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A rapid response system (RRS) is a hospital system devoted to identifying early signs of clinical deterioration in non-intensive care wards and rapidly responding to them with critical care experts who intervene before respiratory or cardiac arrest occurs.[1] A RRS consists of two clinical components (afferent and efferent) and two organizational components (process improvement and administrative).[2]
Components
Afferent Component
The afferent component, also known as the track-and-trigger system, uses standardized tools to track early signs of reversible clinical deterioration and trigger a call to the efferent component.[1] Examples of afferent tools include single-parameter calling criteria and multi-parameter early warning scores.[1] These tools can predict deterioration based upon the patient’s trait (e.g. epileptic) and detect deterioration through the patient’s state (e.g. high respiratory rate).[2] Single-parameter calling criteria require that only one criterion be met before activating the efferent component. Criteria may be based on vital signs, diagnoses, events, subjective observations, or concerns of the patient.[2] Multi-parameter tools are more complex in that they combine several parameters into a single early warning score (EWS).[2]
Efferent Component
The efferent component is a multidisciplinary team of critical care experts who rush to the deteriorating patient’s bedside to prevent respiratory and cardiac arrest in order to improve the patient’s outcomes. Often called the medical emergency team (MET), rapid response team (RRT), critical care outreach team (CCOT), or rover team, the team responds to calls placed by clinicians or families at the bedside who have detected deterioration. It may also provide proactive outreach to patients at high risk for deterioration. Composition of the teams may vary but often include one critical care attending physician or fellow, at least one nurse, and a respiratory therapist.[3]
Process Improvement Component
The process improvement component uses evidence-based evaluation of the RRS to determine its effectiveness and to improve the system through targeted interventions. It works closely with the administrative component, clinicians (especially those on RRTs), and quality improvement experts to evaluate three measures: outcomes measures, process measures, and balancing measures.[3]
Outcomes Measures
Rates of hospital-wide mortality and cardiac arrests and respiratory arrests outside of the ICU, which are exceedingly rare and may or may not be preventable, are common outcome measures.[4] Current evidence on the effectiveness of the RRS in improving patient safety is controversial due to variability in these rates.[4][5] More recent work uses proximal outcome measures, such as the Children’s Resuscitation Intensity Scale (measures level of care within 12 hours pre-transfer),[6] the Clinical Deterioration Metric (measures level of care within 12 hours post-transfer),[7] and UNSAFE transfers (measures level of care within 1 hour post-transfer).[8]
Process Measures
Process measures determine if the RRS is used as intended. Measures include the MET call rate, percentage of MET calls that result in transfer to the ICU, the time between initial physiologic abnormality and admission to ICU, timing of calls, reasons for MET calls, and evaluation of EWSs using sensitivity and specificity.[9][10][11]
Balancing Measures
Balancing measures evaluate any unintended consequences of the RRS. Identified barriers to activating the MET include the primary team’s overconfidence in their ability to stabilize the patient, poor communication, hierarchal problems, and hospital culture.[12][13][14] Interventions to overcome barriers include improved intradisciplinary staff education, protocol requiring activation when calling criteria are met, and use of “champions” to foster cultural change.[15][16]
Administrative Component
The administrative component oversees the planning, implementation, and maintenance phases for the RRS. A formal committee of frontline clinicians and ward and ICU leaders operate the administrative component.[3] Cost effectiveness of RRS implementation has not been rigorously studied.[17]
History of RRSs
Lee and colleagues developed the first reported MET in 1995 in Liverpool Hospital in Australia.[18] The first pediatric RRS was implemented in 2005 by Tibballs, Kinney, and colleagues at Royal Children’s Hospital in Australia which included vital sign ranges that differed by age group.[19] Since its development, the RRS has been implemented around the world. The RRS became a standard of hospitals in the U.S. after its promotion by the Institute for Healthcare Improvement in 2005 and the Joint Commission in 2008.[20][21] Outside the U.S., RRS implementation has been encouraged and adopted by several national organizations, such as the Ministry of Health and Long-term Care in Canada,[22] the UK National Institute for Health and Clinical Excellence,[23] and the Australian Commission on Safety and Quality in Healthcare.[24]
References
- ^ a b c Jones, DA (2011 Jul 14). "Rapid-response teams". The New England Journal of Medicine. 365 (2): 139–46. PMID 21751906.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ a b c d DeVita, MA (2010 Apr). ""Identifying the hospitalised patient in crisis"--a consensus conference on the afferent limb of rapid response systems". Resuscitation. 81 (4): 375–82. PMID 20149516.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ a b c Devita, MA (2006 Sep). "Findings of the first consensus conference on medical emergency teams". Critical care medicine. 34 (9): 2463–78. PMID 16878033.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ a b Chan, PS (2010 Jan 11). "Rapid Response Teams: A Systematic Review and Meta-analysis". Archives of Internal Medicine. 170 (1): 18–26. PMID 20065195.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ Hillman, K (2005 Jun 18-24). "Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial". Lancet. 365 (9477): 2091–7. PMID 15964445.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ Parshuram, CS (2011 Mar). "Implementing the Bedside Paediatric Early Warning System in a community hospital: A prospective observational study". Paediatrics & child health. 16 (3): e18-22. PMID 22379384.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ Bonafide, CP (2012 Apr). "Development of a pragmatic measure for evaluating and optimizing rapid response systems". Pediatrics. 129 (4): e874-81. PMID 22392182.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ Brady, PW (2013 Jan). "Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events". Pediatrics. 131 (1): e298-308. PMID 23230078.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ Oglesby, KJ (2011 Jul 27). "'Score to Door Time', a benchmarking tool for rapid response systems: a pilot multi-centre service evaluation" (PDF). Critical care (London, England). 15 (4): R180. PMID 21794137.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ Santiano, N (2009 Jan). "Analysis of medical emergency team calls comparing subjective to "objective" call criteria". Resuscitation. 80 (1): 44–9. PMID 18952358.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ Fullerton, JN (2012 May). "Is the Modified Early Warning Score (MEWS) superior to clinician judgement in detecting critical illness in the pre-hospital environment?". Resuscitation. 83 (5): 557–62. PMID 22248688.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ Nembhard, IM (2006). "Making it safe: The effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams". Journal of Organizational Behavior. 27 (7): 941–966.
{{cite journal}}: Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ Mackintosh, N (2012 Feb). "Understanding how rapid response systems may improve safety for the acutely ill patient: learning from the frontline". BMJ quality & safety. 21 (2): 135–44. PMID 21972419.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ Shearer, B (2012). "What stops hospital clinical staff from following protocols? An analysis of the incidence and factors behind the failure of bedside clinical staff to activate the rapid response system in a multi-campus Australian metropolitan healthcare service". BMJ Quality and Safety. 21 (7): 569–575.
{{cite journal}}: Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ Theilen, U (2013 Feb). "Regular in situ simulation training of paediatric medical emergency team improves hospital response to deteriorating patients". Resuscitation. 84 (2): 218–22. PMID 22796407.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ DeVita, M (2006). "Potential Sociological and Political Barriers to Medical Emergency Team Implementation". In DeVita M, Hillman K, Bellomo R (ed.). Medical Emergency Teams: Implementation and Outcome Measurement. New York: Springer. pp. 91–103.
{{cite book}}: Unknown parameter|coauthors=ignored (|author=suggested) (help)CS1 maint: multiple names: editors list (link) - ^ Winters, BD (2013 Mar 5). "Rapid-response systems as a patient safety strategy: a systematic review". Annals of internal medicine. 158 (5 Pt 2): 417–25. PMID 23460099.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ Lee, A (1995 Apr). "The Medical Emergency Team". Anaesthesia and intensive care. 23 (2): 183–6. PMID 7793590.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ Tibballs, J (2005 Nov). "Reduction of paediatric in-patient cardiac arrest and death with a medical emergency team: preliminary results". Archives of disease in childhood. 90 (11): 1148–52. PMID 16243869.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ Institute for Healthcare Improvement. "5 Million Lives Campaign". Retrieved 18 October 2013.
- ^ The Joint Commission (2007 July). "The Joint Commission 2008 National Patient Safety Goals". Joint Commission Perspectives. 27 (7): 19.
{{cite journal}}: Check date values in:|date=(help) - ^ Ontario Ministry of Health and Long-term Care. "Critical Care Strategy". Retrieved 18 October 2013.
- ^ UK National Institute for Health and Clinical Excellence (NICE) (2007). "Acutely ill patients in hospital: recognition of and response to acute illness in adults in hospital". Retrieved 18 October 2013.
{{cite web}}: Check date values in:|year=and|year=/|date=mismatch (help) - ^ Australian Commission on Safety and Quality in Health Care (2011). "National Safety and Quality Health Service Standards" (PDF). Sydney. Retrieved 18 October 2013.
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