Resident and RN perceptions of the impact of a medical emergency team on education and patient safety in an academic medical center

Intensive Care Unit Without Walls

Critical illness is a continuum with different phases and trajectories. The "Intensive Care Unit (ICU) without walls" concept refers to a model whereby care is adjusted in response to the patient's needs, priorities, and preferences at each stage from detection, escalation, early decision making, treatment and organ support, followed by recovery and rehabilitation, within which all healthcare staff, and the patient are equal partners. The rapid response system incorporates monitoring and alerting tools, a multidisciplinary critical care outreach team and care bundles, supported with education and training, analytical and governance functions, which combine to optimise outcomes of critically ill patients, independent of location.

Advanced practice providers versus medical residents as leaders of rapid response teams: A 12-month retrospective analysis

Purpose

In a time of worldwide physician shortages, the advanced practice providers (APPs) might be a good alternative for physicians as the leaders of a rapid response team. This retrospective analysis aimed to establish whether the performance of APP-led rapid response teams is comparable to the performance of rapid response teams led by a medical resident of the ICU.

Material and methods

In a retrospective single-center cohort study, the electronic medical record of a tertiary hospital was queried during a 12-months period to identify patients who had been visited by our rapid response team. Patient- and process-related outcomes of interventions of rapid response teams led by an APP were compared with those of teams led by a medical resident using various parameters, including the MAELOR tool, which measures the performance of a rapid response team.

Results

In total, 179 responses of the APP-led teams were analyzed, versus 275 responses of the teams led by a resident. Per APP, twice as many calls were handled than per resident. Interventions of teams led by APPs, and residents did not differ in number of admissions (p = 0.87), mortality (p = 0.8), early warning scores (p = 0.2) or MAELOR tool triggering (p = 0.19). Both groups scored equally on time to admission (p = 0.67) or time until any performed intervention.

Conclusion

This retrospective analysis showed that the quality of APP-led rapid response teams was similar to the quality of teams led by a resident. These findings need to be confirmed by prospective studies with balanced outcome parameters.

Development of Neurological Emergency Simulations for Assessment: Content Evidence and Response Process

OBJECTIVE

To document two sources of validity evidence for simulation-based assessment in neurological emergencies.

BACKGROUND

A critical aspect of education is development of evaluation techniques that assess learner's performance in settings that reflect actual clinical practice. Simulation-based evaluation affords the opportunity to standardize evaluations but requires validation.

METHODS

We identified topics from the Neurocritical Care Society's Emergency Neurological Life Support (ENLS) training, cross-referenced with the American Academy of Neurology's core clerkship curriculum. We used a modified Delphi method to develop simulations for assessment in neurocritical care. We constructed checklists of action items and communication skills, merging ENLS checklists with relevant clinical guidelines. We also utilized global rating scales, rated one (novice) through five (expert) for each case. Participants included neurology sub-interns, neurology residents, neurosurgery interns, non-neurology critical care fellows, neurocritical care fellows, and neurology attending physicians.

RESULTS

Ten evaluative simulation cases were developed. To date, 64 participants have taken part in 274 evaluative simulation scenarios. The participants were very satisfied with the cases (Likert scale 1-7, not at all satisfied-very satisfied, median 7, interquartile range (IQR) 7-7), found them to be very realistic (Likert scale 1-7, not at all realistic-very realistic, median 6, IQR 6-7), and appropriately difficult (Likert scale 1-7, much too easy-much too difficult, median 4, IQR 4-5). Interrater reliability was acceptable for both checklist action items (kappa = 0.64) and global rating scales (Pearson correlation r = .70).

CONCLUSIONS

We demonstrated two sources of validity in ten simulation cases for assessment in neurological emergencies.

Quels sont le fonctionnement, les caractéristiques, les effets et les modalités d’implantation des équipes d’intervention rapide ? Une revue de la littérature

Introduction : Hospitalized patients are at risk of unrecognized clinical deterioration that may lead to adverse events.Context : Rapid Response Teams (RRTs) exist around the world as a strategy to improve patient safety.Objective : To explore how RRTs work, their characteristics, impacts, and methods of implementation.Design : Literature review.Method : Consultation of the databases CINAHL, MEDLINE, PUBMED, COCHRANE library, SCOPUS, and PROQUEST Dissertations and Theses. Keywords : “health care team” and “rapid response team”.Results : 121 articles were included. The collected data were divided into five categories : 1) composition and operation of RRTs, 2) benefits and limitations of RRTs, 3) perceptions of RRTs by health care teams, organizations, and patients, 4) implementation strategies, and 5) facilitators and barriers to implementation.Discussion : Although there are many articles related to RRTs, it appears that : 1) few studies analyze the difference in outcomes in hospitalized patients related to the composition of RRTs, 2) few studies describe how RRTs should work, 3) more studies are needed on the impacts of RRTs on hospitalized patients, 4) organizations’ and patients’ perceptions of RRTs are not well studied, and 5) more studies are needed on the best way to implement an RRT.Conclusion : The results show that there is a lack of studies on the difference in outcomes in hospitalized patients related to the composition of RRTs, on how RRTs should work, on the impacts of RRTs on hospitalized patients, on organizations’ and patients’ perceptions of RRTs, and on the factors that influence the success or failure of the implementation of an RRT.

Predictors of mortality and cost among surgical patients requiring rapid response team activation

Background

Prior studies of rapid response team (RRT) implementation for surgical patients have demonstrated mixed results with respect to reductions in poor outcomes. The aim of this study was to identify predictors of in-hospital mortality and hospital costs among surgical inpatients requiring RRT activation.

Methods

We analyzed data prospectively collected from May 2012 to May 2016 at The Ottawa Hospital. We included patients who were at least 18 years of age, who were admitted to hospital, who received either preoperative or postoperative care, and and who required RRT activation. We created a multivariable logistic regression model to describe mortality predictors and a multivariable generalized linear model to describe cost predictors.

Results

We included 1507 patients. The in-hospital mortality rate was 15.9%. The patient-related factors most strongly associated with mortality included an Elixhauser Comorbidity Index score of 20 or higher (odds ratio [OR] 3.60, 95% confidence interval [CI] 1.96-6.60) and care designations excluding admission to the intensive care unit and cardiopulmonary resuscitation (OR 3.52, 95% CI 2.25-5.52). The strongest surgical predictors included neurosurgical admission (OR 2.09, 95% CI 1.17-3.75), emergent surgery (OR 2.04, 95% CI 1.37-3.03) and occurrence of 2 or more operations (OR 1.73, 95% CI 1.21-2.46). Among RRT factors, occurrence of 2 or more RRT assessments (OR 2.01, 95% CI 1.44-2.80) conferred the highest mortality. Increased cost was strongly associated with admitting service, multiple surgeries, multiple RRT assessments and medical comorbidity.

Conclusion

RRT activation among surgical inpatients identifies a population at high risk of death. We identified several predictors of mortality and cost, which represent opportunities for future quality improvement and patient safety initiatives.

Sustaining Innovations in Complex Health Care Environments: A Multiple-Case Study of Rapid Response Teams

OBJECTIVES

Rapid response teams (RRTs) are one innovation previously deployed in U.S. hospitals with the goal to improve the quality of care. Sustaining RRTs is important to achieve the desired implementation outcomes, reduce the risk of program investment losses, and prevent employee disillusionment and dissatisfaction. This study sought to examine factors that do and do not support the sustainability of RRTs.

METHODS

The study was conceptually guided by an adapted version of the Planning Model of Sustainability. A multiple-case study was conducted using a purposive sample of 2 hospitals with high RRT sustainability scores and 2 hospitals with low RRT sustainability scores. Data collection methods included (a) a hospital questionnaire that was completed by a nurse administrator at each hospital; (b) semistructured interviews with leaders, RRT members, and those activating RRT calls; and (c) a review of internal documents. Quantitative data were analyzed using descriptive statistics; qualitative data were analyzed using content analysis.

RESULTS

Few descriptive differences were found between hospitals. However, there were notable differences in the operationalization of certain factors between high- and low-sustainability hospitals. Additional sustainability factors other than those captured by the Planning Model of Sustainability were also identified.

CONCLUSIONS

The sustainability of RRTs is optimized through effective operationalization of organizational and project design and implementation factors. Two additional factors-individual and team characteristics-should be included in the Planning Model of Sustainability and considered as potential facilitators (or inhibitors) of RRT sustainability.

Improving medical emergency system: Results of a multi-professional questionnaire

OBJECTIVE

This study aimed to identify ways to improve the Medical Emergency System (MES) in its different components and infer Medical Emergency Team (MET) activation failure causes.

METHODS

A questionnaire regarding opinions and attitudes towards the MES was conducted, targeting all professionals at the hospital, which has an implemented MES with Basic Life Support (BLS) since 1998.

RESULTS

Thirty two percent (n=585) of hospital professionals answered, from these 37.8% were neither doctors nor nurses. In mean six years passed since the BLS certification, yet 102 professionals (17.4%) had not done it. A relevant percentage admitted to not being familiarized with the different components of the MES (activation criteria 16.4%, telephone number 4.1%, content of the resuscitation trolleys 42.4% and defibrillator-monitor 47.4%), percentages lessened among those had taken the BLS course. The majority highly valued MET, however 83 (23%) could not confirm that debriefingand 17 (4.4%) that allocation of tasks happened after and during activation, respectively. When activating MET 52 (18.1%) admitted fear of criticism and 38 (13.3%) agreed that they needed validation by another professional, factors not influenced by BLS course completion. Excessive workload as a barrier to recognize ill patients was pointed by 127 (45.7%) of the respondents.

CONCLUSION

Despite educational and auditing efforts, the MES is not fully integrated into hospital culture. BLS certification for all professionals and non-technical skills of MET were identified has major areas for MES improvement. Unfamiliarity with activation criteria, fear of criticism and excessive workload were identified as failure of activation causes.

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

Purpose

To synthesize factors influencing the activation of the rapid response system (RRS) and reasons for suboptimal RRS activation by ward nurses and junior physicians.

Data sources

Nine electronic databases were searched for articles published between January 1995 and January 2016 in addition to a hand-search of reference lists and relevant journals.

Study selection

Published primary studies conducted in adult general ward settings and involved the experiences and views of ward nurses and/or junior physicians in RRS activation were included.

Data extraction

Data on design, methods and key findings were extracted and collated.

Results of data synthesis

Thirty studies were included for the review. The process to RRS activation was influenced by the perceptions and clinical experiences of ward nurses and physicians, and facilitated by tools and technologies, including the sensitivity and specificity of the activation criteria, and monitoring technology. However, the task of enacting the RRS activations was challenged by seeking further justification, deliberating over reactions from the rapid response team and the impact of workload and staffing. Finally, adherence to the traditional model of escalation of care, support from colleagues and hospital leaders, and staff training were organizational factors that influence RRS activation.

Conclusion

This review suggests that the factors influencing RRS activation originated from a combination of socio-cultural, organizational and technical aspects. Institutions that strive for improvements in the existing RRS or are considering to adopt the RRS should consider the complex interactions between people and the elements of technologies, tasks, environment and organization in healthcare settings.

Recognising and responding to in-hospital clinical deterioration: An integrative review of interprofessional practice issues

AIMS AND OBJECTIVES

To identify, appraise and synthesise current evidence regarding organisation-wide interprofessional practice issues that facilitate or inhibit effective recognition and response to clinical deterioration, using a theoretical rapid response system model.

BACKGROUND

Recognition and response to clinical deterioration, in adult general medical-surgical ward patients, is embedded as routine interprofessional practice in acute healthcare organisations worldwide. The process of care escalation is complex and sometimes involves multiple health professionals from different disciplines with varying levels of expertise. While a theoretical rapid response system model offers a formalised structured approach to escalate patient care, it is unclear how the implementation of this model, or similar, influences rapid response system-wide interprofessional practices to effectively recognise and respond to clinical deterioration.

DESIGN

An integrative review.

METHODS

This review was conducted using key words to systematically search four electronic bibliographic databases (PubMed, CINAHL, ProQuest Central, Cochrane Library). Twenty-nine eligible full-text papers were identified. Quality appraisal of methods was performed using recommended guidelines. Study findings were narratively coded, themed and conceptualised in the context of an organisation-wide rapid response system using an interprofessional collaborative practice framework.

RESULTS

Five main themes aligned with the four interprofessional collaborative practice competency domains and a learning continuum of professional development: Organisational culture, Role perceptions and professional accountability, Communication of clinical needs, Team-based practices, and Interprofessional learning opportunities in recognising and responding to clinical deterioration. Within these themes, three notable interprofessional practice issues were highlighted: professional reporting hierarchies (inhibiting), critical care outreach services (facilitating) and interprofessional relationships (facilitating).

CONCLUSIONS

A unique approach for exploring organisation-wide interprofessional practice issues has been presented using an interprofessional collaborative practice framework. Further interpretive organisation-wide research is necessary to develop a more in-depth and meaningful understanding of interprofessional collaborative practice issues that facilitate or inhibit effective recognition and response to clinical deterioration.

RELEVANCE TO CLINICAL PRACTICE

This review presents a unique system-wide approach for exploring how health professionals interprofessionally collaborate in practice to effectively recognise and respond to clinical deterioration.

The limitations in implementing and operating a rapid response system

Despite the widespread introduction of rapid response systems (RRS)/medical emergency teams (MET), there is still controversy regarding how effective they are. While there are some observational studies showing improved outcomes with RRS, there are no data from randomised controlled trials to support the effectiveness. Nevertheless, the MET system has become a standard of care in many healthcare organisations. In this review, we present an overview of the limitations in implementing and operating a RRS in modern healthcare.

Original Research: The Benefits of Rapid Response Teams: Exploring Perceptions of Nurse Leaders, Team Members, and End Users

: The perceived benefits of rapid response teams (RRTs) influence whether RRTs are used and sustained. Perceived benefits are particularly important to sustaining RRTs when limited RRT data are shared with organizational members. Nurse leaders' perceptions of the benefits of RRTs likely influence their support, which is crucial for sustained RRT use. The perceptions of RRT members and end users similarly will affect use. But little is known regarding the perceptions of nurse leaders, RRT members, and RRT users in this regard.This study sought to explore and compare the perceptions of nurse leaders, RRT members, and RRT users regarding the benefits of RRTs.A qualitative, multiple-case study design was used. Semistructured interviews were conducted with nurse leaders, RRT members, and RRT users at four community hospitals, as part of a larger mixed-methods study examining RRT sustainability. Purposive and snowball sampling were used. Recruitment strategies included e-mail and listserv announcements, on-site presentations, direct personal contact, and a study flyer.All participants reported perceiving various ways that RRTs benefit the organization, staff members, and patients. Variations in the benefits perceived were observed between the three participant groups. Nurse leaders' perceptions tended to focus on macro-level benefits. RRT members emphasized the teaching and learning opportunities that RRTs offer. RRT users focused on the psychological support that RRTs can provide.Both similarities and differences were found between nurse leaders, RRT members, and RRT users regarding their perceptions of RRT benefits. Differences may be indicative of organizations' information-sharing processes; of variation in the priorities of nurse leaders, RRT members, and RRT users; and of the challenges nurses face daily in their work environments. Future research should investigate whether the perceived benefits of RRTs are borne out in actuality, as well as the relationships between the perceived benefits of RRTs and organizational and RRT characteristics.

A Survey of Hospitals That Participated in a Statewide Collaborative to Implement and Sustain Rapid Response Teams

OBJECTIVES

To determine the level of sustainability of rapid response teams (RRTs) among a group of hospitals that participated in a statewide collaborative to implement and sustain RRTs.

SETTING AND SAMPLE

Fifty-six hospitals located in a southeastern state in the United States participated in a statewide 9-month collaborative that provided organization leaders with resources to implement and sustain RRTs. Thirty-three of these hospitals completed the electronic survey. Two hospitals were excluded because of missing data.

MEASUREMENT

The RRT-Institutionalization Scale (RRT-IS), adapted from the Level of Institutionalization Scale, measured the degree of institutionalization (i.e., passages, routines, and niche saturation) across four subsystems: production, maintenance, supportive, and managerial.

RESULTS

Thirty-one hospitals participated (response rate 55%). Rapid response team sustainability levels ranged from 1.0 to 5.98 (mean = 3.78, 95% CI = 3.40-4.17). The highest sustainability score was reported in the managerial subsystem (median = 5.3, IQR = 4.5-7.33), and the lowest score was reported in the supportive subsystem (median = 1.0, IQR = 1.0-2.0).

CONCLUSIONS

Rapid response team sustainability levels varied across hospitals in the collaborative. Different levels of sustainability were also observed across organizational subsystems. The lack of resources, staff, and dedicated funds hampered organizations' sustainability efforts.

Designing a critical care nurse-led rapid response team using only available resources: 6 years later

Rapid response teams have been introduced to intervene in the care of patients whose condition deteriorates unexpectedly by bringing clinical experts quickly to the patient's bedside. Evidence supporting the need to overcome failure to deliver optimal care in hospitals is robust; whether rapid response teams demonstrate benefit by improving patient safety and reducing the occurrence of adverse events remains controversial. Despite inconsistent evidence regarding the effectiveness of rapid response teams, concerns regarding care and costly consequences of unaddressed deterioration in patients' condition have prompted many hospitals to implement rapid response teams as a patient safety strategy. A cost-neutral structure for a rapid response team led by a nurse from the intensive care unit was implemented with the goal of reducing cardiopulmonary arrests occurring outside the intensive care unit. The results of 6 years' experience indicate that a sustainable and effective rapid response team response can be put into practice without increasing costs or adding positions and can decrease the percentage of cardiopulmonary arrests occurring outside the intensive care unit.

The effect of a rapid response team on resident perceptions of education and autonomy

BACKGROUND

The impact of rapid response teams (RRTs) on resident physicians' education and clinical autonomy is not well described.

OBJECTIVE

To determine whether resident physicians perceive educational benefit from collaboration with an RRT and whether they believe that the RRT adversely affects their clinical autonomy.

DESIGN

Survey study.

METHODS

Study subjects were asked to participate in a brief online survey. The survey contained 7 demographic items and 20 RRT-related items graded on a 5-point Likert scale ranging from strongly disagree to strongly agree.

SETTING/SUBJECTS

The study was conducted at a tertiary care academic medical center. Subjects included all residents in specialties involving direct patient care and the potential to use the adult RRT.

RESULTS

The response rate was 72%; 35% of respondents were interns, and 69% were in medical fields. Residents agreed that working with the RRT is a valuable educational experience (78%) and disagreed that the RRT decreased their clinical autonomy (76%). Surgical residents were less likely than medical residents to perceive educational value from RRT interactions (P = 0.01) or to report collaborative decision making with the RRT (P = 0.04).

CONCLUSIONS

The majority of resident physicians perceive educational benefit from interaction with the RRT, though this benefit is greater for less experienced residents and for those residents who routinely provide care for critically ill patients and serve as code team leaders. Few residents, irrespective of years of training or specialty, felt that the RRT reduced their clinical autonomy.

Prevalence, characteristics, and opinions of pediatric rapid response teams in the United States

OBJECTIVE

Rapid response teams (RRTs) have been proposed as patient safety initiatives for hospitalized children. The aim of this study was to determine the prevalence, characteristics, and opinions of RRTs in hospitals with PICUs in the United States.

METHODS

This study was conducted as a cross-sectional survey of PICU physicians in adult and children's hospitals that care for children. One survey was sent to the PICU medical director in each hospital. The primary outcome was the presence of an RRT. Other outcomes included RRT characteristics and beliefs regarding their impact on patient safety.

RESULTS

The survey response rate was 64% (134 of 210). Of the responding institutions, 79% (103) had an RRT; most of these teams were implemented in the last 5 years. Family activation was present in 69%, and automatic triggers existed in 34% of cases. RRTs included a median of 3 members and were composed of physicians in 77%, nurses in 100%, and respiratory therapists in 89% of institutions. Respondents with RRTs were more likely to agree that RRTs improve patient safety than respondents without RRTs (76% vs 52%) and more likely to disagree that they are not worth the money invested (82% vs 63%).

CONCLUSIONS

Although the evidence and opinions on the benefit of RRTs are mixed, the majority of US hospitals with PICUs have implemented RRTs. These systems demonstrate variability in activation mechanisms and team composition. Hospitals may be empirically adopting these initiatives without knowledge of the specific characteristics that are optimal for patient outcomes.

The role of the non-ICU staff nurse on a medical emergency team: perceptions and understanding

OBJECTIVE

Medical emergency teams (METs) have been shown to contribute to a decrease in in-hospital cardiac arrests, unplanned ICU admissions, and overall hospital mortality rates. But their use is relatively new and our understanding of them is incomplete; in particular, the role of the non-ICU staff nurse during a MET call has received scant attention. To better understand the role of such nurses, and possibly to increase the effectiveness of these teams, we sought to determine the nursing staff's familiarity with and perceptions of the MET at one hospital.

METHODS

After examining survey formats used in previous studies of nurses' perceptions of and attitudes toward METs, a 30-item survey was developed, consisting of 13 demographic and background items and 17 items based on a 5-point Likert agreement scale. In August 2008, the survey was distributed to the 388 nurses at Allegheny General Hospital in Pittsburgh, Pennsylvania, for whom the MET is a possible resource-that is, non-ICU staff nurses working outside critical care units or the ED. Responses were anonymous and voluntary. Data were entered and analyzed using Microsoft Excel software.

RESULTS

One hundred and thirty-one surveys (34%) were returned. Nearly all of the respondents (97%) were familiar with the MET, and a majority (72%) had participated in a MET call. Initiating the call (77%) and relaying the patient's history (84%) were the most common actions. A majority of respondents agreed or strongly agreed that use of the MET improved patient care (92%) and nurses' working conditions (83%). But only 41% agreed or strongly agreed that they were comfortable with their role as a member of the MET, and 39% reported neutral feelings about this. Just 41% agreed or strongly agreed that they felt prepared to administer nursing care during a MET call. A majority (52%) agreed or strongly agreed that an increase in experience corresponded to an increase in preparedness, but only 28% agreed or strongly agreed that their MET education had prepared them for their role. Nearly a third (31%) reported that they'd been hesitant to call a MET, citing physician discouragement as the most common reason.

CONCLUSIONS

Nurses felt that the MET improved both patient care and their working conditions, something that other studies have found may contribute to nurse retention and recruitment. But the role of the non-ICU staff nurse during a MET call remains unclear; nurses were neutral about their level of understanding of and comfort with their roles as members of the MET. More specific guidelines and further education may help the non-ICU staff nurse feel more valued as a team member and better prepared to administer nursing care during a MET call. Intimidation by other team members proved not to be a significant factor in nurse participation on the team, but the data may not have accurately described the unique relationship between the non-ICU staff nurse and the responding ICU nurses. Some non-ICU staff nurses were hesitant to call the team, for reasons that included physician discouragement; this could seriously undermine the effectiveness of the MET and indicates that better interprofessional education is needed.

KEYWORDS

bedside nurse, medical emergency team, non-ICU staff nurse, nurse attitudes, patient crisis, patient safety, rapid response system, survey.

Quality improvement in medical education: current state and future directions

CONTEXT

During the last decade, there has been a drive to improve the quality of patient care and prevent the occurrence of avoidable errors. This review describes current efforts to teach or engage trainees in patient safety and quality improvement (QI), summarises progress to date, as well as successes and challenges, and lists our recommendations for the next steps that will shape the future of patient safety and QI in medical education.

CURRENT STATUS

Trainees encounter patient safety and QI through three main groups of activity. First are formal curricula that teach concepts or methods intended to facilitate trainees' participation in QI activities. These curricula increase learner knowledge and may improve clinical processes, but demonstrate limited capacity to modify learner behaviours. Second are educational activities that impart specific skills related to safety or quality which are considered to represent core doctor competencies (e.g. effective patient handover). These are frequently taught effectively, but without emphasis on the general safety or quality principles that inform the relevant skills. Third are real-life QI initiatives that involve trainees as active or passive participants. These innovative approaches expose trainees to safety and quality by integrating QI activities into trainees' day-to-day work. However, this integration can be challenging and can sometimes result in tension with broader educational goals.

FUTURE DIRECTIONS

To prepare the next generation of doctors to make meaningful contributions to the quality mission, we propose the following call to action. Firstly, a major effort to build faculty capacity, especially among teachers of QI, should be instigated. Secondly, accreditation standards and assessment methods, both during training and at end-of-training certification examinations, should explicitly target these competencies. Finally, and perhaps most importantly, we must refocus our attention at all levels of training and instil fundamental, collaborative, open-minded behaviours so that future clinicians are primed to promote a culture of safer, higher-quality care.

Clinical emergencies and outcomes in patients admitted to a surgical versus medical service

BACKGROUND

The merit of rapid response systems (RRSs) remains controversial. A tailored approach to specific groups may increase the efficacy of these teams. The purpose of this study was to compare differences in triggers for RRS activation, interventions, and outcomes in patients on medical and surgical services.

METHODS

A retrospective review RRS events was performed. The incidence of out of ICU cardiac arrests and hospital mortality were compared 2 years prior to and following RRS implementation. Call trigger, interventions, and disposition between medical and surgical patients were compared over a 15 month period.

RESULTS

Out of ICU cardiac arrest was significantly more prevalent in the medical group both before and after implementation of RRS. The out of ICU cardiac arrest rate decreased 32% in the surgical group (p=0.05) but hospital mortality did not change. Out of ICU cardiac arrest decreased 40% in the medical group (p<0.001) and hospital mortality decreased 25% (p<0.001) following RRS implementation. There were 1082 RRS activations, 286 surgical and 796 medical. Surgical patients were more likely to have received sedation within 24 h of evaluation (14% vs. 4%, p<0.001). The majority of patients in both cohorts were discharged alive.

CONCLUSION

Implementation of a RRS had greater impact on reduction of out of ICU cardiac arrest and mortality in medical inpatients. Triggers for activation and interventions were similar between groups; however, surgical patients demonstrated substantial risk for decompensation within the first 24 h following operation. More research is needed to evaluate the disproportionate benefit observed between cohorts.

Evolution of a rapid response system from voluntary to mandatory activation

A policy requiring rapid response activation for all patients who met physiologic instability criteria, which was initiated four years after the rapid response system's inception, significantly increased the number of rapid response calls and was associated with a reduction in cardiorespiratory arrests outside of critical care areas.