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Controversies in Rapid Response Systems

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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

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