Rapid response system

{{Further|Early warning score}}

The afferent component, or identification limb, also known as the track-and-trigger system, uses standardized tools to track early signs of reversible clinical deterioration and trigger a call to, and response from the efferent component, or response limb.{{cite web |title=Evidence review and recommendations |url=https://www.ncbi.nlm.nih.gov/books/NBK45953/ |website=Acutely Ill Patients in Hospital: Recognition of and Response to Acute Illness in Adults in Hospital [Internet] |publisher=National Institute for Health and Clinical Excellence (NICE) |access-date=1 October 2023 |language=en |date=July 2007}}{{cite web |last1=Levin |first1=Amanda B. |last2=Brady |first2=Patrick |last3=Duncan |first3=Heather P. |last4=Davis |first4=Aisha Barber |title=Pediatric Rapid Response Systems: Identification and Treatment of Deteriorating Children |url=https://link.springer.com/article/10.1007/s40746-014-0005-1 |website=Current Treatment Options in Pediatrics |access-date=25 October 2023 |pages=76–89 |language=en |doi=10.1007/s40746-014-0005-1 |date=1 March 2015}} Examples of afferent tools include single-parameter calling criteria and multi-parameter early warning scores. These tools can predict clinical deterioration based upon the patient’s medical condition, and detect deterioration through the patient’s state such as a high respiratory rate. Single-parameter calling criteria require that only one criterion be met before activating the efferent component. Criteria may be based on vital signs, diagnoses, events, subjective observations, or concerns of the patient. Multi-parameter tools are more complex in that they combine several parameters into a single early warning score (EWS).

METs were originally activated exclusively by bedside clinicians in need of emergency assistance. Recently, many hospitals have begun to allow families to activate a MET if they feel the care team is not adequately addressing their concerns. The team may differ in composition from the clinician-activated MET such as including a patient relations coordinator.{{cite web |title=Condition Help (Condition H) |url=http://www.josieking.org/conditionh |archive-url=https://web.archive.org/web/20120902134207/http://www.josieking.org/conditionh |url-status=dead |archive-date=September 2, 2012 |accessdate=22 October 2013 |work=Josie King Foundation}}

Family-activated METs were put in place as a response to the preventable death of Josie King in 2001. King was 18-months old when she died at Johns Hopkins Hospital in Baltimore, from medical errors and delays in escalation of care despite her family’s concerns. As a result of the highly publicized death, the Children’s Hospital of Pittsburgh began a program called Condition HELP that allows families to activate a MET. Families receive training on Condition HELP when the patient is admitted and are asked to voice concerns to their care team before activating the MET.

The Ryan's Rule initiative was trialled in some public hospitals in Queensland, Australia in 2013. It allows patients, their carers, friends and family to initiate a graduated escalation of care if they are concerned that the patient is not improving as expected. In 2016, Ryan's Rule was made available across all public hospitals in the Queensland Health system. Similar policies are called "REACH" in New South Wales and "CARE" in Australian Capital Territory.{{cite journal |last1=Flynn |first1=David E. |last2=Flynn |first2=Hannah |last3=Gifford |first3=Shaune |last4=Smith |first4=Kate |date=2022 |title=Can you hear me? Analysis of a Queensland patient-initiated escalation process and the importance of communication in surgical care |journal=ANZ Journal of Surgery |volume=92 |pages=1371-1376 |doi=10.1111/ans.17584}}

Martha's Rule was introduced in NHS England hospitals from April 2024. It is initially being rolled out in 100 hospitals. It will allow patients, their families and carers, and hospital staff, to access a rapid review by the critical care outreach team if they are worried about the patient's condition.{{cite web |title=Martha's Rule |url=https://www.england.nhs.uk/patient-safety/marthas-rule/ |access-date=24 June 2024 |website=NHS England}}

The efferent component is a rapid response team – a multidisciplinary team trained in early resuscitation interventions, and advanced life support that rushes to the deteriorating patient’s bedside to prevent respiratory and cardiac arrest in order to improve the patient’s outcomes. The team is known in the US as a rapid response team (RRT), in the UK as a critical care outreach team (CCOT), and in Australia as a medical emergency team (MET), but rapid response team is also used generically.The team responds to calls placed by clinicians or families at the bedside who have detected deterioration.{{cite journal |last1=Hueckel |first1=Rémi M. |last2=Turi |first2=Jennifer L. |last3=Cheifetz |first3=Ira M. |last4=Mericle |first4=Jane |last5=Meliones |first5=Jon N. |last6=Mistry |first6=Kshitij P. |title=Beyond Rapid Response Teams: Instituting a "Rover Team" Improves the Management of At-Risk Patients, Facilitates Proactive Interventions, and Improves Outcomes |url=https://www.ncbi.nlm.nih.gov/books/NBK43680/ |website=Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools) |publisher=Agency for Healthcare Research and Quality (US) |access-date=1 October 2023 |date=2008|pmid=21249937 }} It may also provide proactive outreach to patients at high risk for deterioration. Composition of the teams may vary but often include one critical care attending physician or fellow, at least one nurse, and a respiratory therapist.{{cite journal|last=Devita|first=MA |author2=Bellomo, R |author3=Hillman, K |author4=Kellum, J |author5=Rotondi, A |author6=Teres, D |author7=Auerbach, A |author8=Chen, WJ |author9=Duncan, K |author10=Kenward, G |author11=Bell, M |author12=Buist, M |author13=Chen, J |author14=Bion, J |author15=Kirby, A |author16=Lighthall, G |author17=Ovreveit, J |author18=Braithwaite, RS |author19=Gosbee, J |author20=Milbrandt, E |author21=Peberdy, M |author22=Savitz, L |author23=Young, L |author24=Harvey, M |author25=Galhotra, S|title=Findings of the first consensus conference on medical emergency teams.|journal=Critical Care Medicine|date=September 2006|volume=34|issue=9|pages=2463–78|pmid=16878033|doi=10.1097/01.CCM.0000235743.38172.6E|s2cid=20076741 }}

The process improvement component uses evidence-based evaluation of the RRS to determine its effectiveness and to improve the system through targeted interventions. It works closely with the administrative component, clinicians (especially those on RRTs), and quality improvement experts to evaluate three measures: outcomes measures, process measures, and balancing measures.

Rates of hospital-wide mortality and respiratory and cardiac arrest, which are exceedingly rare and may or may not be preventable, are common outcome measures.{{cite journal|last=Chan|first=PS|author2=Jain, R |author3=Nallmothu, BK |author4=Berg, RA |author5= Sasson, C |title=Rapid Response Teams: A Systematic Review and Meta-analysis.|journal=Archives of Internal Medicine|date=Jan 11, 2010|volume=170|issue=1|pages=18–26|pmid=20065195|doi=10.1001/archinternmed.2009.424|doi-access=}} Rapid response teams appear to decrease the rates of respiratory and cardiac arrest outside the intensive care unit.{{cite journal|last=Chan|first=PS|author2=Jain, R |author3=Nallmothu, BK |author4=Berg, RA |author5=Sasson, C |title=Rapid Response Teams: A Systematic Review and Meta-analysis.|journal=Archives of Internal Medicine|date=2010-01-11|volume=170|issue=1|pages=18–26|pmid=20065195|doi=10.1001/archinternmed.2009.424|doi-access=}}{{cite journal|last=Winters|first=BD|author2=Weaver, SJ |author3=Pfoh, ER |author4=Yang, T |author5=Pham, JC |author6= Dy, SM |title=Rapid-response systems as a patient safety strategy: a systematic review.|journal=Annals of Internal Medicine|date=Mar 5, 2013|volume=158|issue=5 Pt 2|pages=417–25|pmid=23460099|doi=10.7326/0003-4819-158-5-201303051-00009 |pmc=4695999}}{{cite journal|last1=Kronick|first1=SL|last2=Kurz|first2=MC|last3=Lin|first3=S|last4=Edelson|first4=DP|last5=Berg|first5=RA|last6=Billi|first6=JE|last7=Cabanas|first7=JG|last8=Cone|first8=DC|last9=Diercks|first9=DB|last10=Foster|first10=JJ|last11=Meeks|first11=RA|last12=Travers|first12=AH|last13=Welsford|first13=M|title=Part 4: Systems of Care and Continuous Quality Improvement: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.|journal=Circulation|date=3 November 2015|volume=132|issue=18 Suppl 2|pages=S397–413|pmid=26472992|doi=10.1161/cir.0000000000000258|doi-access=free}} They also appear to decrease the chance of death in hospital.{{cite journal|last1=Solomon|first1=RS|last2=Corwin|first2=GS|last3=Barclay|first3=DC|last4=Quddusi|first4=SF|last5=Dannenberg|first5=MD|title=Effectiveness of rapid response teams on rates of in-hospital cardiopulmonary arrest and mortality: A systematic review and meta-analysis.|journal=Journal of Hospital Medicine|date=June 2016|volume=11|issue=6|pages=438–445|pmid=26828644|doi=10.1002/jhm.2554|doi-access=free}} Overall effectiveness of rapid response teams is somewhat controversial due to the variability across studies{{cite journal|last=Massey|first=D|author2=Aitken, LM |author3=Chaboyer, W |title=Literature review: do rapid response systems reduce the incidence of major adverse events in the deteriorating ward patient?|journal=Journal of Clinical Nursing|date=Dec 2010|volume=19|issue=23–24|pages=3260–73|pmid=21029228|doi=10.1111/j.1365-2702.2010.03394.x|hdl=10072/35936|hdl-access=free}}{{cite journal|last=Winters|first=BD|author2=Pham, JC |author3=Hunt, EA |author4=Guallar, E |author5=Berenholtz, S |author6= Pronovost, PJ |title=Rapid response systems: a systematic review.|journal=Critical Care Medicine|date=May 2007|volume=35|issue=5|pages=1238–43|pmid=17414079|doi=10.1097/01.CCM.0000262388.85669.68}} as is the overall effectiveness of the rapid response system in improving patient safety.{{cite journal|last=Hillman|first=K|author2=Chen, J |author3=Cretikos, M |author4=Bellomo, R |author5=Brown, D |author6=Doig, G |author7=Finfer, S |author8=Flabouris, A |author9= MERIT study, investigators |title=Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial.|journal=Lancet|date=Jun 18–24, 2005|volume=365|issue=9477|pages=2091–7|pmid=15964445|doi=10.1016/S0140-6736(05)66733-5|s2cid=1101381}} More recent work uses proximal outcome measures, such as the Children’s Resuscitation Intensity Scale (measures level of care within 12 hours pre-transfer),{{cite journal|last=Parshuram|first=CS|author2=Bayliss, A |author3=Reimer, J |author4=Middaugh, K |author5= Blanchard, N |title=Implementing the Bedside Paediatric Early Warning System in a community hospital: A prospective observational study.|journal=Paediatrics & Child Health|date=March 2011|volume=16|issue=3|pages=e18–22|pmid=22379384 |pmc=3077313|doi=10.1093/pch/16.3.e18}} the Clinical Deterioration Metric (measures level of care within 12 hours post-transfer),{{cite journal|last=Bonafide|first=CP|author2=Roberts, KE |author3=Priestley, MA |author4=Tibbetts, KM |author5=Huang, E |author6=Nadkarni, VM |author7= Keren, R |title=Development of a pragmatic measure for evaluating and optimizing rapid response systems.|journal=Pediatrics|date=April 2012|volume=129|issue=4|pages=e874–81|pmid=22392182|doi=10.1542/peds.2011-2784|s2cid=22120592 }} and UNSAFE transfers (measures level of care within 1 hour post-transfer).{{cite journal|last=Brady|first=PW |author2=Muething, S |author3=Kotagal, U |author4=Ashby, M |author5=Gallagher, R |author6=Hall, D |author7=Goodfriend, M |author8=White, C |author9=Bracke, TM |author10=DeCastro, V |author11=Geiser, M |author12=Simon, J |author13=Tucker, KM |author14=Olivea, J |author15=Conway, PH |author16=Wheeler, DS|title=Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events.|journal=Pediatrics|date=January 2013|volume=131|issue=1|pages=e298–308|pmid=23230078|doi=10.1542/peds.2012-1364 |pmc=4528338}}

Process measures determine if the RRS is used as intended. Measures include the MET call rate, percentage of MET calls that result in transfer to the ICU, the time between initial physiologic abnormality and admission to ICU, timing of calls, reasons for MET calls, and evaluation of early warning scores using sensitivity and specificity.{{cite journal|last=Oglesby|first=KJ|author2=Durham, L |author3=Welch, J |author4= Subbe, CP |title='Score to Door Time', a benchmarking tool for rapid response systems: a pilot multi-centre service evaluation.|journal=Critical Care|date=Jul 27, 2011|volume=15|issue=4|pages=R180|pmid=21794137|url=http://ccforum.com/content/pdf/cc10329.pdf|doi=10.1186/cc10329 |pmc=3387623 |doi-access=free }}{{cite journal|last=Santiano|first=N |author2=Young, L |author3=Hillman, K |author4=Parr, M |author5=Jayasinghe, S |author6=Baramy, LS |author7=Stevenson, J |author8=Heath, T |author9=Chan, C |author10=Claire, M |author11=Hanger, G|title=Analysis of medical emergency team calls comparing subjective to "objective" call criteria.|journal=Resuscitation|date=January 2009|volume=80|issue=1|pages=44–9|pmid=18952358|doi=10.1016/j.resuscitation.2008.08.010}}{{cite journal|last=Fullerton|first=JN|author2=Price, CL |author3=Silvey, NE |author4=Brace, SJ |author5= Perkins, GD |title=Is the Modified Early Warning Score (MEWS) superior to clinician judgement in detecting critical illness in the pre-hospital environment?|journal=Resuscitation|date=May 2012|volume=83|issue=5|pages=557–62|pmid=22248688|doi=10.1016/j.resuscitation.2012.01.004}}

Balancing measures evaluate any unintended consequences of the RRS. Identified barriers to activating the MET include the primary team’s overconfidence in their ability to stabilize the patient, poor communication, hierarchal problems, and hospital culture.{{cite journal|last=Nembhard|first=IM|author2=Edmondson AC |title=Making it safe: The effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams|journal=Journal of Organizational Behavior|year=2006|volume=27|issue=7|pages=941–966|doi=10.1002/job.413}}{{cite journal|last1=Mackintosh|first1=N|last2=Rainey|first2=H|last3=Sandall|first3=J|author-link3=Jane Sandall|date=February 2012|title=Understanding how rapid response systems may improve safety for the acutely ill patient: learning from the frontline.|journal=BMJ Quality & Safety|volume=21|issue=2|pages=135–44|doi=10.1136/bmjqs-2011-000147|pmid=21972419|s2cid=23492881}}{{cite journal|last=Shearer|first=B|author2=Marshall, S |author3=Buist, MD |author4=Finnigan, M |author5=Kitto, S |author6=Hore, T |author7=Sturgess, T |author8=Wilson, S |author9= Ramsay, W |title=What stops hospital clinical staff from following protocols? An analysis of the incidence and factors behind the failure of bedside clinical staff to activate the rapid response system in a multi-campus Australian metropolitan healthcare service|journal=BMJ Quality and Safety|year=2012|volume=21|issue=7|pages=569–575|doi=10.1136/bmjqs-2011-000692|pmid=22626737|pmc=3382445}} Interventions to overcome barriers include improved intradisciplinary staff education, protocol requiring activation when calling criteria are met, and use of “champions” to foster cultural change.{{cite journal|last=Theilen|first=U|author2=Leonard, P |author3=Jones, P |author4=Ardill, R |author5=Weitz, J |author6=Agrawal, D |author7= Simpson, D |title=Regular in situ simulation training of paediatric medical emergency team improves hospital response to deteriorating patients.|journal=Resuscitation|date=February 2013|volume=84|issue=2|pages=218–22|pmid=22796407|doi=10.1016/j.resuscitation.2012.06.027}}{{cite book|title=Medical Emergency Teams: Implementation and Outcome Measurement|url=https://archive.org/details/medicalemergency00devi|url-access=limited|year=2006|publisher=Springer|location=New York|pages=[https://archive.org/details/medicalemergency00devi/page/n107 91]–103|author=DeVita, M|author2=Hillman, K |veditors=DeVita M, Hillman K, Bellomo R|chapter=Potential Sociological and Political Barriers to Medical Emergency Team Implementation}}

The administrative component oversees the planning, implementation, and maintenance phases for the RRS. A formal committee of frontline clinicians and ward and ICU leaders operate the administrative component. Cost effectiveness of RRS implementation has not been rigorously studied.

Lee and colleagues developed the first reported MET in 1995 in Liverpool Hospital in Australia.{{cite journal|last=Lee|first=A|author2=Bishop, G |author3=Hillman, KM |author4= Daffurn, K |title=The Medical Emergency Team.|journal=Anaesthesia and Intensive Care|date=April 1995|volume=23|issue=2|pages=183–6|pmid=7793590|doi=10.1177/0310057X9502300210|doi-access=free}} The first pediatric RRS was implemented in 2005 by Tibballs, Kinney, and colleagues at Royal Children’s Hospital in Australia which included vital sign ranges that differed by age group.{{cite journal|last=Tibballs|first=J|author2=Kinney, S |author3=Duke, T |author4=Oakley, E |author5= Hennessy, M |title=Reduction of paediatric in-patient cardiac arrest and death with a medical emergency team: preliminary results.|journal=Archives of Disease in Childhood|date=November 2005|volume=90|issue=11|pages=1148–52|pmid=16243869|doi=10.1136/adc.2004.069401 |pmc=1720176}} Since its development, the RRS has been implemented around the world. The RRS became a standard of hospitals in the U.S. after its promotion by the Institute for Healthcare Improvement in 2005 and the Joint Commission in 2008.{{cite web|last=Institute for Healthcare Improvement|title=5 Million Lives Campaign|url=http://www.ihi.org/offerings/Initiatives/PastStrategicInitiatives/5MillionLivesCampaign/Pages/default.aspx|accessdate=18 October 2013}}{{cite journal|last=The Joint Commission|title=The Joint Commission 2008 National Patient Safety Goals|journal=Joint Commission Perspectives|date=July 2007|volume=27|issue=7|pages=19}} Outside the U.S., RRS implementation has been encouraged and adopted by several national organizations, such as the Ministry of Health and Long-term Care in Canada,{{cite web|author1=Ontario Ministry of Health |author2=Long-term Care |title=Critical Care Strategy|url=http://www.health.gov.on.ca/en/pro/programs/criticalcare/|accessdate=18 October 2013}} the UK National Institute for Health and Clinical Excellence,{{cite web|last=UK National Institute for Health and Clinical Excellence (NICE)|title=Acutely ill patients in hospital: recognition of and response to acute illness in adults in hospital|url=http://publications.nice.org.uk/acutely-ill-patients-in-hospital-cg50|accessdate=18 October 2013|date=July 2007}} and the Australian Commission on Safety and Quality in Healthcare.{{cite web|last=Australian Commission on Safety and Quality in Health Care|title=National Safety and Quality Health Service Standards|url=http://www.safetyandquality.gov.au/wp-content/uploads/2011/09/NSQHS-Standards-Sept-2012.pdf|accessdate=18 October 2013|location=Sydney|date=September 2011}}

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Category:Critical emergency medicine

Category:Patient safety