1. Controversies in Rapid Response Systems
Carl Hinkson, RRT
Harborview Medical Center
A year ago Joel gave an eloquent presentation on development, the structure and implementation of RRS that we use at HMC. This year we decided to take a different approach and discuss the controversies in RRS.
In interest of full disclosure I must say I am the one who is wary of the RRS

2. 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

3. 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
Crossing the Quality Chasm Made thirteen recommendations for restructuring the healthcare continuum.

4. 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
The Institute for Healthcare Improvement (IHI) is a not-for-profit organization leading the improvement of health care throughout the world. IHI was founded in 1991 and is based in Cambridge, Massachusetts. IHI's work is funded primarily through our own fee-based program offerings and services, and also through the generous support of a distinguished group of foundations, companies, and individuals.
The IHI has since 2004 increased their campaign to saving 5 million lives

5. 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
Patients Exhibit clinical warning signs 8-12 hours before an event (cardiac arrest or respiratory arrest). The goal is to have clinicians at the bedside before patient deteriorates significantly

6. 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

7. Rapid Response Systems
DeVita et al. Findings of the First Consensus Conference on Medical Emergency Teams. Crit Care Med. 2006; 34(9):

8. What does the evidence say?
Winter’s et al conducted a literature review
Searched medical literature database
From possible articles, 8 were determined to be applicable
2007
Winters et al. Rapid response sytems: A systematic review. Crit Care. 2007; 35(5):

9. Evidence to Support RRS
Winters et al. Rapid response sytems: A systematic review. Crit Care. 2007; 35(5)

10. Evidence to Support RRS
Winters et al. Rapid response sytems: A systematic review. Crit Care. 2007; 35(5)

11. 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
Regardless of the evidence, everyone is going to have a rapid response team anyway.

12. 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

13. 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
These terms come from the first consensus conference on Rapid response systems

14. Which team is best? MET- MD lead Pros: Cons RRT - RN/RT lead Pros Cons
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
Dacey et conducted a pre / post test study where physician assistants were used instead of MDs. Their study showed a decrease in mortality similar to other studies of similar design.

15. Which team is best? MET vs RRT Response Teams:
No mortality difference in observational studies
MET model used in

16. Additional Members? Pharmacists!?
Pharmacists are included in the RRS at Long Beach Memorial
Supported by IHI and SCCM

17. 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)

18. 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”
Scoring systems are popular in the UK and Australia, single parameter criteria “seem” to be more popular in the US

19. Aggregate Scoring Methods
Modified Early Warning System (MEWS)
RRS is activated when score >4 or 5
Combination Scoring System includes MEWS AND when one of the criteria score their maximum score.
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

20. 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:

21. 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

22. Triggering Systems Scoring System Pros Cons Clinical triggers 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

23. 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

24. Triggering Systems
Subjective “worry” criteria versus Objective criteria
Family members activating RRS?

25. Should We Have Continuous Monitoring for Everyone?
Non-invasive bed monitoring system that continuously monitors heart rate and respiratory rate

26. 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’
10,184 RNs surveyed in Pennsylvania
In another study by Aiken et al, the authors demonstrated that In hospitals with higher proportions of nurses educated at the baccalaureate level or higher, surgical patients experienced lower mortality and failure-to-rescue rates.

27. 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