Effect of a Rapid Response Team on the Incidence of In-Hospital Mortality

Abstract

BACKGROUND: Approximately half of the life-limiting events, such as cardiopulmonary arrests or cardiac arrhythmias occurring in hospitals, are considered preventable. These critical events are usually preceded by clinical deterioration. Rapid response teams (RRTs) were introduced to intervene early in the course of clinical deterioration and possibly prevent progression to an event. An RRT was introduced at the Cleveland Clinic in 2009 and transitioned to an anesthesiologist-led system in 2012. We evaluated the association between in-hospital mortality and: (1) the introduction of the RRT in 2009 (primary analysis), and (2) introduction of the anesthesiologist-led system in 2012 and other policy changes in 2014 (secondary analyses). METHODS: We conducted a single-center, retrospective analysis using the medical records of overnight hospitalizations from March 1, 2005, to December 31, 2018, at the Cleveland Clinic. We assessed the association between the introduction of the RRT in 2009 and in-hospital mortality using segmented regression in a generalized estimating equation model to account for within-subject correlation across repeated visits. Baseline potential confounders (demographic factors and surgery type) were controlled for using inverse probability of treatment weighting on the propensity score. We assessed whether in-hospital mortality changed at the start of the intervention and whether the temporal trend (slope) differed from before to after initiation. Analogous models were used for the secondary outcomes. RESULTS: Of 628,533 hospitalizations in our data set, 177,755 occurred before and 450,778 after introduction of our RRT program. Introduction of the RRT was associated with a slight initial increase in in-hospital mortality (odds ratio [95% confidence interval {CI}], 1.17 [1.09–1.25]; P < .001). However, while the pre-RRT slope in in-hospital mortality over time was flat (odds ratio [95% CI] per year, 1.01 [0.98–1.04]; P = .60), the post-RRT slope decreased over time, with an odds ratio per additional year of 0.961 (0.955–0.968). This represented a significant improvement (P < .001) from the pre-RRT slope. CONCLUSIONS: We found a gradual decrease in mortality over a 9-year period after introduction of an RRT program. Although mechanisms underlying this decrease are unclear, possibilities include optimization of RRT implementation, anesthesiology department leadership of the RRT program, and overall improvements in health care delivery over the study period. Our findings suggest that improvements in outcome after RRT introduction may take years to manifest. Further work is needed to better understand the effects of RRT implementation on in-hospital mortality.

Patients Undergoing Elective Inpatient Major Therapeutic Procedures in Florida Had No Significant Change in Hospital Mortality or Mortality-Related Comorbidities Between 2007 and 2019

“…Our finding that, overall, in-hospital mortality for the subset of Florida surgical patients we studied has been without significant change for more than a decade is consistent with the observation by Factora et al 1 among all inpatients (medical and surgical) of an overall 0.1% decrease between 2005 and 2018. Although we do not have data on the prevalence of rapid response teams at Florida hospitals, we expect implementation at multiple hospitals, as observed in survey studies demonstrating that most US hospitals have them.…”

“…We did not calculate a minimum sample size because we used all the available data. However, Factora et al 1 considered 0.174 to be a “narrow” 95% CI width for the odds ratio corresponding to the step change of their intervention. Our corresponding post hoc 99% CI widths for the odds ratios of changes from ICD-9 to ICD-10 -PCS were even smaller, 0.136 for hypothesis 1 and 0.068 for hypothesis 2.…”

“…From 2005 to 2018, other interventions occurred. 1 Nevertheless, the net reduction in mortality was only ≈0.1%, characterized by Dutton in his accompanying editorial as “tepid.” 2 Dutton postulated several reasons why the reduction in mortality was lower than expected. One explanation was an increase in the degree of illness of hospitalized patients, a consequence of the healthier patients progressively receiving more major surgery, oncological infusions, and other previously inpatient care on an ambulatory basis.…”

In-hospital cardiac arrest: the state of the art

“…Most commonly, IHCA now triggers the presence of a team of specially assigned first responders. These teams may be dedicated only to caring for patients in cardiac arrest or more broadly for peri-arrest or critically ill patients and are sometimes referred to as medical emergency teams (MET) or rapid response teams (RRT) [ 24 , 25 ]. However, cardiac arrest/MET teams are not universal and IHCA patients may be treated by location specific teams [ 21 ].…”

“…However, cardiac arrest/MET teams are not universal and IHCA patients may be treated by location specific teams [ 21 ]. The introduction of RRTs has been attributed to creating a downward trend in hospital mortality since their introduction [ 25 ].…”