1. RRT Data Aggregation and Performance Indicators
Julia T. Lim, MD, MPH
CPT(P), MC, USA
Tripler Army Medical Center
Honolulu, Hawaii

2. Overview Literature review General RRT measures
Data collection process
Tripler experiences

3. Brief Literature Review

4. Review of Literature
Some studies demonstrate a positive impact of RRTs
Significant reduction in incidence of and mortality from unexpected cardiac arrests in hospital1
Medical emergency team decreased incidence of postoperative adverse outcomes, postoperative mortality rate, and mean duration of hospital stay2
PA led RRT with specialized critical care skills – significant decrease in rates of in-hospital cardiac arrest and unplanned ICU admissions3
1. Buist et al, British Medical Journal, 2002:
2. Bellomo et al, Crit Care Med, 2004;32(4):
3. Dacey et al, Crit Care Med, 2007; 35:2076–82.
Some studies show a positive impact of the RRT in reducing cardiac arrests, unanticipated ICU admissions, and/or mortality
Buist study - retrospective study in a 300 bed tertiary referral teaching hospital in Australia comparing data from 1996 and 1999, demonstrated a 50% reduction in cardiac arrest, reduction in mortality by 2 patients/1000 hospital admissions
Bellomo et al – studied 4 month control phase and intervention phase in a university affiliated hospital among >2000 patients undergoing major surgeries (>1000 in each arm); significant decrease in the # of cases of respiratory failure, stroke, severe sepsis, ande acute renal failure, emergency ICU admissions
Dacey et al – 350 bed community hospital in Rhode Island with RRT (critical care nurse with >= 5 yrs experience), respiratory therapist, PA as team leader (PA had undergone intensive airway management course, worked 1 month in the ICU with an intensivist); compared 5 months prior to Rapid response system and 13 months after; showed decrease in overall hospital mortality from 2.82% to 2.35%, and decrease in unplanned ICU admissions to 45% to 29%
Over 20,000 combined medical and surgical admissions in Australia demonstrated a two-thirds reduction in cardiac arrest and mortality, and reduction in post-cardiac arrest bed occupancy
Buist et al .: "Effects of a Medical Emergency Team on Reduction of Incidence of and Mortality From Unexpected Cardiac Arrests in the Hospital: Preliminary Study," British Medical Journal (2002):
Bellomo et al: "A Prospective Before-and-After Trial of a Medical Emergency Team," Medical Journal of Australia 179 (2003):
Devita et al.: "Use of Medical Emergency Team Responses to Reduce Hospital Cardiopulmonary Arrests” Quality and Safety in Healthcare 13 (2004):
MERITInvestigators, "Introduction of the Medical Emergency Team," Lancet, 2005, 365:

5. Review of Literature MERIT study
Randomized study of 23 hospitals in Australia
Hospitals with >20,000 admissions/year
Increase in emergency team calling, but no substantial impact on cardiac arrest, unplanned ICU admissions, or unexpected death
MERIT Investigators, Lancet, 2005, 365:
Conflicting data in literature on whether RRTs reduce cardiac arrests, unanticipated ICU admissions, and/or mortality
23 hospitals randomized in Australia to their system w/o a MET and with a medical emergency team; primary outcome was cardiac arrest, unexpected death, or unplanned ICU admission for 6 month f/u period – no significant change/reduction
Buist et al .: "Effects of a Medical Emergency Team on Reduction of Incidence of and Mortality From Unexpected Cardiac Arrests in the Hospital: Preliminary Study," British Medical Journal (2002):
Bellomo et al: "A Prospective Before-and-After Trial of a Medical Emergency Team," Medical Journal of Australia 179 (2003):
Devita et al.: "Use of Medical Emergency Team Responses to Reduce Hospital Cardiopulmonary Arrests” Quality and Safety in Healthcare 13 (2004):
MERITInvestigators, "Introduction of the Medical Emergency Team," Lancet, 2005, 365:

6. Winters BD et al. Critical Care Medicine, 2007, 35(5):1238-43.
Recent Meta-Analysis
Studies reviewed
8 studies, adult patients (5 historical controls, 1 concurrent control, 2 with cluster-randomized design)
Weak evidence that RRTs are associated with a reduction in hospital mortality and cardiac arrest rates
Limitations in the quality of the original studies and heterogenity of the studies
Meta-analysis included the above mentioned studies (except the recent PA study) and others
Winters BD et al. Critical Care Medicine, 2007, 35(5):

7. Rationale for RRTs
Early recognition of deteriorating patients can prompt intervention and prevent adverse outcomes
May improve morbidity and mortality as well as staff and patient satisfaction
The Institute for Health Care Improvement (IHI) identified RRTs as part of the 100,000 Lives Campaign
Joint Commission 2008 National Patient Safety Goal - early recognition and response to a patient’s condition
Rapid Response Team (RRT) - Team bringing critical care expertise to the patient at first evidence of distress BEFORE deterioration
IHI – Institute for Health Care Improvement:
National initiative designed to improve patient outcomes and prevent avoidable deaths
JCAHO: one of the 2008 National Patient Safety Goals
Recognition and Response to Changes in Patient’s Conditions
Goal 16
Improve recognition and response to changes in a patient’s condition.
Requirement 16A
The organization selects a suitable method that enables health care staff
members to directly request additional assistance from a specially trained
individual(s) when the patient’s condition appears to be worsening.
Rationale for Requirement 16A
A significant number of critical inpatient events are preceded by warning signs for
an average of 6 to 8 hours. Critical events such as cardiopulmonary and
respiratory arrests or changes in patient’s vital signs are estimated to occur in 4%
to 17% of inpatient admissions. Early response by a specially trained
individual(s) to changes in a patient’s condition may reduce cardiopulmonary
arrests and patient mortality.
Note: This requirement has a one-year phase-in period that includes defined
expectations for planning, development, and testing (“milestones”) at 3, 6, and 9
months in 2008, with the expectation of full implementation by January 1, 2009.

8. RRT Measures and Data Collection

9. Key Measures for RRT Effectiveness
Overall unadjusted hospital mortality
Codes per 1000 discharges
Codes outside the ICU
Utilization of RRT (number of RRT calls)

10. Other Outcomes
Post-cardiac arrest ICU bed utilization and hospital days
Staff satisfaction with the RRT
Nursing turnover
Average ICU patient length of stay following an RRT call vs. non-RRT
Unplanned medical-surgical ICU admissions
RRT calls transferred to higher levels of care
Post-cardiac arrest survival rate to discharge

11. Calculating Codes per 1000 discharges
Numerator: total inpatient codes
Exclude those in the ED
Denominator: total inpatient discharges
Exclude stillbirths, deaths in ED patients
Calculation: (numerator/denominator) x 1000
Collection: collect data on monthly basis
Getting Started Kit: RRTs, How-to Guide,

12. Sample Graph – Codes per 1000 discharges
Getting Started Kit: RRTs, How-to Guide,

13. Calculating Percent of Codes Outside ICU
Numerator: in-hospital codes outside the ICU
Exclude codes in ED
Denominator: all in-hospital codes
Calculate: numerator/denominator (%)
Getting Started Kit: RRTs, How-to Guide,

14. Sample Graph – Percent of Codes Outside ICU
Getting Started Kit: RRTs, How-to Guide,

15. Utilization of RRT – Sample Graph
Getting Started Kit: RRTs, How-to Guide,

16. Tripler Army Medical Center Rapid Response Team
P OMOTE YOU PATIEN S SAFETY
R R T
Rapid Response Team

17. TAMC Rapid Response Team
Implemented in November 2006
Coverage 24 hours a day, 7 days a week
“Ramp Up” Model
Comprised of an ICU registered nurse and a respiratory therapist
ICU physician reviews each case and is available for immediate consultation
Distinct from Code Blue Team

18. TAMC Activation Criteria
Heart rate <40 or >130
Respiratory rate <8 or >24
Systolic blood pressure <90
O2 sat <90% on supplemental oxygen
Acute mental status changes
Physician, nurse, or family member concern

19. Responsibilities of the RRT
Respond within 5 minutes of the page
Assess the clinical problem
Immediately determine if a Code Blue call is indicated
Assist primary team physicians with bedside testing and therapies to stabilize patient
Help assess need for transfer to higher level of care and assist with transfer
Primary goal of the RRT is patient safety
RRT serves as an advocate for the patient and bedside staff
Also assist with communication and notify the attending physician team if not already done
Provide education and support

20. Initial call record

21. Revised call record
As of late Nov 2007

22. The Impact of the Rapid Response Team on Patient Care at Tripler Army Medical Center
DCI approved research protocol - The Impact of the Rapid Response Team on Patient Care at Tripler Army Medical Center
CPT Silvia Burgess, MC, USA
CPT(P) Julia Lim, MC, USA
Mrs. Christine Loyle, BA
CPT Jason Burris, MC, USA
COL Stephen Salerno, MC, USA

23. Research Protocol: Study Questions, Part 1
What are the baseline characteristics of patients associated with RRT activation?
What are the most common circumstances for RRT activation?
What are the major interventions performed by the RRT?

24. Research Protocol: Study Questions, Part 2
How do rates of unanticipated transfers to higher levels of care (progressive care and intensive care units) compare before and after RRT implementation?
How do hospital mortality rates compare before and after RRT implementation?

25. Methods: Study Design Part 1
Total of 332 RRT call records reviewed (1 November 2006 – 31 October 2007)
Data collection:
Patient characteristics (age, gender)
Reason(s) for RRT activation
Time of call and location of patient
Vitals when RRT arrived and post intervention
Interventions performed
Need for transfer to higher levels of care
Final outcome of patient (discharge, death)
10 month period (1 Nov 2006 – 30 Aug 2007)

26. Methods: Study Design Part 2
Unanticipated transfers:
Retrospective chart review 12 months pre RRT (1 November October 2006)
1354 records reviewed
Retrospective chart review 12 months post RRT (1 November October 2007)
1331 records reviewed
Death data:
Retrospective chart review of patients who died during their hospitalization pre and post RRT
165 records reviewed
- Patient names were obtained from the Patient Administrative Data Section and included a patient who was ever hospitalized in the PROGRESSIVE care unit or ICU – these charts were individually reviewed to determine if they were direct admissions to the ICU or PROG unit or were the result of an unanticipated transfer requiring higher level of care
- Total number of adult admissions obtained from Patient Administrative Data

27. Methods: Death Data
Electronic adult death records individually reviewed who died during admission
Death categorized as expected:
End of life care
Hospice care
Withdrawal of care
Death categorized as unexpected:
None of the above mentioned

28. Methods: Data Analysis
Chi square test to compare vital signs pre and post RRT intervention
Student’s t-test to compare age, gender, mortality rates, and unexpected transfer rates pre and post RRT

29. Results Total of 332 RRT calls over first 12 months
Mean 27 calls per month
Mean age 61.4 years
69% males
Approx 60% of calls were from the Medicine wards and occurred between

30. TAMC Adult RRT Calls Nov ‘06 – Oct ’07 Total 332 Calls Average 27 calls per month

31. RRT Call Locations

32. Results – Reasons for Activation (total number)

33. Results – Interventions (total number)
The majority of patients were provided supplemental oxygen and had an IV started.
Over 50% of patients received oxygen and had an IV placed

34. Results – Call Dispositions
Over half of patients stayed in the room (56%)
<1/3 of patients were transferred to higher levels of care (31%)

35. TAMC Adult RRT Call Dispositions Remained in Room vs
TAMC Adult RRT Call Dispositions Remained in Room vs. Higher Level of Care

36. RRT Calls – Outcomes of Patients Who Remained in Their Room
Total 183 RRT calls
18 patients had repeat RRT calls, 21 had ≥ 2 unanticipated transfers
148 patients
2 remain hospitalized (1.4%)
130 discharged (88%)
14 died during hospitalization (9.5%)
2 incomplete records

37. RRT Calls – Outcomes of Patients Transferred to PROG / ICU
Total 111 RRT calls
9 patients had repeat RRT calls, 25 had ≥ 2 unanticipated transfers
99 patients
5 remain hospitalized (5%)
69 discharged (70%)
25 died during hospitalization (25%)

38. Results - RRT Interventions
RRT arrival
Post intervention
p-value
Systolic BP (mm Hg)
123.80
123.71
0.33
Diastolic BP (mm Hg)
69.96
69.16
0.20
Heart rate
94.56
89.74
<0.01
Respiratory rate
22.06
21.25
0.02
Pulse oximetry
94.46
97.06
Chi-square testing

39. 12 Months Pre RRT 2.3% of admissions were unexpected transfers
9491 adult admissions
2.3% of admissions were unexpected transfers
1354 patients were in the PROG / ICU
environment during hospitalization
1136 patients were direct
PROG / ICU admissions, or expected
post-surgery or procedure
218 (16.1%) patients were unexpectedly transferred to PROG / ICU
35 (2.6%) patients who stayed in PROG/ ICU died during hospitalization

40. 12 Months Post RRT 2.2% of admissions were unexpected transfers
9456 adult admissions
2.2% of admissions were unexpected transfers
1331 patients were in the PROG / ICU
environment during hospitalization
1123 patients were direct
PROG / ICU admissions, or expected
post-surgery or procedure
208 (15.6%) patients were unexpectedly transferred to PROG / ICU
31 (2.3%) patients who stayed in PROG/ ICU died during hospitalization

41. Results – Death Data Total Deaths Total Deaths: Expected Deaths:
Pre-RRT: 82
Post-RRT: 83
Expected Deaths:
Pre-RRT: 33 (4 additional patients were dead on arrival)
Post-RRT: 46
Unexpected Deaths:
Pre-RRT: 45
Post-RRT: 37
Total Deaths

42. Results- Comparison Pre- and Post- RRT
Pre-RRT
Post-RRT
p-value
Total Adult Admissions
9491
9456 NA
Unexpected Transfers
2.3%
2.2%
0.28
Unexpected Deaths
0.47%
0.39%
0.39
Deaths
0.86%
0.88%
0.72
No statistical difference between unexpected transfers and unexpected deaths pre and post RRT, but this is unadjusted by age or co-morbidities
Unexpected transfers rate: numerator (those unexpectedly transferred)/total adult admissions x100 for a percentage
Unexpected death rate: numerator (those who died “unexpectedly)/total adult admissions x 100 for a percentage
Total death rate: numerator (total deaths)/total adult admissions x 100 for a percentage
Death and transfer unadjusted by age or co-morbidities

43. Results Age (years) Gender (% Male) Unexpected Transfers
Pre RRT
Post RRT
p value
Unexpected Transfers
60.5
60.8
0.84
65%
68%
0.96
Unexpected Deaths
77.1
72.8
0.15
87%
73%
0.12
Total Deaths
71.8
72.2
0.74
76%
77%
0.42
Student’s t-test
All others were pretty even
Note that post-RRT, the mean age of males was decreased, and also the percentage of males was less compared to post RRT
No significant difference pre and post RRT between age and gender

44. Discussion – Part 1
Most RRT calls occurred during the day and were from the inpatient Medicine wards
The most common criteria that prompted RRT activation included staff concern and an abnormal vital sign
Most common RRT interventions included IV access and providing supplemental oxygen

45. Discussion – Part 2
Patients had statistically significant decreased heart rates, respiratory rates, and higher pulse oximetry levels following RRT intervention
No significant change in mortality or unexpected transfer rates of patients to higher levels of care

46. Limitations Retrospective chart review Length of study
Examined crude mortality and transfer rates not adjusted for age or co-morbidities
Limited data on cardiac arrests to compare rates pre & post RRT

47. Future Directions
In-depth chart reviews with adjustment of mortality/unexpected transfer rates
Effect of RRT on length of hospital stay
Determination if standardized scoring systems of acuity in non-ICU settings can predict RRT activation
Survey patients and staff for satisfaction
In-depth chart review to examine:
- associations for medical diagnoses
- lab values
- standardized scoring system (APACHE) - length of hospital stay

48. TAMC Adult RRT Staff Survey Results Nov ’06 – Oct ’07
Amounts to approx 140 surveys (mostly nurses). Each RRT call is supposed to be accompanied by a survey

49. Questions?