Our August 2007 “What’s New in the Patient Safety World” column discussed Rapid Response Teams and new guidelines from 2 UK organizations on clinical deterioration in acutely hospitalized patients. The UK NHS National Patient Safety Agency had just published its report “Safer care for the acutely ill patient: learning from serious incidents” and NICE (National Institute for Health and Clinical Excellence) had just released its clinical guideline “Acutely ill patients in hospital. Recognition of and response to acute illness in adults in hospital”.
The National Patient Safety Agency report analyzed serious patient incidents and found a large number of cases in which patients’ clinical deterioration was either not recognized early or not acted upon. Subthemes were that vital signs were often not appropriately observed or there was lack of recognition or lack of response to deteriorating vital signs. The second major theme was that rescuscitation skills and/or inadequate equipment often caused problems with cardiorespiratory rescuscitation. Action points recommended include not only providing appropriate standards and training, but also performing audits of codes and emergency equipment and standardization of rescuscitation equipment.
The NICE guidelines focus on 3 key areas: (1) identification of patients at risk for clinical deterioration or actually already deteriorating (2) response strategies, including timing, communication, and coordination of care between critical care teams and other specialties and (3) discharge of patients from critical care areas back to ward-based care, including monitoring requirements and timing of transfer. They stress the need for physiological track and trigger systems that help identify those patients in need of closer attention or intervention and use of a graded response strategy to those identified by the track and trigger scoring system. They discuss several scoring systems available. They have a good discussion of the key elements in the handover when patients are transferred back to the wards from critical care units. An interesting recommendation is that patients should not be transferred back to wards between 22:00 and 07:00 unless absolutely necessary. This was an evidence-based recommendation, though most of the studies were done in the UK, Canada, Australia, or countries other than the United States.
The NICE documents are well worth reading, particularly if one is interested in the evidence behind the recommendations. The UK work, however, identified there is a current lack of a good evidence base on the cost-effectiveness of these systems.
Now there is a new study published in last week’s JAMA demonstrating significant benefits of RRT’s in pediatric patients in terms of overall mortality and frequency of out-of-ICU arrests. Sharek et al (1) did a cohort design study with historical controls before and after implementation of RRT’s at a free-standing quaternary care Children’s hospital. They showed an 18% reduction in mortality and approximately 70% reduction in several measures of code/arrest frequency after implementation of their RRT program. They estimated that 33 lives were saved in the 19-month post-intervention period. Their team was available 24 x 7 and consisted of a pediatric ICU-trained fellow or attending, an ICU nurse, an ICU respiratory therapist, and a nursing supervisor. The criteria for activation of the RRT were (1) any staff member worried about a patient, (2) acute change in respiratory rate, (3) acute change in oxygen saturation, (4) acute change in heart rate, (5) acute change in blood pressure, and (6) acute change in level of consciousness. No formal cost-effectiveness analysis was performed, though they note the program was implemented with no additional funding for staffing. Two prior pediatric studies had failed to demonstrate statistically significant improvements in hospital mortality but one of those did demonstrate a significant reduction in outside-the-ICU arrests/codes. The biggest problem with a cohort design study such as the Sharek study, however, is the use of historical controls. That makes it very difficult to attribute any post-intervention improvement to the intervention alone. The Sharek study also used a very asymmetrical design (i.e. the pre-intervention period was substantially longer than the post-intervention), further increasing the likelihood of confounding variables.
The same study design issues have plagued most of the adult published studies on RRT’s. A systematic review (2), done on adult hospital RRT’s, concluded that though there is weak evidence that RRT’s result in reductions in mortality and cardiac arrest rates, the issues about quality of the original studies, wide confidence intervals and heterogeneity all highlight the need for large randomized controlled trials before RRT’s are accepted as the standard of care. Most of the studies have been observational studies with historical controls. In fact, the only large well-designed study (3), which used a cluster-randomized design, showed no benefit.
Some have also questioned, given the substantial nationwide shortage of intensivists, whether RRT’s can be implemented in all hospitals. However, as pointed out by Winters and Pronovost (4), the ideal personnel composition of RRT’s is unknown and in many facilities the RRT’s are led by senior-level nurses. They also point out that it remains unclear whether any benefit of RRT’s is dependent upon the team itself rather than the earlier recognition of the need for intervention that leads to activation of the RRT.
While randomized controlled trials may be needed to determine the best method of responding to critical clinical deterioration of a patient, it is intuitive that systems which enhance early identification of such clinical deterioration are desirable. Joint Commission’s new 2008 National Patient Safety Goal requiring a plan to “Improve recognition and response to changes in a patient’s condition” makes sense even if you don’t decide to implement a “traditional” rapid response team (if there is such an entity!).
Update: See also our December 2008 What’s New in the Pateient Safety World column “Rapid Response Teams Don’t Live Up to Expectations and our April 2009 What’s New in the Patient Safety World “Early Emergency Team Calls Reduce Serious Adverse Events” and our December 29, 2009 Patient Safety Tip of the Week “Recognizing Deteriorating Patients”.
Sharek PJ, Parast LM, Leong K, et al. Effect of a Rapid Response
Team on Hospital-wide Mortality and Code Rates Outside the ICU in a Children’s
Hospital. JAMA 2007; 298: 2267-2274
Winters BD, Cuong J, Hunt EA, et al. Rapid response teams: A
systematic review. Critical Care Medicine 2007; 35: 1238-1243
Hillman K, Chen J, Cretikos M, et al. MERIT Study
Investigators. Introduction of the medical emergency team (MET) system: a
cluster-randomized trial. Lancet 2005; 365: 2091-2097
(4) Winters BD, Pronovost PJ. Rapid response system: Let’s not get carried away! (Letters to the Editor). Critical Care Medicine2007; 35: 2235