Rapid Response Teams: Lessons from the Early Experience
Health care organizations throughout the world have identified Rapid Response Teams (RRTs) as a powerful intervention aimed at saving lives by identifying and intervening in patient care at the first sign of clinical deterioration or concern expressed by the health care professional, patient, or, in some cases, family members.(1-5) RRTs function as in-hospital "9-1-1" teams, designed to bring health care professionals, with backgrounds and skills in critical care medicine, to the bedside of patients throughout a hospital or health care facility. Although there was sporadic interest in RRTs in the late 1990s and early 2000s, this interest crescendoed when the Institute for Healthcare Improvement (IHI) chose their implementation as a key strategy in a widely promoted campaign to "save 100,000 lives" [see related interview].
Failing to recognize or, perhaps more often, failing to assign specific meanings to, a given set of clinical changes, such as an increased heart rate, is a well-documented cause of unchecked clinical deterioration and delays in patients receiving care that could prevent a code blue.(6) This overall construct is sometimes called failure to rescue. Although some of the value of the RRT is the recognition that certain clinical changes may be harbingers of potential danger, a core part of the intervention is that an RRT program brings individuals with critical care skills promptly to the bedside. These skills are not only useful for triaging and managing patients rapidly and appropriately, but also for educating the non–critical care staff about how to best manage certain acute problems.
In addition to improving patient outcomes, RRTs may have other salutary effects on the hospital culture and work environment, particularly for nurses.(7) Having a team of specialty-trained providers immediately accessible in often-confusing clinical situations helps create a safe environment in which problems and questions can be addressed. Many nurses find it empowering to have the capacity to activate the RRT simply because, in their judgment, the patient didn't look good and no other first responders were available. Others report that standing by a deteriorating patient with no resources to help—in the absence of an RRT—can be a major stressor and cause of career dissatisfaction. In fact, hospitals that have implemented RRTs have anecdotally reported an increase in nurse satisfaction.
In the months since the IHI recommended nationwide adoption of RRTs, there has been considerable discussion about their value. Studies have demonstrated impressive decreases in death and code blue rates after the implementation of RRTs.(1-5) A recent multi-hospital Australian study found no benefit, but the implementation was somewhat flawed and the follow-up relatively short.(8) In this article, I will not address that debate.
The RRT is a simple concept whose implementation might seem straightforward. However, like most intuitively obvious solutions, barriers, questions, and new adaptations will color this transformation in health care delivery. Many of these recommendations must necessarily be based on anecdotal evidence or impressions—the concept is still too new for all of the relevant issues to have been studied. Knowing that hospitals around the United States and the world are implementing RRTs, which address what I perceive as a fundamental design flaw in the system of care delivery for hospitalized patients, I will answer a series of frequently encountered questions, based on my personal observations and my experience in helping a number of community hospitals implement RRTs.
I believe that all RRT providers need to be on-site. A remote RRT physician may not offer any more value than the patient's remote attending physician, and having the physician be on call to the primary RRT undermines the concept of immediate availability of skilled team members. Moreover, the RRT must be able to implement a plan immediately, which requires a member with the ability to write orders right away; in most cases, this will be a physician. However, developments in technology, such as the availability of remote critical care physician monitoring systems may, in the future, allow the necessary level of physician involvement without requiring around-the-clock, on-site presence.
There are few data to answer this question. My personal feeling is that a seasoned hospital-based provider, such as a hospitalist, could provide this service, particularly if intensivists were available for challenging situations such as management of difficult airways. Early experience seems to bear this out, since some of the available (and positive) studies of RRTs involved hospitalists serving as the physician team members.(1-5) Non-physician providers, such as nurse practitioners or physician assistants, have also been part of some successful RRTs. Here, too, comparisons between providers are inherently difficult. In my experience, the ability of team members to function cooperatively is more important than their training or titles.
No, quite the opposite. These teams are designed to enhance the involvement of the patient's primary care provider or team by enhancing communication and expediting a plan of care. Because the RRT assesses the patient while efforts are being made to reach the patient's primary team or attending physician, communication with the primary physician may be more productive and efficient once he or she is contacted.
Although conflict is unusual, it happens from time to time. Much of it can be avoided if the primary teams and physicians are made aware that (i) the institution has an RRT, (ii) the RRT will be involved in the care of deteriorating patients in an effort to enhance patient safety, (iii) involvement of the primary team or attending physician is welcome and important, and (iv) the RRT's recommendations will be integrated with the primary team's recommendations, once the latter become available.
Again, this is a bit of a data-free zone, and I believe that local culture will determine the "goodness" or "badness" of this model. In thinking about such a time delay, it is vital to consider what defines a "response" by the primary team. If a response is defined as a thorough bedside evaluation by a team member who possesses some critical care skills and the ability to make triage assessments and decisions, then his or her presence might be a perfectly reasonable surrogate for the RRT. However, if the response is simply a returned phone call, then I would not consider that to be an effective substitute.
This is, in fact, two questions. The first is—how can we afford an RRT program? The second is what to do with potential down-time when the team is not dealing with a call. The answer to the first question is relatively simple—how can we not afford it? Beyond the ethical imperative to provide the highest quality care, these teams essentially pay for themselves. The well-documented decreases in ICU resource utilization and length of stay bear this out. For example, facilities typically see a 30% to 50% reduction in non-ICU arrests (3), dramatic reductions in hospital days after arrests (2), and decreases in the number of ICU days post-arrest.(2) In most institutions, unnecessary ICU days are very costly, and, thus, a well-functioning RRT is likely cost-effective.
Of course, it is important to utilize RRT resources thoughtfully. The number of full-time employees needed to fully staff an RRT varies widely, depending on several factors, including facility size, the types of RRT members, the potential need for multiple teams, etc. Since the actual structure, size, and cost of an RRT is likely to vary so much from institution to institution, it is often wise to pilot the intervention during a trial period for the RRT in a limited portion of the hospital, making final resource allocation decisions based on this experience.
The second issue—having team members productive during down-time but immediately available for RRT calls—is more complex, but solvable. Some hospitals have assigned RRT members administrative tasks that can be left at a moment's notice, or they have them make hospital unit rounds to increase their visibility.(1-6) Many hospitals have RRT nurses work as ICU charge nurses (without specific patient assignments). Similarly, some have RRT respiratory therapists assist in the cleaning and overall maintenance of the mechanical ventilators.
- In addition to a nurse and respiratory therapist with critical care skills, does a physician team member need to be "on-site" for the RRT to function effectively?
- Does the physician member of an RRT need to be an intensivist, or can he or she be a hospitalist? What about a non-MD provider such as a trained nurse practitioner or physician assistant?
- Are RRTs designed to exclude the patient's primary attending physician or, in academic medical centers, primary team?
- I have heard that some RRTs are called after a time lag—perhaps 30-60 minutes—during which the primary team or physician is given an opportunity to respond. Is this a good idea?
- Resources are scarce—especially for personnel. Can we afford to have people sitting around all day?
The IHI has a considerable amount of additional information on RRTs on its Web site and is holding frequent teleconferences regarding implementation issues. Interested readers may wish to look there for additional information.
William S. Krimsky, MD Assistant Professor of Medicine, Johns Hopkins University Director of Interventional Pulmonology, Pulmonary and Critical Care Associates of Baltimore Consultant Medical Director, Delmarva Foundation for Medical Care
1.Bellomo R, Goldsmith D, Uchino S, et al. Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med. 2004;32:916-921. [ go to PubMed ]
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5.DeVita MA, Braithwaite RS, Mahidhara R, Stuart S, Foraida M, Simmons RL, and the Medical Emergency Response Improvement Team (MERIT). Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Qual Saf Health Care. 2004;13:251-254. [ go to PubMed ]
6.Franklin C, Mathew J. Developing strategies to prevent in hospital cardiac arrest: analyzing responses of physicians and nurses in the hours before the event. Crit Care Med. 1994;22:244-247. [ go to PubMed ]
7.Committee on the Work Environment for Nurses and Patient Safety, Board on Healthcare Services, Page A, ed. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press; 2004. Available at: http://www.nap.edu/books/0309090679/html
8.Hillman K, Chen J, Cretikos M, et al, for the MERIT study investigators. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet. 2005;365:2091-2097. [ go to PubMed ]