Resuscitation 85 (2014) e61
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Emergency response teams and patient survival Sir, We congratulate Drs McNeill and Bryden for their comprehensive review of the effect of early warning systems and emergency response teams (ERTs) on patient survival.1 We agree with the authors’ conclusion that studies to date describing early warning systems and ERTs suffer from numerous methodological flaws1 whereby, making value assessments of emergency response systems (ERS) difficult. We further support the authors’ belief that future research should focus on robust evaluation of all aspects of ERS components. However, from our organization’s experience, we have found that the traditional endpoints of program success are limited, the literature lacks a consistent and accepted definition of failure to rescue, and despite recommendations from the International Liaison Committee on Resuscitation (ILCOR) in 2007, there is inconsistent application of the Utstein templates related to ERSs.2 The rate of cardiac arrest has been a traditional endpoint. Some have concluded that an insufficient number of ERT activations is a reason for unsuccessful decrease in cardiac arrest rates. While this may be true in some organizations, we have not found this to be the case in ours. Our system averages between 50 and 80 rapid response team (RRT) activations per 1000 discharges each month. Despite this dose, we have found that our non-ICU cardiac arrest rate over the past seven years has remained essentially flat at less than 2 events per 1000 discharges. It is rare, from individual reviews of these events, to find clear evidence of patient deterioration prior to RRT activation. Most often, there is no discernible explanation for these events that would have triggered an RRT activation. Contrary to others, intensive care unit (ICU) admissions within our organization have increased with the implementation of our RRT system. However, assessments of patients admitted to the ICU have demonstrated lower APACHE scores. We believe this increase is multi-factorial and relates to organizational culture, structure and resources. As the authors note, there are wide variations in the ratio of critical care to ward beds; and, unlike many large academic centers, we do not have a shortage of ICU beds. As such, we have very few progressive care (intermediate) level beds in non-ICU settings. Therefore, if it is determined that increased monitoring is needed after an RRT evaluation, the patient is transferred to the ICU. The ICU team is responsible for most of these patients yet they are often classified as intermediate-level care. As a result of this overabundance of ICU beds, we see a lower threshold of tolerance for acute issues that develop on a general floor. At other institutions, many of these issues are likely cared for on the general ward or they may have the ability to expand the monitoring and nursing care ratio without geographically moving the patient. From the examples provided, we propose that future studies related to ERSs should be based on standard definitions and 0300-9572/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.resuscitation.2013.12.032
consistent reporting mechanisms as recommended by ILCOR. The current American Heart Association database for medical emergency teams (MET) is based on these recommendations2 ; however, it is not as robust as the cardiac arrest database. It is important to improve this data collection and reporting as it is difficult to compare traditionally accepted endpoints between different organizations in a meaningful way. Those of us actively involved in ERSs believe that the validity of the concept is strong; however this is not enough. We believe the ultimate measure of success revolves around the concept of failure to rescue. Unfortunately, “failure to rescue” lacks universally accepted definition. A consensus definition would provide a universal endpoint that would allow for the true measure of success of ERSs. This definition may be difficult to achieve, but in doing so the heterogeneity of ERS literature would improve and likely help clarify future research goals. Conflict of interest statement None of the authors have any conflict of interest to disclose. References 1. McNeill G, Bryden D. Do either early warning systems or emergency response teams improve hospital patient survival? A systematic review. Resuscitation 2013;84:1652–67. 2. Peberdy MA, Cretikos M, Abella BS, et al. Recommended guidelines for monitoring, reporting, and conducting research on medical emergency team, outreach, and rapid response systems: an Utstein-style scientific statement: a scientific statement from the International Liaison Committee on Resuscitation (American Heart Association, Australian Resuscitation Council, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, and the New Zealand Resuscitation Council); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiopulmonary, Perioperative, and Critical Care; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research. Circulation 2007;116:2481–500.
a
Sumedh S. Hoskote (MBBS) a,∗ Department of Medicine, Division of Critical Care, Mayo Clinic, Rochester, MN, USA b
c
Jennifer L. Elmer (DNP, RN, CCNS) b Department of Nursing, Mayo Clinic, Rochester, MN, USA
Jeffrey B. Jensen (MD) c Department of Anesthesiology, Division of Critical Care, Mayo Clinic, Rochester, MN, USA ∗ Corresponding
author. E-mail address: [email protected] (S.S. Hoskote) 20 December 2013
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Emergency response teams and patient survival Sir, We congratulate Drs McNeill and Bryden for their comprehensive review of the effect of early warning systems and emergency response teams (ERTs) on patient survival.1 We agree with the authors’ conclusion that studies to date describing early warning systems and ERTs suffer from numerous methodological flaws1 whereby, making value assessments of emergency response systems (ERS) difficult. We further support the authors’ belief that future research should focus on robust evaluation of all aspects of ERS components. However, from our organization’s experience, we have found that the traditional endpoints of program success are limited, the literature lacks a consistent and accepted definition of failure to rescue, and despite recommendations from the International Liaison Committee on Resuscitation (ILCOR) in 2007, there is inconsistent application of the Utstein templates related to ERSs.2 The rate of cardiac arrest has been a traditional endpoint. Some have concluded that an insufficient number of ERT activations is a reason for unsuccessful decrease in cardiac arrest rates. While this may be true in some organizations, we have not found this to be the case in ours. Our system averages between 50 and 80 rapid response team (RRT) activations per 1000 discharges each month. Despite this dose, we have found that our non-ICU cardiac arrest rate over the past seven years has remained essentially flat at less than 2 events per 1000 discharges. It is rare, from individual reviews of these events, to find clear evidence of patient deterioration prior to RRT activation. Most often, there is no discernible explanation for these events that would have triggered an RRT activation. Contrary to others, intensive care unit (ICU) admissions within our organization have increased with the implementation of our RRT system. However, assessments of patients admitted to the ICU have demonstrated lower APACHE scores. We believe this increase is multi-factorial and relates to organizational culture, structure and resources. As the authors note, there are wide variations in the ratio of critical care to ward beds; and, unlike many large academic centers, we do not have a shortage of ICU beds. As such, we have very few progressive care (intermediate) level beds in non-ICU settings. Therefore, if it is determined that increased monitoring is needed after an RRT evaluation, the patient is transferred to the ICU. The ICU team is responsible for most of these patients yet they are often classified as intermediate-level care. As a result of this overabundance of ICU beds, we see a lower threshold of tolerance for acute issues that develop on a general floor. At other institutions, many of these issues are likely cared for on the general ward or they may have the ability to expand the monitoring and nursing care ratio without geographically moving the patient. From the examples provided, we propose that future studies related to ERSs should be based on standard definitions and 0300-9572/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.resuscitation.2013.12.032
consistent reporting mechanisms as recommended by ILCOR. The current American Heart Association database for medical emergency teams (MET) is based on these recommendations2 ; however, it is not as robust as the cardiac arrest database. It is important to improve this data collection and reporting as it is difficult to compare traditionally accepted endpoints between different organizations in a meaningful way. Those of us actively involved in ERSs believe that the validity of the concept is strong; however this is not enough. We believe the ultimate measure of success revolves around the concept of failure to rescue. Unfortunately, “failure to rescue” lacks universally accepted definition. A consensus definition would provide a universal endpoint that would allow for the true measure of success of ERSs. This definition may be difficult to achieve, but in doing so the heterogeneity of ERS literature would improve and likely help clarify future research goals. Conflict of interest statement None of the authors have any conflict of interest to disclose. References 1. McNeill G, Bryden D. Do either early warning systems or emergency response teams improve hospital patient survival? A systematic review. Resuscitation 2013;84:1652–67. 2. Peberdy MA, Cretikos M, Abella BS, et al. Recommended guidelines for monitoring, reporting, and conducting research on medical emergency team, outreach, and rapid response systems: an Utstein-style scientific statement: a scientific statement from the International Liaison Committee on Resuscitation (American Heart Association, Australian Resuscitation Council, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, and the New Zealand Resuscitation Council); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiopulmonary, Perioperative, and Critical Care; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research. Circulation 2007;116:2481–500.
a
Sumedh S. Hoskote (MBBS) a,∗ Department of Medicine, Division of Critical Care, Mayo Clinic, Rochester, MN, USA b
c
Jennifer L. Elmer (DNP, RN, CCNS) b Department of Nursing, Mayo Clinic, Rochester, MN, USA
Jeffrey B. Jensen (MD) c Department of Anesthesiology, Division of Critical Care, Mayo Clinic, Rochester, MN, USA ∗ Corresponding
author. E-mail address: [email protected] (S.S. Hoskote) 20 December 2013
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