Marie R. Baldisseri, MD
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania, USA

The number of medical emergency teams and rapid response systems at the local, national and international level is exploding. What was a relatively unknown concept several years ago is now expected as a standard of care by many healthcare organizations. Initiatives from the Institute for Healthcare Improvement (IHI), the American Medical Association (AMA), the Joint Council on Accreditation of Healthcare Organizations (JCAHO), the American Association of American Medical Colleges (AAMC), the Robert Wood Johnson Foundation and other national and international groups have propelled this movement forward. The first institutions to establish rapid response systems often faced cultural, educational, administrative and economic impediments. Changing the culture and attitude of hospital staff and training them to call for help earlier was difficult at times. However, as the concepts of patient safety and quality improvement (QI) gained momentum worldwide, the next logical step was to create and maintain rapid response systems.

Peter Safar, MD, FCCM, a pioneer in the development of critical care medicine as a specialty, once stated, “critical care is not a location, it is a process. It can take place not only in the ICU, (but) everywhere.” Kenneth Hillman, MB, BS, a leader in rapid response systems in Australia, later described the “critical care without walls” philosophy, which states that critical care physicians are expanding their roles beyond the four walls of the intensive care unit (ICU). They now are involved with strategies such as the medical emergency team – a group of experts who recognize critical illness early and respond rapidly to resuscitate patients outside the walls of the ICU.1 Opponents of this interpretation may argue that clinical interventions performed outside the ICU venue are not part of the mission of intensivists, considering that less than half of patients who have medical crises are not subsequently transferred to the ICU.

Getting the Team Started
As the concept of medical emergency teams began to take hold, the definitions of the response changed, as did the name. At the 1st International Conference on Medical Emergency Team Responses held in June 2005 in Pittsburgh, Pennsylvania, USA, the phrase “medical emergency team” was deemed too constrictive and was replaced by the more inclusive “rapid response system.” Rapid response systems consist of four essential components. The afferent arm uses clinical criteria for event detection, the efferent arm is the team responding to the event, the administrative arm is responsible for supervising and integrating the system into the hospital’s infrastructure, and the QI arm reviews and analyzes the antecedents before the event and follows through with the necessary corrective actions. The concept of a rapid response system is true to its name – rapid assessment at the bedside of a patient who has a significant change in clinical status. Medical crises are managed with expert personnel and timely intervention. The goals are to provide immediate detection and diagnosis, to treat patients early and, ultimately, to mitigate harm by turning adverse events into “near misses.” The system is designed to protect the patient from further harm and to allow for recovery from possible medical errors and system deficiencies.

Several studies and observations show that changes in a patient’s clinical status are rarely “sudden” and rarely occur “out of the blue.” Many patients have early prodromal signs of instability that might have been ignored, overlooked or misinterpreted and, subsequently, left untreated. About 50% to 84% of in-hospital cardiac arrests are preceded by physiologic instability, especially abnormalities of heart rate, respiratory rate and oxygen saturation within the six to eight hours before the cardiac arrest.2-4 Patients frequently manifest changes in simple bedside parameters, which are monitored in most patient wards routinely – heart rate, blood pressure, respiratory rate and oxygen saturation. Changes in these parameters, if detected, could alert the clinician to a significant change in status. One of the first goals of establishing a rapid response team is to identify which abnormal signs require immediate attention. Most frequently, changes in vital signs and in the level of consciousness are recorded. Once clinical criteria are established, the appropriate response team members, along with other staff and clinicians, must be organized and educated about criteria and the specific notification process. Once these steps are completed, the program should be ready to roll out.

Are They Reaching Their Goals?
The success of rapid response systems must be assessed systematically with follow-up QI and patient safety goals in mind. Most institutions with rapid response systems have incorporated post-hoc analyses of the medical crises as an essential component of the program. Data collection and analysis for process improvement are essential to the success of the program. Figure 1 illustrates one example of how a rapid response system could be evaluated.

Almost all hospitals and institutions with rapid response teams have designed specific systems of checks and balances, based on their resources. Most important in the aftermath of a medical crisis are evaluation and critique, specifically looking at QI and patient safety issues as part of a process improvement plan. Identifying problems and resolving issues can occur only with ongoing evaluation of the programs. Committees that deal with code response, critical care, patient safety and QI can all help in recording outcomes. These resources can be utilized to provide peer review and root cause analyses.

Many different types of rapid response systems are appearing, each based on the particular needs of a hospital and its patients. The first rapid response systems were usually generic emergency teams that responded to all patients with evidence of clinical deterioration. Many institutions now have adapted this concept to the needs of specific patients. Similar to the long-standing concept of the “cardiac arrest team,” disease-specific rapid response systems, such as trauma teams, chest pain teams, stroke teams, shock teams and obstetrical teams, are being developed. The literature provides few data to support the effectiveness of these specific rapid response teams compared to the generic response teams in the resolution of medical crises. However, one community hospital in Redding, California, USA, reported its results utilizing a “shock team” to respond to nontrauma patients with evidence of shock and hypoperfusion. The hospital’s mortality rate decreased by 12.5%.5 The most recent data (in press), which spans over five years, show even more improvement. The decrease in mortality rate has doubled.

Challenges in Assessing Success
Despite an extraordinary increase in the number of hospitals that have implemented rapid response systems, objective data to support the efficacy of these systems have lagged behind. For many clinicians, it is intuitive that if you respond to a patient in crisis earlier rather than later, the outcome will improve. In fact, some authors suggest that a delay in implementing rapid response systems, awaiting the so-called “gold standard” evidence of their effectiveness, may be unethical.6 We have amassed some impressive data looking at outcomes from patients resuscitated and treated for medical crises. Outcomes such as hospital and ICU lengths of stay and mortality data are now available. Many of these data have been generated from the institutions that started the early rapid response programs. All of the published studies are based on descriptive and retrospective reviews, cohort studies, observational studies, nonrandomized population-based studies and several prospective before-and-after trials. The studies have used different criteria for evaluation and are difficult to compare in terms of their methodologies. Definitions of data elements and terms have not been standardized to enable aggregate and multicenter analysis. The lack of a uniform reporting format for the interventions performed and the subsequent patient outcomes also may hamper reporting outcomes. Although clinical criteria for identifying medical crises have been similar in most programs, the effector response teams have been dissimilar. Many programs involve various team members depending on the hospital’s resources. Some involve intensivist-driven programs, intensivist consult services or nurse-driven outreach programs.

Despite these handicaps in standardizing terminology and team approaches, the common thread to all studies is a significant decrease in hospital and ICU mortality rates and length of stay, a decrease in the number of unexpected emergency admissions to the ICU, and a decrease in the ICU readmission rate. Hospital and ICU mortality rates have been reported to decrease by 12.5% to 26% and by 5.1% to 17%, respec¬tively.5,8,9,10 The number of cardiac arrests has decreased by 17% to 65% – data once again suggesting that if we respond to patients with crises sooner rather than later, cardiac arrests and subsequent higher rates of mortality may be affected.7,8 One could argue about the rigors of the methodology and the lack of prospective, randomized trials, but clear successes are difficult to refute. Future studies of the impact on critical care utilization and saved dollars and lives are essential to the development and implementation of rapid response systems in all hospitals.

Critics of rapid response systems complain about the lack of adequate data that convincingly demonstrate the cost-effectiveness of rapid response systems. However, the quality of medical care in hospitals today is under intense scrutiny by consumers, healthcare organizations and third-party payers, particularly in light of the escalating costs of healthcare and the diminishing returns. Given this scrutiny, can hospitals afford to wait for additional data to support the use of rapid response systems? Are we denying patients their right to expect timely emergent care while they are hospitalized? Can we, as healthcare professionals, afford not to meet our patients’ expectations?
 

Figure 1: Evaluating Rapid Response Systems