Wednesday, December 30, 2009

Top 10 issues in hospital medicine for 2009, issue 7: rapid response teams, telemetry and early warning scores

The premise behind rapid response teams (RRTs), that intervention in deteriorating patients should avert cardiac arrests and reduce hospital mortality, is appealing. Yet, despite widespread claims that such teams save lives, extensive research has failed to show that they do.

Why wouldn't it be effective? Maybe because customary use of RRTs is to intervene at the last minute when, in most cases, physiologic deterioration begins hours before the crash. That physiologic deterioration may, in cases such as sepsis, be irreversible in the final moments leading to cardiopulmonary arrest. Having a RRT is not a substitute for clinical vigilance.

The consensus of a panel of speakers at SHM 2009 was that while research evidence doesn't show an impact on meaningful clinical outcomes individual institutions may realize intangible benefits. Nurses love the concept. Rapid response calls may lead to advance health care planning discussions. Perhaps most importantly, rapid response systems can be educational tools. When reviewed systematically they may uncover safety issues and drive process improvement.

The panelists discussed tips for more effective use of RRTs, learned from their own institutions. The process should be structured. Define the patient changes that should trigger a call. Formally review all RRT call records. Define post-RRT care and hand-off procedures. The RRT concept can be extended in novel ways such as proactive rounds on high acuity patients and extending coverage beyond the wards to the ED and other areas of the facility.

Whatever the benefits of the RRT for the individual institution, based on the disappointing literature on RRT outcomes no one can legitimately claim that their institution is saving lives just because they have a RRT. Moreover, there is no research basis for making the RRT a reportable quality measure.

Before leaving the topic of RRTs, a word about Joint Commission. Contrary to popular belief Joint Commission does not require hospitals to have RRTs. Instead they require hospitals to have a structured mechanism in place, specific to the needs of the individual facility, whereby help is summoned for deteriorating patients. In addition hospitals are to monitor outcomes before and after implementation.

Have other means of averting cardiac arrest proven effective? Earlier this year I wrote a post about telemetry monitoring. Telemetry monitoring alerts nursing staff of cardiac arrest in progress, but only rarely prevents cardiac arrest and is over-utilized.

Because physiologic changes which progress to cardiac arrest often unfold over hours and may be irreversible in the moments preceding cardiopulmonary arrest, early warning assessment methods have been used. Perhaps the most popular is the modified early warning score (MEWS) a physiologic scoring tool which, in this study, was highly predictive of the risk of in hospital deterioration. This tool can be used at the time of hospital admission and periodically thereafter for early identification of patients at risk so that intervention can take place before the patient is in crisis.

Finally, of related interest this year was this note about Vanderbilt's in patient sepsis early warning and management system.

Image courtesy of the Missouri Historical archives.

No comments: