Rapid Response and Medical Emergency Teams

Background of RRTs and METs

The formation of rapid response teams (RRTs) or Medical Emergency Teams (METs) at hospitals was 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.

Scientific Evidence that RRTs and METs Help

There have been several studies that review the merits of RRTs and METs – the most recent was published by Solomon et al. in 2016.1 The conclusion from the study is that implementation of an RRT/MET is associated with a reduction in both hospital mortality and non-ICU cardiopulmonary arrests.

In addition, the 2015 AHA Guidelines provide the following guidance on RRTs and METs.

For adult patients, RRT or MET systems can be effective in reducing the incidence of cardiac arrest, particularly in general care wards (Class IIa, LOE C-LD). Pediatric MET/RRT systems may be considered in facilities where children with high-risk illnesses are cared for on general in-patient units (Class IIb, LOE C-LD). The use of early warning score systems (EWSS) may be considered for adults and children (Class IIb, LOE C-LD).2

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.3,4

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.5 A standard communication system is set up to call the RRT so members can respond quickly – often within five minutes.

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 who initiated the call.

RRT Documentation

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. Get With The Guidelines 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.6 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
  • Mortality

Institutions may choose to enter their RRT data to Get With The Guidelines, and thus receive standard quarterly and annual reports as well as benchmark their measures of success with other institutions.

1. Soloman, et al. Journal of Hospital Medicine. 2016;11:438-445. 
2. Kronick, et al. Circulation. 2015;Part 4: System of Care and CQI. S400
3. Schein, et al. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest. 1990;98:1388-1392. 
4. 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. 
5. Goodhill, et al. A physiologically-based early warning score for ward patients: the association between score and outcome. Anaesthesia. 2005; 60:547-553. 
6. Cretikos M, et al. Guidelines for the uniform reporting of data for Medical Emergency Teams. Resuscitation. 2006;68:11-25.