Advertisement

In search of the “Holy Grail”: Will we ever prove the efficacy of Rapid Response Systems (RRS)?

      It is hard to think of an intervention in the last two decades that has been implemented in such a widespread fashion, and so effectively, but with so little evidence as Rapid Response Systems.
      • Jones D.A.
      • DeVita M.A.
      • Bellomo R.
      Rapid-response teams.
      No one from an administrative, clinical or research perspective can question the underlying assumptions that underpin RRS utilization. A plethora of research articles in the 1990s and 2000s have described the risk factors for unexpected patient clinical deterioration, that eventually results in either in-hospital cardiac arrest (IHCA), unplanned Intensive Care Unit (ICU) admission from the general ward or unexpected hospital mortality.
      • Schein R.M.
      • Hazdat N.
      • Pena M.
      • et al.
      Clinical antecedents to in-hospital-cardiopulmonary arrest.
      • Franklin C.
      • Mathew J.
      Developing strategies to prevent in-hospital cardiac arrest: analyzing responses of physicians and nurses in the hours before the event.
      • Smith A.F.
      • Wood J.
      Can some in-hospital cardio-respiratory arrests be prevented?. A prospective survey.
      • Buist M.D.
      • Jarmolowski E.
      • Burton P.R.
      • Bernard S.A.
      • Waxman B.P.
      • Anderson J.
      Recognising clinical instability in hospital patients before cardiac arrest or unplanned admission to Intensive Care. A pilot study in a tertiary-care hospital.
      • Hodgetts T.
      • Kenward G.
      • Ioannis V.
      • Payne S.
      • Castle N.
      The identification of risk factors for cardiac arrest and formulation of activation criteria to alert a medical emergency team.
      • Goldhill D.R.
      • Sumner A.
      Outcome of intensive care patients in a group of British intensive care units.
      • Skrifvars M.B.
      • Nurmi J.
      • Ikola K.
      • Saarinen K.
      • Castran M.
      Reduced survival following resuscitation in patients with documented clinically abnormal observations prior to in-hospital cardiac arrest.
      • Kause J.
      • Smith G.
      • Prytherch D.
      • Parr M.
      • Flabouris A.
      • Hillman K.
      A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom – the ACADEMIA study.
      • Hillman K.M.
      • Bristow P.J.
      • Chey T.
      • et al.
      Antecedents to hospital deaths.
      The executive summary of this basic epidemiological work is that such patients do not on the whole suddenly deteriorate, arrest, die, or if they are lucky get an ICU admission with an associated high mortality rate; rather they deteriorate slowly over hours and even days, with the clinical deterioration beautifully documented in the observation chart and the written medical record. The obvious solution is to intervene in some way during this patient deterioration, with appropriate, and timely, diagnosis, treatment and if necessary, resuscitation.
      • Hodgetts T.
      • Kenward G.
      • Ioannis V.
      • Payne S.
      • Castle N.
      The identification of risk factors for cardiac arrest and formulation of activation criteria to alert a medical emergency team.
      • Buist M.
      • Nguyen T.
      • Moore G.
      • Bernard S.
      • Anderson J.
      Association between clinically abnormal bedside observations and subsequent in hospital mortality: a prospective study.
      • Goldhill D.R.
      • McNarry A.F.
      Physiological abnormalities in early warning scores are related to mortality in adult inpatients.
      Alternatively an earlier decision about the appropriateness of resuscitation can be made with the patient and palliative options considered.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Resuscitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Jones D.A.
        • DeVita M.A.
        • Bellomo R.
        Rapid-response teams.
        N Engl J Med. 2011; 365: 139-146
        • Schein R.M.
        • Hazdat N.
        • Pena M.
        • et al.
        Clinical antecedents to in-hospital-cardiopulmonary arrest.
        Chest. 1990; : 1388-1392
        • 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
        • Smith A.F.
        • Wood J.
        Can some in-hospital cardio-respiratory arrests be prevented?. A prospective survey.
        Resuscitation. 1998; 37: 133-137
        • Buist M.D.
        • Jarmolowski E.
        • Burton P.R.
        • Bernard S.A.
        • Waxman B.P.
        • Anderson J.
        Recognising clinical instability in hospital patients before cardiac arrest or unplanned admission to Intensive Care. A pilot study in a tertiary-care hospital.
        Med J Aust. 1999; 171: 22-25
        • Hodgetts T.
        • Kenward G.
        • Ioannis V.
        • Payne S.
        • Castle N.
        The identification of risk factors for cardiac arrest and formulation of activation criteria to alert a medical emergency team.
        Resuscitation. 2002; 54: 125-131
        • Goldhill D.R.
        • Sumner A.
        Outcome of intensive care patients in a group of British intensive care units.
        Crit Care Med. 1998; 28: 1337-1345
        • Skrifvars M.B.
        • Nurmi J.
        • Ikola K.
        • Saarinen K.
        • Castran M.
        Reduced survival following resuscitation in patients with documented clinically abnormal observations prior to in-hospital cardiac arrest.
        Resuscitation. 2006; 70: 215-222
        • Kause J.
        • Smith G.
        • Prytherch D.
        • Parr M.
        • Flabouris A.
        • Hillman K.
        A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom – the ACADEMIA study.
        Resuscitation. 2004; 62: 275-282
        • Hillman K.M.
        • Bristow P.J.
        • Chey T.
        • et al.
        Antecedents to hospital deaths.
        Int Med J. 2001; 31: 343-348
        • Buist M.
        • Nguyen T.
        • Moore G.
        • Bernard S.
        • Anderson J.
        Association between clinically abnormal bedside observations and subsequent in hospital mortality: a prospective study.
        Resuscitation. 2004; 62: 137-141
        • Goldhill D.R.
        • McNarry A.F.
        Physiological abnormalities in early warning scores are related to mortality in adult inpatients.
        Br J Anaesth. 2004; 92: 882-884
        • Buist M.
        • Moore G.
        • Bernard S.
        • Waxman B.
        • Anderson J.
        • Nguyen T.
        Effects of the Medical Emergency Team in the reduction of the incidence and the mortality from unexpected in-hospital cardiac arrest calls: a preliminary study.
        BMJ. 2002; 324: 387-390
        • Bellomo R.
        • Goldsmith D.
        • Uchino S.
        • et al.
        A prospective before and after trial of Medical Emergency Team.
        Med J Aust. 2003; 179: 283-287
        • DeVita M.A.
        • Braithwaite R.S.
        • Mahidhara R.
        • et al.
        Use of the medical emergency team responses to reduce hospital cardiopulmonary arrests.
        Qual Saf Health Care. 2004; 13: 251-254
        • Tiballs J.
        • Kinney S.
        • Duke T.
        • Oakley E.
        • Hennessy M.
        Reduction of paediatric in-patient cardiac arrest and death with a medical emergency team: preliminary results.
        Arch Dis Child. 2005 Nov; 90: 1148-1152
        • MERIT study investigators
        Introduction of the medical emergency team (MET) system: a cluster randomised controlled study.
        Lancet. 2005; 365: 2091-2097
        • Bristow P.
        • HIllman K.
        • Chey T.
        • Daffurn K.
        • Jacques T.
        • Norman S.
        • et al.
        Rates of in-hospital arrests, deaths and intensive care admissions: the effects of a medical emergency team.
        Med J Aust. 2000; 173: 236-240
        • Chen J.
        • Bellomo R.
        • Flabouris A.
        • Hillman K.
        • Finfer S.
        The relationship between early emergency team calls and serious adverse events.
        Crit Care Med. 2009; 37: 148-153
        • Chen J.
        • Bellomo R.
        • Hillman K.
        • Flabouris A.
        • Finfer S.
        MERIT Study Investigators for the Simpson Centre and the ANZICS Clinical Trials Group). Triggers for emergency team activation: a multi centre assessment.
        J Crit Care. 2010; 25: 359
        • Chen J.
        • Ou L.
        • Hillman K.
        • Flabouris A.
        • Bellomo R.
        • Hollis S.
        • et al.
        The impact of implementing a rapid response system: a comparison of cardiopulmonary arrests and mortality among four teaching hospitals in Australia.
        Resuscitation. 2014; 85: 1275-1281
        • Winters B.
        • Pronovost P.
        Rapid Response Systems: should we still question their implementation.
        J Hosp Med. 2013; 8: 278-281