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Medical Emergency Teams: Does Rapid Response Make a Difference?
Abstract & Commentary
By Ruth Kleinpell, PhD, RN, Director, Center for Clinical Research and Scholarship, Rush University Medical Center; Professor, Rush University College of Nursing, Chicago. Dr. Kleinpell reports no financial relationship to this field of study.This article originally appeared in the August 2010 issue of Critical Care Alert. It was edited by David J. Pierson, MD and peer reviewed by Saadia Akhtar, MD. Dr. Pierson is Professor, Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, and Dr. Akhtar works for St. Luke's Idaho Pulmonary Associates, Boise. Drs. Pierson and Akhtar both report no financial relationships relevant to this field of study.
Synopsis: In this before-and-after study of more than 275,000 patients admitted to a Swedish hospital before-and-after implementation of a medical emergency team, in-hospital cardiac arrests decreased and overall in-hospital mortality fell by 10% in the two years following the team's implementation.
Source: Konrad D, et al. Reducing in-hospital cardiac arrests and hospital mortality by introducing a medical emergency team. Intensive Care Med 2010;36:100-106.
The use of a rapid response system (RRS), or medical emergency team (MET), has become established as a patient safety measure to ensure early detection of patient compromise. It has been demonstrated that 50%-80% of in-hospital cardiac arrests are preceded by some clinical signs of instability, such as abnormalities in pulse rate, respiratory rate, mental status, or oxygen saturation (SpO2).1-3 Early detection and response to promote timely recognition of patients with physiological deterioration with the use of a RRS has been identified as a way to decrease mortality rates by intervening and potentially preventing a cardiac arrest.
This prospective before-and-after trial of implementation of an MET at a hospital in Sweden examined the impact on hospital mortality rates over a two-year intervention period that included 73,825 patients compared to a five-year pre-implementation period with 203,892 patients. The MET team consisted of an ICU physician and ICU nurse who responded to calls based on one or more standard triggers, including vital sign changes, changes in mentation, or staff concern about the patient. The primary outcome was the number of cardiac arrests per 1,000 admissions, and secondary outcomes included adjusted hospital mortality and 30- and 180-day mortality for patients receiving an MET intervention.
The number of MET calls was 9.3 per 1,000 hospital admissions. In comparing pre-MET and MET intervals, the number of cardiac arrests decreased from 1.12 per 1,000 patients to 0.83. MET implementation was associated with a reduction in total hospital mortality by 10% (p = 0.003). The results of the study indicated that the introduction of the MET improved outcomes for hospitalized patients.
The findings of the study provide further evidence on the benefit of the use of RRSs in decreasing mortality rates in hospitalized patients. Support for the use of RRSs by quality organizations such as the Institute for Healthcare Improvement, in conjunction with the 2008 Joint Commission's designation of the use of systems to promote health care clinician response to a patient's worsening condition as a National Patient Safety goal have led to widespread implementation of RRSs. However, while studies have shown that an RRS may improve outcome, questions remain about the specific components, best format, and ultimate benefits of the RRS.4
Interpreting the Evidence Related to the Use of Rapid Response Teams. The findings by Konrad and colleagues support the results of other studies that have demonstrated a reduction in in-hospital cardiac arrests with the use of a RRS.4-7 Yet, ongoing debate continues regarding the advantages of implementing a RRS as other studies have found no difference in reducing hospital mortality. The MERIT (Medical Early Response Intervention and Therapy) study, a large 23-hospital Australian study evaluated the use of METs with 12 hospitals receiving training in the MET process and implementing a program, compared to 11 hospitals that did not receive training and were asked to delay introduction of a MET system during the study period.8 During a six-month follow-up period after implementation, no differences were found in cardiac arrests, unplanned ICU admissions, or unexpected death.8 However, the authors cited inadequate utilization of the MET for patients who met clinical criteria and concluded that despite similar outcomes in both study groups, system-based interventions can have an impact on improving monitoring of patients and promoting appropriate clinician response. Additionally, the use of the randomized clinical trial design in demonstrating benefit of the RRS has since been debated.9,10
The findings by Konrad and colleagues also support prior research that has demonstrated a reduction in overall hospital mortality with the use of a RRS. An overall reduction in hospital mortality of 10% was found, lending support to other studies that have shown a reduction in hospital mortality of up to 26%.6 A recent meta-analysis of 18 randomized clinical trials and prospective studies of the use of a RRS found a 33.8% reduction in rates of non-ICU cardiac arrests, but no significant differences in hospital mortality rates for adult patients.11 However, for children, implementation of an RRS was associated with a 37.7% reduction in rates of non-ICU cardiac arrests and a 21.4% reduction in hospital mortality rates.11
To establish consensus on issues related to use of the RRS, a consensus conference of international experts examined characteristics of an "ideal" monitoring system.12 Four specific components of the RRS were considered, including the afferent or crisis detection and response triggering mechanism, an efferent or predetermined rapid response team, the governance/administrative structure, and a mechanism to evaluate crisis antecedents and promote hospital quality improvement processes.12 The findings designated sufficient data to support that hospitals implement a RRS and that outcome benefits exist in terms of reduced deaths, cardiac arrest, hospital length of stay, ICU length of stay, and costs. However, additional research was advocated to determine the magnitude and benefit.12
It becomes evident that hospital-wide initiatives to educate and assist clinicians in early identification and rapid treatment of life-threatening conditions that include a team response and protocols based on best practice guidelines can improve outcomes.13,14 In addition, the use of track and trigger systems, combined with appropriate response algorithms, has been advocated to improve the recognition and management of critical illness.1 As the severity of illness among hospitalized patients continues to increase, it becomes intuitive that RRS would be beneficial in promoting early detection of compromise. The results of research support that rapid response does make a difference, yet the quality of evidence that currently exists necessitates further work to validate the full utility of the RRS.
1. Jansen JO, et al. Current Opin Critical Care. 2010:16:184-190.
2. Lighthall GK, et al. Resuscitation. 2009;80:1264-1269.
3. Buist MD, et al. Med J Aust. 1999;171:22-25.
4. DeVita M, et al. Crit Care Med. 2006;34:2463-2478.
5. Buist MD, et al. BMJ. 2002;324:387-390.
6. Bellomo R, et al. Med J Aust. 2003;179:283-287.
7. DeVita MA, et al. Qual Saf Health Care. 2004;13:251-254.
8. Hillman K, et al; MERIT study investigators. Lancet. 2005;365:2091-2097.
9. Winters BD, et al. Crit Care Med. 2007;35:1238-1243.
10. DeVita MA, Bellomo R. Crit Care Med. 2007;35:1413-1414.
11. Chan PS, et al. Arch Intern Med. 2010;170:18-26.
12. DeVita MA, et al. Resuscitation. 2010;81:375-382.
13. Sebat F, et al. Crit Care Med. 2007;35:2568-2575.
14. Sebat F, et al. Designing, Implementing, and Enhancing a Rapid Response System. Chicago, IL: Society of Critical Care Medicine; 2009.