*Clinical Futile Cycles: Systematic Microeconomic Reform of Health Care by Reform… DOI: http://dx.doi.org/10.5772/intechopen.106034*

reporting it to a more senior team member, either a senior nurse or the most available (usually junior) doctor. However, that decision to escalate the issue can be influenced the workplace culture that exists in the particular micro environment of that bedside and that ward at that time [23]. If the concern or abnormality is escalated, it is to the next person in the care hierarchy of the team looking after that patient. This is often the junior doctor who then needs to attend, assess and then also make a decision about whether or not to escalate the issue to the next person in the hierarchy. This is important because, for the most, the junior doctor does not have the skills or emotional intelligence to appropriately manage a lot of these clinical abnormalities [32–35]. If the issue is escalated, it is often to a middle grade doctor, one who is often a specialist in training and who as such may be difficult to find. Unlike their juniors, usually this grade of doctor does have the technical and clinical abilities to deal with the particular issue. However, they are often over committed with clinics, operating theatre, and ward rounds. Additionally, this grade of doctor is diagnosis focused and often we see them giving instructions to their juniors (usually appropriately) to organise specialised investigations and other speciality consultations. There is nothing wrong with this, except for the fact that it is time consuming (**Figure 6**) [24].

In support of the "Clinical Futile Cycles" model is the literature that has looked at the causation of adverse events in hospitals [14, 15, 25, 26]. All these studies can assign almost all causation to three human factor issues at the patient interface; competency, cognition (or failure thereof) and culture. Perhaps the most disturbing example of this was described in the MERIT study; a randomised cluster control study of Medical Emergency Teams (MET) [27] in 23 Australian hospitals (including private and rural hospitals) in 2002. In the nearly 500 cardiac arrests that occurred during the study, in more than a third of instances staff took abnormal (that broached MET activation criteria) patient observations in the 15 min prior to the cardiac arrest, but did not activate an emergency response. The first thing of note with this phenomenon was that the incidence of not calling for help in an abnormal patient situation was high at 30% in the intervention hospitals, and 40% in the control hospitals. Put another way,

in the average Australian hospital in 2002, if a patient had documented abnormal signs, in the 15 min before a cardiac arrest, in up to 40% of the time the staff did nothing about this. Another thing of note with these findings is that in intervention hospitals that had had an intense education process on the new MET activation policy and procedure, the incidence of calling for help was only 10% greater than the control hospitals [27]. It is here at the bedside with the pre cardiac arrest patient that the staff are trapped in a clinical futile cycle, unable to get out of it due to either clinical incompetency (not able to recognise and act for the pre arrest patient) and/or culture whereby calling for help maybe considered not the norm in that ward, on that shift at that time [28–30].

The "Swiss Cheese" response when RRS fail at the sharp end, or afferent limb failure (ALF), the response is to assume policy and procedure failure, with hospital administrations, all too often, is just to alter the policy and procedure and make the activation criteria mandatory for the bedside staff [31]. This is done without areal understanding of what actually is going on at the bedside, the various heath care worker interactions and the overall socio-cultural environment of the hospital. Despite the intuitive appeal of Rapid Response Systems [32] their potential benefits [33] have been limited by this phenomenon of ALF [34]. In essence the RRS resuscitation teams cannot benefit the deteriorating patient if they are not notified about them. The incidence of bedside staff failure to activate the RRS has been measured at between 17 and 68% albeit that the various studies have used different criteria, definitions and methodologies [29, 34, 35]. What may be going on is that here may be problem with the face validity of RRS due to the very low specificity of the activation criteria [36–38]. Furthermore, there may be problems around staff competency, or cultural issues around staff losing face by calling for help. As a result, rather than trying to understand or deal with this very real issue of face validity, possible competency issues and probable cultural issues, the administrative response, is usually simplistic.
