Authors

1. Gardner, Joycelyn RN, BSN MSN
2. Hampton, Michelle DeCoux RN, PhD, MS

Abstract

Review question/objective: The objective of the review is to document the best available evidence related to the effect of rapid response teams (RRTs) activated by patients or family members on mortality and cardiac arrest on non-intensive care units(ICU).

Background: An estimated 70% of medical complications and deaths among hospitalized patients can be prevented if early signs of deterioration in clinical conditions are identified and followed by immediate assessment and appropriate intervention.1 Signs of clinical deterioration among hospitalized patients include tachycardia, hypotension, dyspnea, changes in level of consciousness,2 decreases in oxygen saturation levels and in urinary output.1

Post-operative complications, including postoperative bleeding, septicemia and pneumonia are among those sometimes not recognized, which leads to late intervention and can negatively impact patient outcomes.1 Increased age and multiple comorbidities are other factors that predispose hospitalized patients to deterioration in health status.1

Cardiac arrest is the most significant adverse event associated with failure to detect early signs of clinical deterioration.3 Mortality and morbidity rates due to cardiac arrest in hospitalized patients remains a significant risk,3 with a survival rate to discharge of only 15% post-hospital discharge following full cardiopulmonary arrest.1 Improvements are needed in the monitoring of hospitalized patients admitted to non-ICU patient care areas to aid in the detection of early signs of clinical deterioration.3

Rapid response teams (RRTs) are resource teams to assist in the management of care of hospitalized patients admitted to non-ICU areas who exhibit signs of clinical deterioration.4 Within hospitals, the primary goal of implementing RRTs is to prevent deaths in non-ICU patients. Medical care provided by RRTs at the patient bedside includes patient assessment, prompt intervention and the transport of patients to higher levels of care as appropriate. Hospital staff education and support are other important services provided by RRTs.1

RRTs were developed in 1990 in response to a need for early recognition of decline in clinical conditions among patients in acute care hospitals to prevent cardiac arrest outside ICUs. Liverpool Hospital in Sydney, Australia, is credited with implementing the first RRT. Later, in 1997, an RRT was created in the United States. As of 2011, more than 25% of hospitals have implemented RRTs.5The Institute for Healthcare Improvement (IHI) also recognized the need for improvements in the monitoring of patients hospitalized on non-ICUs and recommended implementation of RRTs in hospitals throughout the United States. The recommendation was one of six strategies recommended by the institute in 2004 in its 100,000 Lives Campaign.1

'Rapid response system' is a broad term that describes a system that consists of four distinct components: (1) afferent, (2) efferent, (3) process improvement and (4) administration. The afferent limb of the response system serves to identify clinical events and initiate a response. The efferent limb is the component of the system that is ready 24 hours a day within acute care hospitals to provide medical interventions for patients that demonstrate signs of clinical deterioration. The process improvement limb functions to improve patient care and safety. The administrative limb exists to implement and sustain the service.5

Models of rapid response systems vary. In 2006, the International Consensus Conference on Medical Emergency Teams (ICMET) held the first conference to standardize the language used to describe the various models of a rapid response efferent limb. Models identified and described during ICMET were medical emergency teams, RRTs and critical care outreach teams.5 While the composition of each model varies, criteria used when activating rapid response systems are generally consistent among the models.6 Medical emergency team members consist of physicians and nurses.6 These physician-led teams are readily available when summoned and have the authority to prescribe appropriate therapy, manage advanced airways, access central venous blood supplies and initiate advanced medical interventions that are generally performed in ICUs.5

Unlike the medical emergency team, nurses can serve as team leaders for RRTs. Patient care is managed by critical care nurses and respiratory therapists. Physicians serve as support for the team and are readily available to assist when needed.6 RRTs are responsible for patient assessment, initiating basic medical care to stabilize patients and transferring patients to units where they can receive higher levels of care. When an ICU level of care is needed at the bedside and additional resources are summoned, RRTs can then function as a medical emergency team.5

A critical care outreach team is an extended version of an RRT that includes an outreach component, consisting of a critical care team of physicians and nurses.6 The teams have the same responsibilities as RRTs, except critical care outreach teams also work to prevent emergency events among hospitalized patients by identifying the patients most at risk for those types of interventions.5 Patients at risk for clinical deterioration can often be identified by use of trigger systems, such as Early Warning Scores (EWS).7

EWS serve as a framework to track physiological changes in the non-ICU and aid in identifying early signs of clinical deterioration.7Physiological values tracked by EWS include blood pressure, heart rate, respiratory rate, level of consciousness, urinary output and temperature are among the physiological variables measured by EWS. Scores for each variable range from zero to three, with higher scores indicating a progression towards clinical deterioration and need for evaluation and assessment by a critical care outreach team.7

For the purpose of this systematic review, the term RRT will be used to represent the efferent limb, rapid response services that focus on ready access and preventing clinical deterioration.

The Joint Commission: The Joint Commission (TJC) recommends that healthcare organizations have a reliable method to allow staff members within healthcare settings to have direct access to request assistance from healthcare professionals with specialized training to intervene when there appears to be deterioration in health conditions among hospitalized patients.8This goal further highlights the need for patients and their families to be empowered and seek assistance when they are concerned about changes in patients' health status,8.

Criteria for Activating RRTs: Criteria for activating RRTs by healthcare providers include physiological changes in respiration rate (<8 or >28 breaths per minute [bpm]), oxygen saturation (85%-90% sustained for more than five minutes), heart rate (<40 or >160 bpm or 140 bpm with symptoms), systolic blood pressure (<80 mmHg), diastolic blood pressure (>100 mmHg), acute chest pain or chest pain not relieved by nitro glycerine, changes in mental status and level of consciousness, seizure and stroke symptoms.6Changes in skin color and fluid volume are other indicators of a decline in clinical condition.6 Activation of RRT based on a health care professional's 'gut feeling' is encouraged and is a valid criterion for activation of an RRT.9The method by which staff members activate an RRT depends on the policies of the health care facility. Staff members can activate RRTs via healthcare facility operators or by means of emergency numbers that activate the pagers or cellular telephones of RRTs.5

Family members of hospitalized patients play a vital role in detecting signs of deterioration in patient health status, which helps prevent further clinical deterioration. They are often more familiar with the patient's behaviour and health history and better in detecting slight changes in a patient's health status.10 The Institute for Family Centered Care recommended providing patients and family information on activating RRTs upon hospital admission and they are encouraged to activate RRTs about a patient's clinical condition without considering the healthcare facility criteria for staff activated RRT.11

Ideally, the RRT contact number can be used to access RRTs when dialed from areas within and external to healthcare facilities. The ability to access RRTs when outside the healthcare facility allows family members to activate and initiate calls to the RRT when concerns about deteriorating health are detected, e.g. during telephone conversations with hospitalized patients.8

Mortality and cardiac arrests in acute care hospitals: A number of studies support the effectiveness of RRTs for reducing mortality and cardiac arrest in hospitalized patients. A study by Offner et al. of hospitalized patients admitted to a trauma unit showed that activating RRTs resulted in more than a 50% decrease in cardiac arrests. In this study conducted in a non-ICU unit, 27 patients suffered cardiac arrest prior to RRT implementation between March and December 2004, compared to 13 cardiac arrest post-RRT during the same time period in the following year.12

Bietler et al. measured mortality rates in a teaching hospital following implementation of an RRT. Three years post-RRT intervention, hospital-wide mortality per 1,000 hospital discharges decreased from 15.50 to 13.74 (p<0.004).13

Lighthall et al. investigated the impact of rapid response system activation on cardiac arrest and mortality in a study conducted among patients admitted to a United States Veteran Affairs Medical Center. Non-ICU cardiac arrests were measured nine months prior to and 27 months after implementation of a rapid response system. Mortality was calculated 3.5 years prior to and 27 months post rapid response system implementation. There were 5.6 cardiac arrests for every 1,000 hospital discharges (p<.01), a 57% reduction in the number of cardiac arrests. Hospital-wide mortality decreased by 17.3% post rapid response system implementation, which represented 2.24 +/- 0.87 (mean +/- SD) deaths per 100 discharge compared to 2.71 +/- 0.98 (p=0.04) prior to implementation of the RRT.14

Patient and family-activated RRT: The concept of 'patient-centeredness' is used throughout health care. It focuses on individualized care by addressing the unique needs of each patient, with the goal to improve safety and quality in the delivery of care. This approach to care is intended to promote patient engagement and empower patients and their families to advocate for safe health care practices. Healthcare institutions are becoming increasingly aware of the role patients play in creating a safe culture within health care settings and they recognize the need for implementing patient and family-activated RRT.15

The purpose of this systematic review is to examine the effectiveness of patient- and family-activated RRTs as a recommended patient safety practice for the early detection of deteriorating health conditions among non-ICU hospitalized adult patients. They have used measurable outcomes, such as inpatient mortality and cardiopulmonary arrest on non-ICU patients. However, the limited number of studies and small sample sizes limit their power to clearly determine if patient- and family-activated RRTs are an intervention that should be recommended in health care institutions.