Outcomes of second-tier rapid response activations in a tertiary referral hospital: A prospective observational study

Abstract

Introduction: A second-tier rapid response team (RRT) is activated for patients who do not respond to first-tier measures. The premise of a tiered response is that first-tier responses by a ward team may identify and correct early states of deterioration or establish goals of care, thereby reducing unnecessary escalation of care to the RRT. Currently, utilisation and outcomes of tiered RRTs remain poorly described. Methods: A prospective observational study of adult patients (age ≥18 years) who required RRT activations was conducted from February 2018 to December 2019. Results: There were 951 consecutive RRT activations from 869 patients and 76.0% patients had a National Early Warning Score (NEWS) ≥5 at the time of RRT activation. The majority (79.8%) of patients required RRT interventions that included endotracheal intubation (12.7%), point-of-care ultrasound (17.0%), discussing goals of care (14.7%) and intensive care unit (ICU) admission (24.2%). Approximately 1 in 3 (36.6%) patients died during hospitalisation or within 30 days of RRT activation. In multivariate analysis, age ≥65 years, NEWS ≥7, ICU admission, longer hospitalisation days at RRT activation, Eastern Cooperative Oncology Group performance scores ≥3 (OR [odds ratio] 2.24, 95% CI [confidence interval] 1.45–3.46), metastatic cancer (OR 2.64, 95% CI 1.71–4.08) and haematological cancer (OR 2.78, 95% CI 1.84–4.19) were independently associated with mortality. Conclusion: Critical care interventions and escalation of care are common with second-tier RRTs. This supports the need for dedicated teams with specialised critical care services. Poor functional status, metastatic and haematological cancer are significantly associated with mortality, independent of age, NEWS and ICU admission. These factors should be considered during triage and goals of care discussion. Keywords: Clinical deterioration, critical care, intensive care, mortality, rapid response system, rapid response team

In-hospital outcomes among older medical inpatients admitted to aged care wards after activation of a 2-tier rapid response system

“…In New South Wales, the MET and CRC activation criteria have not changed substantially for more than 10 years [ 5 , 17 ]. Many RRS in Australia and in other countries use similar activation criteria, though the number of criteria and thresholds for heart rate, blood pressure, respiratory rate and mental state may vary [ 14 , 18 ]. Whereas the MET was attended by an intensive care registrar, a medical registrar and an intensive care nurse, most CRCs were attended by a single junior doctor.…”

“…Graded RRS have been implemented in Australia, the United Kingdom and Ireland as best practice [ 4 ]. Whereas the United Kingdom uses three levels of response (low, medium and high) [ 4 , 11 ], 2-tier RRS are commonly used in Australia [ 5 , 9 , 12 , 13 ] and elsewhere [ 14 ]. A 2-tier RRS with standard calling criteria and standard observation charts (known as ‘Between the Flags’) was established by the Clinical Excellence Commission [ 15 ] and implemented in 2010 in over 225 New South Wales (Australia) hospitals.…”

“…A 2-tier RRS with standard calling criteria and standard observation charts (known as ‘Between the Flags’) was established by the Clinical Excellence Commission [ 15 ] and implemented in 2010 in over 225 New South Wales (Australia) hospitals. In order to balance clinical effectiveness and limited intensive care resources, similarly structured RRS have been implemented elsewhere in Australia [ 9 , 12 , 13 , 16 ] and overseas [ 14 ]. The primary goals of the first tier are to recognise and correct early physiological instability, identify patients unlikely to benefit from aggressive medical therapy, and reduce the number of more urgent calls.…”

“…The primary goals of the first tier are to recognise and correct early physiological instability, identify patients unlikely to benefit from aggressive medical therapy, and reduce the number of more urgent calls. The main goal of the second tier is to respond to appropriate patients who fail to improve with first-tier interventions [ 14 ]. Tier activation, however, does not necessarily follow this order (e.g., immediate second tier activation for cardiac or respiratory arrests, or serious concern by staff).…”

“…Although multitiered RRS are not a new concept, there is considerable heterogeneity in patient and RRS characteristics of such teams [ 9 , 12 – 14 , 16 ], making it difficult to evaluate the outcomes of patients requiring this intervention. Furthermore, the utilisation and outcomes of multitiered RRS are poorly established in older populations.…”