Transcript Controversies in Rapid Response Systems Carl Hinkson, RRT Harborview Medical Center Table of Contents • • • • Evolution of Rapid Response systems What are Rapid Response systems What evidence supports.

Controversies in Rapid
Response Systems
Carl Hinkson, RRT
Harborview Medical Center
Table of Contents
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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
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
Rapid Response System History
• The Institute of Healthcare Improvement
launched their “Saving 100,000 lives campaign”
which featured six “planks” in 2004
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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
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
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
Rapid Response Systems
DeVita et al. Findings of the First Consensus Conference on Medical
Emergency Teams. Crit Care Med. 2006; 34(9): 2463-2478.
What does the evidence say?
• Winter’s et al conducted a literature review
– Searched medical literature database
– From 10228 possible articles, 8 were
determined to be applicable
Winters et al. Rapid response sytems: A systematic review. Crit Care. 2007; 35(5):
1238-1243
Evidence to Support RRS
Winters et al. Rapid response sytems: A systematic review. Crit Care.
2007; 35(5) 1238-1243.
Evidence to Support RRS
Winters et al. Rapid response sytems: A systematic review. Crit Care. 2007; 35(5)
1238-1243
• 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
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
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
Which team is best?
MET- MD lead
• Pros:
– 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
Which team is best?
• MET vs RRT Response Teams:
• No mortality difference in observational
studies
Additional Members?
• Pharmacists!?
– Pharmacists are included in the RRS at Long
Beach Memorial
– Supported by IHI and SCCM
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) 1238-1243.
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”
Aggregate Scoring Methods
• Modified Early Warning System (MEWS)
– RRS is activated when score >4 or 5
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
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: 853-860
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
Triggering Systems
Scoring System
• 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
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
Triggering Systems
• Subjective “worry” criteria versus Objective
criteria
• Family members activating RRS?
• Should We Have Continuous Monitoring
for Everyone?
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’
Summary
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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