Effects of rapid response systems on clinical outcomes: Systematic review and meta-analysis

Department of Medicine, University of California San Francisco, California 94143-0131, USA.
Journal of Hospital Medicine (Impact Factor: 2.08). 11/2007; 2(6):422-32. DOI: 10.1002/jhm.238
Source: PubMed

ABSTRACT A rapid response system (RRS) consists of providers who immediately assess and treat unstable hospitalized patients. Examples include medical emergency teams and rapid response teams. Early reports of major improvements in patient outcomes led to widespread utilization of RRSs, despite the negative results of a subsequent cluster-randomized trial.
To evaluate the effects of RRSs on clinical outcomes through a systematic literature review.
MEDLINE, BIOSIS, and CINAHL searches through August 2006, review of conference proceedings and article bibliographies.
Randomized and nonrandomized controlled trials, interrupted time series, and before-after studies reporting effects of an RRS on inpatient mortality, cardiopulmonary arrests, or unscheduled ICU admissions.
Two authors independently determined study eligibility, abstracted data, and classified study quality.
Thirteen studies met inclusion criteria: 1 cluster-randomized controlled trial (RCT), 1 interrupted time series, and 11 before-after studies. The RCT showed no effects on any clinical outcome. Before-after studies showed reductions in inpatient mortality (RR = 0.82, 95% CI: 0.74-0.91) and cardiac arrest (RR = 0.73, 95% CI: 0.65-0.83). However, these studies were of poor methodological quality, and control hospitals in the RCT reported reductions in mortality and cardiac arrest rates comparable to those in the before-after studies.
Published studies of RRSs have not found consistent improvement in clinical outcomes and have been of poor methodological quality. The positive results of before-after trials likely reflects secular trends and biased outcome ascertainment, as the improved outcomes they reported were of similar magnitude to those of the control group in the RCT. The effectiveness of the RRS concept remains unproven.

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    • "Defining patient deterioration through ACU and ICU nurses' perspectives patient outcomes were found to improve after their introduction, evidence regarding their impact remains scant (Esmonde et al., 2006; Ranji et al., 2007; Chan et al., 2010). These tools and resources are used infrequently by nurses on ACU (Odell et al., 2009; Donohue and Endacott, 2010) and the issue of patient deterioration not being recognized or acted upon remains. "
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    ABSTRACT: AimTo explore the variations between acute care and intensive care nurses' understanding of patient deterioration according to their use of this term in published literature.Background Evidence suggests that nurses on wards do not always recognize and act upon patient deterioration appropriately. Even if resources exist to call for intensive care nurses' help, acute care nurses use them infrequently and the problem of unattended patient deterioration remains.DesignDimensional analysis was used as a framework to analyze papers retrieved in a nursing-focused database.MethodA thematic analysis of 34 papers (2002–2012) depicting acute care and intensive care unit nurses' perspectives on patient deterioration was conducted.FindingsNo explicit definition of patient deterioration was retrieved in the papers. There are variations between acute care and intensive care unit nurses' accounts of this concept, particularly regarding the validity of patient deterioration indicators. Contextual factors, processes and consequences are also explored.Conclusions From the perspectives of acute care and intensive care nurses, patient deterioration can be defined as an evolving, predictable and symptomatic process of worsening physiology towards critical illness. Contextual factors relating to acute care units (ACU) appear as barriers to optimal care of the deteriorating patient. This work can be considered as a first effort in modelling the concept of patient deterioration, which could be specific to ACU.Relevance to clinical practiceThe findings suggest that it might be relevant to include subjective indicators of patient deterioration in track and trigger systems and educational efforts. Contextual factors impacting care for the deteriorating patient could be addressed in further attempts to deal with this issue.
    Nursing in Critical Care 09/2014; DOI:10.1111/nicc.12114 · 0.87 Impact Factor
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    • "High-capability team; are usually physician led and available 24 hours a day, seven days a week (Lee et al., 1995; Buist et al., 2002; Cretikos & Hillman, 2003;). Two systematic reviews have evaluated the effectiveness of high-capability teams (Ranji et al., 2007; Winters et al., 2007). Both reviews concluded that the evidence available on the effectiveness of high capability teams was inconclusive. "
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    ABSTRACT: To conduct a literature review that explores the impact of rapid response systems on reducing major adverse events experienced by deteriorating ward patients. Patients located on hospitals wards are frequently older, have multiple co-morbidities and are often at risk of life-threatening clinical deterioration. Rapid response systems have been developed and implemented to provide appropriate and timely intervention to these patients. A comprehensive review of the literature. This review used the rapid response systems framework recently developed by experts in the area. Medline, CINAHL, Embase and Cochrane databases were searched from January 1995-June 2009. Sixteen papers were selected that most clearly reflected the research aim. Each paper was critically appraised and systematically assessed. Major themes and findings were identified for each of the studies. The effectiveness of rapid response systems in reducing major adverse events in deteriorating ward patients remains inconclusive. Six studies demonstrated that the introduction of a rapid response systems positively impacted on patient outcomes, but three studies demonstrated no positive impact on patient outcomes. Nursing staff appear reluctant to use rapid response systems; the rationale for this is unclear. However, the continued underuse and inactivation may be one reason why research findings evaluating rapid response systems have been inconclusive.  The paper illustrates two important gaps in the literature. First, 'ramp-up' systems have not been subjected to formal evaluation. Second, rapid response systems are under-activated and underused by nursing staff. There is an urgent need to explore the reasons for this and to identify interventions to improve the activation of these systems in an effort to promote safe and effective care to the deteriorating ward patient. Rapid response systems are multidimensional models. They are relatively new innovations that have important implications for clinical research and implementation policy. This review contributes to the emerging debate on rapid response systems.
    Journal of Clinical Nursing 10/2010; 19(23-24):3260-73. DOI:10.1111/j.1365-2702.2010.03394.x · 1.23 Impact Factor
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    ABSTRACT: HintergrundWeltweit stehen sog. „cardiac arrest teams“ (CAT) zur innerklinischen Notfallversorgung bereit. Zur Prävention werden „medical emergency teams“ (MET) eingesetzt. Die vorliegende Studie untersucht die innerklinische Notfallversorgungsstruktur an niederländischen Kliniken. MethodikEs wurden strukturierte Interviews durchgeführt („mixed methods design“). Erfasst wurden die Struktur der innerklinischen Notfallversorgung und die Ausbildung der Klinikmitarbeiter. Einbezogen wurden 9niederländische Universitätskliniken (Gruppe1), 9Kliniken der Schwerpunktversorgung (Gruppe2) und 9Kliniken der Grundversorgungsstufe (Gruppe3). ErgebnisseInsgesamt 25Kliniken (93%) nahmen an den Interviews teil, von denen 21 (78%) in die Untersuchung integriert wurden. Alle untersuchten Kliniken stellten mindestens ein CAT. Vier der 21Kliniken (19%) hatten zusätzlich ein MET zur Prävention innerklinischer Notfälle. Unterschiede bestanden hinsichtlich der nächtlichen innerklinischen Notfallversorgung und der Ausbildung des Personals in Abhängigkeit von der Versorgungsstufe. DiskussionBei allen Kliniken war eine strukturierte Notfallversorgung durch spezielle Notfallteams implementiert. Die Prävention durch MET ist erweiterungsfähig. Um die innerklinische Notfallversorgung weiter zu verbessern, bieten sich konsequente Notfallschulungen auf Normalstationen an. BackgroundThroughout the world there are so-called cardiac arrest teams (CAT) for in-hospital emergency care. In addition medical emergency teams (MET) are integrated for the prevention of in-hospital emergency situations. The present investigation investigated the structure of emergency care in Dutch hospitals. MethodsThe investigation was performed using structured interviews (mixed methods design). The survey covered the structure of in-hospital emergency care as well as the training of the CAT members. A total of 9university hospitals (group1), 9secondary care hospitals (group2) and 9primary care hospitals (group3) were included in the investigation. ResultsA total of 25physicians agreed to be interviewed (93%) of which 21 were included in the present investigation (78%). Regardless of the level of care, all examined hospitals had at least one CAT and 4 of the 21hospitals had, in addition, a MET for the prevention of in-hospital emergencies (19%). With respect to the in-hospital emergency night time medical care and the skills of the staff, there were differences between the examined hospitals. ConclusionsIn all hospitals there was a structured emergency care by special emergency teams. The in-hospital emergency prevention by MET needs improvement. A possibility to improve the emergency care of hospitalized patients is to train the staff on normal wards. SchlüsselwörterInnerklinisches Notfallmanagement-Innerklinischer Notfall-Innerklinisches Notfallteam (CAT)-Innerklinisches Präventionsteam (MET)-Herz-Lungen-Wiederbelebung KeywordsIn-hospital cardiac arrest management-In-hospital cardiac arrest-Cardiac arrest team (CAT)-Medical emergency team (MET)-Cardiopulmonary resuscitation
    Notfall 13(2):131-137. DOI:10.1007/s10049-009-1266-2 · 0.32 Impact Factor
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