A/Prof Jack Chen MBBS PhD MBA(Exec)

Simpson Centre for Health Services Research

South Western Clinical School & Australia Institute of Health Innovation

The University of New South Wales

Do Rapid Response Teams save lives

– new emerging research evidences

Widespread of the concepts of RRS

2

The Joint Commission of the USA

Australian Commission on Safety and Quality in Health Care

“Between the Flags” (BTF) by Clinical Excellence Commission, NSW

Many many more

Controversies

3

“Rapid response teams--walk, don't run”

Winters BD, Pham J, Pronovost PJ. JAMA; 2006; 296: 1645-7.

“Run, but not walk !”

Hillman KM. Critical care medicine 2012;40:2712-3.

Confusing and conflicting messages from the

systematic reviews

4

Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Rapid response teams: A systematic

review and meta-analysis. Archives of Internal Medicine 2010;170:18-26.

Implementing a RRS reduce cardiac arrests in adult patients by 1/3 but had

no impact on overall hospital mortality

Winters BD, Weaver SJ, Pfoh ER, Yang T, Cuong J, Dy SM. Rapid-response

systems as a patient safety strategy: A systematic review. Annals of Internal

Medicine 2013;158:417-25.

In discussion: “Our update supports the previous conclusions, although the most

recent studies were more likely to show positive results.” p422.

In abstract: “Moderate strength evidence from a high-quality meta-analysis of 18

studies and 26 lower-quality before-and-after studies published after that meta-

analysis showed that RRSs are associated with reduced rates of cardiorespiratory arrest

outside of the intensive care unit and reduced mortality.”

How many inhopsital cardiopulmonary

arrests (IHCA) a year – 1 ?

5

We really don‟t know so far

Too many different definitions (more than 20+)

Too many different data collection methods

No population-based estimates

It is not a standard patient safety indicator

• Is it a cardiopulmonary arrest or a cardiac arrest ?

How many inhopsital cardiopulmonary arrests

(IHCA) a year – 2 ?

6

Most likely between 1-5 cardiac arrests per 1000 patient admissions

Conservatively: 200,000 in-hospital cardiac arrests in the USA ( the

American Heart Association Consensus paper, Circulation

2013;127:1538-63)

But there could be as high as 750,000 inhospital CPR conducted in the

USA per year

Have the rate of IHCA survival to hospital discharge

changed ?

7

There are exciting new technologies

Peak agencies in promoting resuscitation guidelines

Morrison LJ, Neumar RW, Zimmerman JL, et al. Strategies for improving survival after

in-hospital cardiac arrest in the United States: 2013 consensus recommendations: A

consensus statement from the American heart association. Circulation

2013;127:1538-63.

Most studies indicated that little has changed in terms of IHCA

surviving rate during the last several decades

A recent report in NEJM: crude increase in % IHCA surviving to

hospital discharge: 3.9%;(adjusted rate: 8.1%) between 2001-2009

(Girotra S, Nallamothu BK, Spertus JA, Li Y, Krumholz HM, Chan PS. Trends in survival

after in-hospital cardiac arrest. New England Journal of Medicine 2012;367:1912-

20.)

A population based study of the secular trends of cardiopulmonary

arrest and mortality and their association with rapid response

system expansion in NSW (2002-2009)

8

Aims:

To explore the associations between the expansion of RRS in NSW and the trends of

1) IHCA incidence rate: the number of IHCA divided by total number of admissions (including same-day admissions);

2) IHCA-related mortality: the number of deaths among those patients who suffered an IHCA divided by the total number of admissions;

3) Hospital mortality rate: the number of deaths divided by total number of hospital admissions;

4) Proportion of IHCA surviving to discharge: the number of patients who survived to hospital discharge divided by total number of IHCA patients;

5) One year post-discharge mortality of IHCA: the number of deaths within 1-year after discharge alive from hospital among IHCA patients

Aims:

9

Pre-arrest prevention versus post-arrest

treatment : which is the major

contributor to the lives saved?

Method -1

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Patient outcomes and other related variables were derived from

the NSW Admitted Patient Data Collection (APDC) database

All admissions to the study hospitals were linked to the NSW

Registry of Births, Deaths, and Marriages (RBDM) through the

Centre of Health Record Linkage (CHeReL), NSW Ministry of

Health

Two state wide telephone-based surveys (one during the end of

2007 and one in May 2013) and one web-based survey (during

October to December 2012)

A RRS was defined as any system that had a clear objective in

identifying and responding to the deteriorating hospital in-patients

Method - 2

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Death was defined as a patient documented as „deceased‟ within

the APDC database.

A cardiopulmonary arrest in the current study was derived from

the International Classification of Disease Version 10 (ICD 10-

AM, v5.0-v5.1) and defined as a state of pulselessness (I.46) or

cessation of breathing (R09.2 ) which required cardiac message,

defibrillation or any other cardiopulmonary resuscitations.

A patient coded as I.46 or R09.2 in any one of the 54 non-

principal diagnostic fields, but not coded for these as the principal

diagnostic field, was defined as having had a cardiopulmonary

arrest during the hospitalization

Method - 3

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We only studies acute public hospitals (Peer group A – C)

Two children hospitals excluded

Only those older than 14 years patients were included (not for

pediatric patients)

Statistical Analysis

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Crude and adjusted analysis of trends

Risk ratio rather than odds ratio derived through specifying a Poisson distribution and adjusted for cluster effect of the hospital

Elixhauser Index based methodology for the baseline risk groups

Charlson Index derived using recommended coding scheme for ICD-10

Risk-adjustment model include: year, age groups, sex, marital status, country of birth, socio-economic status, geological area of hospitals (urban versus rural) and major hospital peer groups.

Diagram 1: Data linkage and data verification process

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16,046,272 de-identifying records received from CHeReL after the

vertical linkage with unique person key including 497 health care

facilities in NSW 2002-09

9,221,138 from 82 public acute hospitals in NSW

6,812,532 records removed from private and

other health care facilities such as residential

care facilities

12,597 duplicates removed as well as 5 records

were deemed invalid due to out of range of

admission and separation dates

9,221,138 records retained after one-to-one linkage

to RBDM database provided by the CHeReL

Table 1: The trends (2002-2009) of rates (per 1000 admissions)

of IHCA, IHCA-related mortality, hospital mortality, and % of IHCA

surviving to discharge, 1-yr post-discharge mortality after IHCA

15

2002 2003 2004 2005 2006 2007 2008 2009 P for

linear

trend

IHCA incidence(/1000

admissions) 3.72 3.34 2.97 2.71 2.51 2.46 2.12 1.85 <0.001

IHCA mortality (/1000

admissions) 2.71 2.42 2.10 1.91 1.81 1.76 1.47 1.26 <0.001

Hospital

mortality(/1000

admissions)

17.63 17.18 17.03 15.91 15.29 15.46 15.47 14.36 <0.001

IHCA surviving to

discharge (%) 27.2 27.6 29.1 29.6 27.9 28.4 30.8 32.3 0.002

1-yr post-discharge

mortality after IHCA

(%)

5.4 5.1 3.9 4.6 3.7 4.3 3.0 5.6 0.117

Figure 1 Risk-adjusted incidence rates of IHCA, IHCA-related mortality, hospital

mortality (per 1000 admissions), and % of hospitals having a RRS between 2002-

2009

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17.63

16.92 16.57

15.69

14.81 14.81 14.63

13.58

3.72 3.31

2.94 2.68 2.49 2.42

2.08 1.79 2.71

2.38 2.06 1.90 1.79 1.71

1.44 1.22

31.7 34.2

39.0

43.9

47.6

58.5

64.6

74.4

0

10

20

30

40

50

60

70

80

0

2

4

6

8

10

12

14

16

18

20

2002 2003 2004 2005 2006 2007 2008 2009

%

o

f

R

R

S

Nu

mb

er

of

ev

en

ts p

er

1,00

0 ad

mis

sio

ns

Mortality IHCA

IHCA mortality % of RRS

Figure 2 Risk-adjusted % of IHCA surviving to hospital

discharge and 1-year post-discharge mortality after IHCA

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27.2 27.7 29.1 29.4

28.0 28.6

30.2 31.3

5.4 5.0 3.9

4.5 3.6 4.2

3.0

5.5

0

5

10

15

20

25

30

35

2002 2003 2004 2005 2006 2007 2008 2009

%

% IHCA Survival to dishcharge 1yr post-dishcarge mortliaty after IHCA

Key findings: -1

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Hospitals with a RRS more than doubled over this period .

Over the same time, there was also

a greater than 50% reduction in the incidence of IHCA;

a greater than 50% reduction in IHCA-related mortality;

a 23% overall reduction in hospital mortality;

a 4.1% increase in the proportion of IHCA patients who

survived to discharge.

However, there was no change in 1-year post-discharge

mortality among IHCA patients.

.

Key findings - 2

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The adjusted rate reduction in IHCA-related mortality was

1.49 patients per 1000 admissions (2.71-1.22=1.49;

RR=0.45; p<0.001) and accounted for 36.8% of the

adjusted hospital mortality reduction (17.63-13.58=4.05 per

1000 admissions; RR=0.77; p<0.001).

The reduction in IHCA incidence and the increase in IHCA

survival accounted for 95% and 5% of the IHCA-related

mortality reduction, respectively (5%= 4.1% x 1.79/1.49)

Implications: Lives saved

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Assuming a similar rate of uptake of RRS across other Australian states (8.6 million patients older than 14 years ),the number of estimated lives saved due to the reduction in annual IHCA related mortality would be over 12,800 in Australia in 2011-2012.

Greater than the total number of Australians who died of bowel cancer (3982), prostate cancer (3235), breast cancer (2864) and pancreatic cancer (2434) in 2012.

Assuming a 200,000/year IHCA incidence, with a 20% survival rate, 80,000 cardiac arrest associated deaths would potentially be prevented each year in the USA by a doubling in the implementation of RRS‟s.

Implications:

21

Prevention IHCA is the main contributor to the lives

saved (95% vs 5%)

No evidence of systematic mismanagement of

patients due to more NFR orders (i.e, consistent 5%

1-yr post-discharge mortality after IHCA)

A feasible, cheap way in tracking patient safety and

hospital performances

Four hospitals head-to-head comparison

22

The same study data

One MET versus three non-MET hospitals

MET hospital: Liverpool hospital, a large teaching hospital of the

University of New South Wales(UNSW) which had pioneered the

Medical Emergency Team (MET) system in 1990.

Three non-MET hospitals: three large hospitals (H1,H2,H3), also

belong to the same top principal referral group of hospitals as defined

by the NSW Health.

Each hospital situates within the metropolitan area of Sydney.

Hospitals H1 and H3 did not implement a RRS until 2009 and

hospital H2 formally started its RRS in January 2010.

Aims and methods

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Primary outcomes: rates of IHCA, IHCA-related mortality,

hospital mortality

We specifically compared the primary outcomes between the

MET hospital and other non-MET hospitals at three different

stages:

1) the three outcomes (pooled between 2002-2008);

2) the changes of three outcomes between 2008 and 2009;

3) the three outcomes in 2009.

Figure 3: The rates of IHCA, IHCA-related mortality and hospital

mortality (per 1000 admissions) between 2002-2009

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Liverpool hospital

H2

H1

H3

Pre-RRS Post-RRS

1011

1213

1415

1617

1819

Hos

pita

l mor

talit

y (p

er

1000

adm

issi

ons

)

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Hospital mortality

LIverpool hospital

H1

H2

H3 Pre-RRS Post-RRS

1.0

2.0

3.0

4.0

5.0

6.0

7.0

IHC

A r

ate

(per

100

0 ad

mis

sion

s)

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

IHCA rate

Liverpool hospital

H1

H2

H3Pre-RRS Post-RRS

1.0

2.0

3.0

4.0

5.0

IHC

A r

ela

ted

mor

talit

y (

per

100

0 ad

mis

sion

s)

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

IHCA related mortality

Table 2 The outcome differences between MET hospital and non-

RRS hospitals(2002-2008) and 2009, respectively

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Outcome Non-

MET

MET

hospital

Crude RR

(95%CI) P Adjusted RR P

Year 2002 to 2008

IHCA incidence (/1000

admissions) 3.97 2.09

0.53 (0.49-

0.57) <0.001 0.48 (0.44 - 0.53) <0.001

IHCA related mortality (/1000

admissions) 2.72 1.62

0.60 (0.55 -

0.65) <0.001 0.60 (0.54 - 0.67) <0.001

Hospital mortality (/1000

admissions) 15.20 12.76

0.84 (0.81-

0.87) <0.001 0.94 (0.90 - 0.98) 0.002

Year 2009

IHCA incidence (/1000

admissions) 2.81 2.09

0.75 (0.62 -

0.90) 0.002 0.77(0.60 - 0.98) 0.037

IHCA-related mortality

(/1000 admissions) 1.87 1.56

0.83 (0.67 -

1.04) 0.101 0.93 (0.69 - 1.25) 0.617

Hospital mortality (/1000

admissions) 13.24 10.95

0.83(0.76 -

0.90) <0.001 0.93 (0.83 - 1.04) 0.224

Table 3 The rate ratio (2009/2008) between MET hospital and

Non-MET hospitals

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Outcome Rates

(2009/2008)

Adjusted RR

(95%CI)

P values

Non-MET hospitals

IHCA incidence (/1000 admissions) 2.81/3.56

0.80 (0.70 - 0.91) 0.001

IHCA mortality (/1000 admissions) 1.87/2.35

0.80 (0.68 - 0.94) 0.006

Hospital mortality (/1000

admissions) 13.2/14.85

0.89 (0.84 - 0.95) <0.001

MET hospital

IHCA incidence (/1000 admissions) 2.09/1.98 1.05 (0.84 - 1.33)

0.655

IHCA mortality (/1000 admissions) 1.50/1.42 1.11 (0.85 - 1.45)

0.456

Hospital mortality (/1000

admissions) 10.95/11.07 1.00 (0.91 - 1.11)

0.923

The results

27

Between 2002-2008:

50% reduction in IHCA and 40% reduction in IHCA-

related mortality in the MET hospital compared to the

non-MET hospitals

Between 2008-2009:

the MET hospital did not have a before-after change

the non-MET hospitals had a 20% reduction in both

IHCA incidence and IHCA-related mortality

In 2009:

the MET hospital still had a lower IHCA incidence than

the non-MET hospitals

Conclusions:

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The concurrent comparison (2002-2008) between the MET hospital and non-MET hospitals supported the notion that implementing a RRS improved patient safety and saved lives.

The significant reduction of IHCA and related mortality between 2008 and 2009 during implementing a RRS among all non-MET hospital demonstrated the feasibility and generalisabeility of such concept.

The gap between the non-MET hospitals and MET hospital in 2009 indicated that longer time may be needed to perfect such a complex system in hospitals.

Summary

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Both our population-based study and the four hospitals

concurrent comparison study showed that implementing a

RRS was associated with significant lives saved

Despite the improvement in advanced resuscitation

technology and promulgation of the clinical guidelines,

prevention of IHCA is still the leading cause of the reduced

IHCA-related mortality

More efforts should be devoted to develop optimal

implementation strategies of a RRS and supporting self-

learning of hospitals through performance measures related to

IHCA

“Run, but not walk !”

30

Thank You !