Admission to an inpatient rehabilitation unit requires that a patient must be able to participate in varied therapy sessions for at least 3 hours a day. This requirement assumes that an individual has an improving clinical condition and the stamina to engage in these daily therapy sessions. However, patients in acute rehabilitation may experience an unexpected clinical deterioration that leads to poor clinical outcomes, such as unplanned intensive care unit (ICU) admission, prolonged hospital stay, in-hospital cardiac arrest, and death (Agrawal et al., 2017; Mitchell et al., 2014). The U.S. Department of Health and Human Services Office of Inspector General issued a report in 2016 that indicated that approximately 29% of Medicare beneficiaries experience an adverse event during their rehabilitation unit stay. Approximately half of these unfavorable outcomes cost $92 million per year. To overcome the challenges of in-hospital adverse events, most hospitals in the world have developed rapid response teams (RRTs) to prevent adverse incidents. Rapid response teams-also known as medical emergency teams, and critical care outreach teams-are multidisciplinary health teams that include nurses, physicians, pharmacists, and respiratory therapists. These teams aim to provide early recognition and treatment of patients' clinical deterioration to avoid unfavorable outcomes (Currey et al., 2022; Kolovos et al., 2018). The ideal utilization rate of the RRT in adult and pediatric settings has been reported to be 40 calls per 1000 admissions (Lyons et al., 2018).

Background

Development of RRTs is attributed to the Institute for Healthcare Improvement "100,000 Lives Campaign" in the United States, an initiative intended to prevent 100,000 unnecessary deaths through enhancement in the quality care and safety of tertiary care hospitals (Institute for Healthcare Improvement, 2022). Evidence suggests that RRTs have been established in most developed and developing countries' hospitals. Substantial evidence of RRT outcome data are embedded in the "Get With The Guidelines-Resuscitation," formerly known as the American Heart Association's National Registry of Cardiopulmonary Resuscitation (American Heart Association, 2022).

The RRT differs from the code blue team in that it assesses the patient with clinical deterioration before the need for cardiopulmonary resuscitation (CPR) to prevent serious adverse outcomes (Smith et al., 2017). The composition of the RRT differs based on the institution type, organizational structure, trained staff, and available resources. The RRT has two limbs: the afferent and the efferent. Bedside nurses, other healthcare professionals, and family members make up the afferent limb. These individuals can recognize that a patient is deteriorating and promptly activate the efferent limb, the RRT, to rescue the patient by providing appropriate care (Song & Lee, 2021). More commonly, RRT activation has been augmented with the Early Warning Score (EWS) tool. The tool uses alterations in vital signs, oxygen saturation, and level of consciousness to calculate a score, which identifies patients at risk for clinical deterioration. Each element has a score from 0 to 3, with higher scores indicating clinical deterioration. Each institution determines the EWS threshold scores to activate the RRT as a higher level of care may be needed. The EWS can be automated based on vital signs and oxygen saturation readings, or the EWS can be used by the bedside nurse in combination with nursing assessment (Jensen et al., 2018). Not all institutions use the EWS. Some continue to rely on bedside nursing assessment or create their own parameters for RRT activation (Michard & Kalkman, 2021).

Rehabilitation nurses are a vital part of the afferent limb and often activate the RRT based on a patient's deteriorating symptoms. They rely not only on the EWS score, but as symptom experts, they often react and escalate care for their patients based on their own assessment. An abundance of literature addresses the change in patient outcomes after the implementation of the RRT in an organization; however, literature has not been synthesized to identify the common symptoms that trigger RRT activation. In addition, literature specifically based on rehabilitation units for RRT calls is rare. Because rehabilitation nurses are the bedside caregivers, it is critical for them to understand which symptoms trigger activation of the RRT to avoid unfavorable patient outcomes. This integrative review focuses on the general characteristics of RRT calls and their outcomes; it is not specific to rehabilitation units.

The Review

Aims

This integrative review synthesized primary sources and posed the following research questions: (a) What are the common triggers that require RRT activation in both pediatric and adult populations? (b) What are the outcomes following RRT activation in relation to CPR, ICU transfer, length of stay (LOS), and mortality? (c) What are the similarities and differences in RRT activation for the pediatric and adult populations?

Design

This integrative review used the Whittemore and Knafl (2005) methodology where a wide variety of searches were performed to ensure that a robust literature was evaluated. According to Whittemore and Knafl (2005), clear problem identification, robust literature search, data evaluation and analysis, and clear presentation are needed elements of an integrative review.

Search Methods

Three large databases, PubMed, Ovid Medline, and CINAHL, were searched for relevant articles published within the last 5 years (2017-2022) in the English language. Key search strategies used both MeSH terms and title searches. Key terms used were rapid response team, medical emergency team, critical care outreach team, triggers, pediatric, adult, cardiac resuscitation, transfer to ICU, length of stay, and mortality. The term pediatric was defined as children under the age of 18 years, and the term adult was defined as individuals 18 years and older. Multiple search terms were combined with Boolean operators such as "AND" and "OR" to specify the search.

Search Outcome

Twenty-five articles are included in this review (Figure 1). Studies were included if (a) patients were hospitalized, (b) triggers for RRT were identified, and (c) at least one outcome of interest was reported. Pilot studies, quality improvement studies, and tool development or comparison studies were excluded, as were studies that concerned outpatients, did not specify RRT activation trigger(s), and concerned RRT for patients with specific diagnoses only. No systematic reviews or meta-analyses were available on the topic of interest.

Figure 1. Flowchart of the article selection process.

Quality Appraisal

The National Institutes of Health (NIH) study quality assessment tools developed for different types of study design were used (NIH, 2021). The tool evaluates multiple items based on the study design. The items assess for potential bias, confounding variables, sample size, design validity, and other issues. Reviewer(s) have the option of selecting yes, no, or other (cannot determine/not reported/not applicable) in response to each item on the tool. Based on the item analysis and total responses of yes to the items in the checklist, a designation of good, fair, or poor quality was assigned. An arbitrary range of 80%-100% of yes responses was viewed as good, 50%-79.9% as fair, and below 50% as poor quality (Tables 1 and 3).

Table 1 Quality of Studies of Rapid Response Team Activation Triggers in Pediatric Patients Assessed Using National Institutes of Health Study Quality Assessment Tools

Table 3 Quality of Studies of Rapid Response Team Triggers in Adult Patients Using National Institutes of Health Study Quality Assessment Tools

Data Abstraction and Synthesis

The matrix method was used for data extraction. Data from each study that met the inclusion criteria were extracted using a table that included title, authors, year published, aims/purpose, study design, sample measures, results, and comments. Authors of the current study were divided into two teams, one abstracted data from the pediatric studies and the other team abstracted and synthesized data for the adult studies. When the first round of abstraction was completed, teams traded their studies and repeated abstraction to ensure consistency and rigor.

Data abstracted were then synthesized using a matrix method for triggers, as well as for the outcomes of CPR, ICU transfer, LOS, and mortality. Data for the pediatric and adult populations were then compared for triggers, outcomes, and demographic characteristics, and limitations were noted.

Results

Pediatric Triggers

The literature on the triggers for RRT activation for the pediatric population is not robust. Eight articles (Table 1) evaluated pediatric RRT triggers and their outcomes (Table 2). Of these, only three studies (Martinez et al., 2018; Meulmester et al., 2018, 2021) directly measured the RRT triggers. The remaining five studies (Jayaram et al., 2017; Kolovos et al., 2018; Kun et al., 2019; Lockwood et al., 2021; McKelvie et al., 2017) reported on triggers as their secondary outcomes.

Table 2 Pediatric Rapid Response Team Triggers and Outcomes

Tachypnea is the most common trigger for RRT activation for children. Respiratory distress may manifest as tachypnea, oxygen desaturation, labored breathing, respiratory depression, and carbon dioxide (CO₂) retention (Jayaram et al., 2017; Kun et al., 2019; Martinez et al., 2018; Meulmester et al., 2021). Others used nonspecific terms, such as respiratory concerns or respiratory physiological derangement (Kolovos et al., 2018; McKelvie et al., 2017). Lockwood et al. (2021) mentioned only vital signs as RRT triggers. Meulmester et al. (2018) reported that 59% of their RRT calls were due to respiratory concerns.

A cardiovascular symptom, tachycardia, was the second most common trigger for the pediatric population (Jayaram et al., 2017; Kun et al., 2019; Martinez et al., 2018). Other cardiovascular constellations of symptoms, such as bradycardia and blood pressure changes, were reported less frequently (Jayaram et al., 2017; Kun et al., 2019). Seizures, changes in mental status, and agitation were the top three neurological triggers for RRT activation in hospitalized pediatric patients (Kun et al., 2019; Martinez et al., 2018; Meulmester et al., 2018, 2021).

Two studies reported staff concerns as the reason for activating the RRT. However, what constitutes staff concerns was not specified (Martinez et al., 2018; Meulmester et al., 2021). Incidents of repeat RRT activation were reported in two studies (McKelvie et al., 2017; Meulmester et al., 2021), with the triggers for repeat activation comparable to those for initial RRT calls. Most studies included in this review were retrospective in nature and did not account for confounding variables, such as patients' body mass index and prior respiratory or cardiac status. Therefore, it is possible that underlying preexisting conditions dictate the RRT activation rather than the presenting symptoms alone.

Vital signs appear to be a more consistent indicator of distress requiring RRT activation. New onset of bradycardia or respiratory difficulty provides clues to caregivers to activate the RRT (Jayaram et al., 2017; Meulmester et al., 2021). Jayaram et al. (2017) report a troubling trend that despite abnormal vital signs 1 hour prior to CPR, the RRT was not activated and two thirds of the patients were not evaluated by the RRT before emergent CPR. This indicates that the EWS system and bedside surveillance may not be sufficiently sensitive to activate the RRT. In addition, Lockwood et al. (2021) raise the concern that EWSs do not consider dynamic clinical data, including laboratory test results. Kun et al. (2019) specifically evaluated hospitalized home mechanically vented patients and found that a trigger for RRT was needed for mechanical ventilation in 54% of RRT activations, whereas 40% of these activations occurred when patients were waiting for initial home discharge.

The literature is consistent that boys ages 2-6 years are at higher risk than other children for RRT activation (Jayaram et al., 2017; Kun et al., 2019; Martinez et al., 2018; McKelvie et al., 2017; Meulmester et al., 2018, 2021). Only Jayaram et al. (2017) included ethnicity in their demographics, reporting that boys who are Black are at higher risk than others for RRT activation. Not surprisingly, studies indicate that pediatric patients with underlying complex medical issues are at greater risk for RRT activation (Jayaram et al., 2017; Martinez et al., 2018; McKelvie et al., 2017; Meulmester et al., 2018, 2021). Martinez et al. (2018) reported an RRT activation rate of 4.2 per 1,000 admissions; however, the rate that Kun et al. (2019) reported is twice that (8.733/1,000 admissions) for children who were mechanically vented awaiting home discharge. A common reason for RRT activation in children with mechanical ventilation was respiratory distress. However, this rate may be underreported because most studies lacked power analysis.

Pediatric Outcomes After RRT Activation

Cardiac Resuscitation

The outcome of cardiac resuscitation was reported in four studies (Jayaram et al., 2017; Kolovos et al., 2018; Kun et al., 2019; Martinez et al., 2018). One study (Jayaram et al., 2017) reported that 22% of patients with an RRT call required CPR. There were missed opportunities to prevent cardiac arrest. Over 77% did not have a RRT call prior to the CPR event, even though at least one abnormal sign was present prior to CPR. Similarly, Martinez et al. (2018) reported that RRT activation led to 29% of pediatric patients requiring CPR, none of them having "do not resuscitate" orders. On the other hand, Kolovos et al. (2018) reported CPR rates dropping from 9.1 events per 1,000 patient-days to 6.4 after RRT implementation (p < .001). Home mechanically vented patients had a threefold increase in CPR events compared with hospitalized children who were not vented (Kun et al., 2019).

Transfer to ICU

Wide variations have been reported for ICU transfer, and the factors that prompted the transfer of pediatric patients to ICU after an RRT event are unclear. Meulmester et al. (2021) reported that 78% of pediatric patients were transferred to ICU, whereas Lockwood et al. (2021) reported a 66% rate of transfer after the RRT call. Martinez et al. (2018) found that only 24% of patients were transferred after the RRT event. Meulmester et al. (2018) reported that 47% of patients were transferred to ICU after one RRT event; however, 76% were transferred after a repeat event. Kun et al. (2019) reported a threefold increase in transfer to ICU for home mechanically ventilated patients compared with others without ventilation. Variations certainly exist regarding RRT composition, hospital culture and size, and use of an EWS system across different settings, but these details are not available in the literature.

Length of Stay

The literature findings are mixed for LOS in pediatric patients after an RRT event. Meulmester et al. (2021) found that pediatric patients with respiratory triggers were younger than 2 years and less likely to have an increased LOS compared with pediatric patients with nonrespiratory triggers. McKelvie et al. (2017) reported that younger children had increased LOS from 3 to 10 days with one RRT event. Length of stay increased from 3 to 23 days for pediatric patients who had two or more RRT events. Similarly, Meulmester et al. (2018) reported that repeat RRT activation increased LOS (p < .001). Furthermore, Kolovos et al. (2018) reported that LOS decreased from 5.8 to 4.7 days (p = .02) after the RRT call. Given that their study is based on a single-center retrospective report, its generalizability is in question.

Mortality

The gravest outcome following an RRT event is loss of life. Martinez et al. (2018) reported 1% mortality for their study period. Once again, the literature has conflicting findings. According to Meulmester et al. (2021), pediatric patients with respiratory triggers were less likely to die than those with nonrespiratory triggers (p < .01), whereas Jayaram et al. (2017) reported that mortality was higher (5%) with respiratory triggers. Not surprisingly, repeated RRT calls led to increased risk of mortality. McKelvie et al. (2017) reported that with one RRT call, mortality increased from 0.034% to 1.1%, and with more than one, it increased to 4.7%. None of the children in the Kun et al. (2019) study died. Kolovos et al. (2018) reported a decrease in mortality from 4.9% to 3.8% (p < .001) after RRT implementation in their institution. Several methodological concerns such as data collection through review of health records, missing data, single-center reports, and unstandardized reports decrease confidence in the findings.

Adult Triggers

Seventeen articles assessed adult RRT triggers and their outcomes (Table 3). Respiratory, cardiovascular, and neurological were the three most frequently cited symptom categories for RRT activation (Table 4). Ten studies identified respiratory symptoms, specifically tachypnea at >25 breaths per minute and oxygen saturation at <90%, as the top triggers for RRT activation (Byrne et al., 2021; Churpek et al., 2017; Considine et al., 2017; Currey et al., 2022; Fernando et al., 2019; Lyons et al., 2019; Sebat et al., 2020; Shappell et al., 2018; Tirkkonen et al., 2017; Viana et al., 2021). The RRT was also activated for new-onset breathing difficulty, bradypnea, acute respiratory distress, chronic respiratory disease, and complex respiratory failure (Byrne et al., 2021; Fernando et al., 2019; Lyons et al., 2019; Na et al., 2020; Orosz et al., 2020; Shappell et al., 2018; Smith et al., 2017; Tirkkonen et al., 2017; Viana et al., 2021).

Table 4 Rapid Response Team Activation Triggers and Outcomes for Adult Hospital Patients

Cardiovascular was the second most common activation category, with six studies identifying these issues as the top concern for RRT activation (Kim et al., 2021; Na et al., 2020; Padilla & Mayo, 2019; Sebat et al., 2020; Shoaib et al., 2021; Smith et al., 2017). Among all the studies included in this review, heart rate at >130 beats per minute and hemodynamic instability required RRT calls (Byrne et al., 2021; Chalwin et al., 2019; Considine et al., 2017; Currey et al., 2022; Fernando et al., 2019; Kim et al., 2021; Lyons et al., 2019; Na et al., 2020; Shappell et al., 2018; Shoaib et al., 2021; Smith et al., 2017). Arrhythmias were less frequently reported (Viana et al., 2021). Interestingly, Shappell et al. (2018) found systolic blood pressure to be the most important predictor of clinical deterioration, whereas Fernando et al. (2019) highlighted tachyarrhythmias/arrhythmias as common factors for recurrent RRT activation. Sebat et al. (2020) found prolonged capillary refill time at >3 seconds as the second most reported trigger (after hypoxia) and that it was an independent predictor of mortality and poor clinical outcomes.

Neurological derangements were the third most reported activation category (Byrne et al., 2021; Churpek et al., 2017; Currey et al., 2022; Fernando et al., 2019; Kim et al., 2021; Lyons et al., 2019; Padilla & Mayo, 2019; Shoaib et al., 2021; Smith et al., 2017), with acute changes in levels of consciousness as the most common trigger. Chalwin et al. (2019) found decreases in level of consciousness as their most common trigger. Oversedation, delirium, agitation, and seizures were less commonly reported triggers (Lyons et al., 2019; Shappell et al., 2018; Smith et al., 2017; Tirkkonen et al., 2017).

This review of the literature found bedside nurses' concerns regarding patients' deteriorating conditions to constitute a fourth activation category. Five studies (Chalwin et al., 2019; Considine et al., 2017; Currey et al., 2022, Fernando et al., 2019; Na et al., 2020) reported staff concern as the triggering criterion, but they did not specify the symptoms that prompted staff to activate the RRT. Other studies (Orosz et al., 2020; Padilla & Mayo, 2019; Tirkkonen et al., 2017) did not specifically identify triggers; rather, they reported respiratory, cardiovascular, or neurological issues as concerning to staff.

Most studies included in this review were retrospective in nature; thus, they were subject to the limitations inherent in retrospective studies, such as missing or incorrectly categorized data and other such weaknesses. Most studies did not mention power analysis, and they were often single-center studies, which limits generalizability. Despite these challenges, important patterns are noted. Most of the studies highlighted patient characteristics including male patients, with the age group of >60 years and admitted for noncardiac, medical illness considered as a high-risk category for RRT activation (Kim et al., 2021; Lyons et al., 2019; Orosz et al., 2020; Sebat et al., 2020; Shappell et al., 2018; Smith et al., 2017; Viana et al., 2021). Demographic characteristics such as ethnicity and socioeconomic and marital status are missing from the RRT literature.

Adult Outcomes After RRT

Cardiopulmonary Arrest

The primary aim of the RRT is to prevent cardiopulmonary arrest in non-ICU settings. Several studies reported a decrease in the incidence of CPR after RRT activation (Currey et al., 2022; Kollef et al., 2017; Lyons et al., 2019; Sebat et al., 2020), with a significant reduction in cardiopulmonary arrest because of respiratory cause after RRT implementation (Viana et al., 2021). However, one of the studies reported an increased incidence of CPR significantly associated with a lower frequency of RRT calls from 1:00 a.m. to 6:59 a.m. (Churpek et al., 2017).

ICU Admissions and Transfers

The RRT activation often requires patients to be transferred to ICU. The literature reports varying practices and rates for ICU transfer after the RRT calls. Kim et al. (2021) found the incidence of ICU transfer was 7.4%, whereas Lyons et al. (2019) reported 30% of patients being transferred to the ICU after RRT evaluation. Orosz et al. (2020) reported that patients of advanced age, with sepsis, cardiovascular, neurological, and respiratory diagnoses often required ICU transfer following RRT evaluation. Diagnoses such as chronic liver disease and hematological malignancies were major risk factors requiring ICU admission (Currey et al., 2022; Fernando et al., 2019). Considine et al. (2017) found that tachypnea and hypotension during RRT evaluation were the strongest predictors of ICU admission (11.8% vs. 0.7%). Rapid response team activations within 72 hours of emergency admission were 16 times more likely to require transfer to ICU.

Length of Stay

Conflicting findings regarding LOS after RRT activation were found. Currey et al. (2022) found that after an initial RRT activation, the median LOS decreased from 9 to 5 days, whereas Fernando et al. (2019) reported an increase from 12 to 21 days. Delay in RRT activation for more than 1 hour can increase LOS to 32.4 days compared with 19.9 days for RRT activation without delay (Padilla & Mayo, 2019). Unsurprisingly, patients with recurrent deterioration had prolonged LOS compared with patients with single RRT activation (21.0 days vs. 12.0 days; Fernando et al., 2019). Rapid response team activation within 72 hours of emergency admission was also associated with an increase of 3 (median) days for LOS (Considine et al., 2017; Lyons et al., 2019). Prolonged capillary refill time was found to be an independent predictor of increased LOS (15.3 vs. 13.5 days) after an RRT call (Sebat et al., 2020).

Mortality

Many studies have evaluated in-hospital mortality after RRT implementation, with estimates ranging from 8% to 15% (Currey et al., 2022; Lyons et al., 2019; Shoaib et al., 2021; Smith et al., 2017). Gong et al. (2020) reported that RRT implementation reduced overall in-hospital mortality by 40%; however, two studies (Considine et al., 2017; Padilla & Mayo, 2019) highlighted that delayed RRT activation were strongly associated with a higher rate of in-hospital mortality. Considine et al. (2017) reported that patients who received RRT activation within 72 hours of emergency admission were four times more vulnerable and had a 10-fold increase in unexpected in-hospital death. Furthermore, literature also reported that patients who required recurrent RRT activation demonstrated higher mortality as compared with those with a single RRT activation (Byrne et al., 2021; Chalwin et al., 2019; Lyons et al., 2019).

Comparative Analysis for Children and Adults

The needs of pediatric and adult patients differ. Although children and adults experience adverse events differently because of underlying physiology, they appear to share the most common RRT trigger categories: respiratory, cardiovascular, and neurological.

Trigger Characteristics

Respiratory symptoms are the top RRT activation trigger for both pediatric and adult patients; however, the specific symptoms are different. Comparing the common triggers of respiratory derangements in both populations, tachypnea and decreased oxygen saturation appear to be most common. Acute respiratory distress, chronic respiratory disease, and complex respiratory failure were the prominent respiratory triggers in adults, whereas labored breathing, respiratory depression, and CO₂ retention were frequently identified triggers in children.

Six studies identified cardiovascular symptoms, such as tachycardia and blood pressure changes, as their top concern, whereas only one study (Martinez et al., 2018) in the pediatric population did so. Tachycardia is a common trigger in both groups, whereas hypotension, hypovolemia, cardiac arrest, and arrhythmias were more frequently reported triggers among adults requiring RRT activation. Bradycardia and blood pressure changes were the most prominent triggers in children.

The neurological symptoms of change in level of consciousness, changes in the Glascow Coma Scale scores, and seizures were reported triggers for both populations. However, delirium and oversedation were reported triggers only in the adult population. In addition, staff concern was noted in the literature as an RRT trigger for both populations.

Demographic Characteristics

Demographic information of patients is scant in the RRT literature. In both populations, RRTs were activated more often for male patients; children ages 2 through 6 years and patients older than 60 years required frequent RRT activation. Very few of the studies in this review addressed race and ethnicity. One study (Jayaram et al., 2017) identified Black children as requiring more RRT activation, whereas another (Churpek et al., 2017) identified non-Hispanic adult White patients at greater risk. In both populations, patients with multiple comorbidities and noncardiac medical illness were at higher risk for RRT activation.

Discussion

These results indicate that tachypnea, tachycardia, and decrease in oxygen saturation are the most common triggers requiring RRT activation in both populations. Because these triggers are part of vital signs monitoring, it is recommended that nurses be vigilant in tracking their patients' vital signs and oxygen saturation because they provide early clues of deterioration. Monitoring vital signs and oxygen saturation is simple, does not use additional resources, and allows nurses to use their expertise. In addition, the act of obtaining vital signs and oxygen saturation provides nurses cues about patients' level of consciousness and hemodynamic stability. Most hospitals in the United States have delegated the function of obtaining vital signs to the nursing assistant. Given patient complexity, workload, and time constraints, this task is well suited for delegation; however, at the same time, it may not allow nurses to review vital signs in the full context of patient care because nurse and nursing assistant workflow may differ. Consequences may be that the missed vital signs information may lead to repeat or delayed RRT activation.

The patient outcomes of CPR, transfer to ICU, LOS, and mortality are adversely affected by RRT activation. Not all studies reported on all outcomes. Mortality is one of the most common outcomes reported in both populations, whereas the need for CPR after the RRT activation is less frequently reported. In general, earlier interventions by the RRT appear to be beneficial in both populations. Delayed RRT response negatively affects patients, leading to increases in LOS and mortality. Mortality ranges from 0.5% to 43% in adults (Table 4) and from 1% to 10% in children (Table 2). This vast difference in mortality rate between populations is not surprising because older populations tend to have more complex underlying comorbidities than children.

A few gaps were noted during the literature review. Rapid response team calls were not evaluated based on the nature of the hospital unit, that is, rehabilitation or neurology units. Therefore, variations in RRT calls based on setting are not available. Future research must explore RRT triggers in a unit-specific context because the current body of literature is limited. We advocate for more prospective research design in the area of RRT activation in the future to avoid misclassification and missing data. In addition, use of power analysis, along with a stronger design that accounts for confounding variables (e.g., underlying comorbidities, medication profile, and prior hospitalization), is needed to better understand the patterns of RRT activation in both populations. At minimum, we advocate that full demographic characteristics, such as ethnicity and socioeconomic status, be obtained.

Limitations

This integrative review includes extensive literature on the triggers of RRT activations in adult and pediatric populations; however, limitations do exist. Although the quality of the studies was evaluated based on NIH criteria, the distinction between poor, fair, and good is arbitrary based on authors' decisions and may have introduced bias. It is recommended that readers base their decisions of the study quality on the actual "yes" responses. This literature uses the lens of triggers only; therefore, triggers based on specific diagnoses were not analyzed. In addition, some articles did not provide distinct triggers; rather, they evaluated patient outcomes based on body systems (respiratory, cardiovascular, and neurological). Most available literature in this area of inquiry is retrospective in nature; therefore, methodological concerns due to data classification and abstraction exist.

Implications for Rehabilitation Nursing Practice

Rehabilitation nurses are symptom experts and holistic thinkers. Their practice is dynamic, and they respond to patients' needs in real time. Their observation skills and intuition play a significant role in patient recovery. The consistent mention of staff worries leading to RRT activation indicates that nurses' keen observation skills lead to an RRT call. Rehabilitation nurses are sensitive to patients' demeanor, responses, and body positions, which are highly subjective in nature. There is a need to clearly identify what constitutes "staff worry" and how to translate these nursing insights into a tangible body of knowledge.

In the era of a pandemic where nursing care is constrained because of overwhelming patient load and lack of time and resources, the simple act of close monitoring of vital signs may not only provide early clues, but it also has the potential to reduce nursing burden. The traditional means of manual vital signs monitoring has now been replaced by automation in most countries around the world. However, the practice of manual vital signs monitoring may be part of nursing practice in some developing nations. Automatic vital sign monitors reduce the nursing workload and give accurate readings. However, automation does not allow nurses to discern pulse rhythm or respiratory pattern, which often provide clues of clinical deterioration. We advocate for rehabilitation nurses to pay close attention to heart and lung sound assessments, especially as patients return from their rigorous therapy sessions. These assessments provide clues for early deterioration of breathing and cardiovascular anomalies. Nurses may consider obtaining vital signs and oxygen saturation readings with close monitoring through automation to identify clinical abnormality and activate the RRT in a timely fashion, which is essential to reduce morbidity and mortality and improve patient outcomes.

Conclusions

It is important to delineate what triggers a RRT call. The top triggers for RRT activation in the adult and pediatric populations are tachypnea, oxygen saturation, tachycardia, and blood pressure changes. Close monitoring of vital signs is of utmost importance because delayed RRT activation is associated with increased LOS and mortality. Validating staff concerns is a well-founded trigger for RRT activation that should be evaluated through future research. Understanding of population-specific triggers aids in timely activation of the RRT and improving rehabilitation patient outcomes.

Key Practice Points

* Overall, RRT triggers are similar in pediatric and adult patients; both share the most common RRT trigger categories: respiratory, cardiovascular, and neurological.

* In adults, acute respiratory distress and complex respiratory failure are the respiratory triggers, whereas labored breathing, respiratory depression, and carbon dioxide retention are common in children.

* Rehabilitation nurses should be vigilant in tracking their patients' vital signs because they provide early clues of clinical deterioration.

Conflict of Interest

The authors declare no conflict of interest.

Acknowledgment

The authors would like to thank the TKN group and Dr. Salma Rattani, who facilitated the international collaboration.

Funding

The authors declare that there is no funding associated with this project.

REFERENCES