Rapid Response Systems
Background
Rapid response teams represent an intuitively simple concept: When a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to the bedside to immediately assess and treat the patient with the goal of preventing intensive care unit transfer, cardiac arrest, or death. Such teams have become a widely used patient safety intervention due in large part to their inclusion in the Institute for Healthcare Improvement's "100,000 Lives Campaign" in 2005. However, the rapid response team concept has come to exemplify the tension between those arguing for swift implementation of conceptually attractive patient safety interventions supported by anecdotal evidence of benefit and those advocating a more rigorous, evidence-based—and inevitably slower—approach.
Patients whose condition deteriorates acutely while hospitalized often exhibit warning signs (such as abnormal vital signs) in the hours before experiencing adverse clinical outcomes. In contrast to standard cardiac arrest or "code blue" teams, which are summoned only after cardiopulmonary arrest occurs, rapid response teams are designed to intervene during this critical period, usually on patients on general medical or surgical wards.
Several different models of rapid response teams exist (see Table 1), and a 2006 consensus conference advocated use of the term "rapid response system" (RRS) as a unifying term. Hospitalists are increasingly assuming RRS duties, either as the primary responder or to assist nurse-led teams.
A useful construct is to consider RRSs as having "afferent" (the criteria for calling) and "efferent" (responsive) arms. Despite differences in team structure, the criteria used to summon the teams are generally similar. Bedside staff are encouraged to call the team when any of a number of prespecified criteria (Table 2) are met. At certain hospitals, patients and family members are also permitted to call the team. Recent research has focused on development of more sophisticated "track-and-trigger" bedside monitoring systems that could be used to automatically trigger intervention when certain physiologic abnormalities are detected.
Evidence of Effectiveness
Early publications on RRSs reported significant improvements in clinical outcomes, but multiple subsequent systematic reviews have markedly tempered the initial enthusiasm. The best available evidence indicates that while RRSs may slightly reduce cardiac arrests in ward patients, they have no effect on rates of unplanned ICU transfers or on overall in-hospital mortality. Little comparative data exists to support one RRS model over another, nor are there data on the cost-effectiveness of RRS. The reasons for RRSs' apparent lack of effect are complex, and in some cases, may be related to local practice and cultural reasons that result in the team being underutilized.
Current Context
The strong endorsement of RRSs by the Institute for Healthcare Improvement, coupled with the 2008 Joint Commission National Patient Safety Goal—which does not mandate RRS per se but does require hospitals to implement systems to enable "healthcare staff members to directly request additional assistance from a specially trained individual(s) when the patient's condition appears to be worsening"—have led to widespread implementation of RRS, despite continued controversy around their clinical benefit. It is likely that some form of RRS exists in most US hospitals, as nearly half of had established a rapid response team as of 2006.
Rapid response teams represent an intuitively simple concept: When a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to the bedside to immediately assess and treat the patient with the goal of preventing intensive care unit transfer, cardiac arrest, or death. Such teams have become a widely used patient safety intervention due in large part to their inclusion in the Institute for Healthcare Improvement's "100,000 Lives Campaign" in 2005. However, the rapid response team concept has come to exemplify the tension between those arguing for swift implementation of conceptually attractive patient safety interventions supported by anecdotal evidence of benefit and those advocating a more rigorous, evidence-based—and inevitably slower—approach.
Patients whose condition deteriorates acutely while hospitalized often exhibit warning signs (such as abnormal vital signs) in the hours before experiencing adverse clinical outcomes. In contrast to standard cardiac arrest or "code blue" teams, which are summoned only after cardiopulmonary arrest occurs, rapid response teams are designed to intervene during this critical period, usually on patients on general medical or surgical wards.
Several different models of rapid response teams exist (see Table 1), and a 2006 consensus conference advocated use of the term "rapid response system" (RRS) as a unifying term. Hospitalists are increasingly assuming RRS duties, either as the primary responder or to assist nurse-led teams.
| Table 1. Rapid Response System Models | ||
|---|---|---|
| Model | Personnel | Duties |
| Medical Emergency Team | Physicians (critical care or hospitalist) and nurses |
|
| Critical Care Outreach | Critical care physicians and nurses |
|
| Rapid Response Team | Critical care nurse, respiratory therapist, and physician (critical care or hospitalist) backup |
|
| Table 2. Typical Rapid Response System Calling Criteria |
|---|
Any staff member may call the team if one of the following criteria is met:
|
o Heart rate over 140/min or less than 40/min
|
o Respiratory rate over 28/min or less than 8/min
|
o Systolic blood pressure greater than 180 mmHg or less than 90 mmHg
|
o Oxygen saturation less than 90% despite supplementation
|
o Acute change in mental status
|
o Urine output less than 50 cc over 4 hours
|
o Staff member has significant concern about the patient's condition
|
Additional criteria used at some institutions:
|
o Chest pain unrelieved by nitroglycerin
|
o Threatened airway
|
o Seizure
|
o Uncontrolled pain
|
Early publications on RRSs reported significant improvements in clinical outcomes, but multiple subsequent systematic reviews have markedly tempered the initial enthusiasm. The best available evidence indicates that while RRSs may slightly reduce cardiac arrests in ward patients, they have no effect on rates of unplanned ICU transfers or on overall in-hospital mortality. Little comparative data exists to support one RRS model over another, nor are there data on the cost-effectiveness of RRS. The reasons for RRSs' apparent lack of effect are complex, and in some cases, may be related to local practice and cultural reasons that result in the team being underutilized.
Current Context
The strong endorsement of RRSs by the Institute for Healthcare Improvement, coupled with the 2008 Joint Commission National Patient Safety Goal—which does not mandate RRS per se but does require hospitals to implement systems to enable "healthcare staff members to directly request additional assistance from a specially trained individual(s) when the patient's condition appears to be worsening"—have led to widespread implementation of RRS, despite continued controversy around their clinical benefit. It is likely that some form of RRS exists in most US hospitals, as nearly half of had established a rapid response team as of 2006.
What's New in Rapid Response Systems on AHRQ PSNet
STUDY
The impact of a nurse led rapid response system on adverse, major adverse events and activation of the medical emergency team.
Massey D, Aitken LM, Chaboyer W. Intensive Crit Care Nurs. 2015 Feb 6; [Epub ahead of print].
STUDY
Factors affecting attitudes and barriers to a medical emergency team among nurses and medical doctors: a multi-centre survey.
Radeschi G, Urso F, Campagna S, et al. Resuscitation. 2015;88:92-98.
STUDY
Hospital system barriers to rapid response team activation: a cognitive work analysis.
Braaten JS. Am J Nurs. 2015;115:22-32.
STUDY
Rapid response systems and collective (in)competence: an exploratory analysis of intraprofessional and interprofessional activation factors.
Kitto S, Marshall SD, McMillan SE, et al. J Interprof Care. 2014 Nov 28; [Epub ahead of print].
STUDY
Developing and evaluating the success of a family activated medical emergency team: a quality improvement report.
Brady PW, Zix J, Brilli R, et al. BMJ Qual Saf. 2015;24:203-211.
The impact of a nurse led rapid response system on adverse, major adverse events and activation of the medical emergency team.
Massey D, Aitken LM, Chaboyer W. Intensive Crit Care Nurs. 2015 Feb 6; [Epub ahead of print].
STUDY
Factors affecting attitudes and barriers to a medical emergency team among nurses and medical doctors: a multi-centre survey.
Radeschi G, Urso F, Campagna S, et al. Resuscitation. 2015;88:92-98.
Hospital system barriers to rapid response team activation: a cognitive work analysis.
Braaten JS. Am J Nurs. 2015;115:22-32.
Rapid response systems and collective (in)competence: an exploratory analysis of intraprofessional and interprofessional activation factors.
Kitto S, Marshall SD, McMillan SE, et al. J Interprof Care. 2014 Nov 28; [Epub ahead of print].
Developing and evaluating the success of a family activated medical emergency team: a quality improvement report.
Brady PW, Zix J, Brilli R, et al. BMJ Qual Saf. 2015;24:203-211.
Rapid Response Teams: Lessons from the Early Experience.
William S. Krimsky, MD. AHRQ WebM&M [serial online]. November 2005
William S. Krimsky, MD. AHRQ WebM&M [serial online]. November 2005
JOURNAL ARTICLE
Rapid-response teams.Jones DA, DeVita MA, Bellomo R. N Engl J Med. 2011;365:139-146.
Rapid response teams: a systematic review and meta-analysis.Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Arch Intern Med. 2010;170:18-26.
Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a children’s hospital.Sharek PJ, Parast LM, Leong K, et al. JAMA. 2007;298:2267-2274.
The tension between needing to improve care and knowing how to do it.Auerbach AD, Landefeld CS, Shojania KG. N Engl J Med. 2007;357:608-613.
Jones D, Baldwin I, McIntyre T, et al. Qual Saf Health Care. 2006;15:427-432.
Rapid response teams—walk, don't run.Winters BD, Pham J, Pronovost PJ. JAMA. 2006;296:1645-1647.
Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial.MERIT study investigators. Lancet. 2005;365:2091-2097.
Use of medical emergency team responses to reduce hospital cardiopulmonary arrests.DeVita MA, Braithwaite RS, Mahidhara R, et al. Qual Saf Health Care. 2004;13:251-254.
Oakbrook Terrace, IL: The Joint Commission; 2015.
Wang SS. Washington Post. September 4, 2007;Health section:1.
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