Rapid response teams improve outcomes: no

Abstract

Rapid response systems (RRS) have been widely endorsed and adopted by hospital systems in industrialized countries to respond to deteriorating patients outside the intensive care unit (ICU) [1]. There is face validity in the idea that a system that promotes early recognition of deterioration and the implementation of time-critical interventions would save lives. Recent systematic reviews point to the potential effectiveness of RRS, but important caveats need to be considered [2][3][4].The vast majority of studies included in these analyses were before-after studies with no contemporaneous control (Table 1) [2,3]. Whilst this methodology is simple to implement and understand, the absence of a control group limits causal inference. The observed effects may be due to changes in case-mix, referral patterns, or overall improvements of ward-based care over time independent of an RRS. It is often unclear from the reported studies whether there were other interventions occurring at the same time.Bristow and colleagues performed a controlled beforeafter study comparing an intervention hospital to two control hospitals contemporaneously [5]. This methodology can account for secular trends, but does not completely account for baseline differences. Hospitals may experience changes not attributable to the intervention and not accounted for by regression techniques. The unadjusted analysis suggested benefit from implementation of the RRS, but the adjusted analysis yielded conflicting results [5]. After adjustment one control hospital performed worse while the other performed better than the RRS hospital. This suggests that the observed treatment effect of the RRS may be significantly attributable to observed and unobserved baseline imbalances.The interrupted time series (ITS) conducted by Howell and colleagues is a more robust methodology [6]. Their study of an RRS in an academic center found a reduction in unexpected mortality [patients without a do not attempt resuscitation (DNAR) order], but no reduction in overall hospital mortality [6]. The reasons for this observation are unclear. About 8 % of RRS activations led to a DNAR order, but it is unlikely that increased utilization of DNAR orders would completely account for the observed difference in expected and overall hospital mortality. The ITS design does not account for time-varying confounders and other unmeasured events unrelated to the study intervention. For example, the introduction of the RRS may have coincided with a general increased utilization of DNAR orders independent of the RRS. This study utilized the patient's usual care team and mandated communication with the patient's treating physician within 1 h of activation using explicit criteria [6]. This raises the possibility that the RRS acted as a substitute for timely senior clinical input from the usual care team [7].Priestley and Hillman performed experimental evaluations of RRS [8,9]. Rapid response systems are applied at a system level and individual patient randomization risks contamination between cont...

Factors influencing the activation of the rapid response system for clinically deteriorating patients by frontline ward clinicians: a systematic review

“…Some proponents have questioned the existence of the tangible benefits of the RRS and suggested the need for higher level research and randomized controlled trials while others argued that the benefits are self-evident. Several authors have also attributed the conflicting evidence regarding the effectiveness of the RRS to delay or failure in ward clinicians to activate the RRT despite patients fulfilling the activation criteria [ 24 , 27 , 29 – 32 ]. An epidemiology review of adult RRT patients in Australia revealed that close to 50% of the activations were delayed [ 33 ].…”

Patient characteristics, interventions and outcomes of 1151 rapid response team activations in a tertiary hospital: a prospective study

“…The most common medical comorbidities were moderate to severe chronic kidney disease (defined as baseline estimated glomerular filtration rate <60 mL/min) affecting 239 (29.9%) patients, chronic pulmonary disease (219; 27.4%), ischaemic heart disease (202; 25.3%) and diabetes mellitus (193; 24.1%). The median Charlson comorbidity index (Table ) was six (IQR = 6), with 285 (35.6%) patients having a very high score (score >7), 166 (20.8%) a high score (score , ), 145 (18.1%) a medium score (score , ) and 204 (25.5%) a low score (0–3).…”

“…Such systems aim to rapidly identify clinically deteriorating patients (afferent limb) and activate appropriately trained teams (rapid response teams (RRT)) who provide resuscitative interventions (efferent limb), thereby preventing subsequent cardiac arrests and in‐hospital deaths . Whether RRS actually achieve these outcomes is still debated . Multiple studies, including several systematic reviews, report mixed results with regards to overall in‐hospital mortality …”

The Simulation-Based Assessment of Pediatric Rapid Response Teams

“…12,13,14,15 There is evidence of both improvement and lack thereof in patient outcomes in studies of RRTs. 16,17 Numerous factors may contribute to negative results, particularly in pediatrics, including the training and composition of RRTs and the diverse clinical conditions that pediatric RRTs must recognize and manage. In addition, the impact of a RRT may be attenuated at an institution where there is a strong preexisting patient care infrastructure.…”