Tweaking rapid response teams

Automation, new team members improving outcomes at some hospitals.

Rapid response systems have proliferated over the past decade since the Institute for Healthcare Improvement declared them a national patient safety goal. The concept makes sense in theory: Deploying specially trained teams to intervene as soon as patients show signs of deterioration could potentially avoid ICU admissions and lower the incidence of cardiac arrest and in-hospital mortality.

However, numerous studies have failed to demonstrate that rapid response teams (RRTs) improve outcomes. According to experts, that's not necessarily because they don't work but because many hospitals are still figuring out the best way to implement them.

Photo by Thinkstock
Photo by Thinkstock

“The answer to why rapid response teams haven't been more successful is a combination of two things,” said Dana Edelson, MD, medical director of rescue care and resiliency at the University of Chicago. “We don't call them often or early enough, and when we get there we don't always do the right thing.”

To address those issues, a few hospitals are experimenting with computerized real-time monitoring and automatic triggers to minimize the potential for human error in activating RRTs. They're also tweaking the composition of teams, implementing novel training methods, and working closely with palliative care specialists.

“The key is to think about all the pieces,” said Dr. Edelson. “Once you have an RRT, you need to think about how to encourage people to use it and ensure that the team is responding effectively.”

Innovative models

At the University of California San Diego (UCSD) Medical Center, outcomes improved significantly after the hospital implemented a novel RRT configuration and training program. In-hospital mortality fell from 2.12% before RRT implementation to 1.74% 4 years later, and there was also a significant drop in non-ICU cardiac arrests, according to findings published earlier this year in the Journal of Hospital Medicine (JHM).

Two features were integral to the model's success, said the study's lead author, Daniel Davis, MD, director of UCSD's Center for Resuscitation Science. A charge nurse from each unit was enlisted to be part of the RRT, along with a dedicated critical care nurse and respiratory therapist. In addition, all team members underwent Advanced Resuscitation Training (ART), a program that Dr. Davis created as an alternative to the standard Advanced Cardiac Life Support (ACLS) and Basic Life Support (BLS) model.

“The piece that consistently gets left out of the equation is the bedside provider, but our model shows that focusing education on them can lead to tremendous improvements in outcomes,” said Dr. Davis.

Training unit-based charge nurses to be the “eyes and ears” at the bedside was a departure from RRT models where a dedicated critical care nurse rounds on all high-risk patients, said Dr. Davis. The idea is that unit-based nurses are more familiar with patients they see regularly and will feel a sense of ownership over detecting signs of deterioration.

The ART program is more geared toward early recognition and response and continuous re-evaluation of activation criteria than ACLS/BLS, said Rebecca Sell, MD, medical director of resuscitation at UCSD and co-author of the JHM study. Following the success of UCSD's program, Dr. Sell was asked to help launch ART at the Veterans Affairs (VA) Hospital System in San Diego.

The VA subsequently saw a drop in inpatient cardiac arrests and an increase in survival to discharge among patients with such arrests from 21% to 45%, according to findings published in Circulation in 2013. It has since had to switch back to ACLS/BLS in response to a national mandate by the VA, but clinicians are working to incorporate elements of ART into its standard curriculum.

“Whereas ACLS/BLS is a protocol that is relatively inflexible and not responsive to change quickly within the institution, ART includes everything from the equipment you use to how you train your faculty and staff and how you respond to changes over time,” said Dr. Sell. “ACLS is great for setting a baseline standard, but it needs to be modified based on your experience and the tools you have at your own institution.”

Results from a 6-month pilot program conducted at the University of Rochester Medical Center in Rochester, N.Y., suggest that adding a pharmacist to the RRT also has the potential to improve outcomes. Initiated by 2 pharmacists trained in critical care and emergency medicine, the program called for a pharmacist to be included in the RRT bedside evaluation to consult about medication selection and catch any potential errors or adverse events.

Although the study did not measure impact on mortality, the results, published by the Journal of Pharmacy Practice in 2014, were promising. Working in alternate shifts, the pharmacists responded to a total of 32 RRT alerts during which 45 medications were administered. The pharmacists provided 49 interventions in 21 patients related to medication facilitation, dose, therapy recommendations, and addition or discontinuation of medications.

Being present at the bedside, rather than consulting by phone, allowed the pharmacist to review the patient's existing medications and alert the team to any drugs that might have been contributing to mental status changes or to recommend alternatives, said Nicole Acquisto, PharmD, who spearheaded the pilot along with Christine Groth, PharmD. Pharmacists also sped the process of getting drugs to the bedside because they were very familiar with where medications are stored on the different units.

In one case, for example, a pharmacist was instrumental in stopping a patient's seizure by recommending an alternative first-line treatment that was stored close by on the unit, said Dr. Groth. The alternative was also easier to administer than an infusion drug the team was initially considering.

Another example of where pharmacists can help is in quick administration of antibiotics, Dr. Acquisto said. “We know that [giving a patient] early antibiotics improves mortality,” she noted, “and including the pharmacist can speed up administration by facilitating the right drug and dose and getting medications to the bedside faster.”

Refining triggers

No matter how a team is composed, it can't be effective if it isn't used. As a result, many efforts to improve RRT outcomes are focused on developing more sophisticated systems for detecting deteriorating patients as early as possible.

“There are a lot of structures for what constitutes a rapid response system, but without the early triggers being implemented, the team won't be used effectively,” said Adel Bassily-Marcus, MD, FACP, director of the critical care consult service and critical care informatics at Mount Sinai Health System in New York City. “How to activate the response remains a major challenge.”

Using the vast stores of clinical data in electronic health record systems is one of the most promising pathways to improving RRT triggers, said Bruce Darrow, MD, PhD, chief medical information officer at Mount Sinai.

“An intelligent system that incorporates vital signs and triggers teams automatically could potentially lead to earlier detection than the current system of waiting for a clinician to get to the room, look at the patient, and decide if they need help,” he said. “Technology can support RRTs by detecting the patient who is clinically worsening as early as possible and using an algorithm to pull from available data.”

In a retrospective study performed at a large academic medical center, 24-hour EHR-triggered RRT activation resulted in lower ICU admissions and better surgical outcomes compared with cases activated by traditional calling criteria. The results, published in Critical Care Medicine, suggest that EHR-based triggering could overcome a common barrier to RRT activation: Bedside teams often don't call because they feel uncomfortable asking for help.

Electronic screening “could identify both the patient at risk, before he or she reaches the status required for an activation call, and the patient who should have triggered a call by doctors or nurses on the general ward but did not,” the study authors wrote. Patients identified by the EHR were more likely to need assessment and guidance rather than urgent management, they noted.

The criteria used by the system included abnormal lab data, which is not part of traditional calling criteria. In the study, 23% of EHR-based team activations were based on lab criteria, suggesting that lab factors might be an important element in successful screening.

Lower-tech methods can also be effective, however. In 1 study, Easton Hospital, an academic community hospital in Easton, Pa., saw improved outcomes after implementing a paper-based modified early warning system (MEWS) that helps clinicians calculate risk scores based on temperature, blood pressure, pulse, respiratory rate, and level of consciousness. The RRT is called when a patient's risk score reaches a predetermined level.

Using the MEWS led to higher utilization of the RRT and a drop in cardiopulmonary arrests, said the study's senior author, Mahesh Krishnamurthy, MD, FACP, hospitalist program director at Easton. It was also associated with a decrease in overall inpatient mortality from 2.3% in 2011 to 1.2% in 2014, according to results published in the Journal of Community Hospital Internal Medicine Perspectives. The hospital has since incorporated the scoring system into its EHR.

Researchers are now trying to build on the basic MEWS model, developing more sophisticated algorithms that pull together large amounts of data quickly and automatically activate the RRT, said Dr. Edelson.

For example, the electronic cardiac arrest risk triage system (e-CART), which Dr. Edelson helped developed at the University of Chicago, calculates a patient's risk score based on a rapid analysis of dozens of variables that, when taken together, signal changes in a patient's condition that may be too subtle for clinicians to detect.

“A lot of hospitals are currently using MEWS involving very simple algorithms for risk prediction that use a few vital sign parameters and expert opinion,” she said. “But we can now use new statistical techniques that didn't exist 10 years ago to create models that are more predictive and result in fewer false positives.”

Further refining electronic triggering systems is key to realizing the full benefits of RRTs, said Dr. Darrow. To do that, clinicians must work in partnership with information technology specialists to ensure that the criteria used to create new algorithms reflect actual clinical experience.

“We need to ensure that clinical best practices are incorporated into technology platforms,” he said. “Well-designed systems give clinicians the ability to move in the direction of guideline-supported therapy while leaving them the flexibility to make judgment calls.”

One size doesn't fit all

The algorithms and detection tools used to trigger RRTs tend to be fairly consistent across hospitals, experts said. However, the composition of teams varies considerably, ranging from a nurse and respiratory therapist to larger multidisciplinary teams that also include intensivists, hospitalists, pharmacists, and advanced practice providers.

“It's not uniform, because the needs are different in a small hospital dealing mainly with pneumonia and respiratory infections than in a large tertiary center dealing with transplants and trauma,” said Dr. Darrow. “The composition should accommodate what the needs are.”

Some studies suggest that having a physician lead the RRT can discourage nurses from calling because they feel intimidated or feel it may be interpreted as a sign of weakness, said Dr. Edelson.

Use of palliative care is another variable that can impact outcomes. In the study at Easton, early response by the RRT was associated with more palliative care consults, which likely contributed to the decrease in overall mortality, noted Dr. Krishnamurthy.

“A side effect of identifying these patients earlier is having more time to discuss end-of-life issues, including hospice,” he said. “Identifying a person 6 to 8 hours earlier gives us more options in terms of treatment but also more time to offer counseling.”

It's important for RRTs to consider palliative care in cases where the patient cannot be saved and the family has indicated that they prefer comfort measures to be taken over lifesaving treatment, said Dr. Edelson. “We need to train RRTs to think about that possibility and potentially involve the palliative care team or to do some of the palliative care work themselves,” she said.