Patient Safety Tip of the Week
November 27, 2007 More on Rapid Response Teams
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!).
Resources
such as IHI’s
initiatives on rapid response teams , or ICSI’s (Institute for
Clinical Systems Improvement) Rapid
Response Team Protocol remain quite
useful.
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”.
References:
(1)
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
http://jama.ama-assn.org/cgi/content/full/298/19/2267
(2)
Winters BD, Cuong J, Hunt EA, et al. Rapid response teams: A
systematic review. Critical Care Medicine 2007; 35: 1238-1243
(3)
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
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