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

An exploratory study on the effect of rescuer team size on basic and advanced life support technical skills in a high-fidelity simulation of canine cardiopulmonary arrest

OBJECTIVE

To evaluate the effect of rescuer team size on objective skill measures of basic life support (BLS) and advanced life support (ALS) using high-fidelity canine CPR simulation.

DESIGN

Prospective, experimental study.

SETTING

Veterinary clinical simulation center.

SUBJECTS

Forty-eight Reassessment Campaign on Veterinary Resuscitation CPR-certified veterinary students.

MEASUREMENTS AND MAIN RESULTS

Five groups of participants each conducted 3 CPR simulations in configurations of 4, 6, and 8 rescuers. Simulations represented a shock patient declining into asystole, followed by ventricular fibrillation and return of spontaneous circulation. Resuscitation efforts were video-recorded to evaluate BLS and ALS tasks. Mean (±SD) was derived and data were compared among team sizes using ANOVA and Tukey's post hoc analysis. Significance was set at P < 0.05. Among teams of 4, 6, and 8 rescuers, time to first chest compression (13 s [±6], 9 s [±2], 8 s [±4]; P = 0.24) and positive-pressure breath (101 s [±37], 56 s [±15], 67 s [±24]; P = 0.05) were not significantly different. Chest compression (100/min [±5], 108/min [±6], 107/min [±6]; P = 0.12) and ventilatory rates (9/min [±1], respectively, P = 0.52) were not significantly different. Time without chest compressions/total length of CPR was not significantly different (72 s [±16], 61 s [±16], 54 s [±8]; P = 0.15). Capnography and ECG monitoring were used by all teams. Time to first vasopressor administration was significantly different among team sizes (268 s [±70], 164 s [±65], 174 s [±34]; P = 0.04), with vasopressors being most quickly administered by teams of 6 rescuers. Time to electrical defibrillation was not significantly different (486 s [±45], 424 s [±22], 488 s [±181]; P = 0.57). Incorrect ALS interventions occurred in 60%, 0%, and 40% of CPR events in 4, 6, and 8 rescuer teams, respectively.

CONCLUSIONS

Although the achievement of BLS tasks was comparable in teams of 4 rescuers, teams of 6 rescuers may be preferable based on differences in the rate of guideline-incompliant treatments and ALS task efficiency. Teams of 8 rescuers were neither more efficient nor more accurate at conducting BLS and ALS tasks.

Educational Interventions for Rapid Response Team Members: A Narrative Literature Review

BACKGROUND

Research continues to be conducted on rapid response systems as patient outcomes associated with rapid response team activations are still not consistently showing benefit. One particular area of focus that is a growing area is the literature regarding training and education for individual team members of the rapid response team.

OBJECTIVE

The purpose of this narrative review was to describe the current literature regarding educational interventions for rapid response team members.

METHODS

This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. To be included in the narrative review, studies needed to be reporting on educational interventional research for rapid response team members of the efferent limb. No studies were excluded based upon study design or publication years.

RESULTS

This narrative review included 6 studies. Four studies assessed outcomes associated with rapid response team members, and 2 of the studies assessed patient outcomes associated with implementing education routinely for rapid response teams. All studies found a positive impact of implementing educational interventions.

DISCUSSION

Our narrative review found that limited research has been conducted in the area of educational interventions for rapid response team members, and of the articles identified, most did not assess patient-associated outcomes. The findings demonstrate that this area of research is in its early stages, and further work is needed to identify what content should be provided in the education and what educational methodologies should be employed, and to continue to assess patient health outcomes associated with educational interventions for rapid response team members.

The effect of a dedicated intensivist staffing to a medical emergency team on airway management in general wards

Although medical emergency teams (METs) have been widely introduced, studies on the importance of a dedicated intensivist staffing to METs are lacking. A single-center retrospective before-and-after study was performed. Deteriorating patients who required emergency airway management in general wards by MET were included in this study. We divided the study period according to the presence of a dedicated intensivist staff in MET: (1) non-staffed period (from January 2016 to February 2018, n = 971) and (2) staffed period (from March 2018 to December 2019, n = 651), and compared emergency airway management-related variables and outcomes between the periods. Among 1622 patients included, mean age was 63.0 years and male patients were 64.2% (n = 1042). The first-pass success rate was significantly increased in the staffed period (85.9% in the non-staffed vs 89.2% in the staffed; P = .047). Compliance to rapid sequence intubation was increased (9.4% vs 34.4%; P < .001) and vocal cords were more clearly open (P < .001) in the staffed period. The SpO2/FiO2 ratio (median [interquartile range], 125 [113-218] vs 136 [116-234]; P = .007) and the ROX index (4.6 [3.4-7.6] vs 5.1 [3.6-8.5]; P = .013) at the time of intubation was higher in the staffed period, suggesting the decision on intubation was made earlier. The post-intubation hypoxemia was less commonly occurred in the staffed period (7.2% vs 4.2%, P = .018). In multivariate analysis, the rank of operator was a strong predictor of the first-pass success (adjusted OR [95% CI], 2.280 [1.639-3.172]; P < .001 for fellow and 5.066 [1.740-14.747]; P < .001 for staff, relative to resident). In our hospital, a dedicated intensivist staffing to MET was associated with improved emergency airway management in general wards. Staffing an intensivist to MET needs to be encouraged to improve the performance of MET and the patient safety.

Effect of Implementing a Commercial Electronic Early Warning System on Outcomes of Hospitalized Patients

Despite the widespread adoption of early warning systems (EWSs), it is uncertain if their implementation improves patient outcomes. The authors report a pre-post quasi-experimental evaluation of a commercially available EWS on patient outcomes at a 700-bed academic medical center. The EWS risk scores were visible in the electronic medical record by bedside clinicians. The EWS risk scores were also monitored remotely 24/7 by critical care trained nurses who actively contacted bedside nurses when a patient's risk levels increased. The primary outcome was inpatient mortality. Secondary outcomes were rapid response team calls and activation of cardiopulmonary arrest (code-4) response teams. The study team conducted a regression discontinuity analysis adjusting for age, gender, insurance, severity of illness, risk of mortality, and hospital occupancy at admission. The analysis included 53,229 hospitalizations. Adjusted analysis showed no significant change in inpatient mortality, rapid response team call, or code-4 activations after implementing the EWS. This study confirms the continued uncertainty in the effectiveness of EWSs and the need for further rigorous examinations of EWSs.

A Rapid Response Team (RRT) System at a Cancer Center: Innovative Approaches to System Organization and Clinical RRT Pathways

The Rapid Response Team (RRT) system at Memorial Sloan Kettering Cancer Center led by critical care medicine (CCM) advanced practice providers (APPs) expanded exponentially between 2009 and 2021. CCM-APPs are trained for care of critically ill patients as well as to oversee rapid response calls. The RRT is composed of a CCM-based RRT-APP, respiratory therapist, RRT-RN, and nursing supervisor. Since program inception, 11 RRT pathways and interventions have been developed and adjusted to improve multidisciplinary patient management. Pathways vary in complexity and require multidisciplinary collaboration. In some circumstances, the RRT patient may require transfer to outside facilities for services not provided at our oncology-based facility. RRT data are tracked across the hospital continuum with on-line reporting through RRT website dashboards. 2021 RRT data on electronic sepsis alerts, behavioral RRT and stroke alerts are presented. The RRT program is monitored through robust quality assurance. The APP-led RRT system's scope of care has been continuously expanded through the creation of RRT pathways to meet the increasingly complex medical needs of our patients.

Managing deteriorating patients with a physiotherapy critical care outreach service: A mixed-methods study

BACKGROUND

Critical care outreach teams support ward staff to manage patients who are seriously ill or after discharge from the intensive care unit (ICU). Respiratory deterioration is a common reason for (re)admission to the ICU. Physiotherapists are health professionals with skills to address acute respiratory concerns. Experienced respiratory physiotherapists play a role in supporting junior clinicians, particularly in managing deteriorating patients on the ward.

OBJECTIVES

The objective of this study was to evaluate a novel respiratory physiotherapy critical care outreach-style service. The primary objective was to describe service referrals and the patient cohort. Other objectives were to compare the effects of this model of care on ICU readmission rates to a historical cohort and explore clinician perceptions of the model of care and its implementation.

METHODS

A new physiotherapy model of care worked alongside an existing nurse-led outreach service to support physiotherapists with the identification and management of patients at risk of respiratory deterioration or ICU (re)admission. Purpose-built and pre-existing databases were used for prospective data collection and for a historical ICU readmissions control group. Questionnaires and semistructured group interviews were utilised to evaluate clinician satisfaction and perceptions.

RESULTS

The service accepted referrals for 274 patients in 6 months (on average 2.25/working day; commonly after trauma [29%] and abdominal surgery [19%]). During the implementation period of the model of care, fewer preventable respiratory ICU readmissions were reported (n = 1/20) than in the historical cohort (n = 6/19: Fisher's exact test, p < 0.05). Likelihood of respiratory ICU readmission, compared to all-cause readmissions, was not affected (intervention: 31%, historical control: 41%; odds ratio: 0.63 [95% confidence interval: 0.29 to 1.4]). Postimplementation surveys and focus groups revealed clinicians highly valued the support and perceived a positive impact on patient care.

CONCLUSIONS

Critical care outreach-style physiotherapy services can be successfully implemented and are positively perceived by clinicians, but any effect on ICU readmissions is unclear.

Construct and clinical verification of a nurse-led rapid response systems and activation criteria

Background

Effective team leadership and good activation criteria can effectively initiate rapid response system (RRS) to reduce hospital mortality and improve quality of life. The first reaction time of nurses plays an important role in the rescue process. To construct a nurse-led (nurse-led RRS) and activation criteria and then to conduct a pragmatic evaluation of the nurse-led RRS.

Methods

We used literature review and the Delphi method to construct a nurse-led RRS and activation criteria based on the theory of “rapid response system planning.” Then, we conducted a quasi-experimental study to verify the nurse-led RRS. The control group patients were admitted from August to October 2020 and performed traditional rescue procedures. The intervention group patients were admitted from August to October 2021 and implemented nurse-led RRS. The primary outcome was success rate of rescue.

Setting

Emergency department, Gansu Province, China.

Results

The nurse-led RRS and activation criteria include 4 level 1 indicators, 14 level 2 indicators, and 88 level 3 indicators. There were 203 patients who met the inclusion criteria to verify the nurse-led RRS. The results showed that success rate of rescue in intervention group (86.55%) was significantly higher than that in control group (66.5%), the rate of cardiac arrest in intervention group (33.61%) was significantly lower than that in control group (72.62%), the effective rescue time of intervention group (46.98 ± 12.01 min) was shorter than that of control group (58.67 ± 13.73 min), and the difference was statistically significant (P < 0.05). The rate of unplanned ICU admissions in intervention group (42.85%) was lower than that in control group (44.04%), but the difference was not statistically significant (P > 0.05).

Conclusions

The nurse-led RRS and activation criteria can improve the success rate of rescue, reduce the rate of cardiac arrest, shorten the effective time of rescue, effectively improve the rescue efficiency of patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-022-01087-7.

National Survey: How Do We Approach the Patient at Risk of Clinical Deterioration outside the ICU in the Spanish Context?

BACKGROUND

Anticipating and avoiding preventable intrahospital cardiac arrest and clinical deterioration are important priorities for international healthcare systems and institutions. One of the internationally followed strategies to improve this matter is the introduction of the Rapid Response Systems (RRS). Although there is vast evidence from the international community, the evidence reported in a Spanish context is scarce.

METHODS

A nationwide cross-sectional research consisting of a voluntary 31-question online survey was performed. The Spanish Society of Intensive, Critical and Coronary Care Medicine (SEMICYUC) supported the research.

RESULTS

We received 62 fully completed surveys distributed within 13 of the 17 regions and two autonomous cities of Spain. Thirty-two of the participants had an established Rapid Response Team (RRT). Common frequency on measuring vital signs was at least once per shift but other frequencies were contemplated (48.4%), usually based on professional criteria (69.4%), as only 12 (19.4%) centers used Early Warning Scores (EWS) or automated alarms on abnormal parameters. In the sample, doctors, nurses (55%), and other healthcare professionals (39%) could activate the RRT via telephone, but only 11.3% of the sample enacted this at early signs of deterioration. The responders on the RRT are the Intensive Care Unit (ICU), doctors, and nurses, who are available 24/7 most of the time. Concerning the education and training of general ward staff and RRT members, this varies from basic to advanced and specific-specialized level, simulating a growing educational methodology among participants. A great number of participants have emergency resuscitation equipment (drugs, airway adjuncts, and defibrillators) in their general wards. In terms of quality improvement, only half of the sample registered RRT activity indicators. In terms of the use of communication and teamwork techniques, the most used is clinical debriefing in 29 centers.

CONCLUSIONS

In terms of the concept of RRS, we found in our context that we are in the early stages of the establishment process, as it is not yet a generalized concept in most of our hospitals. The centers that have it are in still in the process of maturing the system and adapting themselves to our context.

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.

Going Silent: Redesigning the Activation Process for In-Hospital Cardiopulmonary Arrests

INTRODUCTION

Reducing environmental noise has become a priority for many health systems. Following a 10-week preparation period, our health system transitioned from an overhead-activated to a silently activated in-hospital code team notification system. The goal of this initiative was to reduce environmental noise and support code team communication and function without adversely affecting response time, provider availability, or key quality metrics.

METHODS

Transitioning from overhead to silently activated events involved a three-step quality improvement approach. Input from key stakeholders and preimplementation education were of key importance. Multiple timed trials and a full in situ simulation were completed before going live with the new process.

RESULTS

Evaluation of 6-month pre- and postimplementation quality metrics showed no significant difference in compliance with defibrillating shockable rhythms within two minutes, event survival, or survival to discharge. Provider survey data and Hospital Consumer Assessment of Healthcare Providers and Systems "quiet at night" scores were not significantly different.

CONCLUSION

By utilizing a multistep implementation approach, transitioning from overhead pages to a silently activated system for in-hospital code team activation was feasible and safe. Abandoning the overhead paging system did not lead to a decrease in key quality metrics nor impair team perception of code function.

Comparison of clinical outcomes between nurse practitioner and registrar-led medical emergency teams: a propensity-matched analysis

OBJECTIVE

Medical emergency teams (MET) are mostly led by physicians. Some hospitals are currently using nurse practitioners (NP) to lead MET calls. These are no studies comparing clinical outcomes between these two care models. To determine whether NP-led MET calls are associated with lower risk of acute patient deterioration, when compared to intensive care (ICU) registrar (ICUR)-led MET calls.

METHODS

The composite primary outcome included recurrence of MET call, occurrence of code blue or ICU admission within 24 h. Secondary outcomes were mortality within 24 h of MET call, length of hospital stay, hospital mortality and proportion of patients discharged home. Propensity score matching was used to reduce selection bias from confounding factors between the ICUR and NP group.

RESULTS

A total of 1343 MET calls were included (1070 NP, 273 ICUR led). On Univariable analysis, the incidence of the primary outcome was higher in ICUR-led MET calls (26.7% vs. 20.6%, p = 0.03). Of the secondary outcome measures, mortality within 24 h (3.4% vs. 7.7%, p = 0.002) and hospital mortality (12.7% vs. 20.5%, p = 0.001) were higher in ICUR-led MET calls. Propensity score-matched analysis of 263 pairs revealed the composite primary outcome was comparable between both groups, but NP-led group was associated with reduced risk of hospital mortality (OR 0.57, 95% CI 0.35-0.91, p = 0.02) and higher likelihood of discharge home (OR 1.55, 95% CI 1.09-2.2, p = 0.015).

CONCLUSION

Acute patient deterioration was comparable between ICUR- and NP-led MET calls. NP-led MET calls were associated with lower hospital mortality and higher likelihood of discharge home.

Gaps in Training: Misunderstandings of Airway Management in Medical Students and Internal Medicine Residents

Objectives

(1) Evaluate baseline airway knowledge of medical students (MSs) and internal medicine (IM) residents. (2) Improve MS and IM resident understanding of airway anatomy, general tracheostomy and laryngectomy care, and management of airway emergencies.

Methods

A before-and-after survey study was carried out over a single academic year. MS and IM resident knowledge was evaluated before and after an educational, grand rounds–style lecture reviewing airway anatomy, tracheostomy tube components, tracheostomy and laryngectomy care, and clinical vignettes. The primary outcome measure was change in pre- and postlecture survey scores.

Results

Prelecture surveys were completed by 90 participants, and 83 completed a postlecture assessment. Postlecture scores were statistically improved for all questions on the assessment ( P < .001). Level of training did not confer an improved pre- or postlecture survey score.

Discussion

While the majority of participants in our study had previously cared for patients with a tracheostomy or laryngectomy, less than half were able to correctly address basic airway emergencies. Senior IM residents were no more proficient than MSs in addressing airway emergencies. The lack of formal airway training places patients at risk with routine care and in emergencies, demonstrating the need for formal airway education for early medical trainees.

Implications for Practice

Our data demonstrate a serious gap in MS and IM resident knowledge with respect to emergent airway care in patients with tracheostomies and laryngectomies. An interdepartmental collaborative curriculum offers a realistic and potentially life-saving solution for medical trainees.

Rapid Response and Cardiac Arrest Teams: A Descriptive Analysis of 103 American Hospitals

Despite improvements in the management of in-hospital cardiac arrest over the past decade, in-hospital cardiac arrest continues to be associated with poor prognosis. This has led to the development of rapid response systems, hospital-wide efforts to improve patient outcomes by centering on prompt identification of decompensating patients, expert clinical management, and continuous quality improvement of processes of care. The rapid response system may include cardiac arrest teams, which are centered on identification and treatment of patients with in-hospital cardiac arrest. However, few evidence-based guidelines exist to guide the formation of such teams, and the degree of their variation across the United States has not been well described.

DESIGN

Descriptive cross-sectional, internet-based survey.

SETTING

Cohort of preidentified clinicians involved in their hospital's adult rapid response system across the United States.

SUBJECTS

Clinicians who had been identified by study team members using personal and professional contacts over a 7-month period from June 2018 to December 2018.

INTERVENTIONS

An 80-item survey was developed by the investigators. It sought information on the afferent (identification and notification of providers) and efferent (response of providers to patient) limbs of the rapid response system, as well as management of patients post in-hospital cardiac arrest.

MEASUREMENTS AND MAIN RESULTS

One-hundred fourteen surveys were distributed. Of these, 109 (96%) were completed. Six were duplicates and were excluded, leaving a total of 103 surveys from 103 hospitals in 30 states. Seventy-six percent of hospitals were academic, 30% were large hospitals (> 750 inpatient beds), and 58% had large ICUs (> 50 ICU beds). We found wide variation in the structure and function in both the afferent and efferent limbs of the rapid response system. The majority of hospitals had a rapid response team and a cardiac arrest team. Most rapid response teams contained a provider, a critical care nurse, and a respiratory therapist. In hospitals with training programs in internal medicine, anesthesia, emergency medicine, or critical care, 45% of rapid response teams and 75% of cardiac arrest teams were led by trainees, with inconsistent attending presence. Targeted temperature management and coronary catheterization were widely used post in-hospital cardiac arrest, but indications varied considerably.

CONCLUSIONS

We have demonstrated substantial variation in the structure and function of rapid response systems as well as in management of patients during and after in-hospital cardiac arrest.