Rapid response teams in adult hospitals: time for another look?

Abstract

Rapid response teams (RRT), alternatively termed medical emergency teams, have become part of the clinical landscape in the majority of adult hospitals throughout Australia and New Zealand. These teams aim to bring critical care expertise to the bedside of clinically deteriorating patients residing in general hospital wards with the aim of preventing adverse outcomes, in particular death or cardiorespiratory arrests. While the concept of RRT has considerable face validity, there is little high quality evidence of their effectiveness and much uncertainty as to the optimal methods for identifying patients in need of RRT and calling the RRT (afferent limb) and how, and with whom, the RRT should then respond (efferent limb). Adverse unintended consequences of RRT systems and the opportunity costs involved in maintaining such systems have not been subject to study, amid concerns RRT may be compensating for other potentially remediable system of care failures. This article presents an overview of the current state of play of RRT in hospital practice as they pertain to the care of adult patients and identifies several issues around their implementation and evaluation that should be subject to further research.

The limitations in implementing and operating a rapid response system

“…Failed activation has also been observed in mature systems with incidences as high as 42% . Failed activation may be due to ‘failure to monitor’ (especially respiratory rate which traditionally is not accurately documented), ‘failure to recognise’ (triggers used for clinical deterioration not appreciated by ward staff) or ‘failure to escalate’ (not activating RRT despite patient criteria) . ALF amplified not only the patient's morbidity and mortality but also hospital resource utilisation through increased unanticipated ICU admissions .…”

“…The generic ‘worry’ significantly increased the RRT activation 35‐fold when compared with activation based on vital signs . The number of RRT activations as a result of false positive calls has not been investigated . The trend of patient relatives having the right to initiate the RRT directly may bypass the chain of command and in fact increase the number of RRTs.…”

“…RRT systems have inadvertently been used to safeguard patients from dangers of system failure, exploiting the over‐burdened RRS. These system failures include staffing shortages or suboptimal staff‐to‐patient ratios, inappropriate triage and disposition of emergency patients, premature discharge of unstable patients from critical care areas, bed pressures, inadequately trained junior medical staff and insufficient on‐site presence of senior medical staff . The Australian government implemented the national emergency access target in 2010 (‘4‐h rule’) aiming for >90% patients’ disposition from ED within 4 h .…”

Nursing physical assessment for patient safety in general wards: reaching consensus on core skills

“…Bed pressures, access block and problems with maintaining patient flow also contribute to triage error, outliers and premature discharge of unstable patients from critical care units, so that acutely ill patients are admitted to general wards with inadequate levels of monitoring and care (Litvak & Pronovost , White et al . ). Staff shortages mean that the most junior nursing and medical staff are responsible for deteriorating patients in general acute wards, without sufficient support from experienced senior clinicians.…”

“…While organisational initiatives such as rapid response systems (RRSs) designed as a safety net for patients have been instituted to compensate for system failures (White et al . ), arguably these have unintended adverse consequences by further diminishing nursing autonomy (Douglas et al . , Kitto et al .…”