REVIEW
Rapid response teams in adult hospitals: time for another look? K. White,1 I. A. Scott,2 A. Vaux3 and C. M. Sullivan4 1 Department of Internal Medicine and Clinical Epidemiology, 3Intensive Care Unit, 4Division of Medicine, Princess Alexandra Hospital and 2School of Medicine, University of Queensland, Brisbane, Queensland, Australia
Key words rapid response team, adult, effectiveness, implementation. Correspondence Ian A. Scott, Department of Internal Medicine and Clinical Epidemiology, Level 5A, Princess Alexandra Hospital, Ipswich Road, Brisbane, Qld 4102, Australia. Email: [email protected] Received 22December June 2015;2014; accepted 23 June Received 27 accepted 23 June 2015. 2015 doi:10.1111/imj.12845 doi:
Abstract Rapid response teams (RRT), alternatively termed medical emergency teams, have become part of the clinical landscape in the majority of adult hospitals throughout Australia and New Zealand. These teams aim to bring critical care expertise to the bedside of clinically deteriorating patients residing in general hospital wards with the aim of preventing adverse outcomes, in particular death or cardiorespiratory arrests. While the concept of RRT has considerable face validity, there is little high quality evidence of their effectiveness and much uncertainty as to the optimal methods for identifying patients in need of RRT and calling the RRT (afferent limb) and how, and with whom, the RRT should then respond (efferent limb). Adverse unintended consequences of RRT systems and the opportunity costs involved in maintaining such systems have not been subject to study, amid concerns RRT may be compensating for other potentially remediable system of care failures. This article presents an overview of the current state of play of RRT in hospital practice as they pertain to the care of adult patients and identifies several issues around their implementation and evaluation that should be subject to further research.
Introduction Rapid response teams (RRT), previously termed medical emergency teams, have been widely adopted throughout adult hospitals in Australia and New Zealand with a single aim: the early recognition of clinically deteriorating patients, leading to prompt review by appropriately trained staff and consequent prevention of adverse outcomes. RRT systems now exist within two‐thirds of all Australian hospitals and affect more than 14700 patients each year.1 The characteristics of RRT calls and patients in this country have recently been reviewed and summary findings from 28 studies are listed in Table1.2 The requirement for hospitals to implement RRT systems has been enshrined as a national health service standard by the Australian Commission of Quality and Safety in Health Care.3 While the basic premise underpinning RRT has considerable face validity, empirical validation of effectiveness is necessary, if only because many practice standards based on seemingly sound pathophysiological rationales have been found wanting when subjected to robust scrutiny.4 In addition, RRT consume resources and may have unintended consequences that offset some of the benefits.
Funding: None Conflict of interest: None
© 2015 Royal Australasian College of Physicians
This article provides an overview of the effectiveness and processes of RRT as they pertain to the care of adult patients, and poses several questions that deserve attention from health service researchers.
Background The foundation of RRT rests on the observation that adverse events in acutely ill patients are frequently preceded by an observable period of derangement in physiological parameters.5,6 Clinical deterioration occurs in 66–84% of patients up to 6h prior to in‐hospital cardiac arrest.5,7 Furthermore, 60% of patients transferred urgently to intensive care units (ICU) with potentially life‐threatening conditions were documented as showing worsening in vital signs during the 8h before their admission.8 Between 18% and 76% of adverse events precipitating such transfers are considered potentially preventable.9 Patients requiring RRT have a 25% in‐ hospital mortality, and 20% of patients who die in hospital are reviewed by RRT.1 RRT systems were implemented with the goal of detecting clinical deterioration early and intervening in a timely manner to improve patient outcomes. The RRT system consists of three components: 1 early detection of clinical deterioration based on recording of bedside observations;
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White et al. Table 1 Summary of epidemiology of Australian adult RRT patients2 • Frequency of RRT activations varies considerably from 1.3 to 71 per 1000 admissions. • Point prevalence studies of RRT activation criteria show that 1 in 30 patients fulfil such criteria at any one time but only 4% undergo RRT review and up to 50% of these have delayed activation. • Between 15% and 20% of patients seen by RRT have a repeat RRT call during admission in association with increased mortality, ICU transfers and length of hospital stay. • Calls for RRT peak around times of nursing handover and vital sign measurement and frequently occur after hours and within 24h of admission. • About a quarter of RRT calls are triggered by ‘worry’ criteria alone. • Admission to critical care areas occurs in 10%–25% of patients seen by RRT. • Up to one-third of RRT calls occur in patients with end of life care issues. • Rates of ICU admission following RRT calls vary from 13% to 45%. • In-hospital mortality of RRT patients is 25% overall, and 15% in those with no limitations of medical therapy. ICU, intensive care unit; RRT, rapid response teams.
2 activation of the RRT by ward‐based staff once these observations exceed pre‐specified thresholds or triggers; 3 response by the RRT. Components 1 and 2 together comprise the afferent limb, and component 3 the efferent limb of the RRT system.
Benefits of RRT The clinical benefits of RRT systems have not been clearly established. In this review, we specifically focus on literature directed to the care of adult patients, and hence articles related to the care of paediatric patients have not been included. The majority of evidence has come from low to moderate quality single‐centre, before‐and‐after observational studies. Some of these demonstrated a reduction in in‐hospital mortality outside of the ICU,10–12 others only found a reduction in in‐hospital cardiac arrests,13,14 while yet others,15 including the only large‐scale, multi‐site randomised controlled trial (RCT) of RRT ever conducted,16 concluded there was no demonstrable reduction in either in‐hospital mortality or cardiac arrests. With multiple studies yielding mixed results, investigators have turned to performing systematic reviews of all relevant studies in deriving a more precise estimate of benefit. A high quality review that pooled data from 13 studies published to November 2008 revealed implementation of a RRT system resulted in a 33% reduction in unexpected non‐ICU cardiac arrest in adults, but was not associated with lower hospital mortality rates in the adult population.17 In this 1212
review, studies were rated as high quality if they were randomised trials or observational studies that adjusted for confounders and for secular trends over time by using either concurrent control groups or an interrupted time series. Only 5 of the 13 studies of adult patients (2 RCT, 3 observational studies) fulfilled these criteria and their results are listed in Table2.15,16,18,19 A more recent high quality review of studies published to October 2012 identified 26 additional effectiveness studies published since November 2008, none of which was randomised or used a concurrent control group.20 Only one study adjusted for secular trends21 and its results are added to Table2. The authors undertook a search for any additional effectiveness studies published from October 2012 to December 2014 and found none that met criteria of high quality as defined by the preceding reviews. The results of all six studies in Table2 show that only two yielded decrease in in‐hospital mortality18,21 and only one saw a reduction in non‐ICU cardiorespiratory arrests.21 Other systematic reviews have concluded that effectiveness of RRT remains unproven, noting poor adjustment of results for secular trends, biased outcome ascertainment, and significant heterogeneity in design and implementation of RRT systems.22–24 While RRT systems directed at adult patients may not seem to impact overall hospital mortality, it is possible that certain patient subgroups may benefit from RRT, with one study reporting a mortality benefit of RRT in medical but not surgical patients.25 Differential benefits could also exist according to the timing of RRT calls in that patients who have RRT calls within the first 24h of emergency admission are much less likely to require ICU admission, have further RRT calls, or endure a prolonged length of stay compared with those having RRT calls later in the admission.26 Other factors, such as patient location (general ward vs critical care ward or acute medical ward) and type of hospital (tertiary vs secondary) may also be predictors of outcome. Few studies have examined RRT impact on other patient outcomes, such as subsequent adverse events or complications (other than death or cardiorespiratory arrest), length of hospital stay, symptoms (pain, dyspnoea) or function. While some have assessed rates of unplanned admission to ICU, we view this to be a very unreliable outcome measure as thresholds for admitting patients to ICU vary considerably from site to site, depending on bed availability and illness severity.27 One study that examined health related quality of life (HRQOL) following RRT calls in a surgical cohort showed no change as measured by 3 HRQOL scales.28 The exact mechanism by which RRT achieves benefits in those studies reporting favourable outcomes is unclear. RRT may not actually prevent arrests in patients, but © 2015 Royal Australasian College of Physicians
© 2015 Royal Australasian College of Physicians
Prospective cohort comparison RRT hospital (18338) versus Control Hospital (13059) 6 months Prospective cohort comparison RRT hospital (18338) versus control hospital (19545) 6 months Cohort design; historical controls Pre RRT implementation (77021) versus post RRT implementation (79013) 36 months
Bristow et al. 2000 (1 vs 2)15
Single tertiary hospital Adult and paediatric; medical, surgical, obstetrics, psychiatry and rehab wards
Two public hospitals Patients >14 years of age
No data on use of CCOT service
CCOT: ICU nurse led Critical care medical support on request only No data on interventions ICU nurse and respiratory therapist; ICU fellow (on request only) Interventions: IV fluids 16% Intubation 7% NIV 11% ICU registrar, senior nurse, medical registrar No data on interventions ICU registrar, senior nurse, Medical registrar No data on interventions Medical resident, senior house officer, ICU nurse and respiratory therapist Interventions: Oxygen 62% IV fluids 30% Intubation 16% CPR 4%
Threatened airway, RR 36, HR 140, SBP < 90, Decrease in GCS > 2 points, repeated or extended seizures OR Clinical judgement Vital sign criteria: SO2 14 years of age
Single tertiary hospital Adults only; medical, surgical and obstetric wards
Single general hospital Adult only; medical, surgical and older patient wards
Ward (cluster) randomised design with phased introduction of intervention 7172 cases 32 weeks Prospective cohort design Pre RRT implementation (24193) versus Post RRT implementation (24978) 20 months
Priestley et al. 200418
Chan et al. 200819
23 Australian hospitals with >20000 admissions per year Patients' age >14 on general wards
Site, type and number of hospitals Patient population
Randomised control trial RRT hospitals versus control hospitals 6 months
Study design Patient number Study period
Hillman et al. 200516
Study, Date, Reference
Table 2 Review of high quality RRT studies
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instead, in consultation with attending teams, result in an increase in do‐not‐resuscitate (DNR) orders and/or liberalisation of RRT trigger criteria so that when patients do deteriorate again, a RRT call is obviated and any subsequent arrest is not recorded or acted on.29,30 Facilitating a more dignified death with less aggressive intervention and earlier access to palliative care in itself may be regarded as a ‘benefit’ of RRT systems. In one study, patients whose end of life status changed as a result of a RRT had more than 50% decrease in transfers to ICU (8.4% vs 17%) and a tripling in palliative care referrals (25% vs 8%).31 In a systematic review of 16 studies, limitations of medical therapy were instituted in between 2% and 31% of RRT calls.32 However, such benefits were not seen in every study,33 up to 15% of RRT calls are activated despite DNR orders,34 and many patients undergoing calls should have been classified as in need of palliative care well before such calls were activated.35 We would argue that the systematic use of pre‐emptive advance care plans by attending medical teams is a better approach to orchestrating end of life care36 than the less elegant and more invasive scenario of a RRT call.
Potential harms of RRT Theoretically, RRT systems may exert unintended adverse consequences. These include de‐skilling and loss of autonomy of ward staff in acute care of their patients, although surveys of nurses in Canada and Australia37,38 and of residents in the US39 suggest the opposite effect, especially for more inexperienced staff. Communication errors and lack of collaborative decision‐making between RRT members and staff may lead to disjointed care of individual patients.40 Diversion of staff involved in RRT calls away from their usual duties may compromise the quality of care of their own patients and interrupt work schedules resulting in inefficiencies and impaired patient flow.40 This issue was examined in a recent prospective study conducted at Concord hospital, 41 which attempted to determine the rate of adverse incidents occurring as a result of hospital staff having to leave normal duties to attend RRT calls that averaged 2.6 per day and 30 min per call. While this study reported significant disruption to normal hospital routine and inconvenience to staff in just over 20% of RRT calls, there was no demonstrable harm to patients, although the rate of formal incident reporting was very low at the study hospital.
implementation across different hospitals. The 2013 review20 addressed this issue by specifically searching for and analysing 17 studies, both quantitative and qualitative, that analysed implementation issues. Wide variation was seen in composition of RRT teams, activation criteria, and implementation processes that were dominated by local needs and resources. Low call rates of RRT are regarded as one key reason for failure of effect that appears to increase over time in most reports as RRT systems evolve over a period of years.42–44 Reported RRT call rates range from 25 to 55 calls per 1000 admissions in hospitals with so‐called ‘mature’ RRT systems.1 An inverse correlation between the annual number of RRT calls and the annual number of cardiac arrests for the same year has been noted in several studies,14,45 with one estimating one less cardiac arrest for every 17 RRT calls.14 This has given rise to the concept of a minimum ‘RRT dose’46 (measured by calls per 1000 admissions) to ensure RRT effectiveness, although exactly what this number and its lower and upper limits are, and how long it takes on average to be achieved, remain uncertain. It could be argued that the short duration (less than 1 year) of many negative RRT studies may not have allowed sufficient time for complete embedding of RRT culture into hospital practice such that benefits could be realised. Among the 6 trials listed in Table2, only 2 had RRT implementation periods longer than a year – 20 months19 and 3 years,21 with the former showing no impact on arrests or mortality with a call rate of 15 per 1000 admissions, while the latter showed significant reductions in both outcomes with a call rate of 11 per 1000 admissions. Several factors may impact the afferent limb of RRT in regard to nurse‐led RRT activation (Table3) and are subject to ongoing investigation.47,48 The efferent limb of RRT is also subject to considerable variation with differences in the roles and composition of RRT teams; the use of post‐RRT outreach visits from intensive care teams; the extent of direct liaison with attending consultants when the same patient has had one or more RRT calls; and RRT interventions depending on the dynamics of interactions between RRT and ward‐based teams. In the following sections some of these under‐ investigated implementation issues are considered in more detail.
RRT activation
Implementation of RRT
Activation processes
When faced with negative effectiveness studies, researchers have considered whether the problem is not the validity of RRT as a concept but its poor or uneven
Different studies have used different criteria for activating RRT, including single physiological triggers on colour‐ coded observation charts, aggregate early warning scoring
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Table 3 Factors that impact activation rates of RRT47,48 • • • • • • • • • • •
Adequate education of all staff on the purpose and role of RRT Clinical expertise of nursing and medical staff in RRT processes Support from medical and nursing staff for RRT Nurses' familiarity with and advocacy for the patient Frequency, accuracy and completeness of vital sign measurement Level of understanding and ambiguity of triggers or criteria for activating RRT intervention Circuitous chains of command that disempower staff and inhibit rapid RRT activation Nurse and medical staff workloads that distract from monitoring and recognition of clinical deterioration Lack of cultural support for calling for help and criticism or punishment for RRT activation Communication and teamwork involving nursing staff and attending medical teams Perceptions about the relative helpfulness of the attending team or the RRT to nurses and patients
RRT, rapid response teams.
systems that sum several different triggers (some with weighting and others not) and simple clinical judgement of nurses on the basis of subjective ‘worry’ or ‘general concern’. In most Australian centres, the presence of any one trigger is sufficient for RRT activation, with multi‐ parameter weighted scoring systems being viewed as too time‐consuming and prone to inaccurate calculation.49 To what extent single versus multiple trigger systems suffer from excessive ‘false positive’ calls has not been investigated. In many reports RRT activation is voluntary although, in practice, many hospitals in this country have moved to mandatory activation once trigger alerts are noted.50 Evidence clearly indicates that standardised approaches based on coded observation charts with trigger thresholds and use of explicit call criteria leads to more RRT calls than relying on intuitive interpretation and individual judgement of non‐categorised observations.51,52 In one study, RRT calls were separated into ‘Code Blue’ calls (for cardiorespiratory arrests) and ‘RRT’ calls (with physiological and ‘worried’ criteria), the latter associated with a 60% increase in total calls (now combined Code Blue/RRT).53 Another study showed that adding more generic ‘worry’ criteria multiplied the number of RRT activations by a factor of 35 compared to activation based on vital signs.54 However, no study has evaluated the appropriateness of such calls and their impact on patient outcomes. The predictive value of abnormal vital sign thresholds or ‘worry’ criteria in identifying patients who are actually clinically deteriorating and at high risk of adverse outcomes also remains to be determined. Increasing RRT call rates must overcome three failure points: (i) ‘failure to monitor’ whereby vital signs, especially respiratory rate,55 are not accurately or consistently © 2015 Royal Australasian College of Physicians
recorded at the bedside; (ii) ‘failure to recognise’ whereby triggers used to signal clinical deterioration are too insensitive or not appreciated by ward staff; and (iii) ‘failure to escalate’ whereby cultural or professional barriers prevent nurses and others from being able to activate RRT once triggers are present, with one audit of RRT activation reporting a 14% failure rate.56 Attempts to overcome these failures have concentrated on professional education and training programmes, especially directed at nurses, and initiatives aimed at improving safety attitudes and culture more generally.57 Another approach under consideration is electronic observation and activation, in the form of computerised remote monitoring alerts linked with direct, automated RRT activation. A recent study of an electronic patient surveillance system linked with electronic health records (EHR) and analytic algorithms, aimed at early identification of decompensating patients, showed an absolute reduction in in‐hospital mortality of 1.4% across 56 diagnosis groups within 2 hospitals in the UK.58 Such results have implications for Australian hospitals currently implementing EHR and associated computerised decision support systems. Early warning systems These systems attempt to risk‐stratify patients into those who are more or less likely to activate a RRT call, the aim being to pre‐empt such calls by closer observation and more intense intervention. Two recent systematic reviews on the outcome of early warning systems (EWS) were inconclusive. One included 21 studies with 13 unique models in which EWS demonstrated a predictive ability for death and cardiac arrest, but had no impact on mortality and resource utilisation.59 Another included seven studies, with two reporting no significant difference in in‐hospital mortality rate, two finding a significant reduction in in‐ hospital mortality, and two describing a trend towards improved survival.60 Authors from both reviews cited the lack of a universally agreed EWS as a possible barrier to realising their full benefit. Activation by non clinicians RRT activation by patients or their family independently of clinical staff has been studied in a trauma centre with beneficial effects,61 which is of interest given the recent introduction into Queensland public hospitals of ‘Ryan's Rule’, which allows family members to call RRT teams if they harbour major safety concerns. Tiered RRT responses Only one study that we are aware of has investigated tiered RRT calls dependent on the assessed level of clinical 1215
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urgency. In a tertiary hospital, which includes both adult and paediatric patients, introduction of a two‐tier response (first tier: less urgent clinical review criteria; second tier: more serious criteria triggering review by RRT) was not associated with decreased rates of cardiac arrest or hospital mortality.62 However, the introduction of the two‐tier system was associated with a progressive and significant increase in both tier 1 and tier 2 responses.
RRT – too much too soon? As RRT systems constitute a quality and safety improvement intervention, certain criteria deserve consideration when deciding if the intervention is ready for widespread adoption.69 In the case of RRT the intervention is already well established, but with limitations in its implementation and outcome assessment according to our application of one evaluative framework (Table4).
RRT composition The optimal composition of the response team remains uncertain. Traditionally RRT have included critical care trained doctors who are able to care for unwell, complex patients and deal competently with airway problems. A before–after time series analysis examined a RRT system relying on the patient's usual care team, not ICU‐based teams, and found an independent association with reduced unexpected mortality.63 Another mostly retrospective study showed that involvement of the usual care team in RRT systems led to more transfers to ICU and more changes in resuscitation status, and was perceived by RRT leaders as facilitating better communication.64 In contrast, a retrospective observational study comparing ICU‐led and resident physician‐led RRT found no difference in cardiac arrests, ICU admissions, or hospital mortality.65 A 6‐year study of an ICU nurse‐led RRT reported sustained reductions in cardiopulmonary arrests.66
RRT actions Few Australian studies have characterised how long RRT personnel attend each call and what they actually do in terms of resuscitating patients, adjusting pre‐existing management plans, facilitating transfer to critical care wards, revising acute resuscitation plans, or initiating palliative care. The most commonly reported interventions include administering supplemental oxygen or intravenous fluids, suctioning patients' upper airways, securing intravenous access, and ordering basic investigations (ECG, arterial blood gases, chest X‐ray).10,16,67 To date no study has assessed the relationship between actions undertaken during RRT calls and clinical outcomes. In some hospitals, including the authors', patients who have had a RRT call are reviewed by critical care outreach teams over the ensuing 24h to monitor patient status and RRT‐mediated changes in management, with the aim of reducing the risk of further RRT calls. While there is evidence that such outreach lessens the risk of readmission to the ICU of patients recently discharged from the ICU,68 there has been no study to document whether similar benefits are seen with post‐RRT outreach. 1216
RRT as a rescue mechanism to compensate for other system failures It can be argued that RRT systems have taken hold to protect patients from the hazards of suboptimal care and ‘failure to rescue’ induced by system of care failures.70 These include staffing shortages or suboptimal staff to patient ratios, inappropriate triage and disposition of emergency patients, outlying patients in non‐home wards, premature discharge of unstable patients from critical care units and post‐operative observation units due to bed pressures, inadequate training of junior medical and nursing staff in general wards in acute care, and insufficient on‐site presence of experienced senior clinicians to guide patient management. In one study, one of three RRT activations was associated with medical errors,71 while in another more than 75% of RRT calls to surgical units were classified preventable errors of omission due to limited after‐hours coverage.72 In an Australian study, more rapid exiting of inpatients from emergency departments to meet 4‐h emergency access targets was associated with a 53% increase over 4 years in RRT calls for such patients within the first 24h of admission, from 9.2 to 14.1 per 1000 admissions.73 These system failures have occurred on a background of increasingly complex patient casemix, tight budgets, high hospital bed occupancy and greater patient throughput. It could be argued that a greater investment in correcting system failures would improve patient safety over the long term and reduce the need for RRT to rescue deteriorating patients.
The need for more research into RRT The ability of RRT systems to bring appropriately trained staff to the bedside of acutely unwell patients quickly and consistently has strong prima facie attraction from a patient safety perspective. This, together with some evidence that they improve outcomes and little to suggest harm, means they will remain a fixture within Australian hospitals. However, researchers should attempt to identify the circumstances and mode of operation © 2015 Royal Australasian College of Physicians
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Table 4 Application to RRT of a framework for assessing its readiness for widespread adoption68 Was the problem to be addressed by RRT fully characterised? Does a sound theory of behaviour change underpin the intervention?
Was there preliminary testing in confirming proof of concept? Is the RRT standardised and replicable?
Have effects been evaluated with a sufficient level of xrigour? Were outcome measures standardised and appropriate?
Quality assurance procedures for data collection? Minimisation of risk of confounding?
Have observed effects been reconciled with underpinning theoretical framework? Were data collected that adequately tested theory? Were process evaluations reported?
Has potential for adverse and unintended effects been evaluated? Have resource use and costs been assessed? Have effects been clinically plausible and consistent?
Has sustainability of effect been assessed? Have methodological limitations and conflicts of interest been assessed? Is publication bias likely?
Yes – multiple studies have documented deterioration in vital signs up to 12h prior to cardiac arrest that have not been correctly interpreted and/or acted on by attending medical or nursing staff for various reasons. No – intervention has several components: designing RRT call criteria and notification procedures, team make up, roles and training; staff and management agreement to RRT implementation. Potential difficulties in implementation based on change theories include break from traditional hierarchy of seeking review from usual attendant medical team; challenges patient ownership; perceived loss of autonomy in calling RRT; variation in monitoring of vital signs; differing interpretation of call criteria; delays in activating RRT. How these barriers to implementation were to be overcome were not addressed in designing the intervention. No – there were no reports prior to large scale implementation studies. To some extent – significant variation across hospitals and between studies in team composition, links with ICU, call activation criteria, target populations (only surgical patients, patients in shock, all patients outside critical care areas). Interventions performed at patient level by RRT were not standardised.
No – all cause mortality, unexpected cardiac arrests and unplanned ICU transfers – only in patients with no do not resuscitate (DNR) status – are the most appropriate outcome measures that many studies did not report. Definition of cardiac arrest did not adopt standardised terminology and varied between studies as did inclusion of patients with DNR status. No – most studies did not report quality assurance procedures for data collection. Only to a limited extent. Of more than 60 studies reported up to 2014, 19 were prospective and only 7 studies (6 involving adults – see Table2) were categorised as high quality in using analytic methods that adjusted for possible confounders.
No – survey data related to theory based impediments were performed independently of clinical trials with little reporting of intended solutions or their effectiveness. Some trials undertook process evaluations that showed call rates to vary considerably, from 2.7 to 48.7 calls per 1000 admissions. Others reported RRT utilisation was proportional to staff education about, and interpretation of, call activation criteria, understanding of RRT functions, and positive attitude to RRT. No – potential harms were not assessed prior to widespread adoption. No – cost or cost effectiveness analyses have not been reported. No – there is significant heterogeneity in mortality outcome. In pooled analyses of 11 prospective 17 studies involving adults reported in the high quality 2010 systematic review, two studies showed significant reduction, one reported a decreased trend, six reported no effect, one reported an increased trend, and one reported increased mortality. The numbers of deaths prevented were disproportionate to reductions in the numbers of cardiopulmonary arrests, suggesting unidentified confounders. To some degree although reports that have assessed effects beyond 2 years are few in number. While many studies have discussed limitations, conflicts of interest statements have been lacking. Probably not – systematic reviews of prospective studies concluded no evidence of publication bias.
ICU, intensive care unit; QSII, quality and safety improvement; RRT, rapid response teams.
under which the RRT system yields the most patient benefit for the lowest use of limited resources. This need is being recognised by some of the strongest advocates of RRT.74 In taking another look at RRT, we would pose the questions listed in Table5 as priorities for further research. © 2015 Royal Australasian College of Physicians
Conclusion The introduction of RRT into hospital practice has been driven by the belief that they make hospitals safer and prevent adverse outcomes in clinically deteriorating 1217
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Table 5 Future research questions RRT benefits • What are the benefits of RRT in regard to outcomes other than in hospital mortality and out of ICU cardiorespiratory arrests? • Are there groups of patients who derive greater benefit from RRT and should be targeted for more intense monitoring? • Do the benefits of RRT vary according to their timing, patient location and classification, type of hospital and other patient or system of care factors? RRT activation • What is the predictive value of current clinical signs and ‘worried’ or ‘concern’ criteria used to activate RRT? • What are the factors most responsible for afferent and efferent limb failures and how might they be overcome? • What proportion of RRT calls are activated for patients who are not actually clinically deteriorating? What proportion of RRT calls result in no change in management plan? • Does RRT activation by non clinicians add to patient safety and improve clinical outcomes? • Would systematic use of advance care planning in high risk patients reduce need for RRT activation? • Do early warning systems enable more targeted monitoring of patients more likely to require RRT calls? • Are electronic patient surveillance and automated RRT activation systems likely to reduce instances of failed RRT activation? • Is there a relationship between RRT activation trigger, RRT interventions and RRT outcome? Could such a relationship be used to educate staff in responding to different clinical scenarios in ways that obviate unnecessary RRT calls? RRT composition • What is the optimal composition of the RRT? Is a critical care trained doctor necessary for all responses? • Would a usual care team led response team result in less inappropriate investigations and interventions, and improved patient outcomes? RRT actions • Which RRT actions are most responsible for improved outcomes? • Does post RRT follow up by ICU outreach teams alter outcomes? Can such follow up be targeted to patients that are at higher risk of repeat decompensation? RRT cost, unintended adverse effects, competing priorities • What are the adverse consequences of widespread adoption of the RRT system, including opportunity resource costs incurred by frequent RRT calls? • What are the costs and cost effectiveness of RRT in comparison to other strategies that could be used to optimise patient safety? • To what extent is investment in RRT systems compensating for other system of care failures? Would greater investment in correcting such failures reduce the number of clinically deteriorating patients and hence number of RRT calls? RRT, rapid response teams.
patients sited in general hospital wards. However, high quality evidence supporting their effectiveness related to the care of adult patients is lacking and numerous controversies exist as to the optimal methods of implementation. More research is needed in better understanding the
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admission. Intensive Care Med 2002; 28: 1629–34. 9 Vlayen A, Verelst S, Bekkering GE, Schrooten W, Hellings J, Claes N. Incidence and preventability of adverse events requiring intensive care admission: a systematic review. J Eval Clin Pract 2012; 18: 485–97. 10 Ranji SR, Auerbach AD, Hurd CJ, O'Rourke K, Shojania KG. Effects of rapid response systems on clinical outcomes: systematic review and meta‐ analysis. J Hosp Med 2007; 2: 422–32. 11 Buist MD, Moore GE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study. BMJ 2002; 324: 387–90. © 2015 Royal Australasian College of Physicians
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12 Bellomo R, Goldsmith D, Uchino S, Buckmaster J, Hart GK, Opdam H et al. A prospective before‐and‐after trial of a medical emergency team. Med J Aust 2003; 179: 283–87. 13 Konrad D, Jaderling G, Bell M, Granath F, Ekbom A, Martling CR. Reducing in‐hospital cardiac arrests and hospital mortality by introducing a medical emergency team. Intensive Care Med 2010; 36: 100–6. 14 Jones D, Bellomo R, Bates S, Warrillow S, Goldsmith D, Hart G et al. Long term effect of a medical emergency team on cardiac arrests in a teaching hospital. Crit Care 2005; 9: R808–15. 15 Bristow PJ, Hillman KM, Chey T, Daffurn K, Jacques TC, Norman SL et al. Rates of in‐hospital arrests, deaths and intensive care admissions: the effect of a medical emergency team. Med J Aust 2000; 173: 236–40. 16 Hillman K, Chen J, Cretikos M, Bellomo R, Brown D, Doig G et al. Introduction of the medical emergency team (MET) system: a cluster‐randomised controlled trial. Lancet 2005; 365: 2091–7. 17 Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Rapid response teams: a systematic review and meta‐analysis. Arch Intern Med 2010; 170: 18–26. 18 Priestley G, Watson W, Rashidian A, Mozley C, Russell D, Wilson J et al. Introducing Critical Care Outreach: a ward‐ randomised trial of phased introduction in a general hospital. Intensive Care Med 2004; 30: 1398–404. 19 Chan PS, Khalid A, Longmore LS, Berg RA, Kosiborod M, Spertus JA. Hospital‐wide code rates and mortality before and after implementation of a rapid response team. JAMA 2008; 300: 2506–13. 20 Winters BD, Weaver SJ, Pfoh ER, Yang T, Pham JC, Dy SM. Rapid‐response systems as a patient safety strategy: a systematic review. Ann Intern Med 2013; 158: 417–25. 21 Beitler JR, Link N, Bails DB, Hurdle K, Chong DH. Reduction in hospital‐wide mortality after implementation of a rapid response team: a long‐term cohort study. Crit Care 2011; 15: R269. 22 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. 23 Ranji SR, Auerbach AD, Hurd CJ, O'Rourke K, Shojania KG. Effects of rapid response systems on clinical
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outcome: a systematic review and meta‐analysis. J Hosp Med 2007; 2: 422–32. McGaughey J, Alderdice F, Fowler R, Kapila A, Mayhew A, Moutray M. Outreach and early warning systems (EWS) for the prevention of intensive care and death of critically ill adult patients on general hospital wards. Cochrane Database Syst Rev 2007; CD005529. Sarani B, Palilonis E, Sonnad S, Bergey M, Sims C, Pascual JL et al. Clinical emergencies and outcomes in patients admitted to a surgical versus medical service. Resuscitation 2011; 82: 415–8. Considine J, Charlesworth D, Currey D. Characteristics and outcomes of patients requiring rapid response system activation within hours of emergency admission. Crit Care Resusc 2014; 16: 184–9. Stelfox HT, Hemmelgam BR, Bagshaw SM, Gao S, Doig CJ, Nijssen‐Jordan C et al. Intensive care unit bed availability and outcomes for hospitalised patients with sudden clinical deterioration. Arch Intern Med 2012; 172: 467–74. Simmes F, Schoonhoven L, Mintjes J, Fikkers BG, van der Hoeven JG. Effects of a rapid response system on quality of life: a prospective cohort study in surgical patients before and after implementing a rapid response system. Health Qual Life Outcomes 2013; 11: 74–80. Jones DA, McIntyre T, Baldwin I, Mercer I, Kattula A, Bellomo R. The medical emergency team and end‐of‐life care: a pilot study. Crit Care Resusc 2007; 9: 151–6. Chen J, Flabouris A, Bellomo R, Hillman K, Finfer S, Centre MSIftS et al. The Medical Emergency Team System and not‐for‐resuscitation orders: results from the MERIT study. Resuscitation 2008; 79: 391–7. Tam B, Salib M, Fox‐Robichaud A. The effect of rapid response teams on end‐of‐life care: a retrospective chart review. Can Respir J 2014; 21: 302–306. Tan LH, Delaney A. Medical emergency teams and end‐of‐life care: a systematic review. Crit Care Resusc 2014; 16: 62–8. Downar J, Barua R, Rodin D, Lejnieks B, Gudimella R, McCredie V et al. Changes in end of life care 5 years after the introduction of a rapid response team: a multicentre retrospective study. Resuscitation 2013; 84: 1339–44.
34 Coventry C, Flabouris A, Sundararajan K, Cramey T. Rapid response team calls to patients with a pre‐existing not for resuscitation order. Resuscitation 2013; 84: 1035–39. 35 Visser P, Dwyer A, Moran J, Britton M, Heland M, Ciavarella F et al. Medical emergency response in a sub‐acute hospital: improving the model of care for deteriorating patients. Aust Health Rev 2014; 38: 169–76. 36 Scott IA, Mitchell GK, Reymond EJ, Daly MP. Difficult but necessary conversations–the case for advance care planning. Med J Aust 2013; 199: 662–6. 37 Buist M, Bellomo R. MET: the emergency medical team or the medical education team? Crit Care Resusc 2004; 6: 88–91. 38 Jones D, Baldwin I, McIntyre T, Story D, Mercer I, Miglic A et al. Nurses' attitudes to a medical emergency team service in a teaching hospital. Qual Saf Health Care 2006; 15: 427–32. 39 Butcher BW, Quist CE, Harrison JD, Ranji SR. The effect of a rapid response team on resident perceptions of education and autonomy. J Hosp Med 2015; 10: 8–12. 40 Benin AL, Borgstrom CP, Jenq GY, Roumanis SA, Horwitz LI. Defining impact of a rapid response team: qualitative study with nurses, physicians and hospital administrators. BMJ Qual Saf 2012; 21: 391–8. 41 The Concord Medical Emergency Team Incidents Study Investigators. Incidents resulting from staff leaving normal duties to attend medical emergency team calls. Med J Aust 2014; 201: 528–31. 42 DeVita MA, Braithwaite RS, Mahidhara R, Stuart S, Foraida M, Simmons RL et al. Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Qual Saf Health Care 2004; 13: 251–4. 43 Jones D, Bates S, Warrillow S, Goldsmith D, Kattula A, Way M et al. Effect of an education programme on the utilization of a medical emergency team in a teaching hospital. Intern Med J 2006; 36: 231–6. 44 Buist M, Harrison J, Abaloz E, Van Dyke S. Six year audit of cardiac arrests and medical emergency team calls in an Australian outer metropolitan teaching hospital. BMJ 2007; 335: 1210–2. 45 Chen J, Bellomo R, Flabouris A, Hillman K, Finter S. The relationship between early emergency team calls and serious adverse events. Crit Care Med 2009; 37: 148–53.
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46 Jones D, Bellomo R, DeVita MA. Effectiveness of the Medical Emergency Team: the importance of dose. Crit Care 2009; 13: 313–7. 47 Astroth KS, Woith WM, Stapleton SJ, Degitz RJ, Jenkins SH. Qualitative exploration of nurses' decisions to activate rapid response teams. J Clin Nurs 2013; 22: 2876–82. 48 Braaten JS. Hospital system barriers to rapid response team activation: a cognitive work analysis. Am J Nurs 2015; 115: 22–32. 49 Gao H, McDonnell A, Harrison DA et al. Systematic review and evaluation of physiological track and trigger warning systems for identifying at‐risk patients on the ward. Intensive Care Med 2007; 33: 667–79.
team activations: tracking decisions and outcomes in practice. Crit Care Resusc 2013; 15: 266–72. 57 Lazzara EH, Benishek LE, Sonesh SC, Patzer B, Robinson P, Wallace R et al. The 6 ‘ws’ of rapid response systems: best practices for improving development, implementation, and evaluation. Crit Care Nurs Q 2014; 37: 207–18. 58 Schmidt PE, Meredith P, Prytherch DR, Watson D, Watson V, Killen RM. Impact of introducing an electronic physiological surveillance system on hospital mortality. BMJ Qual Saf 2015; 24: 10–20.
50 Jones CM, Bleyer AJ, Petree B. Evolution of a rapid response system from voluntary to mandatory activation. Jt Comm J Qual Patient Saf 2010; 36: 266–70, 41.
59 Smith ME, Chiovaro JC, O'Neil M, Kansagara D, Quinones AR, Freeman M et al. Early warning system scores for clinical deterioration in hospitalized patients: a systematic review. Ann Am Thorac Soc 2014; 11: 1454–65.
51 Kansal A, Havill K. The effects of introduction of new observation charts and calling criteria on call characteristics and outcome of hospitalised patients. Crit Care Resusc 2012; 14: 38–43.
60 Alam N, Hobbelink EL, van Tienhoven AJ, van de Ven PM, Jansma EP, Nanayakkara PW. The impact of the use of the Early Warning Score (EWS) on patient outcomes: a systematic review. Resuscitation 2014; 85: 587–94.
52 Mitchell IA, McKay H, Van Leuvan C, Berry R, McCutcheon C, Avard B et al. A prospective controlled trial of the effect of a multi‐faceted intervention on early recognition and intervention in deteriorating hospital patients. Resuscitation 2010; 81: 658–66.
61 Gerdik C, Vallish RO, Miles K, Godwin SA, Wludyka PS, Panni MK. Successful implementation of a family and patient activated rapid response team in an adult level 1 trauma center. Resuscitation 2010; 81: 1676–1681.
53 Jones DA, Mitra B, Barbetti J, Choate K, Leong T, Bellomo R. Increasing the use of an existing medical emergency team in a teaching hospital. Anaesth Intensive Care 2006; 34: 731–5. 54 Genardi ME, Cronin SN, Thomas L. Revitalizing an established rapid response team. Dimens Crit Care Nurs 2008; 27: 104–9. 55 Cretikoris MA, Bellomo R, Hillman K, Chen J, Finfer S, Flabouris A. Respiratory rate: the neglected vital sign. Med J Aust 2008; 188: 657–9. 56 Guinane JL, Bucknall TK, Currey J, Jones DA. Missed medical emergency
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62 Frost SA, Chapman A, Aneman A, Chen J, Parr MJ, Hillman K. Hospital outcomes associated with introduction of a twotiered response to the deteriorating patient. Crit Care Resusc 2015; 17: 77–82. 63 O'Horo JC, Berrios RAS, Elmer J, Velagapudi V, Caples SM, Kashyap R et al. The role of the primary care team in the rapid response system. J Crit Care 2015; 30: 353–7. 64 Howell MD, Ngo L, Folcarelli P, Yang J, Mottley L, Marcantonio ER et al. Sustained effectiveness of a primary‐team‐based rapid response system. Crit Care Med 2012; 40: 2562–68.
65 Morris DS, Schweickert W, Holena D, Handzel R, Sims C, Pascual JL et al. Differences in outcomes between ICU attending and senior resident physician led medical emergency team responses. Resuscitation 2012; 83: 1434–7. 66 Mitchell A, Schatz M, Francis H. Designing a critical care nurse‐led rapid response team using only available resources: 6 years later. Crit Care Nurse 2014; 34: 41–55. 67 Bellomo R, Goldsmith D, Uchino S, Buckmaster J, Hart G, Opdam H et al. Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med 2004; 32: 916–21. 68 Niven DJ, Bastos JF, Stelfox HT. Critical care transition programs and the risk of readmission or death after discharge from an ICU: a systematic review and meta‐analysis. Crit Care Med 2014; 42: 179–87. 69 Scott IA, Wakefield JB. Deciding when quality and safety improvement interventions warrant widespread adoption. Med J Aust 2013; 198: 408–10. 70 Litvak E, Pronovost P. Rethinking rapid response teams. JAMA 2010; 304: 1375–6. 71 Braithwaite R, De Vita M, Mahidhara R, Simmons R, Stuart S, Foraida M. Use of medical emergency team (MET) responses to detect medical errors. Qual Saf Health Care 2004; 13: 255–9. 72 Kaplan LJ, Maerz LL, Schuster K, Lui F, Johnson D, Roesler D et al. Uncovering system errors using a rapid response team: cross‐coverage caught in the crossfire. J Trauma 2009; 67: 173–9. 73 Hillman KM, Chen J, Jones D. Rapid response systems. Med J Aust 2014; 201: 519–21. 74 Sullivan C, Flores J, Staib A, Aggarwal L, Scanlon A, Martin J et al. Aiming to be NEAT: safely improving and sustaining access to emergency care in a tertiary referral hospital. Aust Health Rev 2014; 38: 564–74.
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Rapid response teams in adult hospitals: time for another look? K. White,1 I. A. Scott,2 A. Vaux3 and C. M. Sullivan4 1 Department of Internal Medicine and Clinical Epidemiology, 3Intensive Care Unit, 4Division of Medicine, Princess Alexandra Hospital and 2School of Medicine, University of Queensland, Brisbane, Queensland, Australia
Key words rapid response team, adult, effectiveness, implementation. Correspondence Ian A. Scott, Department of Internal Medicine and Clinical Epidemiology, Level 5A, Princess Alexandra Hospital, Ipswich Road, Brisbane, Qld 4102, Australia. Email: [email protected] Received 22December June 2015;2014; accepted 23 June Received 27 accepted 23 June 2015. 2015 doi:10.1111/imj.12845 doi:
Abstract Rapid response teams (RRT), alternatively termed medical emergency teams, have become part of the clinical landscape in the majority of adult hospitals throughout Australia and New Zealand. These teams aim to bring critical care expertise to the bedside of clinically deteriorating patients residing in general hospital wards with the aim of preventing adverse outcomes, in particular death or cardiorespiratory arrests. While the concept of RRT has considerable face validity, there is little high quality evidence of their effectiveness and much uncertainty as to the optimal methods for identifying patients in need of RRT and calling the RRT (afferent limb) and how, and with whom, the RRT should then respond (efferent limb). Adverse unintended consequences of RRT systems and the opportunity costs involved in maintaining such systems have not been subject to study, amid concerns RRT may be compensating for other potentially remediable system of care failures. This article presents an overview of the current state of play of RRT in hospital practice as they pertain to the care of adult patients and identifies several issues around their implementation and evaluation that should be subject to further research.
Introduction Rapid response teams (RRT), previously termed medical emergency teams, have been widely adopted throughout adult hospitals in Australia and New Zealand with a single aim: the early recognition of clinically deteriorating patients, leading to prompt review by appropriately trained staff and consequent prevention of adverse outcomes. RRT systems now exist within two‐thirds of all Australian hospitals and affect more than 14700 patients each year.1 The characteristics of RRT calls and patients in this country have recently been reviewed and summary findings from 28 studies are listed in Table1.2 The requirement for hospitals to implement RRT systems has been enshrined as a national health service standard by the Australian Commission of Quality and Safety in Health Care.3 While the basic premise underpinning RRT has considerable face validity, empirical validation of effectiveness is necessary, if only because many practice standards based on seemingly sound pathophysiological rationales have been found wanting when subjected to robust scrutiny.4 In addition, RRT consume resources and may have unintended consequences that offset some of the benefits.
Funding: None Conflict of interest: None
© 2015 Royal Australasian College of Physicians
This article provides an overview of the effectiveness and processes of RRT as they pertain to the care of adult patients, and poses several questions that deserve attention from health service researchers.
Background The foundation of RRT rests on the observation that adverse events in acutely ill patients are frequently preceded by an observable period of derangement in physiological parameters.5,6 Clinical deterioration occurs in 66–84% of patients up to 6h prior to in‐hospital cardiac arrest.5,7 Furthermore, 60% of patients transferred urgently to intensive care units (ICU) with potentially life‐threatening conditions were documented as showing worsening in vital signs during the 8h before their admission.8 Between 18% and 76% of adverse events precipitating such transfers are considered potentially preventable.9 Patients requiring RRT have a 25% in‐ hospital mortality, and 20% of patients who die in hospital are reviewed by RRT.1 RRT systems were implemented with the goal of detecting clinical deterioration early and intervening in a timely manner to improve patient outcomes. The RRT system consists of three components: 1 early detection of clinical deterioration based on recording of bedside observations;
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White et al. Table 1 Summary of epidemiology of Australian adult RRT patients2 • Frequency of RRT activations varies considerably from 1.3 to 71 per 1000 admissions. • Point prevalence studies of RRT activation criteria show that 1 in 30 patients fulfil such criteria at any one time but only 4% undergo RRT review and up to 50% of these have delayed activation. • Between 15% and 20% of patients seen by RRT have a repeat RRT call during admission in association with increased mortality, ICU transfers and length of hospital stay. • Calls for RRT peak around times of nursing handover and vital sign measurement and frequently occur after hours and within 24h of admission. • About a quarter of RRT calls are triggered by ‘worry’ criteria alone. • Admission to critical care areas occurs in 10%–25% of patients seen by RRT. • Up to one-third of RRT calls occur in patients with end of life care issues. • Rates of ICU admission following RRT calls vary from 13% to 45%. • In-hospital mortality of RRT patients is 25% overall, and 15% in those with no limitations of medical therapy. ICU, intensive care unit; RRT, rapid response teams.
2 activation of the RRT by ward‐based staff once these observations exceed pre‐specified thresholds or triggers; 3 response by the RRT. Components 1 and 2 together comprise the afferent limb, and component 3 the efferent limb of the RRT system.
Benefits of RRT The clinical benefits of RRT systems have not been clearly established. In this review, we specifically focus on literature directed to the care of adult patients, and hence articles related to the care of paediatric patients have not been included. The majority of evidence has come from low to moderate quality single‐centre, before‐and‐after observational studies. Some of these demonstrated a reduction in in‐hospital mortality outside of the ICU,10–12 others only found a reduction in in‐hospital cardiac arrests,13,14 while yet others,15 including the only large‐scale, multi‐site randomised controlled trial (RCT) of RRT ever conducted,16 concluded there was no demonstrable reduction in either in‐hospital mortality or cardiac arrests. With multiple studies yielding mixed results, investigators have turned to performing systematic reviews of all relevant studies in deriving a more precise estimate of benefit. A high quality review that pooled data from 13 studies published to November 2008 revealed implementation of a RRT system resulted in a 33% reduction in unexpected non‐ICU cardiac arrest in adults, but was not associated with lower hospital mortality rates in the adult population.17 In this 1212
review, studies were rated as high quality if they were randomised trials or observational studies that adjusted for confounders and for secular trends over time by using either concurrent control groups or an interrupted time series. Only 5 of the 13 studies of adult patients (2 RCT, 3 observational studies) fulfilled these criteria and their results are listed in Table2.15,16,18,19 A more recent high quality review of studies published to October 2012 identified 26 additional effectiveness studies published since November 2008, none of which was randomised or used a concurrent control group.20 Only one study adjusted for secular trends21 and its results are added to Table2. The authors undertook a search for any additional effectiveness studies published from October 2012 to December 2014 and found none that met criteria of high quality as defined by the preceding reviews. The results of all six studies in Table2 show that only two yielded decrease in in‐hospital mortality18,21 and only one saw a reduction in non‐ICU cardiorespiratory arrests.21 Other systematic reviews have concluded that effectiveness of RRT remains unproven, noting poor adjustment of results for secular trends, biased outcome ascertainment, and significant heterogeneity in design and implementation of RRT systems.22–24 While RRT systems directed at adult patients may not seem to impact overall hospital mortality, it is possible that certain patient subgroups may benefit from RRT, with one study reporting a mortality benefit of RRT in medical but not surgical patients.25 Differential benefits could also exist according to the timing of RRT calls in that patients who have RRT calls within the first 24h of emergency admission are much less likely to require ICU admission, have further RRT calls, or endure a prolonged length of stay compared with those having RRT calls later in the admission.26 Other factors, such as patient location (general ward vs critical care ward or acute medical ward) and type of hospital (tertiary vs secondary) may also be predictors of outcome. Few studies have examined RRT impact on other patient outcomes, such as subsequent adverse events or complications (other than death or cardiorespiratory arrest), length of hospital stay, symptoms (pain, dyspnoea) or function. While some have assessed rates of unplanned admission to ICU, we view this to be a very unreliable outcome measure as thresholds for admitting patients to ICU vary considerably from site to site, depending on bed availability and illness severity.27 One study that examined health related quality of life (HRQOL) following RRT calls in a surgical cohort showed no change as measured by 3 HRQOL scales.28 The exact mechanism by which RRT achieves benefits in those studies reporting favourable outcomes is unclear. RRT may not actually prevent arrests in patients, but © 2015 Royal Australasian College of Physicians
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Prospective cohort comparison RRT hospital (18338) versus Control Hospital (13059) 6 months Prospective cohort comparison RRT hospital (18338) versus control hospital (19545) 6 months Cohort design; historical controls Pre RRT implementation (77021) versus post RRT implementation (79013) 36 months
Bristow et al. 2000 (1 vs 2)15
Single tertiary hospital Adult and paediatric; medical, surgical, obstetrics, psychiatry and rehab wards
Two public hospitals Patients >14 years of age
No data on use of CCOT service
CCOT: ICU nurse led Critical care medical support on request only No data on interventions ICU nurse and respiratory therapist; ICU fellow (on request only) Interventions: IV fluids 16% Intubation 7% NIV 11% ICU registrar, senior nurse, medical registrar No data on interventions ICU registrar, senior nurse, Medical registrar No data on interventions Medical resident, senior house officer, ICU nurse and respiratory therapist Interventions: Oxygen 62% IV fluids 30% Intubation 16% CPR 4%
Threatened airway, RR 36, HR 140, SBP < 90, Decrease in GCS > 2 points, repeated or extended seizures OR Clinical judgement Vital sign criteria: SO2 14 years of age
Single tertiary hospital Adults only; medical, surgical and obstetric wards
Single general hospital Adult only; medical, surgical and older patient wards
Ward (cluster) randomised design with phased introduction of intervention 7172 cases 32 weeks Prospective cohort design Pre RRT implementation (24193) versus Post RRT implementation (24978) 20 months
Priestley et al. 200418
Chan et al. 200819
23 Australian hospitals with >20000 admissions per year Patients' age >14 on general wards
Site, type and number of hospitals Patient population
Randomised control trial RRT hospitals versus control hospitals 6 months
Study design Patient number Study period
Hillman et al. 200516
Study, Date, Reference
Table 2 Review of high quality RRT studies
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instead, in consultation with attending teams, result in an increase in do‐not‐resuscitate (DNR) orders and/or liberalisation of RRT trigger criteria so that when patients do deteriorate again, a RRT call is obviated and any subsequent arrest is not recorded or acted on.29,30 Facilitating a more dignified death with less aggressive intervention and earlier access to palliative care in itself may be regarded as a ‘benefit’ of RRT systems. In one study, patients whose end of life status changed as a result of a RRT had more than 50% decrease in transfers to ICU (8.4% vs 17%) and a tripling in palliative care referrals (25% vs 8%).31 In a systematic review of 16 studies, limitations of medical therapy were instituted in between 2% and 31% of RRT calls.32 However, such benefits were not seen in every study,33 up to 15% of RRT calls are activated despite DNR orders,34 and many patients undergoing calls should have been classified as in need of palliative care well before such calls were activated.35 We would argue that the systematic use of pre‐emptive advance care plans by attending medical teams is a better approach to orchestrating end of life care36 than the less elegant and more invasive scenario of a RRT call.
Potential harms of RRT Theoretically, RRT systems may exert unintended adverse consequences. These include de‐skilling and loss of autonomy of ward staff in acute care of their patients, although surveys of nurses in Canada and Australia37,38 and of residents in the US39 suggest the opposite effect, especially for more inexperienced staff. Communication errors and lack of collaborative decision‐making between RRT members and staff may lead to disjointed care of individual patients.40 Diversion of staff involved in RRT calls away from their usual duties may compromise the quality of care of their own patients and interrupt work schedules resulting in inefficiencies and impaired patient flow.40 This issue was examined in a recent prospective study conducted at Concord hospital, 41 which attempted to determine the rate of adverse incidents occurring as a result of hospital staff having to leave normal duties to attend RRT calls that averaged 2.6 per day and 30 min per call. While this study reported significant disruption to normal hospital routine and inconvenience to staff in just over 20% of RRT calls, there was no demonstrable harm to patients, although the rate of formal incident reporting was very low at the study hospital.
implementation across different hospitals. The 2013 review20 addressed this issue by specifically searching for and analysing 17 studies, both quantitative and qualitative, that analysed implementation issues. Wide variation was seen in composition of RRT teams, activation criteria, and implementation processes that were dominated by local needs and resources. Low call rates of RRT are regarded as one key reason for failure of effect that appears to increase over time in most reports as RRT systems evolve over a period of years.42–44 Reported RRT call rates range from 25 to 55 calls per 1000 admissions in hospitals with so‐called ‘mature’ RRT systems.1 An inverse correlation between the annual number of RRT calls and the annual number of cardiac arrests for the same year has been noted in several studies,14,45 with one estimating one less cardiac arrest for every 17 RRT calls.14 This has given rise to the concept of a minimum ‘RRT dose’46 (measured by calls per 1000 admissions) to ensure RRT effectiveness, although exactly what this number and its lower and upper limits are, and how long it takes on average to be achieved, remain uncertain. It could be argued that the short duration (less than 1 year) of many negative RRT studies may not have allowed sufficient time for complete embedding of RRT culture into hospital practice such that benefits could be realised. Among the 6 trials listed in Table2, only 2 had RRT implementation periods longer than a year – 20 months19 and 3 years,21 with the former showing no impact on arrests or mortality with a call rate of 15 per 1000 admissions, while the latter showed significant reductions in both outcomes with a call rate of 11 per 1000 admissions. Several factors may impact the afferent limb of RRT in regard to nurse‐led RRT activation (Table3) and are subject to ongoing investigation.47,48 The efferent limb of RRT is also subject to considerable variation with differences in the roles and composition of RRT teams; the use of post‐RRT outreach visits from intensive care teams; the extent of direct liaison with attending consultants when the same patient has had one or more RRT calls; and RRT interventions depending on the dynamics of interactions between RRT and ward‐based teams. In the following sections some of these under‐ investigated implementation issues are considered in more detail.
RRT activation
Implementation of RRT
Activation processes
When faced with negative effectiveness studies, researchers have considered whether the problem is not the validity of RRT as a concept but its poor or uneven
Different studies have used different criteria for activating RRT, including single physiological triggers on colour‐ coded observation charts, aggregate early warning scoring
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Table 3 Factors that impact activation rates of RRT47,48 • • • • • • • • • • •
Adequate education of all staff on the purpose and role of RRT Clinical expertise of nursing and medical staff in RRT processes Support from medical and nursing staff for RRT Nurses' familiarity with and advocacy for the patient Frequency, accuracy and completeness of vital sign measurement Level of understanding and ambiguity of triggers or criteria for activating RRT intervention Circuitous chains of command that disempower staff and inhibit rapid RRT activation Nurse and medical staff workloads that distract from monitoring and recognition of clinical deterioration Lack of cultural support for calling for help and criticism or punishment for RRT activation Communication and teamwork involving nursing staff and attending medical teams Perceptions about the relative helpfulness of the attending team or the RRT to nurses and patients
RRT, rapid response teams.
systems that sum several different triggers (some with weighting and others not) and simple clinical judgement of nurses on the basis of subjective ‘worry’ or ‘general concern’. In most Australian centres, the presence of any one trigger is sufficient for RRT activation, with multi‐ parameter weighted scoring systems being viewed as too time‐consuming and prone to inaccurate calculation.49 To what extent single versus multiple trigger systems suffer from excessive ‘false positive’ calls has not been investigated. In many reports RRT activation is voluntary although, in practice, many hospitals in this country have moved to mandatory activation once trigger alerts are noted.50 Evidence clearly indicates that standardised approaches based on coded observation charts with trigger thresholds and use of explicit call criteria leads to more RRT calls than relying on intuitive interpretation and individual judgement of non‐categorised observations.51,52 In one study, RRT calls were separated into ‘Code Blue’ calls (for cardiorespiratory arrests) and ‘RRT’ calls (with physiological and ‘worried’ criteria), the latter associated with a 60% increase in total calls (now combined Code Blue/RRT).53 Another study showed that adding more generic ‘worry’ criteria multiplied the number of RRT activations by a factor of 35 compared to activation based on vital signs.54 However, no study has evaluated the appropriateness of such calls and their impact on patient outcomes. The predictive value of abnormal vital sign thresholds or ‘worry’ criteria in identifying patients who are actually clinically deteriorating and at high risk of adverse outcomes also remains to be determined. Increasing RRT call rates must overcome three failure points: (i) ‘failure to monitor’ whereby vital signs, especially respiratory rate,55 are not accurately or consistently © 2015 Royal Australasian College of Physicians
recorded at the bedside; (ii) ‘failure to recognise’ whereby triggers used to signal clinical deterioration are too insensitive or not appreciated by ward staff; and (iii) ‘failure to escalate’ whereby cultural or professional barriers prevent nurses and others from being able to activate RRT once triggers are present, with one audit of RRT activation reporting a 14% failure rate.56 Attempts to overcome these failures have concentrated on professional education and training programmes, especially directed at nurses, and initiatives aimed at improving safety attitudes and culture more generally.57 Another approach under consideration is electronic observation and activation, in the form of computerised remote monitoring alerts linked with direct, automated RRT activation. A recent study of an electronic patient surveillance system linked with electronic health records (EHR) and analytic algorithms, aimed at early identification of decompensating patients, showed an absolute reduction in in‐hospital mortality of 1.4% across 56 diagnosis groups within 2 hospitals in the UK.58 Such results have implications for Australian hospitals currently implementing EHR and associated computerised decision support systems. Early warning systems These systems attempt to risk‐stratify patients into those who are more or less likely to activate a RRT call, the aim being to pre‐empt such calls by closer observation and more intense intervention. Two recent systematic reviews on the outcome of early warning systems (EWS) were inconclusive. One included 21 studies with 13 unique models in which EWS demonstrated a predictive ability for death and cardiac arrest, but had no impact on mortality and resource utilisation.59 Another included seven studies, with two reporting no significant difference in in‐hospital mortality rate, two finding a significant reduction in in‐ hospital mortality, and two describing a trend towards improved survival.60 Authors from both reviews cited the lack of a universally agreed EWS as a possible barrier to realising their full benefit. Activation by non clinicians RRT activation by patients or their family independently of clinical staff has been studied in a trauma centre with beneficial effects,61 which is of interest given the recent introduction into Queensland public hospitals of ‘Ryan's Rule’, which allows family members to call RRT teams if they harbour major safety concerns. Tiered RRT responses Only one study that we are aware of has investigated tiered RRT calls dependent on the assessed level of clinical 1215
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urgency. In a tertiary hospital, which includes both adult and paediatric patients, introduction of a two‐tier response (first tier: less urgent clinical review criteria; second tier: more serious criteria triggering review by RRT) was not associated with decreased rates of cardiac arrest or hospital mortality.62 However, the introduction of the two‐tier system was associated with a progressive and significant increase in both tier 1 and tier 2 responses.
RRT – too much too soon? As RRT systems constitute a quality and safety improvement intervention, certain criteria deserve consideration when deciding if the intervention is ready for widespread adoption.69 In the case of RRT the intervention is already well established, but with limitations in its implementation and outcome assessment according to our application of one evaluative framework (Table4).
RRT composition The optimal composition of the response team remains uncertain. Traditionally RRT have included critical care trained doctors who are able to care for unwell, complex patients and deal competently with airway problems. A before–after time series analysis examined a RRT system relying on the patient's usual care team, not ICU‐based teams, and found an independent association with reduced unexpected mortality.63 Another mostly retrospective study showed that involvement of the usual care team in RRT systems led to more transfers to ICU and more changes in resuscitation status, and was perceived by RRT leaders as facilitating better communication.64 In contrast, a retrospective observational study comparing ICU‐led and resident physician‐led RRT found no difference in cardiac arrests, ICU admissions, or hospital mortality.65 A 6‐year study of an ICU nurse‐led RRT reported sustained reductions in cardiopulmonary arrests.66
RRT actions Few Australian studies have characterised how long RRT personnel attend each call and what they actually do in terms of resuscitating patients, adjusting pre‐existing management plans, facilitating transfer to critical care wards, revising acute resuscitation plans, or initiating palliative care. The most commonly reported interventions include administering supplemental oxygen or intravenous fluids, suctioning patients' upper airways, securing intravenous access, and ordering basic investigations (ECG, arterial blood gases, chest X‐ray).10,16,67 To date no study has assessed the relationship between actions undertaken during RRT calls and clinical outcomes. In some hospitals, including the authors', patients who have had a RRT call are reviewed by critical care outreach teams over the ensuing 24h to monitor patient status and RRT‐mediated changes in management, with the aim of reducing the risk of further RRT calls. While there is evidence that such outreach lessens the risk of readmission to the ICU of patients recently discharged from the ICU,68 there has been no study to document whether similar benefits are seen with post‐RRT outreach. 1216
RRT as a rescue mechanism to compensate for other system failures It can be argued that RRT systems have taken hold to protect patients from the hazards of suboptimal care and ‘failure to rescue’ induced by system of care failures.70 These include staffing shortages or suboptimal staff to patient ratios, inappropriate triage and disposition of emergency patients, outlying patients in non‐home wards, premature discharge of unstable patients from critical care units and post‐operative observation units due to bed pressures, inadequate training of junior medical and nursing staff in general wards in acute care, and insufficient on‐site presence of experienced senior clinicians to guide patient management. In one study, one of three RRT activations was associated with medical errors,71 while in another more than 75% of RRT calls to surgical units were classified preventable errors of omission due to limited after‐hours coverage.72 In an Australian study, more rapid exiting of inpatients from emergency departments to meet 4‐h emergency access targets was associated with a 53% increase over 4 years in RRT calls for such patients within the first 24h of admission, from 9.2 to 14.1 per 1000 admissions.73 These system failures have occurred on a background of increasingly complex patient casemix, tight budgets, high hospital bed occupancy and greater patient throughput. It could be argued that a greater investment in correcting system failures would improve patient safety over the long term and reduce the need for RRT to rescue deteriorating patients.
The need for more research into RRT The ability of RRT systems to bring appropriately trained staff to the bedside of acutely unwell patients quickly and consistently has strong prima facie attraction from a patient safety perspective. This, together with some evidence that they improve outcomes and little to suggest harm, means they will remain a fixture within Australian hospitals. However, researchers should attempt to identify the circumstances and mode of operation © 2015 Royal Australasian College of Physicians
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Table 4 Application to RRT of a framework for assessing its readiness for widespread adoption68 Was the problem to be addressed by RRT fully characterised? Does a sound theory of behaviour change underpin the intervention?
Was there preliminary testing in confirming proof of concept? Is the RRT standardised and replicable?
Have effects been evaluated with a sufficient level of xrigour? Were outcome measures standardised and appropriate?
Quality assurance procedures for data collection? Minimisation of risk of confounding?
Have observed effects been reconciled with underpinning theoretical framework? Were data collected that adequately tested theory? Were process evaluations reported?
Has potential for adverse and unintended effects been evaluated? Have resource use and costs been assessed? Have effects been clinically plausible and consistent?
Has sustainability of effect been assessed? Have methodological limitations and conflicts of interest been assessed? Is publication bias likely?
Yes – multiple studies have documented deterioration in vital signs up to 12h prior to cardiac arrest that have not been correctly interpreted and/or acted on by attending medical or nursing staff for various reasons. No – intervention has several components: designing RRT call criteria and notification procedures, team make up, roles and training; staff and management agreement to RRT implementation. Potential difficulties in implementation based on change theories include break from traditional hierarchy of seeking review from usual attendant medical team; challenges patient ownership; perceived loss of autonomy in calling RRT; variation in monitoring of vital signs; differing interpretation of call criteria; delays in activating RRT. How these barriers to implementation were to be overcome were not addressed in designing the intervention. No – there were no reports prior to large scale implementation studies. To some extent – significant variation across hospitals and between studies in team composition, links with ICU, call activation criteria, target populations (only surgical patients, patients in shock, all patients outside critical care areas). Interventions performed at patient level by RRT were not standardised.
No – all cause mortality, unexpected cardiac arrests and unplanned ICU transfers – only in patients with no do not resuscitate (DNR) status – are the most appropriate outcome measures that many studies did not report. Definition of cardiac arrest did not adopt standardised terminology and varied between studies as did inclusion of patients with DNR status. No – most studies did not report quality assurance procedures for data collection. Only to a limited extent. Of more than 60 studies reported up to 2014, 19 were prospective and only 7 studies (6 involving adults – see Table2) were categorised as high quality in using analytic methods that adjusted for possible confounders.
No – survey data related to theory based impediments were performed independently of clinical trials with little reporting of intended solutions or their effectiveness. Some trials undertook process evaluations that showed call rates to vary considerably, from 2.7 to 48.7 calls per 1000 admissions. Others reported RRT utilisation was proportional to staff education about, and interpretation of, call activation criteria, understanding of RRT functions, and positive attitude to RRT. No – potential harms were not assessed prior to widespread adoption. No – cost or cost effectiveness analyses have not been reported. No – there is significant heterogeneity in mortality outcome. In pooled analyses of 11 prospective 17 studies involving adults reported in the high quality 2010 systematic review, two studies showed significant reduction, one reported a decreased trend, six reported no effect, one reported an increased trend, and one reported increased mortality. The numbers of deaths prevented were disproportionate to reductions in the numbers of cardiopulmonary arrests, suggesting unidentified confounders. To some degree although reports that have assessed effects beyond 2 years are few in number. While many studies have discussed limitations, conflicts of interest statements have been lacking. Probably not – systematic reviews of prospective studies concluded no evidence of publication bias.
ICU, intensive care unit; QSII, quality and safety improvement; RRT, rapid response teams.
under which the RRT system yields the most patient benefit for the lowest use of limited resources. This need is being recognised by some of the strongest advocates of RRT.74 In taking another look at RRT, we would pose the questions listed in Table5 as priorities for further research. © 2015 Royal Australasian College of Physicians
Conclusion The introduction of RRT into hospital practice has been driven by the belief that they make hospitals safer and prevent adverse outcomes in clinically deteriorating 1217
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Table 5 Future research questions RRT benefits • What are the benefits of RRT in regard to outcomes other than in hospital mortality and out of ICU cardiorespiratory arrests? • Are there groups of patients who derive greater benefit from RRT and should be targeted for more intense monitoring? • Do the benefits of RRT vary according to their timing, patient location and classification, type of hospital and other patient or system of care factors? RRT activation • What is the predictive value of current clinical signs and ‘worried’ or ‘concern’ criteria used to activate RRT? • What are the factors most responsible for afferent and efferent limb failures and how might they be overcome? • What proportion of RRT calls are activated for patients who are not actually clinically deteriorating? What proportion of RRT calls result in no change in management plan? • Does RRT activation by non clinicians add to patient safety and improve clinical outcomes? • Would systematic use of advance care planning in high risk patients reduce need for RRT activation? • Do early warning systems enable more targeted monitoring of patients more likely to require RRT calls? • Are electronic patient surveillance and automated RRT activation systems likely to reduce instances of failed RRT activation? • Is there a relationship between RRT activation trigger, RRT interventions and RRT outcome? Could such a relationship be used to educate staff in responding to different clinical scenarios in ways that obviate unnecessary RRT calls? RRT composition • What is the optimal composition of the RRT? Is a critical care trained doctor necessary for all responses? • Would a usual care team led response team result in less inappropriate investigations and interventions, and improved patient outcomes? RRT actions • Which RRT actions are most responsible for improved outcomes? • Does post RRT follow up by ICU outreach teams alter outcomes? Can such follow up be targeted to patients that are at higher risk of repeat decompensation? RRT cost, unintended adverse effects, competing priorities • What are the adverse consequences of widespread adoption of the RRT system, including opportunity resource costs incurred by frequent RRT calls? • What are the costs and cost effectiveness of RRT in comparison to other strategies that could be used to optimise patient safety? • To what extent is investment in RRT systems compensating for other system of care failures? Would greater investment in correcting such failures reduce the number of clinically deteriorating patients and hence number of RRT calls? RRT, rapid response teams.
patients sited in general hospital wards. However, high quality evidence supporting their effectiveness related to the care of adult patients is lacking and numerous controversies exist as to the optimal methods of implementation. More research is needed in better understanding the
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