Though the concept behind deployment of Rapid Response Teams (RRT’s) makes good sense, the impact on patient outcomes after deployment of RRT’s has been disappointing to date. We first talked about Rapid Response Teams in our August 2007 What’s New in the Patient Safety World column “Rapid Response Teams Don’t Live Up to Expectations” we discussed the weakness of the evidence supporting a positive effect of rapid response teams on patient outcomes and discussed many of the methodological problems in studies on RRT’s.”. Then, in our November 27, 2007 Patient Safety Tip of the Week “ ” and our December 2008 What’s New in the Patient Safety World column “
Now the researchers (Chen et al 2009) involved in one of the largest prospective randomized trials of RRT’s have reanalyzed the data from the MERIT study (Medical Emergency Response Intervention and Therapy) and found evidence to support the concept of the early emergency call. The MERIT study was a cluster randomized controlled trial in which hospitals in Australia were randomized into 2 groups: those that had rapid response systems and those that did not. That study failed to demonstrate any significant improvement in outcomes between the RRT hospitals and the control ones. However, when they analyzed the data, they noted that almost half the calls to the cardiac arrest teams in control hospitals were “early” calls (i.e. before a cardiac arrest) and that at the RRT hospitals many patients who met the criteria for a call to the RRT never had such a call. They speculated that this “contamination” may have been responsible for the insignificant results in MERIT.
So they reviewed the data, asking the new question “were early calls associated with improved outcomes?”. Indeed, they found that early calls were associated with reductions in the rate of cardiac arrests and unexpected deaths. For every 10% increase in early calls, there was a 2.2 per 100,000 reduction in cardiac arrests and a 0.94 per 100,000 reduction in unexpected deaths. There was no statistical reduction of overall deaths, unplanned ICU admissions, or an aggregate measure of all the outcomes combined.
So the data do support the concept of developing systems to recognize patients who are clinically deteriorating and respond earlier. What is unclear is what “early warning” systems work best and how to best respond.
As we have said before, all the negative evidence on use of RRT’s does not negate the logic of having a culture of safety that helps recognize early patients that are in need of “rescue”. Although it does raise many questions about committing many resources to develop RRT’s without better evidence-based validation of the RRT concept, the idea remains a sound one but the most appropriate targets, the triggers, the makeup of teams, the mode of response, the logistics, and the best outcome measures all need to be validated before hospitals rush willy-nilly into developing RRT’s. The Chen paper would suggest that refining the criteria and system for early recognition may be the best place to start.
In our August 2007 What’s New in the Patient Safety World column “Safer care for the acutely ill patient: learning from serious incidents” and NICE (National Institute for Health and Clinical Excellence) has just released its clinical guideline “Acutely ill patients in hospital. Recognition of and response to acute illness in adults in the hospital”. The NICE guideline discusses several scoring systems for identification of patients clinically deteriorating, including the MET (single parameter), MEWS (aggregate scoring system) and ASSIST (assessment score for sick patient identification and step-up in treatment – aggregate scoring system) systems.” we discussed 2 UK organizational guidelines on clinical deterioration in acutely hospitalized patients. The UK NHS National Patient Safety Agency had just published its report “
While randomized controlled trials may be needed to determine the best method of responding to critical clinical deterioration of a patient, it remains intuitive that systems which enhance early identification of such clinical deterioration are desirable. Joint Commission’s National Patient Safety Goal requiring a plan to “Improve recognition and response to changes in a patient’s condition” makes sense even if a “traditional” rapid response team is not the best way to intervene.
Chen J, Bellomo R, Flabouris A, Hillman K, Finfer S; MERIT Study Investigators for the Simpson Centre; ANZICS Clinical Trials Group. The relationship between early emergency team calls and serious adverse events. Crit Care Med. 2009 Jan;37(1):148-53.
UK NHS National Patient Safety Agency. Safer care for the acutely ill patient: learning from serious incidents. 2007
NICE (National Institute for Health and Clinical Excellence). Acutely ill patients in hospital. Recognition of and response to acute illness in adults in hospital. July 2007
Update: See also our December 29, 2009 Patient Safety Tip of the Week “Recognizing Deteriorating Patients”.
In a prospective multicenter randomized controlled trial, Timsit et al. (Timsit et al 2009) demonstrated that use of chlorhexidine-impregnated sponges in dressings for intravascular catheters reduced rates of catheter-related bloodstream infections (CRI’s) by 60%, even in a population with a low baseline rate of CRI’s. The reduction was statistically significant, though the number needed to treat (NNT) to prevent one CRI for every catheter was 117. Significant contact dermatitis occurred in 10.4 per 1000 patients or 5.3 per 1000 catheters.
They also demonstrated that changing unsoiled adherent dressings could safely be done every 7 days rather than every 3 days.
The encouraging results were obtained even though most evidence-based practices were already in place to reduce the frequency of CRI’s.
Timsit J-F, Schwebel C, Bouadma L, et al for the Dressing Study Group. Chlorhexidine-Impregnated Sponges and Less Frequent Dressing Changes for Prevention of Catheter-Related Infections in Critically Ill Adults: A Randomized Controlled Trial. JAMA. 2009;301(12):1231-1241
AHRQ has put some new Patient Safety Culture Assessment Tools on its website. The following surveys on patient safety culture are available:
These tools are quite good. Not only do they assess the culture of safety, but they also get you thinking about some of the key patient safety areas you may need to spend more time on.
Speaking of patient safety culture surveys, Press Ganey has released their 2009 report on Safety Culture and it contains some very interesting observations and recommendations. Of the 13 dimensions of safety culture they address, the two areas most in need of improvement are non-punitive response to error and handoffs/transitions.
The perception of safety culture varies greatly by staff position, degree of patient contact, number of hours worked, amount of years in an organization, work area, organization size, and even governance. Management and staff with little patient contact tend to have much higher perceptions of patient safety culture than do front-line workers. Similarly, staff in very complex clinical areas have lower perceptions of safety culture. And new staff have better perceptions than staff who have been employed for longer periods.
The report provides some examples of how specific organizations have been able to use the results of their surveys to improve patient safety culture. Concepts like safety “chats” and “safety coaches” are highlighted. And they stress the importance of continued training in patient safety for all staff, not just at the time of initial orientation. This report is worth reading. It’s clear that Press Ganey uses its survey tools to help organizations actually improve patient safety, not just to make the organizations feel good about it.
And while you are at it, take a look at ECRI Institute’s new programs for physician practice patient safety and risk management. They cover a broad range of topics that will improve the safety of your patients and improve your overall efficiency and probably your bottom line.
AHRQ. Patient Safety Culture Surveys. 2009
Press Ganey. P u l s e R e port 2009®. Safety Culture. Staff Perspectives on American Health Care. 2009
ECRI Institute. Patient Safety, Risk Assessment and Management
Our January 27, 2009 Pattient Safety Tip of the Week “Oxygen Therapy: Everything You Wanted to Know and More!” summarized the new British Thoracic Society (BTS) guideline on oxygen therapy.
A 2-part series on implementation of these guidelines from a nursing perspective has appeared in Nursing Times in March 2009 (Smith et al 2009 Part 1, Smith et al 2009 Part 2). While this largely reiterates many of the key points in the BTS guideline, it does have some very practical tips. For example, it describes barriers to appropriate management, such as need for removal of nail polish to prevent inaccurate pulse oximetry readings or use of an ear probe in patients severely vasoconstricted peripherally. It also points out that oxygen therapy is intended to treat hypoxemia, not breathlessness. But it does discuss approaches to the breathless patient. In a discussion about mucus plugging, it notes that there is little evidence that humidification with high-flow oxygen is effective and the oxygen guideline recommends that a bubble bottle should not be used but that single doses of nebulised normal saline have been shown to help in sputum clearance and reduce breathlessness in patients with COPD
Smith, S.M.S. et al. Emergency oxygen delivery in adults 1: updating nursing practice. Nursing Times 2009; 105: 10, 16–18 March 13, 2009
Smith, S.M.S. et al. Emergency oxygen delivery 2: patients with asthma and COPD. Nursing Times 2009; 105: 11 March 24, 2009