Presentation on theme: "Controversies in Rapid Response Systems"— Presentation transcript:
1 Controversies in Rapid Response Systems Carl Hinkson, RRTHarborview Medical CenterA 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 systemsWhat evidence supports their useWhat are the different teams and which is bestWhat triggers should be used to activateOther controversies
3 Rapid Response System History In 1999 the Institute of Medicine published a report, To Err is Human: Building a Safer SystemReport concluded 44,000 – 98,000 people die each year as a result of preventable medical errorsFollowed by the IM Crossing the Quality ChasmCrossing 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 2004Medication ReconciliationPrevention of surgical site infectionsPrevention of ventilator associated pneumoniaEvidence-based care for acute myocardial infarctionsPrevention of central line infectionsRapid Response TeamsThe 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 mechanismTeam provides rapid assessment and triageHere to stay – JCAHO is requiring hospitals to have “rapid response system” in placePatients 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 ComponentsAfferent LimbHow RRS is activatedEfferent LimbHow the RRS respondsEvaluative ProcessData collection on RRS effectivenessAdministrative or Governance StructureHiring/ 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 reviewSearched medical literature databaseFrom possible articles, 8 were determined to be applicable2007Winters 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 ratesLarge randomized trials are needed to prove that RRS are effectiveObservational studies may have been influenced by “Hawthorne” effectRegardless 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 hospitalsSudden decrease in end-points in controlStudy was underpowered
13 What are the different teams and which is best? Medical Emergency Teams (MET)Physician-leadRN & RT supportRamp down modelRapid Response Teams (RRT)RN & RT lead w/ dedicated on call physicianRamp up modelCritical Care Outreach (CCO)RRT/ MET with prospective / proactive componentThese 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 treatmentAdvanced airway management and central venous accessConsExpensiveIntimidating to bedside staff to activateRRT - RN/RT leadProsLess expensiveLess intimidating to beside staff to activateConsLess efficient;Delay to definitive treatmentDacey 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 studiesMET model used in
16 Additional Members? Pharmacists!? Pharmacists are included in the RRS at Long Beach MemorialSupported by IHI and SCCM
17 What triggers should be used? A wide variety of activation criteria existsThere is little evidence to support their validityWinters et al. Rapid response sytems: A systematic review. Crit Care. 2007; 35(5)
18 Types of Triggering Systems Aggregate Scoring SystemsScores combining several physiologic parametersModified Early Warning System (MEWS)Patient At Risk Team (PART) calling criteriaSingle Parameter criteriaRoutine observations of vital signsHarborview RRT calling criteriaCombination scoring systemIncorporates aggregate scoring systemTeam 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 5Combination 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) criteriaRRS activated when patient meets 3 or more criteria or absolute criteriaGoldhill 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 alarmsHigher scores are able to predict poor outcomesConsMore complex for bedside staffSome do not include subjective criteriaClinical triggersProsEasy for bedside staff to useConsMore false alarms
23 Triggering Systems What does the evidence say? At present no studies have compared different activation criteriaNo single activation criteria has been adequately validatedA systematic review by Gao et al was unable adequately compare data due to heterogenity
24 Triggering SystemsSubjective “worry” criteria versus Objective criteriaFamily 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 rescueBetter 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 PennsylvaniaIn 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 systemsWhat evidence supports their useWhat are the different teams and which is bestWhat triggers should be used to activateOther controversies