Are rapid response teams saving lives? A new study says no

JAMA article reports no difference in mortality after intervention

While a rapid response is important in trying to save lives and prevent in-hospital deaths from cardiac arrest, the vehicle for that response is now called into question. A report in the Dec. 3, 2008, issue of the Journal of the American Medical Association (JAMA) examines the effect of a rapid response team intervention on hospital-wide code and mortality rates. The conclusion: "Implementation of a rapid response team was not associated with lower hospital-wide code rates. Similarly, rapid response intervention was not associated with improvements in the clinically meaningful outcome of hospital-wide mortality."1

In what the authors say is the first study to look at the adult population and non-ICU code rates, data were gathered prospectively at Saint Luke's Hospital, a tertiary care 404-bed hospital in Kansas City, MO. Data represented either a pre- or post-intervention period, before or after rapid response team intervention. Before the RRTs, comprising two ICU nurses and a respiratory therapist, were rolled out, staff were educated for four months on using the intervention, and standard criteria for activation were employed.

"One of the major reasons we decided to do the study was to get a better sense of whether or not these rapid response teams have a significant difference in the hospital setting," says lead author Paul S. Chan, MD, MSc, of the Mid America Heart Institute and the University of Missouri. "The literature on rapid response teams has been quite mixed, and part of it is there are differences in how those studies have been performed and what was being measured, and we felt pretty strongly from the get-go that because prior studies had not measured code rates outside the intensive care rate," it was important to do that, he says.

Looking only at code rates is "just a surrogate outcome for the truly important outcome of post-survival and mortality," Chan says, and if the team had found a statistically significant decrease in either ICU or non-ICU code rates, there are multiple factors that could have influenced that, such as activation of a DNR in which the code would not be made or transfers to higher levels of care.

The Joint Commission, in Patient Safety Goal #16, asks that hospitals "improve recognition and response to changes in a patient's condition," and as part of its elements of performance specifies that a facility has in place an early recognition and response method suitable to the organization, though this does not necessarily mean that a rapid response team has to be the method selected.

The Institute for Healthcare Improvement in 2004, began to call for hospitals to establish rapid response teams as part of its 100,000 Lives Campaign, which has now morphed into the 5 Million Lives Campaign. (For a list of IHI tools on implementation and measurement information, see www.ihi.org/IHI/Programs.)

Could a different conclusion be made?

Although the IHI acknowledges the technical sophistication and methods used in the study, in an online discussion of the article, President Don Berwick questioned that the hospital-wide code rate per 1,000 admission could be considered statistically significant if one used the Bayesian model in looking at the p value.

Paul J. Sharek, MD, MPH, chief clinical patient safety officer at Lucile Packard, was lead author of a 2007 JAMA study showing a favorable effect on codes and mortality rates outside of the pediatric ICU setting in which a RRT intervention was made.2

He points to the study's primary outcome of hospital-wide code rates vs. codes outside of the ICU. "This is a big difference. Most sites who implement RRTs do so to address codes outside of the ICU setting, recognizing that codes in non- ICU settings are not likely to go as well as those in the ICU environment where ICU specialists are available immediately and have much more experience running codes.

"If we compared our primary outcome of codes outside ICU rates with this study, both studies showed statistically significant decreases. The mortality decreases clearly don't always occur, as has been shown in other studies as well, so this is not as surprising," he says.

Berwick concurs that the problem with the study "has to do with interpretation," specifically with the raw data comparing the pre- and post-intervention periods. "There was actually quite a dramatic effect on out-of-ICU code rates per 1,000 admissions. That code rate fell from about 11 to about eight — a major reduction," he says.

But Chan says according to their criteria, that value was not statistically significant, and "it doesn't even matter if we did [find a decrease in code rates], because we didn't change survival."

Successes in the field

The IHI reiterates that it has seen and heard from many hospitals that have had success with the implementation of RRTs. And Kim Barnhardt, RN, accreditation specialist, and Rhonda Wright, director of nursing administration and clinical care services, at Carolinas Medical Center-Northeast in Concord, NC, say they've seen successes since they rolled out RRTs in 2004.

"We continue to enjoy [the early] successes [with the model], and we have the data to show it. We have cardiac arrests remaining down, and mortality decreasing over the years. We're meeting the goals we've set. We're pleased with our rapid responses," Wright says.

The composition of RRTs varies from hospital to hospital, but at their facility, Wright and Barnhardt say they have found most success using a respiratory therapist and an ICU nurse. Since intensivists are in-house 24/7, they say the team can call on physician help when needed.

In addition to education on RRT activation, the two celebrate hospital successes while continuing to educate by highlighting individual successes stories once a month and sharing them with staff.

Caveats

In its discussion, the IHI cautions how the public, and particularly the media, highlight the study, by concluding that there is a no evidence supporting the use of rapid response teams. Berwick reiterates that this is a single study in a single institution and that hospitals in the field report successes that "are positive and buoyant and affirming."

"I do think when a study comes out and it's labeled as a negative study, that that can sometimes influence hospital behavior," IHI's vice president Joe McCannon tells Hospital Peer Review. "[I] think we've got to be clear that we can always learn more but that for the moment we feel that this approach and other early detection strategies are important, and we are not backing off of them."

McCannon encourages hospitals that are having successes to share those data and says that "if a preponderance of evidence suggests to us that we need to make a change in our advice to hospitals, we'll do that. But I think in this case, we feel that this approach and other early detection strategies are important ways to address failure to rescue."

Patti Muller-Smith, RN, EdD, CPHQ, a Shawnee, OK-based consultant who works with hospitals on performance improvement and regulatory compliance, says one must remember we're looking at a single study in a single institute and to look at the original intent of the RRT intervention: to focus on non-ICU patients and those data, including non-ICU codes.

"In the hospitals that are reporting globally rather than pulling out non-ICU data and data for all events," she says, "it may not really reflect how effective the teams are."

She says if one were to look at the data on patients without transfers to the ICU and non-code activation with DNR cases, you might have a different conclusion.

Chan does not discount the importance of early detection methods, but rather that rapid response teams are the most effective detection strategy. He says the research team is still looking at whether the rapid response team intervention had an effect on the use of ICU days in the hospital.

"On face value," he says, "we were not decreasing days in the ICU. What I can say is if we haven't reduced mortality, we haven't necessarily reduced code rates as much as we think we'd like to, and we may not even be decreasing utilization. And we're using resources that could be used for more effective quality improvement plans... So the question is whether we're spending time using resources for personnel and finances when other programs may have more clear benefits."

Chan, like the IHI, says further, larger studies are needed. Until then, he says, "we need to take a step back and think about whether or not we should be disseminating the use uniformly across hospitals when clearly there are other priorities on the hospital QI level."

To quality directors, Chan says, "I think we need to go back to the drawing board. Until then, each hospital needs to re-examine their own policies for quality improvement and the resources that are available to it."

Reference

  1. Chan PS, Khalid A, Longmore LS, et al "Hospital-wide code rates and mortality before and after implementation of a rapid response team" JAMA 2008 Dec 3; 300(21):2,506-13.
  2. Sharek PJ, Parast LM, Leong K, et al "Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a Children's Hospital" JAMA 2007 Nov 21;298(19):2267-74.