Online Letters to the Editor 3. Central Bureau for Statistics. Available at: http://www.cbs.nl/ nl-NL/menu/themas/gezondheid-welzijn/publicaties/artikelen/ archief/2003/2003-1334-wm.htm. Accessed November 11, 2013 4. Bistrian BR: What is early and adequate feeding? Crit Care Med 2012; 40:307–308 5. Ibrahim EH, Mehringer L, Prentice D, et al: Early versus late enteral feeding of mechanically ventilated patients: Results of a clinical trial. JPEN J Parenter Enteral Nutr 2002; 26:174–181 6. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Rice TW, Wheeler AP, Thompson BT, et al: Initial trophic vs full enteral feeding in patients with acute lung injury: The EDEN randomized trial. JAMA 2012; 307:795–803 7. Alberda C, Gramlich L, Jones N, et al: The relationship between nutritional intake and clinical outcomes in critically ill patients: Results of an international multicenter observational study. Intensive Care Med 2009; 35:1728–1737 8. Arabi YM, Haddad SH, Tamim HM, et al: Near-target caloric intake in critically ill medical-surgical patients is associated with adverse outcomes. JPEN J Parenter Enteral Nutr 2010; 34:280–288 DOI: 10.1097/CCM.0000000000000196
Appreciating the Complexity of Rapid Response Teams: Not All Are the Same To the Editor:
I
n a recent issue of Critical Care Medicine, the study by Karpman et al (1) showed that rapid response team (RRT) implementation was associated with an increase in the number of ICU admissions, increase in transfers from the ward of less severely ill patients, and increase in the mortality in ICU admissions including those admitted from the ward and nonward areas. The authors attributed the changes to RRT. However, this interpretation should be taken with caution for several reasons. First, only one third of patients transferred from the ward to the ICU during the RRT period actually had RRT calls. It is unclear what was the process of transfer of the other two thirds of patients (Is it critical care consultation, direct transfer by the primary team, or other?). It is also unclear whether these two thirds of patients met RRT criteria before ICU admission. Our expectation is that they actually did meet RRT criteria, and the question is then why RRT was not activated? Was RRT activation designed to be optional, or was there an issue with compliance? With this low activation rate, it is important to have information about the timeliness of activations in those who had RRT call. We find it difficult to attribute all changes to ICU admissions from the wards to RRT, when only one third were admitted after RRT. We find it more difficult to attribute the changes to ICU admissions from the emergency department and the operating room when none of these patients had RRT activation. Second, coincided with RRT activation, the ICU adopted 24/7 onsite attending coverage: a factor that could contribute to some of the observed changes, especially that such a change would affect admissions from all sources (total 10,045 patients), including the small fraction (884 patients) who were admitted after RRT. For example, easier access to the Critical Care Medicine
ICU may allow shifting severely ill patients to die in the ICU. Whether the RRT was involved in addressing end-oflife issues and possibly in avoiding futile admissions is not addressed in the article (2). Third, with the low number of RRT calls: 1.45/d in the first year and 1.84/d in the last year, it appears that the RRT staff (attending fellow, nurse, and respiratory therapist) were not fully dedicated to RRT (although this is not mentioned explicitly in the article). Could the addition of assignment to the existing ICU staff to run RRT have diverted resources from ICU and lead to worse ICU outcomes? Fourth, there are no data comparing the case mix of hospitalized patients between the pre-RRT and post-RRT periods. However, the number of hospital admissions declined which may be an indirect sign of a change of acuity of illness, which may contribute to some of the observed findings. Fifth, there was an increase in the number of medical patients admitted to surgical ICU from 4% to 8.6%, which is another confounding change that may contribute to the findings. This study illustrates the complexity of RRT systems and highlights that not all RRTs are the same. In our study (3), RRT was implemented in a hospital that had critical care on-site intensivists 24/7 in the pre- and post-RRT periods (4). RRT had its dedicated staff and RRT activation preceded all admissions from the wards. In this setting, we demonstrated that the number of admissions from the wards actually declined and ICU mortality for admissions from the wards decreased. Mortality from admissions from the emergency department and operating room did not change as one would expect with RRT. It is critical when reviewing RRT studies to appreciate the details of how RRT was designed and implemented in order to make an informed interpretation of the findings and in order, for those of us who plan to implement RRT, to get a clear sense of the features of RRT that are likely or unlikely to lead to positive outcomes. The authors have disclosed that they do not have any potential conflicts of interest. Yaseen M. Arabi, MD, FCCP, FCCM, Saad Al-Qahtani, MD, MMEd, MAHA, FRCPC, Intensive Care Department, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
REFERENCES
1. Karpman C, Keegan MT, Jensen JB, et al: The Impact of Rapid Response Team on Outcome of Patients Transferred From the Ward to the ICU: A Single-Center Study. Crit Care Med 2013; 41:2284–2291 2. Vagts DA, Mutz CW: Rapid response teams—Is reducing mortality the only goal or can being too fast be detrimental for patients? Crit Care Med 2013; 41:2436–2437 3. Al-Qahtani S, Al-Dorzi HM, Tamim HM, et al: Impact of an intensivist-led multidisciplinary extended rapid response team on hospitalwide cardiopulmonary arrests and mortality. Crit Care Med 2013; 41:506–517 4. Arabi Y, Alshimemeri A, Taher S: Weekend and weeknight admissions have the same outcome of weekday admissions to an intensive care unit with onsite intensivist coverage. Crit Care Med 2006; 34:605–611 DOI: 10.1097/CCM.0000000000000112 www.ccmjournal.org
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Appreciating the Complexity of Rapid Response Teams: Not All Are the Same To the Editor:
I
n a recent issue of Critical Care Medicine, the study by Karpman et al (1) showed that rapid response team (RRT) implementation was associated with an increase in the number of ICU admissions, increase in transfers from the ward of less severely ill patients, and increase in the mortality in ICU admissions including those admitted from the ward and nonward areas. The authors attributed the changes to RRT. However, this interpretation should be taken with caution for several reasons. First, only one third of patients transferred from the ward to the ICU during the RRT period actually had RRT calls. It is unclear what was the process of transfer of the other two thirds of patients (Is it critical care consultation, direct transfer by the primary team, or other?). It is also unclear whether these two thirds of patients met RRT criteria before ICU admission. Our expectation is that they actually did meet RRT criteria, and the question is then why RRT was not activated? Was RRT activation designed to be optional, or was there an issue with compliance? With this low activation rate, it is important to have information about the timeliness of activations in those who had RRT call. We find it difficult to attribute all changes to ICU admissions from the wards to RRT, when only one third were admitted after RRT. We find it more difficult to attribute the changes to ICU admissions from the emergency department and the operating room when none of these patients had RRT activation. Second, coincided with RRT activation, the ICU adopted 24/7 onsite attending coverage: a factor that could contribute to some of the observed changes, especially that such a change would affect admissions from all sources (total 10,045 patients), including the small fraction (884 patients) who were admitted after RRT. For example, easier access to the Critical Care Medicine
ICU may allow shifting severely ill patients to die in the ICU. Whether the RRT was involved in addressing end-oflife issues and possibly in avoiding futile admissions is not addressed in the article (2). Third, with the low number of RRT calls: 1.45/d in the first year and 1.84/d in the last year, it appears that the RRT staff (attending fellow, nurse, and respiratory therapist) were not fully dedicated to RRT (although this is not mentioned explicitly in the article). Could the addition of assignment to the existing ICU staff to run RRT have diverted resources from ICU and lead to worse ICU outcomes? Fourth, there are no data comparing the case mix of hospitalized patients between the pre-RRT and post-RRT periods. However, the number of hospital admissions declined which may be an indirect sign of a change of acuity of illness, which may contribute to some of the observed findings. Fifth, there was an increase in the number of medical patients admitted to surgical ICU from 4% to 8.6%, which is another confounding change that may contribute to the findings. This study illustrates the complexity of RRT systems and highlights that not all RRTs are the same. In our study (3), RRT was implemented in a hospital that had critical care on-site intensivists 24/7 in the pre- and post-RRT periods (4). RRT had its dedicated staff and RRT activation preceded all admissions from the wards. In this setting, we demonstrated that the number of admissions from the wards actually declined and ICU mortality for admissions from the wards decreased. Mortality from admissions from the emergency department and operating room did not change as one would expect with RRT. It is critical when reviewing RRT studies to appreciate the details of how RRT was designed and implemented in order to make an informed interpretation of the findings and in order, for those of us who plan to implement RRT, to get a clear sense of the features of RRT that are likely or unlikely to lead to positive outcomes. The authors have disclosed that they do not have any potential conflicts of interest. Yaseen M. Arabi, MD, FCCP, FCCM, Saad Al-Qahtani, MD, MMEd, MAHA, FRCPC, Intensive Care Department, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
REFERENCES
1. Karpman C, Keegan MT, Jensen JB, et al: The Impact of Rapid Response Team on Outcome of Patients Transferred From the Ward to the ICU: A Single-Center Study. Crit Care Med 2013; 41:2284–2291 2. Vagts DA, Mutz CW: Rapid response teams—Is reducing mortality the only goal or can being too fast be detrimental for patients? Crit Care Med 2013; 41:2436–2437 3. Al-Qahtani S, Al-Dorzi HM, Tamim HM, et al: Impact of an intensivist-led multidisciplinary extended rapid response team on hospitalwide cardiopulmonary arrests and mortality. Crit Care Med 2013; 41:506–517 4. Arabi Y, Alshimemeri A, Taher S: Weekend and weeknight admissions have the same outcome of weekday admissions to an intensive care unit with onsite intensivist coverage. Crit Care Med 2006; 34:605–611 DOI: 10.1097/CCM.0000000000000112 www.ccmjournal.org
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