Differences in outcomes between ICU attending and senior resident physician led medical emergency team responses

Rapid Response Systems

The hospital rapid response system (RRS) is a patient safety and quality intervention that responds quickly to clinical deteriorations on general wards with the goal of preventing cardiopulmonary arrests, reducing hospital mortality, and facilitating triage and level of care escalations. The RRS is one of the first organized, and systematic, elements of the "ICU without walls" model. RRSs have been shown to be effective in preventing deterioration to cardiopulmonary arrest on general hospital wards and reducing total and unexpected hospital mortality. Recent studies have demonstrated that this benefit can be enhanced through targeted improvements and modifications of existing RRSs.

Pro-Con Debate: Universal Versus Selective Continuous Monitoring of Postoperative Patients

In this Pro-Con commentary article, we discuss use of continuous physiologic monitoring for clinical deterioration, specifically respiratory depression in the postoperative population. The Pro position advocates for 24/7 continuous surveillance monitoring of all patients starting in the postanesthesia care unit until discharge from the hospital. The strongest arguments for universal monitoring relate to inadequate assessment and algorithms for patient risk. We argue that the need for hospitalization in and of itself is a sufficient predictor of an individual's risk for unexpected respiratory deterioration. In addition, general care units carry the added risk that even the most severe respiratory events will not be recognized in a timely fashion, largely due to higher patient to nurse staffing ratios and limited intermittent vital signs assessments (e.g., every 4 hours). Continuous monitoring configured properly using a "surveillance model" can adequately detect patients' respiratory deterioration while minimizing alarm fatigue and the costs of the surveillance systems. The Con position advocates for a mixed approach of time-limited continuous pulse oximetry monitoring for all patients receiving opioids, with additional remote pulse oximetry monitoring for patients identified as having a high risk of respiratory depression. Alarm fatigue, clinical resource limitations, and cost are the strongest arguments for selective monitoring, which is a more targeted approach. The proponents of the con position acknowledge that postoperative respiratory monitoring is certainly indicated for all patients, but not all patients need the same level of monitoring. The analysis and discussion of each point of view describes who, when, where, and how continuous monitoring should be implemented. Consideration of various system-level factors are addressed, including clinical resource availability, alarm design, system costs, patient and staff acceptance, risk-assessment algorithms, and respiratory event detection. Literature is reviewed, findings are described, and recommendations for design of monitoring systems and implementation of monitoring are described for the pro and con positions.

Indications and measures of medical emergency teams: a retrospective evaluation of in-hospital emergency operations of the German Resuscitation Register

BACKGROUND

The present study examines characteristics and interventions of medical emergency teams (MET) in in-hospital emergency care.

METHODS

Analysis of all in-hospital emergencies in patients ≥18 years at 62 hospitals with established MET from the database of the German Resuscitation Registry between 2014-2019. The evaluation covered indications for activation using the ABCDE-scheme, time intervals of arrival and patient care as well as the performed invasive/medical interventions.

RESULTS

Out of 62 hospitals 14,166 in-hospital emergencies (male: 8033 [56.7%]; mean age: 64±18 years) were included. Causes of activation were circulation (5760 [40.7%]), disability (4076 [28.8%]), breathing (3649 [25.8%]) and airway-problems (1589 [11.2%]). Average arrival time at the emergency scene was 4±3 minutes, supply time of MET was 24±23 minutes. Endotracheal intubation was required in 1757 (12.4%) and difficult intubation occurred in 201 (11.4%) patients with the necessity for cricothyroidotomy in eight cases (3.9%). Invasive blood-pressure-measurement was indicated in 1074 (7.6%) patients. Catecholamines were required for hemodynamic stabilization in 2421 (17.1%) patients (norepinephrine: 1520 [10.7%], epinephrine: 430 [3.0%], dobutamine: 26 [0.2%]).

CONCLUSIONS

Current in-hospital emergency care requires special skills in invasive hemodynamic and airway interventions. Recommendations from professional societies are necessary to optimize equipment (e.g. videolaryngoscopy, invasive blood pressure management), training, care algorithms and staff composition against the background of an increasing shortage of resources in the healthcare system.

Failure to Rescue Deteriorating Patients: A Systematic Review of Root Causes and Improvement Strategies

OBJECTIVES

"Failure to rescue" (FTR) is the failure to prevent a death resulting from a complication of medical care or from a complication of underlying illness or surgery. There is a growing body of evidence that identifies causes and interventions that may improve institutional FTR rates. Why do patients "fail to rescue" after complications in hospital? What clinically relevant interventions have been shown to improve organizational fail to rescue rates? Can successful rescue methods be classified into a simple strategy?

METHODS

A systematic review was performed and the following electronic databases searched between January 1, 2006, to February 12, 2018: MEDLINE, PsycINFO, Cochrane Library, CINAHL, and BNI databases. All studies that explored an intervention to improve failure to rescue in the adult population were considered.

RESULTS

The search returned 1486 articles. Eight hundred forty-two abstracts were reviewed leaving 52 articles for full assessment. Articles were classified into 3 strategic arms (recognize, relay, and react) incorporating 6 areas of intervention with specific recommendations.

CONCLUSIONS

Complications occur consistently within healthcare organizations. They represent a huge burden on patients, clinicians, and healthcare systems. Organizations vary in their ability to manage such events. Failure to rescue is a measure of institutional competence in this context. We propose "The 3 Rs of Failure to Rescue" of recognize, relay, and react and hope that this serves as a valuable framework for understanding the phases where failure of patient salvage may occur. Future efforts at mitigating the differences in outcome from complication management between units may benefit from incorporating this proposed framework into institutional quality improvement.

Strategies for successful implementation and permanent maintenance of a rapid response system

Rapid response systems (RRSs) have been introduced to intervene with patients experiencing non-code medical emergencies and operate widely around the world. An RRS has four components: an afferent limb, an efferent limb, quality improvement, and administration. A proper triggering system, a hospital culture that embraces the RRS from the afferent limb, experienced primary responders, and dedicated physicians from the efferent limb are key for successful implementation. After initial implementation, quality improvement through objective outcome measures and self-evaluation are crucial, which lead to a better outcome when this process is well performed. Furthermore, better outcomes lead to more investment, which is essential for effective development of the system. The RRS is successfully maintained when these four components are closely interconnected.

Relationship between the presence of dedicated doctors in rapid response systems and patient outcome: a multicenter retrospective cohort study

BACKGROUND

Rapid response systems (RRSs) improve patients' safety, but the role of dedicated doctors within these systems remains controversial. We aimed to evaluate patient survival rates and differences in types of interventions performed depending on the presence of dedicated doctors in the RRS.

METHODS

Patients managed by the RRSs of 9 centers in South Korea from January 1, 2016, through December 31, 2017, were included retrospectively. We used propensity score-matched analysis to balance patients according to the presence of dedicated doctors in the RRS. The primary outcome was in-hospital survival. The secondary outcomes were the incidence of interventions performed. A sensitivity analysis was performed with the subgroup of patients diagnosed with sepsis or septic shock.

RESULTS

After propensity score matching, 2981 patients were included per group according to the presence of dedicated doctors in the RRS. The presence of the dedicated doctors was not associated with patients' overall likelihood of survival (hazard ratio for death 1.05, 95% confidence interval [CI] 0.93‒1.20). Interventions, such as arterial line insertion (odds ratio [OR] 25.33, 95% CI 15.12‒42.44) and kidney replacement therapy (OR 10.77, 95% CI 6.10‒19.01), were more commonly performed for patients detected using RRS with dedicated doctors. The presence of dedicated doctors in the RRS was associated with better survival of patients with sepsis or septic shock (hazard ratio for death 0.62, 95% CI 0.39‒0.98) and lower intensive care unit admission rates (OR 0.53, 95% CI 0.37‒0.75).

CONCLUSIONS

The presence of dedicated doctors within the RRS was not associated with better survival in the overall population but with better survival and lower intensive care unit admission rates for patients with sepsis or septic shock.

Quels sont le fonctionnement, les caractéristiques, les effets et les modalités d’implantation des équipes d’intervention rapide ? Une revue de la littérature

Introduction : Hospitalized patients are at risk of unrecognized clinical deterioration that may lead to adverse events.Context : Rapid Response Teams (RRTs) exist around the world as a strategy to improve patient safety.Objective : To explore how RRTs work, their characteristics, impacts, and methods of implementation.Design : Literature review.Method : Consultation of the databases CINAHL, MEDLINE, PUBMED, COCHRANE library, SCOPUS, and PROQUEST Dissertations and Theses. Keywords : “health care team” and “rapid response team”.Results : 121 articles were included. The collected data were divided into five categories : 1) composition and operation of RRTs, 2) benefits and limitations of RRTs, 3) perceptions of RRTs by health care teams, organizations, and patients, 4) implementation strategies, and 5) facilitators and barriers to implementation.Discussion : Although there are many articles related to RRTs, it appears that : 1) few studies analyze the difference in outcomes in hospitalized patients related to the composition of RRTs, 2) few studies describe how RRTs should work, 3) more studies are needed on the impacts of RRTs on hospitalized patients, 4) organizations’ and patients’ perceptions of RRTs are not well studied, and 5) more studies are needed on the best way to implement an RRT.Conclusion : The results show that there is a lack of studies on the difference in outcomes in hospitalized patients related to the composition of RRTs, on how RRTs should work, on the impacts of RRTs on hospitalized patients, on organizations’ and patients’ perceptions of RRTs, and on the factors that influence the success or failure of the implementation of an RRT.

Characteristics of Rapid Response Calls in the United States: An Analysis of the First 402,023 Adult Cases From the Get With the Guidelines Resuscitation-Medical Emergency Team Registry

OBJECTIVES

To characterize the rapid response team activations, and the patients receiving them, in the American Heart Association-sponsored Get With The Guidelines Resuscitation-Medical Emergency Team cohort between 2005 and 2015.

DESIGN

Retrospective multicenter cohort study.

SETTING

Three hundred sixty U.S. hospitals.

PATIENTS

Consecutive adult patients experiencing rapid response team activation.

INTERVENTIONS

Rapid response team activation.

MEASUREMENTS AND MAIN RESULTS

The cohort included 402,023 rapid response team activations from 347,401 unique healthcare encounters. Respiratory triggers (38.0%) and cardiac triggers (37.4%) were most common. The most frequent interventions-pulse oximetry (66.5%), other monitoring (59.6%), and supplemental oxygen (62.0%)-were noninvasive. Fluids were the most common medication ordered (19.3%), but new antibiotic orders were rare (1.2%). More than 10% of rapid response teams resulted in code status changes. Hospital mortality was over 14% and increased with subsequent rapid response activations.

CONCLUSIONS

Although patients requiring rapid response team activation have high inpatient mortality, most rapid response team activations involve relatively few interventions, which may limit these teams' ability to improve patient outcomes.

Should critical care doctors be part of the cardiac arrest call team?

The composition of the cardiac arrest team varies widely both throughout the UK and the world. There are no agreed standards regarding the composition of the resuscitation team, and variety in teams is often dictated by availability of staff and financial constraints. This article discusses the evidence for and against the inclusion of critical care doctors on the cardiac arrest call team.

Outcomes of rapid response team implementation in tertiary private hospitals: a prospective cohort study

BACKGROUND

Cardiopulmonary arrest may result in high mortality rate in hospitals where the rapid response team is not implemented. A rapid response system can recognize patients at high risk of cardiopulmonary arrest and provide the needed medical management to prevent further deterioration. The rapid response system has shown a dramatic reduction in mortality rate and cardiopulmonary arrest.

OBJECTIVE

To evaluate the effectiveness of the rapid response team (RRT) implementation in reducing the mortality rate, number of cardiopulmonary arrests, and number of ICU admission.

DESIGN

A pre- and post-rapid response team system implementation.

SETTING

Four tertiary private hospitals in Saudi Arabia.

PATIENTS

A total of 154,869 patients in the 3-year before rapid response system period (January 2010 to December 2012) and a total of 466,161 during the 2.5-year post-RRT implementation period (January 2014 to June 2016).

RESULTS

Results indicated that ward nurses activated RRT more often than physicians (1104 activations [69%] vs. 499 activations [31%]), with cardiovascular and respiratory abnormalities being the most common triggers. Serious concern about the patient condition by the ward staff was the trigger for 181 (11.29%) activations. The RRT provided a variety of diagnostic and therapeutic interventions. Most patients cared for by RRT were admitted to ICU 1103 (68.81%), and the rest 500 (31.19%) were managed in the ward. After the implementation of the RRT project, the hospital mortality rate dropped from 7.8 to 2.8 per 1000 hospital admission. Hospital cardiopulmonary arrest rate has dropped from 10.53 per 1000 hospital admissions to 2.58. Rapid response team implementation also facilitated end-of-life care discussions.

CONCLUSION

Implementation of the RRT project has shown a dramatic reduction in the total ICU admissions, average ICU occupancy rate, total hospital mortality, and total ICU mortality. These findings reinforce the evidence that RRT implementation is effective in reducing hospital mortality and cardiopulmonary arrest rates in addition to other outcomes related to healthcare quality.

Characterising variation in composition and activation criteria of rapid response and cardiac arrest teams: a survey of Medicare participating hospitals in five American states

OBJECTIVES

To characterise the variation in composition, leadership, and activation criteria of rapid response and cardiac arrest teams in five north-eastern states of the USA.

DESIGN

Cross-sectional study consisting of a voluntary 46-question survey of acute care hospitals in north-eastern USA.

SETTING

Acute care hospitals in New York, New Jersey, Rhode Island, Vermont, and Pennsylvania.

PARTICIPANTS

Surveys were completed by any member of the rapid response team (RRT) with a working knowledge of team composition and function. Participants were all Medicare-participating acute care hospitals, including teaching and community hospitals as well as hospitals from rural, urban and suburban areas.

RESULTS

Out of 378 hospitals, contacts were identified for 303, and 107 surveys were completed. All but two hospitals had an RRT, 70% of which changed members daily. The most common activation criteria were clinical concern (95%), single vital sign abnormalities (77%) and early warning score (59%). Eighty one per cent of hospitals had a dedicated cardiac arrest team.RRT composition varied widely, with respiratory therapists, critical care nurses, physicians and nurse managers being the most likely to attend (89%, 78%, 64% and 51%, respectively). Consistent presence of critical care physicians was uncommon and both cardiac arrest teams and teams were frequently led by trainee physicians, often without senior supervision.

CONCLUSIONS

As the largest study to date in the USA, we have demonstrated wide heterogeneity, rapid team turnover and a lack of senior supervision of RRT and cardiac arrest teams. These factors likely contribute to the mixed results seen in studies of RRTs.

Emergency response teams in and outside of medicine-structurally crafted to be worlds apart

Medical emergency response teams (MERTs) are widespread throughout inpatient hospital care facilities. Besides the rise of the ubiquitous rapid response team, current MERTs span trauma, stroke, myocardial infarction, and sepsis in many hospitals. Given the multiplicity of teams with widely varying membership, leadership, and functionality, the structure of MERTs is appropriate to review to determine opportunities for improvement. Since nonmedical ERTs predate MERT genesis and are similar across multiple disciplines, nonmedical ERTs provide a standard against which to compare and review MERT design and function.Nonmedical ERTs are crafted to leverage team members who are fully trained and dedicated to that domain, whose skills are regularly updated, with leadership tied to unique skill sets rather than based on hierarchical rank; activity is immediately reviewed at the conclusion of each deployment and teams continue to work together between team deployments. Medical emergency response teams, in sharp contradistinction, often incorporate trainees into teams that do not train together, are not focused on the discipline required to be leveraged, are led based on arrival time or hierarchy, and are usually reviewed at a time remote from team action; teams rapidly disperse after each activity and generally do not continue to work together in between team activations. These differences between ERTs and MERTs may impede MERT success with regard to morbidity and mortality mitigation. Readily deployable approaches to bridge identified gaps include dedicated Advanced Practice Provider (APP) team leadership, reductions in trainee MERT leadership while preserving participation, discipline-dedicated rescue teams, and interteam integration training.Emergency response teams in medical and nonmedical domains share parallels yet lack congruency in structure, function, membership, roles, and performance evaluation. Medical emergency response team structural redesign may be warranted to embrace the beneficial elements of nonmedical ERTs to improve patient outcome and reduce variation in rescue practices and team functionality.

Rapid response systems

INTRODUCTION

Rapid response systems are commonly employed by hospitals to identify and respond to deteriorating patients outside of the intensive care unit. Controversy exists about the benefits of rapid response systems.

AIMS

We aimed to review the current state of the rapid response literature, including evolving aspects of afferent (risk detection) and efferent (intervention) arms, outcome measurement, process improvement, and implementation.

DATA SOURCES

Articles written in English and published in PubMed.

RESULTS

Rapid response systems are heterogeneous, with important differences among afferent and efferent arms. Clinically meaningful outcomes may include unexpected mortality, in-hospital cardiac arrest, length of stay, cost, and processes of care at end of life. Both positive and negative interventional studies have been published, although the two largest randomized trials involving rapid response systems - the Medical Early Response and Intervention Trial (MERIT) and the Effect of a Pediatric Early Warning System on All-Cause Mortality in Hospitalized Pediatric Patients (EPOCH) trial - did not find a mortality benefit with these systems, albeit with important limitations. Advances in monitoring technologies, risk assessment strategies, and behavioral ergonomics may offer opportunities for improvement.

CONCLUSIONS

Rapid responses may improve some meaningful outcomes, although these findings remain controversial. These systems may also improve care for patients at the end of life. Rapid response systems are expected to continue evolving with novel developments in monitoring technologies, risk prediction informatics, and work in human factors.

Outcome of adult patients attended by rapid response teams: A systematic review of the literature

BACKGROUND

An abundance of studies have investigated the impact of rapid response teams (RRTs) on in-hospital cardiac arrest rates. However, existing RRT data appear highly variable in terms of both study quality and reported uses of limitations of care, patient survival and patient long-term outcome.

METHODS

A systematic electronic literature search (January, 1990-March, 2016) of the PubMed and Cochrane databases was performed. Bibliographies of articles included in the full-text review were searched for additional studies. A predefined RRT cohort quality score (range 0-17) was used to evaluate studies independently by two reviewers.

RESULTS

Twenty-nine studies with a total of 157,383 RRT activations were included in this review. The quality of data reporting related to RRT patients was assessed as modest, with a median quality score of 8 (range 2-11). Data from the included studies indicate that a median 8.1% of RRT reviews result in limitations of medical treatment (range 2.1-25%) and 23% (8.2-56%) result in a transfer to intensive care. A median of 29% (6.9-35%) of patients transferred to intensive care died during that admission. The median hospital mortality of patients reviewed by RRT is 26% (12-60%), and the median 30-day mortality rate is 29% (8-39%). Data on long-term survival is minimal. No data on functional outcomes was identified.

CONCLUSIONS

Patients reviewed by rapid response teams have a high and variable mortality rate, and limitations of care are commonly used. Data on the long-term outcomes of RRT are lacking and needed.

The Impact of Adding a Physician Assistant to a Critical Care Outreach Team

Rationale

Hospitals are increasingly using critical care outreach teams (CCOTs) to respond to patients deteriorating outside intensive care units (ICUs). CCOT staffing is variable across hospitals and optimal team composition is unknown.

Objectives

To assess whether adding a critical care medicine trained physician assistant (CCM-PA) to a critical care outreach team (CCOT) impacts clinical and process outcomes.

Methods

We performed a retrospective study of two cohorts—one with a CCM-PA added to the CCOT (intervention hospital) and one with no staffing change (control hospital)—at two facilities in the same system. All adults in the emergency department and hospital for whom CCOT consultation was requested from October 1, 2012-March 16, 2013 (pre-intervention) and January 5-March 31, 2014 (post-intervention) were included. We performed difference-in-differences analyses comparing pre- to post-intervention periods in the intervention versus control hospitals to assess the impact of adding the CCM-PA to the CCOT.

Measurements and Main Results

Our cohort consisted of 3,099 patients (control hospital: 792 pre- and 595 post-intervention; intervention hospital: 1114 pre- and 839 post-intervention). Intervention hospital patients tended to be younger, with fewer comorbidities, but with similar severity of acute illness. Across both periods, hospital mortality (p = 0.26) and hospital length of stay (p = 0.64) for the intervention vs control hospitals were similar, but time-to-transfer to the ICU was longer for the intervention hospital (13.3–17.0 vs 11.5–11.6 hours, p = 0.006). Using the difference-in-differences approach, we found a 19.2% reduction (95 confidence interval: 6.7%-31.6%, p = 0.002) in the time-to-transfer to the ICU associated with adding the CCM-PA to the CCOT; we found no difference in hospital mortality (p = 0.20) or length of stay (p = 0.52).

Conclusions

Adding a CCM-PA to the CCOT was associated with a notable reduction in time-to-transfer to the ICU; hospital mortality and length of stay were not impacted.

Impact of a Local Low-Cost Ward-Based Response System in a Canadian Tertiary Care Hospital

Background. Medical emergency teams (METs) or rapid response teams (RRTs) facilitate early intervention for clinically deteriorating hospitalized patients. In healthcare systems where financial resources and intensivist availability are limited, the establishment of such teams can prove challenging. Objectives. A low-cost, ward-based response system was implemented on a medical clinical teaching unit in a Montreal tertiary care hospital. A prospective before/after study was undertaken to examine the system's impact on time to intervention, code blue rates, and ICU transfer rates. Results. Ninety-five calls were placed for 82 patients. Median time from patient decompensation to intervention was 5 min (IQR 1–10), compared to 3.4 hours (IQR 0.6–12.4) before system implementation (p < 0.001). Total number of ICU admissions from the CTU was reduced from 4.8/1000 patient days (±2.2) before intervention to 3.3/1000 patient days (±1.4) after intervention (IRR: 0.82, p = 0.04 (CI 95%: 0.69–0.99)). CTU code blue rates decreased from 2.2/1000 patient days (±1.6) before intervention to 1.2/1000 patient days (±1.3) after intervention (IRR: 0.51, p = 0.02 (CI 95%: 0.30–0.89)). Conclusion. Our local ward-based response system achieved a significant reduction in the time of patient decompensation to initial intervention, in CTU code blue rates, and in CTU to ICU transfers without necessitating additional usage of financial or human resources.

Rapid response teams in adult hospitals: time for another look?

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.

Improving Resident Performance Through a Simulated Rapid Response Team: A Pilot Study

BACKGROUND

The Joint Commission requires hospitals to develop systems in which a team of clinicians can rapidly recognize and respond to changes in a patient's condition. The rapid response team (RRT) concept has been widely adopted as the solution to this mandate. The role of house staff in RRTs and the impact on resident education has been controversial. At Christiana Care Health System, eligible residents in their second through final years lead the RRTs.

OBJECTIVE

To evaluate the use of a team-based, interdisciplinary RRT training program for educating and training first-year residents in an effort to improve global RRT performance before residents start their second year.

METHODS

This pilot study was administered in 3 phases. Phase 1 provided residents with classroom-based didactic sessions using case-based RRT scenarios. Multiple choice examinations were administered, as well as a confidence survey based on a Likert scale before and after phase 1 of the program. Phase 2 involved experiential training in which residents engaged as mentored participants in actual RRT calls. A qualitative survey was used to measure perceived program effectiveness after phase 2. In phase 3, led by senior residents, simulated RRTs using medical mannequins were conducted. Participants were divided into 5 teams, in which each resident would rotate in the roles of leader, nurse, and respiratory therapist. This phase measured resident performance with regard to medical decision making, data gathering, and team behaviors during the simulated RRT scenarios. Performance was scored by an attending and a senior resident.

RESULTS

A total of 18 residents were eligible (N=18) for participation. The average multiple choice test score improved by 20% after didactic training. The average confidence survey score before training was 3.44 out of 5 (69%) and after training was 4.13 (83%), indicating a 14% improvement. High-quality team behaviors correlated with medical decision making (0.92) more closely than did high-quality data gathering (0.11). This difference narrowed during high-pressure scenarios (0.84 and 0.72, respectively).

CONCLUSION

Our data suggest that resident training using a team-based, interdisciplinary RRT training program may improve resident education, interdisciplinary team-based dynamics, and global RRT performance. In turn, data gathering and medical decision making may be enhanced, which may result in better patient outcomes during RRT scenarios.

Rapid response systems: a systematic review and meta-analysis

INTRODUCTION

Although rapid response system teams have been widely adopted by many health systems, their effectiveness in reducing hospital mortality is uncertain. We conducted a meta-analysis to examine the impact of rapid response teams on hospital mortality and cardiopulmonary arrest.

METHOD

We conducted a systematic review of studies published from January 1, 1990, through 31 December 2013, using PubMed, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and the Cochrane Library. We included studies that reported data on the primary outcomes of ICU and in-hospital mortality or cardiopulmonary arrests.

RESULTS

Twenty-nine eligible studies were identified. The studies were analysed in groups based on adult and paediatric trials that were further sub-grouped on methodological design. There were 5 studies that were considered either cluster randomized control trial, controlled before after or interrupted time series. The remaining studies were before and after studies without a contemporaneous control. The implementation of RRS has been associated with an overall reduction in hospital mortality in both the adult (RR 0.87, 95 % CI 0.81-0.95, p<0.001) and paediatric (RR=0.82 95 % CI 0.76-0.89) in-patient population. There was substantial heterogeneity in both populations. The rapid response system team was also associated with a reduction in cardiopulmonary arrests in adults (RR 0.65, 95 % CI 0.61-0.70, p<0.001) and paediatric (RR=0.64 95 % CI 0.55-0.74) patients.

CONCLUSION

Rapid response systems were associated with a reduction in hospital mortality and cardiopulmonary arrest. Meta-regression did not identify the presence of a physician in the rapid response system to be significantly associated with a mortality reduction.

The Impact of Implementation of an ICU Consult Service on Hospital-Wide Outcomes and ICU-Specific Outcomes

BACKGROUND

Rapid response teams (RRTs) were developed to promote assessment of and early intervention for clinically deteriorating hospitalized patients. Although the ideal composition of RRTs is not known, their implementation does require significant resources.

OBJECTIVE

To test the effectiveness of a dedicated daytime/weekday intensive care unit (ICU) consult service without formal training of ward teams.

METHODS

Pre- and postintervention study with weekends/nights during implementation period acting as a concurrent control.

SETTING

An adult tertiary care university center in Montreal without an RRT.

INTERVENTION

A daytime/weekday ICU consult service with a dedicated intensivist.

RESULTS

Total hospital mortality rate did not differ between the control and the implementation period (6.65% vs 6.60%; P = .84). The hospital code blue rates also did not differ (1.21/1000 vs 1.14/1000 patient days; P = .58). In contrast, 30-day mortality of patients admitted to the ICU following an ICU consult decreased (39% vs 24% P = .01). Multivariate analysis confirmed this effect on 30-day mortality (odds ratio for implementation period: 0.53 [95% confidence interval: 0.33-0.85] P = .009). The 14-day ICU readmission rate was reduced with the intervention (5.1% vs 4.1%; P < .001). The effect on 30-day mortality and ICU readmissions were only present during daytime/weekdays.

CONCLUSION

Implementation of an ICU consult service without any formal afferent limb training was associated with decreased mortality and 14-day readmission rates of patients admitted to the ICU. In contrast, hospital-wide mortality and code blue rates were unaffected.

Automated detection of physiologic deterioration in hospitalized patients

OBJECTIVE

Develop and evaluate an automated case detection and response triggering system to monitor patients every 5 min and identify early signs of physiologic deterioration.

MATERIALS AND METHODS

A 2-year prospective, observational study at a large level 1 trauma center. All patients admitted to a 33-bed medical and oncology floor (A) and a 33-bed non-intensive care unit (ICU) surgical trauma floor (B) were monitored. During the intervention year, pager alerts of early physiologic deterioration were automatically sent to charge nurses along with access to a graphical point-of-care web page to facilitate patient evaluation.

RESULTS

Nurses reported the positive predictive value of alerts was 91-100% depending on erroneous data presence. Unit A patients were significantly older and had significantly more comorbidities than unit B patients. During the intervention year, unit A patients had a significant increase in length of stay, more transfers to ICU (p = 0.23), and significantly more medical emergency team (MET) calls (p = 0.0008), and significantly fewer died (p = 0.044) compared to the pre-intervention year. No significant differences were found on unit B.

CONCLUSIONS

We monitored patients every 5 min and provided automated pages of early physiologic deterioration. This before-after study found a significant increase in MET calls and a significant decrease in mortality only in the unit with older patients with multiple comorbidities, and thus further study is warranted to detect potential confounding. Moreover, nurses reported the graphical alerts provided information needed to quickly evaluate patients, and they felt more confident about their assessment and more comfortable requesting help.

The association of intensivists with failure-to-rescue rates in outlier hospitals: results of a national survey of intensive care unit organizational characteristics

PURPOSE

Critical care is often an integral part of rescue for patients with surgical complications. We sought to understand critical care characteristics predictive of failure-to-rescue (FTR) performance at the hospital level.

METHODS

Using 2009 to 2011 FTR data from Hospital Compare, we identified 144 outlier hospitals with significantly better/worse performance than the national average. We surveyed intensive care unit (ICU) directors and nurse managers regarding physical structures, patient composition, staffing, care protocols, and rapid response teams (RRTs). Hospitals were compared using descriptive statistics and logistic regression.

RESULTS

Of 67 hospitals completing the survey, 56.1% were low performing, and 43.9% were high performing. Responders were more likely to be teaching hospitals (40.9% vs 25.0%; P=.05) but were similar to nonresponders in terms of size, region, ownership, and FTR performance. Poor performers were more likely to serve higher proportions of Medicaid patients (68.4% vs 20.7%; P<.0001) and be level 1 trauma centers (55.9% vs 25.9%; P=.02). After controlling for these 2 characteristics, an intensivist on the RRT (adjusted odds ratio, 4.27; confidence interval, 1.45-23.02; P=.005) and an internist on staff in the ICU (adjusted odds ratio, 2.13; P=.04) were predictors of high performance.

CONCLUSIONS

Intensivists on the RRT and internists in the ICU may represent discrete organizational strategies for improving patient rescue. Hospitals with high Medicaid burden fare poorly on the FTR metric.