbourne, Australia. Participants: Adult patients with MET calls related to sepsis/infection were included. Main outcome measures: The primary outcome measure was the proportion of MET calls during which both a blood culture and lactate level were ordered. Secondary outcomes included the frequency with which new antimicrobials were commenced by the MET, and the presence and class of administered antimicrobials. Results: There were 985 and 955 MET calls in the baseline and after periods, respectively. Patient features, MET triggers, limitations of treatment and disposition after the MET call were similar in both groups. Compliance with the acquisition of lactates (p = 0.101), respectively. There was a slight reduction in compliance with lactate acquisition in the after period (97% vs 99%; p = 0.06). In contrast, there was a significant increase in acquisition of blood cultures in the after period (69% vs 78%; p = 0.035). Conclusions: Introducing a sepsis management guideline and enhanced linkage with an AMS program increased blood culture acquisition and decreased broad spectrum antimicrobial use but didn't change in-hospital mortality.

Intensive care unit admission from the emergency department in the setting of National Emergency Access Targets.

Purpose: Since the introduction of National Emergency Access Targets (NEATs) in 2012 there has been little research examining patients admitted to the intensive care unit (ICU).We assessed differences in baseline characteristics and outcomes of patients admitted from the Emergency Department (ED) to the ICU within 4 hours compared with patients who were not. Methods: This retrospective observational study included all adults (≥18 years old) admitted to the ICU from the ED of Austin Hospital, Melbourne, Australia, between 1 January 2017 and 31st December 2019 inclusive. Results: 1544 patients were admitted from the ED to the ICU and 65% had an ED length of stay (EDLOS) > 4 hour. Such patients were more likely to be older, female, with less urgent triage category scores and lower illness severity. Sepsis and respiratory admission diagnoses, and winter presentations were significantly more prevalent in this group.After adjustment for confounders, patients with an EDLOS > 4 hours had lower hospital mortality; 8% v 21% (p = 0.029; OR, 1.62), shorter ICU length of stay 2.2 v 2.4 days (p = 0.043), but a longer hospital length of stay 6.2 v 6.8 days (p = < 0.001). Conclusion: Almost two thirds of patients breached the NEAT of 4 hours. These patients were more likely to be older, female, admitted in winter with sepsis and respiratory diagnoses, and have lower illness severity and less urgent triage categories. NEAT breach was associated with reduced hospital mortality but an increased hospital length of stay.

Findings from a decade of experience following implementation of a Rapid Response System into an Asian hospital.

Aim: Rapid response systems (RRS) are present in many acute hospitals in western nations but are not widely adopted in Asia. The influence of healthcare culture and the effect of implementing an RRS over time are infrequently reported. We describe the introduction a RRS into a Singaporean hospital and the barriers encountered. The efferent limb activation rates, cardiac arrest rates and unplanned intensive care unit (ICU) admissions are trended over eleven years. Methods: We conducted a retrospective observational study using prospectively collected data derived from administrative and Medical Emergency Team (MET) databases. Results: The RRS used a MET with a single parameter track and trigger and physician led efferent limb. Barriers encountered included clinical leadership buy-in, assembling and equipping the efferent team, maintaining a non-punitive mindset, improving accessibility to MET and communicating the impact of the MET. Over an 11-year period with 488,252 hospital admissions, MET activation rates increased from 1.6/1000 admissions (2009) to 14.1/1000 admissions (2019). Code blue activations and unplanned ICU admission rates decreased from 2.9 to 1.7 and from 8.8 to 2.0/1000 admissions, respectively over the 11 years. There were associations between increasing MET activation rate and reduction in code blue activations (p = 0.013) and unplanned medical ICU admission rates (p = 0.001). Conclusion: Implementing, sustaining and continued improvement of an RRS in Singapore is possible despite challenges encountered. With increasing activation rates over a decade, there were reductions in cardiac arrest rates and unplanned medical ICU admissions.

Estimating Australian Hospitalization Ratios and Costs for Wildtype SARS-CoV-2 in 2020.

Utilizing a retrospective cohort study of SARS-CoV-2 wildtype (Wuhan) strain, we aimed to 1) utilize the unique Australian experience of temporarily eliminating SARS-CoV-2 to document and estimate the hospitalization demand; and 2) estimate the inpatient hospital costs associated with treatment. Case data was based on Victoria Australia from March 29 to December 31, 2020. Outcomes measures included hospitalization demand and case fatality ratio and inpatient hospitalization costs. Population adjusted results indicated that 10.2% (CI 9.9%-10.5%) required ward only admission, 1.0% (CI 0.9%-1.1%) required ICU admission plus 1.0% (CI 0.9%-1.1%) required ICU with mechanical ventilation. The overall case fatality ratio was 2.9% (CI 2.7%-3.1%). Mean ward only patient costs ranged from $22,714 to $57,100 per admission whilst ICU patient costs ranged from $37,228 to $140,455. With delayed, manageable outbreaks and public health measures leading to temporary elimination of community transmission, the Victorian COVID-19 data provides insight into initial pandemic severity and hospital costs.

Rapid Response System Components and In-Hospital Cardiac Arrests Rates 21 Years After Introduction Into an Australian Teaching Hospital.

OBJECTIVES: The aims of the study are: (1) to evaluate the epidemiology of in-hospital cardiac arrests (IHCAs) 21 years after implementing a rapid response teams (RRTs); and (2) to summarize policies, procedures, and guidelines related to a national standard pertaining to recognition of and response to clinical deterioration in hospital. METHODS: The study used a prospective audit of IHCA (commencement of external cardiac compressions) in ward areas between February 1, 2021, and January 31, 2022. Collation, summary, and presentation of material related to 8 "essential elements" of the Australian Commission for Safety and Quality in Health Care consensus statement on clinical deterioration. RESULTS: There were 3739 RRT calls and 244 respond blue calls. There were 20 IHCAs in clinical areas, with only 10 occurring in general wards (0.36/1000 admissions). The median (interquartile range) age was 69.5 years (60-77 y), 90% were male, and comorbidities were relatively uncommon. Only 5 patients had a shockable rhythm. Survival was 65% overall, and 80% and 50% in patients on the cardiac and general wards, respectively. Only 4 patients had RRT criteria in the 24 hours before IHCA. A detailed summary is provided on policies and guidelines pertaining to measurement and documentation of vital signs, escalation of care, staffing and oversight of RRTs, communication for safety, education and training, as well as evaluation, audit, and feedback, which underpinned such findings. CONCLUSIONS: In our mature RRT, IHCAs are very uncommon, and few are preventable. Many of the published barriers encountered in successful RRT use have been addressed by our policies and guidelines.

Exploring interdisciplinary communication pathways for escalating pre-medical emergency team deterioration: a mixed-methods study.

Objective To explore clinicians' use and perceptions of interdisciplinary communication pathways for escalating care within the pre-medical emergency team (pre-MET) tier of rapid response systems. Method A sequential mixed-methods study was conducted using observations and interviews. Participants were clinicians (nurses, allied health, doctors) caring for orthopaedic and general medicine patients at one hospital. Descriptive and thematic analyses were conducted. Results Escalation practices were observed for 13 of 27 pre-MET events. Leading communication methods for escalating pre-MET events were alphanumeric pagers (61.5%) and in-person discussions (30.8%). Seven escalated pre-MET events led to bedside pre-MET reviews by doctors. Clinician interviews (n = 29) culminated in two themes: challenges in escalation of care, and navigating information gaps. Clinicians reported deficiencies in communication methods for escalating care that hindered interdisciplinary communication and clinical decision-making pertaining to pre-MET deterioration. Conclusion Policy-defined escalation pathways were inconsistently utilised for pre-MET deterioration. Available communication methods for escalating pre-MET events inadequately fulfilled clinicians' needs. Variable perceptions of escalation pathways illuminated a lack of of a shared mental model about clinicians' roles and responsibilities. To optimise timely and appropriate management of patient deterioration, communication infrastructure and interdisciplinary collaboration must be enhanced.

The frequency and nature of barriers to escalation of care in two Australian teaching hospitals.

BACKGROUND: Nurses and junior doctors are often the first clinicians to recognise signs of deterioration in patients. However, there can be barriers to having conversations about escalation of care. OBJECTIVES: The aim of this study was to study the frequency and nature of barriers encountered during discussions related to escalation of care for deteriorating hospitalised patients. METHODS: This was a prospective observational study with daily experience sampling surveys related to escalation of care discussions. The study setting involved two teaching hospitals in Victoria, Australia. Consented doctors, nurses, and allied health staff members involved in routine care of adult ward patients participated in the study. The main outcome measures included the frequency of escalation conversations and the frequency and nature of barriers encountered during such conversations. RESULTS/FINDINGS: 31 clinicians participated in the study and completed an experience sampling survey 294 times, mean (standard deviation) = 9.48 (5.82). On 166 (56.6%) days, staff members were on clinical duties, and escalation of care discussions occurred on 67 of 166 (40.4%) of these days. Barriers to escalation of care occurred in 25 of 67 (37.3%) of discussions and most frequently involved lack of staff availability (14.9%), perceived stress in the contacted staff member (14.9%), perceptions of criticism (9.0%), being dismissed (7.5%), or indication of lack of clinical appropriateness in the response (6.0%). CONCLUSIONS: Discussions related to escalation of care by ward clinicians occur in almost half of clinical days and are associated with barriers in one-third of discussions. Interventions are needed to clarify roles and responsibilities and outline behavioural expectations on both sides of the conversation and enable respectful communication amongst individuals involved in discussions of escalation of patient care.

Pre-medical emergency team activations - Patient characteristics, outcomes and predictors of deterioration.

BACKGROUND: Pre-medical emergency team (MET) calls are an increasingly common tier of Rapid Response Systems, but the epidemiology of patients who trigger a Pre-MET is not well understoof. OBJECTIVES: This study aims to examine the epidemiology and outcomes of patients who trigger a pre-MET activation and identify risk factors for further deterioration. METHODS: This is a retrospective cohort study of pre-MET activations in a university-affiliated metropolitan hospital in Australia, between 13 April 2021 and 4 October 2021. A multivariable regression model was used to identify variables associated with further deterioration, defined as a MET call or Code Blue within 24 h of pre-MET activation. RESULTS: From a total of 39 664 admissions, there were 7823 pre-MET activations (197.2 per 1000 admissions). Compared to inpatients that did not trigger a pre-MET, the patients were older (68.8 vs 53.8 years, p < 0.001), were more likely to be male (51.0 vs 47.6%, p < 0.001), had an emergency admission (70.1% vs 53.3%, p < 0.001), and were under a medical specialty (63.7 vs 54.9%, p < 0.001). They had a longer hospital length of stay (5.6 vs 0.4 d, p < 0.001) and higher in-hospital mortality (3.4% vs 1.0%, p < 0.001). A pre-MET was more likely to progress to a MET call or Code Blue if it was activated for fever, cardiovascular, neurological, renal, or respiratory criteria (p < 0.001), if the patient was under a paediatric team (p = 0.018), or if there had been a MET call or Code Blue prior to the pre-MET activation (p < 0.001). CONCLUSION: Pre-MET activations affect almost 20% of hospital admissions and are associated with a higher risk of mortality. Certain characteristics may predict further deterioration to a MET call or Code Blue, suggesting the potential for early intervention via clinical decision support systems.

Automated rapid response system activation-Impact on nurses' attitudes and perceptions towards recognising and responding to clinical deterioration: Mixed-methods study.

AIM: To explore general ward nurses' attitudes and perceptions towards recognising and responding to clinical deterioration in a hospital with automated rapid response system activation. BACKGROUND: There is growing interest in deploying automated clinical deterioration notification systems to reduce delayed or failed recognition and response to clinical deterioration of ward patients. However, little is known about its impact on ward nurses' perspectives and work patterns. DESIGN: A mixed-methods study. METHODS: Online survey of 168 registered nurses and individual interviews with 10 registered nurses in one acute hospital in Singapore. The study adhered to the STROBE checklist for cross-sectional studies and the COREQ guidelines for qualitative studies. RESULTS: Many nurses (38.1%) rarely performed patient assessments or observations other than vital signs assessment to assess for early signs of clinical deterioration. About 30% were worried about being criticised for calling the primary team doctors. Four themes emerged from the qualitative analysis: automated rapid response system activation as a safety net, being more cautious with vital signs monitoring, the NEWS2 alone is inadequate, and ward nurses as the 'middleman' between the intensive care unit outreach nurse and primary team doctors. CONCLUSIONS: Although nurses value the automated rapid response system activation as a safety net to minimise delays in accessing urgent critical care resources, it does not address the sociocultural barriers inherent in escalation of care. Although the automated system led nurses to be more cautious with vital signs monitoring, it does not encourage them to perform comprehensive patient assessments to detect early signs of deterioration. RELEVANCE TO CLINICAL PRACTICE: Nurse education on assessing for clinical deterioration should focus on the use of broader patient assessment skills other than vital signs. Sociocultural barriers to escalation of care remain a key issue that needs to be addressed by hospital management. NO PATIENT OR PUBLIC CONTRIBUTION: No patients, service users, care-givers or members of the public were involved in the study.