Extended involvement maximizes gains from rapid response teams

An intensivist-led, multidisciplinary rapid-response team (RRT) with extended involvement in patient care yields multiple benefits, say researchers.

Introduction of the RRT at a tertiary care center in Saudi Arabia reduced cardiopulmonary arrests and patient mortality, empowered ward staff, and improved end-of-life care, report Yaseen Arabi (King Saud bin Abdulaziz University for Health Sciences, Riyadh) and co-workers.

RRTs have a mixed track record, with some studies finding no benefit. This may be due to differences in setting or in methodology, say Arabi et al. In their system, the role of the team extends beyond the initial RRT activation, providing follow up until clinical stabilization for ward patients and post-discharge follow up for patients who were transferred to the intensive care unit (ICU).

The RRT was led by an intensivist and could be activated by nurses as well and doctors. Indeed, nurses were responsible for 61.8% of activations. Activation was based primarily on physiologic parameters, but staff could also summon the RRT purely because of "serious concern," which was the case in 23.1% of activations. This "enhanced the culture of safety," says the team.

A total of 98,391 patients were treated in the 2 years preceding implementation of the RRT, and 157,804 were treated in the 3 years after its inception. Between these two periods, the numbers of cardiopulmonary arrests fell significantly, from 1.4 to 0.9 per 1000 hospital admissions, as did in-hospital mortality, from 22.5 to 20.2 per 1000 hospital admissions.

Most interventions by the RRT involved fluid administration, most commonly an intravenous crystalloid bolus, which was given to nearly half of the patients, and respiratory management, with oxygen supplementation given to about two-thirds. More advanced interventions were rare.

Nevertheless, among patients who required ICU admission, Acute Physiology and Chronic Health Evaluation II scores on admission fell from an average of 29.3 to 26.9, and in-hospital mortality fell from 57.4% to 48.7%.

These findings "demonstrate that timely administration of 'simple' interventions was what [was] needed to prevent clinical deterioration in many patients; a task that RRT was designed for and qualified to deliver," say the researchers in Critical Care Medicine.

Finally, introduction of the RRT resulted in an increase in the number of do-not-resuscitate (DNR) orders given to ward patients, suggesting that the actions of the team facilitated timely discussion of patients' views on end-of-life care. By contrast, DNR orders in ICU patients declined, suggesting that patients were not given futile care.

"These decisions were appropriate because the total ward deaths did not increase, but actually decreased," say Arabi et al.

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