Reduction in hospital-wide mortality after implementation of a rapid response team: a long-term cohort study

Abstract

IntroductionRapid response teams (RRTs) have been shown to reduce cardiopulmonary arrests outside the intensive care unit (ICU). Yet the utility of RRTs remains in question, as most large studies have failed to demonstrate a significant reduction in hospital-wide mortality after RRT implementation.MethodsA cohort design with historical controls was used to determine the effect on hospital-wide mortality of an RRT in which clinical judgment, in addition to vital-signs criteria, was widely promoted as a key trigger for activation. All nonprisoner patients admitted to a tertiary referral public teaching hospital from 2003 through 2008 were included. In total, 77, 021 admissions before RRT implementation (2003 through 2005) and 79, 013 admissions after RRT implementation (2006 through 2008) were evaluated. The a priori primary outcome was unadjusted hospital-wide mortality. A Poisson regression model was then used to adjust for hospital-wide mortality trends over time. Secondary outcomes defined a priori were unadjusted out-of-ICU mortality and out-of-ICU cardiopulmonary-arrest codes.ResultsIn total, 855 inpatient RRTs (10.8 per 1, 000 hospital-wide discharges) were activated during the 3-year postintervention period. Forty-seven percent of RRTs were activated for reasons of clinical judgment. Hospital-wide mortality decreased from 15.50 to 13.74 deaths per 1, 000 discharges after RRT implementation (relative risk, 0.887; 95% confidence interval (CI), 0.817 to 0.963; P = 0.004). After adjusting for inpatient mortality trends over time, the reduction in hospital-wide mortality remained statistically significant (relative risk, 0.825; 95% CI, 0.694 to 0.981; P = 0.029). Out-of-ICU mortality decreased from 7.08 to 4.61 deaths per 1, 000 discharges (relative risk, 0.651; 95% CI, 0.570 to 0.743; P < 0.001). Out-of-ICU cardiopulmonary-arrest codes decreased from 3.28 to 1.62 codes per 1, 000 discharges (relative risk, 0.493; 95% CI, 0.399 to 0.610; P < 0.001).ConclusionsImplementation of an RRT in which clinical judgment, in addition to vital-signs criteria, was widely cited as a rationale for activation, was associated with a significant reduction in hospital-wide mortality, out-of-ICU mortality, and out-of-ICU cardiopulmonary-arrest codes. The frequent use of clinical judgment as a criterion for RRT activation was associated with high RRT utilization.

Part 8: Education, Implementation, and Teams

“…218 The other study demonstrated a significant difference between control wards and intervention wards (introduction of a critical care outreach service) with all patients (OR, 0.70; 95% CI, 0.50-0.97), and matched randomized patients (OR, 0.52; 95% CI, 0.32-0.85). 219 Of the 33 nonrandomized studies reporting mortality, no studies reported statistically significant worse outcomes for the intervention; 15 studies with no adjustment demonstrated no significant improvement [220][221][222][223][224][225][226][227][228][229][230][231][232][233][234] ; 6 studies with no adjustment demonstrated significant improvement [235][236][237][238][239][240] ; 1 study with no adjustment reported on rates, which improved with MET, but did not report on significance 241 ; 1 study with no adjustment demonstrated significant improvement for medical patients but not surgical patients (combined significance not reported) 242 ; 4 studies with adjustment demonstrated significant improvement both before and after adjustment 243,244,250,252 ; 2 studies with adjustment demonstrated no significant improvement both before and after adjustment 245,246 ; 2 studies with adjustment demonstrated significant improvement before adjustment but not after adjustment 247,251 ; 1 study with adjustment demonstrated significant improvement before adjustment but not after adjustment 27 ; 1 study that reported on both unexpected mortality and overall mortality showed significant improvement both before and after adjustment for unexpected mortality but no significant improvement both before and after adj...…”

Rapid Response Systems: Are they Really Effective?

“…Results of earlier studies in terms of hospital mortality were conflicting, with several studies [8,14], [17][18][19][20][21][22][23] showing a reduction and others [9,11,13,[24][25][26][27][28] showing no change or even an increase [29] in hospital mortality following rapid response system implementation. A systematic review and meta-analysis from Chan et al [11] did not demonstrate any overall benefit from rapid response systems in terms of hospital mortality (pooled RR = 0.96 [0.84-1.09]) with a significant heterogeneity of results (I 2 = 90.3%; p < 0.001).…”

“…Only a few studies [8,11,14,20,24,30,31] limited the analysis to cardiac arrests outside the ICU and none of these studies conducted any blinded outcome assessment. Almost all studies on rapid response systems have a before-and-after design, which makes them prone to bias.…”

Designing a Critical Care Nurse–Led Rapid Response Team Using Only Available Resources: 6 Years Later

“…33 In addition to vital signs criteria, judgment that prompt assistance was needed at the bedside was emphasized to staff as an important criterion for RRT activation by Beitler and colleagues. 40 As a result, they reported significant reductions in hospital-wide mortality, out-of-ICU mortality, and out-of-ICU cardiopulmonary arrests. 40 Although outcomes vary from study to study, the beneficial effects of RRTs are becoming clearer as the intervention is more universally applied.…”

“…40 As a result, they reported significant reductions in hospital-wide mortality, out-of-ICU mortality, and out-of-ICU cardiopulmonary arrests. 40 Although outcomes vary from study to study, the beneficial effects of RRTs are becoming clearer as the intervention is more universally applied. Benefit has been reported in many hospital settings using a variety of RRS models even though this has not firmly translated into a consistent reduction in overall hospital mortality.…”