Controversies in Rapid Response Systems

Carl Hinkson, RRT

Harborview Medical Center

Table of Contents

• Evolution of Rapid Response systems

• What are Rapid Response systems

• What evidence supports their use

• What are the different teams and which is best

• What triggers should be used to activate

• Other controversies

Rapid Response System History• In 1999 the Institute of

Medicine published a report, To Err is Human: Building a Safer System– Report concluded 44,000 –

98,000 people die each year as a result of preventable medical errors

– Followed by the IM Crossing the Quality Chasm

Rapid Response System History

• The Institute of Healthcare Improvement launched their “Saving 100,000 lives campaign” which featured six “planks” in 2004 – Medication Reconciliation– Prevention of surgical site infections– Prevention of ventilator associated pneumonia– Evidence-based care for acute myocardial infarctions– Prevention of central line infections– Rapid Response Teams

Rapid Response Systems• A team of clinicians who respond to

patients hospitalized outside the ICU when they meet a “clinical trigger” or other predetermined mechanism

• Team provides rapid assessment and triage

• Here to stay – JCAHO is requiring hospitals to have “rapid response system” in place

Rapid Response Systems• Components

– Afferent Limb• How RRS is activated

– Efferent Limb• How the RRS responds

– Evaluative Process• Data collection on RRS effectiveness

– Administrative or Governance Structure• Hiring/ firing etc

Rapid Response Systems

DeVita et al. Findings of the First Consensus Conference on Medical Emergency Teams. Crit Care Med. 2006; 34(9): 2463-2478.

What does the evidence say?

• Winter’s et al conducted a literature review– Searched medical literature database– From 10228 possible articles, 8 were

determined to be applicable

Winters et al. Rapid response sytems: A systematic review. Crit Care. 2007; 35(5): 1238-1243

Evidence to Support RRS

Winters et al. Rapid response sytems: A systematic review. Crit Care. 2007; 35(5) 1238-1243.

Evidence to Support RRS

Winters et al. Rapid response sytems: A systematic review. Crit Care. 2007; 35(5) 1238-1243

• Winters et al Conclusions:– “weak to moderate” level of evidence to

support RRS in reducing hospital mortality and cardiac arrest rates

– Large randomized trials are needed to prove that RRS are effective

– Observational studies may have been influenced by “Hawthorne” effect

Merit Study• Large cluster-randomized trial• Showed no effect• Criticism of Merit Study include:

– Increase in “RRS-like” activities in control hospitals– Sudden decrease in end-points in control – Study was underpowered

What are the different teams and which is best?

• Medical Emergency Teams (MET)– Physician-lead – RN & RT support– Ramp down model

• Rapid Response Teams (RRT)– RN & RT lead w/ dedicated on call physician– Ramp up model

• Critical Care Outreach (CCO)– RRT/ MET with prospective / proactive component

Which team is best?

MET- MD lead• Pros:

– Immediate definitive treatment

– Advanced airway management and central venous access

• Cons– Expensive– Intimidating to bedside

staff to activate

RRT - RN/RT lead• Pros

– Less expensive– Less intimidating to

beside staff to activate

• Cons– Less efficient; – Delay to definitive

treatment

Which team is best?

• MET vs RRT Response Teams:

• No mortality difference in observational studies

Additional Members?

• Pharmacists!?– Pharmacists are included in the RRS at Long

Beach Memorial– Supported by IHI and SCCM

What triggers should be used?

• A wide variety of activation criteria exists

• There is little evidence to support their validity

Winters et al. Rapid response sytems: A systematic review. Crit Care. 2007; 35(5) 1238-1243.

Types of Triggering Systems• Aggregate Scoring Systems

– Scores combining several physiologic parameters• Modified Early Warning System (MEWS)• Patient At Risk Team (PART) calling criteria

• Single Parameter criteria– Routine observations of vital signs

• Harborview RRT calling criteria

• Combination scoring system– Incorporates aggregate scoring system – Team is activated if any single parameter scores “at

Highest”

Aggregate Scoring Methods• Modified Early Warning System (MEWS)

– RRS is activated when score >4 or 5

Gardner-Thorpe et al. The value of modified early warning score (MEWS) in a surgical in-patients: a prospective observational study Ann R Coll Surg Engl. 2006; 88:571-5

Aggregate Scoring Methods

• Patient At Risk Team (PART) criteria– RRS activated when patient meets 3 or more

criteria or absolute criteria

Goldhill et al. The patient-at-risk team: identifying and managing seriously ill ward patients. Anaesthesia. 1999; 54: 853-860

Single parameter trigger criteria

Intuitive sense that something is wrong with patient

Acute change in mental status New onset of agitation or restlessness Acute change in respiratory status: Stridor – noisy airway Respiratory rate < 12 > 32 Increased WOB SaO2 < 92% with increased FiO2

ABG requested for respiratory concern Acute change in CV status HR < 55 > 120 SBP <90 > 170 New onset of chest pain Acute change in temp. < 35 > 39.5

Triggering Systems

Scoring System• Pros

– Less False alarms– Higher scores are able

to predict poor outcomes

• Cons– More complex for

bedside staff– Some do not include

subjective criteria

Clinical triggers• Pros

– Easy for bedside staff to use

• Cons– More false alarms

Triggering Systems

• What does the evidence say?– At present no studies have compared different

activation criteria– No single activation criteria has been

adequately validated– A systematic review by Gao et al was unable

adequately compare data due to heterogenity

Triggering Systems

• Subjective “worry” criteria versus Objective criteria

• Family members activating RRS?

• Should We Have Continuous Monitoring for Everyone?

Would better bedside staffing & training help

• Better nursing staff levels?– Aiken et al demonstrated that higher patient to

nurse ratios resulted in higher risk for 30 day mortality and failure to rescue

• Better education for bedside caregivers?– RNs’ with 4 year education had lower 30 day

mortality and failure to rescue than did 2 year educated RNs’

Summary

• Evolutions of Rapid Response systems• What are Rapid Response systems• What evidence supports their use• What are the different teams and which is best• What triggers should be used to activate• Other controversies