The creation of rapid response teams (RRTs) at acute care institutions was based on the perception that there was a lack of intensive care training for the staff members who work on the floor areas of the hospital. The thinking was that if the patient’s condition deteriorates, it is better to have an expert backup team available to head off any further deterioration.
There seem to be consistent issues that lead to failure of a patient receiving timely care in a situation of deterioration:
- lack of communication;
- failure to acknowledge the deterioration in the patient;
- no medical plan for the patient’s duration of stay; and
- hesitation of the primary caregiver to call in additional resources
Rapid response teams were seen as a means of addressing some of these issues, but now controversy seems to be surrounding them. Are they a Band-Aid on a bigger problem as some have suggested? Many studies about the efficacy of RRTs are being published in the literature, and many questions are being asked as we look more closely at the cost-benefit analysis of running an RRT. Do they work? Are there better solutions? What is the effectiveness of these teams? How do we measure their success?
Many factors determine the success or failure of RRTs. Although numerous hospitals have set protocols in place, many have not. What are the conditions that are to be met prior to calling a rapid response? How trained are the primary caregivers in understanding their patients’ conditions? Do the primary caregivers have a complete understanding about the rapid response program? There are so many variables in these situations that it is difficult to predict patient outcomes or even where the issues lie.
In a Journal of the American Medical Association paper, Eugene Litvak, PhD, Institute for Healthcare Optimization, Newton, Mass, and colleague Peter Pronovost, MD, PhD, Johns Hopkins University School of Medicine, Baltimore, stated, “Such teams—widely used across the country—do save human lives ….” but argue, “They are a Band-Aid solution, needed only because hospital beds are poorly managed in the first place.”1
Although certain data do seem to indicate that—perhaps due to cost cutting—patients are being moved out of the intensive care units (ICUs) at a rate that borders on patient danger, another factor also affects bed availability: bed allocation. Bed allocation is an issue throughout the United States, which ranks 27th in the world in hospital beds per population at 3.6 per 1,000 people.2 In the end, better bed management may need to be looked at in conjunction with other solutions, but to handle the situation at this time, RRTs, if used properly, seem to alleviate some of the crisis clinical conditions that are happening on the general floors of our hospitals.
Support of Rapid Response Teams
Current research shows that there has been a vast improvement in alleviating cardiac arrests, postoperative arrests, and respiratory failure outside the ICU setting, post-RRT initiation:
- 50% reduction in the occurrence of cardiac arrest outside the ICU3;
- 17% decrease in the incidence of cardiopulmonary arrests (6.5 versus 5.4 per 1,000 admissions)4;
- Severe postoperative adverse events (ie, respiratory failure, stroke, severe sepsis, acute renal failure) reduced by 58%5;
- Emergency ICU admissions reduced by 44%5;
- Postoperative deaths reduced by 37%, and mean duration of hospital stay decreased from 23.8 to 19.8 days in surgical patients5; and
- There has been a decrease in the number of unnecessary transfers to a higher level of care by a mean of 30%.6
So the data in these studies tend to show that RRTs do work when used appropriately. There are, however, certain limitations on the use of these teams, and there even are studies reporting that the above findings have used historical controls and not been randomized.
The MERIT study, which used a prospective cluster randomized design involving 23 hospitals in Australia, found no significant difference in cardiac arrests in patients without a do-not-resuscitate order, unplanned ICU admissions, and unexpected deaths taking place in general wards in those hospitals with a medical emergency team (MET) versus those hospitals without an MET. Thus, further scientific study is needed to demonstrate the efficacy of these teams.7
Do RRTs work? I witnessed a situation that deserves mentioning as a good example of a clinical situation that could have turned out with a mortality instead of a discharge if not for the astuteness of a rapid response team member.
A patient was being discharged. A respiratory therapist was talking with the patient, who stated she just did not feel right. The patient looked somewhat pale and “just not the same,” according to the therapist interviewed. After the RT spoke with the nurse and physician, the team decided to proceed with an arterial blood gas analysis, despite no immediate respiratory distress noted. The results were at the level of requiring critical intervention, namely, noninvasive respiratory support. This patient did not show the traditional distress that would normally be noted, but, due to the RT’s rapid response training and timeliness, along with her experience, she was able to note the change in condition and diverted what could have been certain disaster had the patient gone home. The patient, unfortunately, did not respond to bilevel positive airway pressure and was intubated. The patient has since recovered, however, and is now on her way to recovery; at the time of this writing, she has been discharged home.
A Cautionary Note
Rapid response teams are dependent on clinical coordination. The primary caregiver must understand the patient’s conditions, understand the rapid response protocols that are in place, and understand to call if necessary. The primary caregiver must feel comfortable in calling a rapid response without fear of retribution or looks of disdain if the patient turns out to be clinically sound.
Rapid response team members should not be responsible for another clinical area. Their minds should be focused on the crisis at hand. Often hospitals tend to place their ICU staff on the RRT, notwithstanding that staff members may have a full patient complement of their own. Thus, the stress of managing their own patients plus emergent situations often can lead to bad decision-making or frustration if a call is unwarranted.
How many people are trained for rapid response in medical facilities across the United States? Often when RTs (or other medical professionals) are hired, they are just placed on the team on a particular shift. To be fair, usually the most experienced personnel are placed on the team, but often with a complement load to worry about. These health care providers are placed in a position of high stress, so thorough training should be in place. The roles of the RRT should be consistent, and the expectations should be clear.
Several roles RRT team members play include but are not limited to:
- assisting the primary caregiver in stabilizing the patient
- education of the primary caregiver
- transferring the patient to a higher level of care, particularly the ICU, if appropriate.
“How is it working and how do you know?” said Michael Westley, MD, medical director of critical care and respiratory therapy, Virginia Mason Medical Center, Seattle. “We need to close the loop by showing how well we are identifying, and getting resources to, patients in trouble.”8
Several ways of measuring the effectiveness of the RRT have been suggested, and I am not sure a correct way has yet been shown. What is important, however, is that we look at objective data and consistently track the data on the RRTs.
Some metrics used to measure effectiveness include9:
- codes per 1,000 discharged
- codes outside of the ICU
- number of unplanned ICU admissions
- utilization of the RRT
- mortality rates
Early indications are that the establishment of RRTs has had a definite impact on mortality and patient outcomes. Health care practitioners as well as health care administration need to promote prevention of deterioration of the patient outside of the ICU and identify barriers to the implementation of RRTs. This process will need to include all disciplines, and a collaborative effort will need to be made by all members of the health care team. Many institutions have already formed an RRT, and information on the Institute for Healthcare Improvement Web site10 can provide beneficial information on the setting up of RRTs and recommend ways in which these teams can be organized.
Michael V. Frey, RRT-NPS, is team leader, respiratory care, Abrazo Healthcare, West Valley Hospital, Goodyear, Ariz. For further information, contact [email protected]
Learn more about rapid response teams by reading our new digital edition.—Ed.
- Litvak E, Pronovost P. Rapid response teams sign of poor bed management. JAMA. 2010;304(12):1375-1376.
- Hospital beds by country OECD. Available at: www.NationMaster.com/red/graph/hea_hos_bed-health-hospital-beds&b_printable=1. Accessed January 23, 2012.
- 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.
- Braithwaite RS, DeVita MA, Mehidhara R, et al. Use of medical emergency team (MET) responses to reduce hospital cardiopulmonary arrests. Qual Saf Health Care. 2004;13:251-4.
- Bellomo R, Goldsmith D, Uchino S, et al. Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med. 2004;32:916-21.
- Goldhill DR, Worthington L, Mulcahy A, Tarling M, Sumner A. The patient-at-risk team: identifying and managing seriously ill ward patients. Anesthesia. 1999;54:853-60.
- Hillman K, Chen J, Cretikos M, et al. Introduction of the medical emergency team (MERIT) system: a cluster-randomised controlled trial. Lancet. 2005;365:2091-7.
- Coldwell J. Rapid Response teams are in place, but do they work? Available at: www.acphospitalist.org/archives/2011/05/rrt.htm. Accessed January 23, 2012.
- Rapid Response and Medical Emergency Teams. Available at: www.resuscitationcentral.com/documentation/rapid-response-medical-emergency-team/. Accessed January 23, 2012.
- Institute for Healthcare Improvement. Available at: http: www.ihi.org/Pages/default.aspx. Accessed January 23, 2012.