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The Institute for Healthcare Improvement (IHI) is a not-for-profit organization dedicated to the improvement of health by advancing the quality of health care.

Special Feature: Rapid Response Teams: Are the Benefits Worth the Costs?

January 1, 2006

Special Feature

Rapid Response Teams: Are the Benefits Worth the Costs?

By Stephen W. Crawford MD, Pulmonary Medicine, Naval Medical Center, San Diego, CA, is Associate Editor for Critical Care Alert.

Dr. Crawford is a consultant for Cubist Pharmaceuticals, and is on the speaker’s bureau for Ortho Biotech.

The Institute for Healthcare Improvement (IHI) is a not-for-profit organization dedicated to the improvement of health by advancing the quality of health care. A major focus of the IHI is an attempt to save the lives of 100,000 patients over 18-months. The "100,000 Lives Campaign" is an initiative to engage hospitals in a commitment to implement changes in care "proven" to improve patient care and prevent avoidable deaths.

The IHI encourages hospitals to implement 6 specific patient safety interventions:

  1. Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction;
  2. Prevent Adverse Drug Events;
  3. Prevent Central Line Infections;
  4. Prevent Surgical Site Infections;
  5. Prevent Ventilator-Associated Pneumonia; and
  6. Deploy Rapid Response Teams.

Most of these interventions do not substantially increase the cost of care for these patients, and there is reason to believe that the healthcare costs will be reduced due to a reduction in complications. However, the deployment of "Rapid Response Teams" may require an expenditure of potentially significant personnel costs. For this reason, it is relevant to review the rationale behind and data supporting these interventions. Many providers interpreted the initial reports of these teams as proof of their effectiveness in decreasing adverse patient outcomes. More recent studies and a re-assessment of the previous studies suggest a very limited impact.

Background of the Rapid Response Team

The Rapid Response Team (RRT), also known as the Medical Emergency Team (MET), is a team of clinicians who bring expertise to the patient's bedside whenever it is needed. The goal is to respond to early clinical deterioration before a cardiopulmonary arrest or "code blue."

The impetus for these teams was born from several studies that noted that clinical physiologic instability precedes most arrests by several hours. In the 1990s, studies reported that 66-70% of patients demonstrated deterioration in physiological parameters 6-8 hours before cardiopulmonary arrest.1,2 These warning signs of impending arrest included changes in heart rate, respiratory rate or blood pressure, chest pain and changes in mental status. Moreover nursing staff notified physicians of the alterations in a minority of cases.2

Given the premonitory signs of deterioration and a high rate of hospital complications, cardiopulmonary arrest, ICU transfers and mortality, several investigators created RRTs to deal quickly with these patients. These RRTs are smaller than and distinct from the "code" team. A variety of clinicians comprised the RRTs: critical care physicians, ICU-trained nurses, and respiratory therapists. Any staff member of the hospital can call the RRT due to any concern about a patient’s condition. A nurse initiates most calls usually guided by specific criteria of physiologic changes in pulse, respirations, blood pressure, oxygenation, and neurological status.

The following are examples of indications for calling a Rapid Response Team:

  1. Acute change in heart rate to < 40 or > 130 beats/min;
  2. Acute change in systolic blood pressure to < 90 mm Hg;
  3. Acute change in respiratory rate to < 8 or > 28 breaths/min;
  4. Acute change in saturation to < 90% despite supplemental oxygen;
  5. Acute change in conscious state;
  6. Acute change in urinary output to < 50 mL in 4 hours.

Initial Studies Support Use of the Rapid Response Team

Two Australian groups reported the most widely quoted studies, each conducted at teaching hospitals. In 2002, Buist et al3 described a 50% adjusted reduction in unexpected cardiac arrests after institution in 1997 of RRTs comprised of 2 physicians and 1 senior intensive care nurse. They compared the incidence in 1996 (3.77 per 1000 admissions, n = 73, before RRT) to that of 1999 (2.05 per 1000 admissions, n = 47, after RRT). Moreover, the mortality rate among the unexpected arrests decreased from 77% to 55%. In 2004, Bellomo et al4 reported reductions in ICU transfers (44% decline) and postoperative deaths (37% decline) among patients undergoing major surgeries after initiation of RRTs. Their RRT was composed of the duty intensive care fellow and a designated ICU nurse. The mean response time after the RRT was called was less than 2 minutes. According to the IHI, a number of hospitals in the United States have RRTs in place and also report declines in unexpected complications.

On the basis of these published studies and anecdotal reports, it appeared that in-hospital arrests, mortality and ICU-transfers declined after the institution of RRTs. Nurses appreciate having someone experienced available at a moment’s notice to assist in the assessment and management of a potentially critically ill patient. The RRT assists the staff member in assessing and stabilizing the patient’s condition and organizing information to be communicated to the patient’s physician. The RRT also takes on the role of educator and support to the staff. If necessary, the RRT assists with the patient transfer to a higher level of care.

Various combinations of clinicians can comprise the RRT: ICU nurse, respiratory therapist, and either a resident, intensivist, hospitalist or physician assistant.

The IHI recommends that team members should have specific qualifications:

  1. Be available to respond immediately when called and not be constrained by competing responsibilities;
  2. Be onsite and accessible; and
  3. Have the critical care skills necessary to assess and respond.

A Cause for Doubt

Do RRTs really decrease cardiac arrests, ICU transfers and mortality? While the IHI believes they do, there are reasons for doubt. The study by Buist et al3 confined their statistical analysis to data for 12-month periods before and after implementation of the RRT. The analyses demonstrate highly significant declines in cardiac arrests and in-hospital mortality. Buist et al attribute the changes to the effects of the teams. However, they failed to account for trends in the data and used statistical analyses appropriate for steady states. From 1994 to 1997, before the RRT was implemented, both the incidence of arrests and mortality rates were already dropping, from 3.8 to 2 (per 1000 patients) and 25 to 20 (per 1000 patients) respectively. Small further declines continued during the first year of implementation when activation of the teams was minimal (arrests, 1 per 1000 patient; mortality, 17 per 1000 patients). As the number of RRT calls then increased from 1998 to 2000, there were no associated decreases in either arrests or mortality. These data suggest that the authors identified a coincidental improvement in patient outcome and the implementation of the RRT.

Similarly, the study by Bellomo et al4 noted a significant decrease in postoperative adverse events, mortality and hospital length of stay during a 4-month period after establishing an RRT in 1999. However, the effects on adverse events and the decrease in the number of patients affected (n 3) were only partly accounted for by the number of RRT interventions (n = 47). Thus, at least some of the benefit was due to something other than the direct intervention by the team.

A collaborative study performed in Australia, published this year, raises the greatest doubt about the impact of RRTs on patient outcomes. The MERIT Study investigators5 including Buist and Bellomo, undertook a very ambitious randomized evaluation of the effects of RRTs. After collecting baseline data regarding cardiac arrests, unplanned ICU admissions and unexpected deaths, they randomized the 23 participating hospitals to either no changes or a 4-month educational program and introduction of an RRT. After 6 months of use of the teams they again collected the data.

This is the only randomized study of the RRT concept and it revealed no significant differences in the rates of cardiac arrests, unplanned ICU admissions and unexpected deaths between the control hospitals and those that implemented the RRT. More importantly, at both groups of hospitals there were statistically significant declines in the rates of cardiac arrest and unexpected death. Adverse events declined despite not having an RRT system in place. It is notable that the baseline rate of the adverse outcomes in the study was one-fifth of that they predicted based on previous studies. Another recent study performed in England noted no statistically significant decline in these adverse events over 1-year after introduction of an RRT system.6

The MERIT study strongly suggests that improvements in adverse outcomes are unrelated to implementation of an RRT, and documents improving trends in the rates independent of the RRT.

The Problems

Staffing an RRT requires either additional personnel or adding additional clinical responsibilities to existing staff (in conflict with the specific qualifications recommended by the IHI as noted above). There is a significant cost associated with adding staff to cover the RRT on a 24-hour per day, 7-days per week basis. Some facilities utilize ICU nurses with the RRT as an additional clinical duty and require that other nurses assume the responsibility for their patients during a call. In a marginally staffed ICU, this presents a patient safety concern of its own. In California there already is a severe nursing shortage and a state-mandated patient-nurse ratio (1:6). Developing a functioning RRT is a financial and personnel strain.

In addition, the reports from Australia3,4 stress the importance of training both the RRT and the hospital’s nurses about the appropriate clinical indications for calling. There is a cost for educators and a cost associated with staff downtime for training. Staff turnover mandates that training be a continuous process and expense.

In order for the RRT system to function, nursing staff must recognize physiological indicators of impending critical illness. This lack of recognition was suspected as a cause for the high number of unexpected arrests and deaths and in part accounted for the prolonged period of clinical decompensation noted before the events. It is likely that this awareness of the warning signs of impending arrest alone could motivate the staff to initiate appropriate care and improve outcomes.

Anecdotal experience with the APACHE II scoring system of predicted mortality rates suggests that implementation of an educational program that targets the recognition and early treatment of sepsis to staff outside of the ICU results in improved survival within the ICU after patients are transferred. I believe that focused attention outside the ICU improves survival rates for patients within the ICU.

Conclusions and Recommendations

Many data suggest that patient outcomes have improved over time. The reasons are unclear. These improvements follow on the heels of an increasing awareness of patient safety issues, such as that highlighted by the Institute of Medicine’s "To Err is Human" report in 1999.7 The data now strongly suggest that the apparent improvement in patient outcomes noted in previous studies was not related to the implementation of RRTs. The initial studies failed to adequately account for declining trends in adverse events that were independent of program implementation. In addition, these teams impose staffing and personnel burdens on already overstretched systems.

The concept of an RRT is attractive as a mechanism to support clinical staff and provide early intervention for patients with warning signs of impending arrest. It is understandable why less experienced hospital staff would like to have expert clinicians at their beck and call to assist with problems. I have heard numerous anecdotes about experienced nurses coming to the assistance of a junior nurse, interceding with the medical staff and saving the patient. While the anecdotes are compelling, it is clear from the randomized study that the global improvements in patient outcomes are independent of implementation of an RRT.

Before a hospital considers implementation of an RRT, they should establish their rates of in-hospital unexpected deaths and cardiac arrests, as well as where and when these occur. Without these parameters, it is impossible to determine if any procedural change is required. Moreover, monitoring of these variables is necessary to assess the impact of implementation of any intervention.

In lieu of an RRT there are alternatives that address many of the concerns targeted by this intervention. These approaches are based on:

  1. education of all primary care givers about the warning signs of impending arrest;
  2. development of standing orders for immediate interventions by nursing staff; and
  3. implementation that mandates immediate notification of designated medical staff of the events.

Education of nursing staff regarding recognition of potentially critically ill patients is of paramount importance to patient safety, as well as to decreasing the hospital’s liability exposure. All clinical staff must be capable of recognizing and initially dealing with physiologic instability. Achieving this goal will require on-going education and widespread dissemination of specific hemodynamic, respiratory and neurological findings that warrant action and immediate physician notification. This education would be required for the implementation of an RRT, and may obviate the need for the team. Posting the "warning signs" in clinical areas is a minimal step.

Hospital policy should mandate standing orders for diagnostic and treatment interventions for specific problems that may be warning signs for impending arrest. Nurses should be empowered to obtain electrocardiograms, chest radiographs, and blood tests, and to administer oxygen based on specific criteria, while also notifying the patient’s physician. Also, if there is concern that nurses require experienced medical support for patients with impending arrest, hospital policy should mandate that a senior physician on-call be notified with the specific physiological data and results of ancillary studies.

In addition, the growing trend toward hospital coverage by intensivists and hospitalists will provide additional support for the nurse. However, unless the primary caregiver recognizes the initial warning signs, no system will be effective. The keys to patient safety are education and guidelines for action, not the creation of more teams.

The opinions expressed do not necessarily reflect those of the US Navy or Department of Defense.

References

  1. Schein RM, et al. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest. 1990;98:1388-1392.
  2. Franklin C, Mathew J. Developing strategies to prevent in hospital cardiac arrest: analyzing responses of physicians and nurses in the hours before the event. Crit Care Med. 1994;22:244-247.
  3. Buist MD, et al. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study. BMJ. 2002;324:387-390.
  4. Bellomo R, et al. Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med. 2004;32:916-921.
  5. Hillman K, et al. Introduction of the medical emergency team (MET) system: a cluster randomised controlled trial. Lancet. 2005:365:2091-2097; Erratum in: Lancet. 2005;366:1164.
  6. Kenward G, et al. Evaluation of a medical emergency team one year after implementation. Resuscitation. 2004;61:257-263.
  7. To Err Is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS, eds. Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC, USA: National Academies Press; 1999.