RAPID RESPONSE AND MEDICAL EMERGENCY TEAMS
Background of RRTs and METs
The formation of rapid response teams (RRTs) at hospitals is founded on the concept of “failure to rescue.” Failure to rescue refers to the lack of caregivers’ ability to recognize early signs and symptoms of deterioration in a patient’s condition, or acting too late to prevent a cardiac arrest. The phrase is not intended to imply negligence or wrongdoing, but is a measure of the overall performance of a hospital.
Three fundamental problems lead to failure to rescue in hospitals:
- Failures in planning (including assessments, treatments and goals)
- Breakdown of communication between patients and staff or between staff and other staff
- Failure to recognize early signs of deterioration in a patient’s condition
In its 5 Million Lives Campaign from December 2006 to December 2008, the Institute for Healthcare Improvement (IHI) encouraged American hospitals to implement RRTs. Many institutions have jumped on the bandwagon and implemented RRTs locally since they have become an established standard of care.
Scientific Evidence that RRTs and METs Help
Research has shown that with RRTs:
- 50% reduction in the occurrence of cardiac arrest outside the ICU
(Buist, M.D. et al. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study. BMJ 2002;324:1-6)
- 17% decrease in the incidence of cardiopulmonary arrests (6.5 vs 5.4 per 1000 admissions)
(DeVita, M.A. et al. Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Quality and Safety in Health Care 2004;13(4):251-254)
- Severe postoperative adverse events (i.e., respiratory failure, stroke, severe sepsis, acute renal failure) were reduced by 58%, emergency ICU admissions were reduced by 44%, postoperative deaths were reduced by 37%, and mean duration of hospital stay decreased from 23.8 to 19.8 days in surgical patients
(Bellomo, R. et al. Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Critical Care Medicine 2004;32:916-921)
- Decrease in the number of unnecessary transfers to a higher level of care by a mean of 30% (Goldhill, D.R. et al. The patient-at-risk team: identifying and managing seriously ill ward patients. Anesthesia 1999;54:853-860)
Studies reporting the above findings have used historical controls and not been randomized. The MERIT study, with a prospective cluster randomized design involving 23 hospitals in Australia, found no significant difference in cardiac arrests in patients without a do not resuscitate (DNR) order, unplanned ICU admissions and unexpected deaths taking place in general wards in those hospitals with a medical emergency team (MET) team versus those hospitals without a MET team. Thus, further scientific study is needed to demonstrate the efficacy of these teams.
(MERIT study investigators. Introduction of the medical emergency team (MERIT) system: a cluster-randomised controlled trial. Lancet 2005;365:2091-2097)
What Is an RRT?
An RRT is a designated group of healthcare clinicians who can be assembled quickly to deliver critical care expertise in response to grave clinical deterioration of a patient located outside a critical care unit.
RRTs may consist of any of the following staff positions:
- Physician – senior resident or intensivist or hospitalist
- Physician’s assistant
- Critical care RN
- Clinical nurse specialist
- Respiratory therapist
Some hospitals have their whole CPR team respond instead of a smaller team. In every model, there are three key features of the team members:
- They must be available to respond immediately when called, and not be constrained by competing responsibilities.
- They must be onsite and accessible.
- They must have the critical care skills necessary to assess and respond.
When Does the RRT Respond?
A hospital usually has a set of criteria that signify a patient’s condition is deteriorating, for which the staff nurse will activate the RRT. The goal is to treat these warning signs early so that the patient’s outcome may be improved and a cardiac arrest prevented. It has been shown that 2/3 of patients show evidence of identifiable signs of deterioration within 6-8 hours of arrest.
(Schein, R.M. et al. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest 1990;98:1388-1392 and Franklin, C. & Mathew, J. Developing strategies to prevent inhospital cardiac arrest. Analyzing responses of physicians and nurses in the hours before the event. Critical Care Medicine 1994;22:244-247)
The RRT may be called for physiologic changes in heart rate, systolic blood pressure, respiratory rate, pulse oximetry saturation, mental status or urinary output. Changes in laboratory values such as sodium, glucose and potassium could also indicate a patient’s condition is deteriorating. The nurse may also call the RRT because of a gut feeling that all is not right. Some hospitals have pioneered the use of “Early Warning Scoring Systems” to more reliably identify patients in trouble and trigger the appropriate, often lifesaving response. A standard communication system is set up to call the RRT so members can respond quickly – often within five minutes.
(Goodhill, D.R. et al. A physiologically-based early warning score for ward patients: the association between score and outcome. Anaesthesia 2005;60:547-553)
What Is the Role of the RRT?
The RRT has several key roles:
- Assists the staff member in assessing and stabilizing the patient condition.
- Assists the staff member in organizing information to be communicated to the patient’s physician.
- Educates and supports the staff as they care for the patient.
- If circumstances warrant, assists with patient transfer to a higher level of care.
Note that the RRT is not intended to replace care provided by the patient’s physician, since right after the consultation by the RRT the appropriate physician is called. The person who calls the RRT should become a key member of the team and assist the RRT; the RRT is not there to take over and assume care of the patient. The team is usually trained to communicate and receive communication using SBAR (Situation, Background, Assessment, Recommendation). All team members should respond in a professional and friendly manner, providing non-judgmental, non-punitive feedback to the person that initiated the call.
A structured documentation form should be used by the RRT. A template for an RRT documentation tool can be found at the IHI web site. The National Registry of CPR also provides a documentation template. Guidelines for the tracking and reporting of MET data along with a MET call record form have been published by authors in Australia. (Cretikos, M. et al. Guidelines for the uniform reporting of data for Medical Emergency Teams. Resuscitation 2006;68:11-25) The team can use a form to capture and organize information about the patient’s condition prior to calling them, as well as interventions that were required. This information can be used to analyze responses and plan quality-improvement activities where needed. Aggregate and quality data can also serve as a base for staff education. It is important that feedback be provided to staff about the successes of the RRT and lessons learned when responding to patients in crisis.
Measurement of Effectiveness of the RRT
It has been suggested that several key measures be used to evaluate the effectiveness of the RRT:
- Codes per 1000 discharges
- Codes outside the ICU
- Number of unplanned ICU admissions
- Utilization of the RRT
Institutions may choose to enter their RRT data into the NRCPR, and thus receive standard quarterly and annual reports as well as benchmark their measures of success with other institutions.