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: 2.3).
11/2007; 2(6):422-32. DOI: 10.1002/jhm.238
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.
Available from: Patrick Lavoie
- "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.
Available from: Antony Tobin
- "Before-and-after studies from a number of institutions support the premise that a MET reduces mortality [13-15], although the only randomised multicentre trial looking at the effect of MET on mortality failed to show a benefit , and two recent meta-analyses questioned their effect on hospital mortality [17,18]. Using routinely collected hospital administrative data we have previously reported that the introduction of a MET at our institution was associated with a reduction in all-cause hospital mortality over a number of years . "
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Medical emergency teams (MET) are implemented to ensure prompt clinical review of patients with deteriorating physiology with the intention of averting further deterioration, cardiac arrest and death. We sought to determine if MET implementation has led to reductions in hospital mortality across a large metropolitan health network utilising routine administrative data submitted by hospitals to the Department of Health Victoria.
The Victorian admissions episodes data set (VAED) contains data on all individual hospital separations in the State of Victoria, Australia. After gaining institutional ethics approval, we extracted data on all acute admissions to metropolitan hospitals for which we had information on the presence and timing of a MET system. Using logistic regression we determined whether there was an effect of MET implementation on mortality controlling for age, gender, Charlson comorbidity diagnostic groupings, emergency admission, same day admission, ICU admission, mechanical ventilation, year, indigenous ethnicity, liaison nurse service and hospital designation.
5911533 individual admissions and 73,599 associated deaths from July 1999 to June 2010 were included in the analysis. 52.2% were male and median age was 57(42-72 IQR). Mortality rates for MET and non-MET periods were 3.92 (3.88-3.95 95%CI) and 4.56 (4.51-4.61 95%CI) deaths per 1000 patient days with a rate ratio after adjustment for year of 0.88 (0.86-0.89 95%CI) P < 0.001. In a multivariable logistic regression, mortality was associated with a MET team being active in the hospital for more than 2 years. The odds ratio for mortality in hospitals where a MET system had been in place for greater than 4 years duration was 0.90 (0.88-0.92). Mortality during the first 2 years of a MET system being in place was not statistically different from pre-MET periods.
Utilising routinely collected administrative data we demonstrated that the presence of a hospital MET system for greater than 2 years was associated with an independent reduction in hospital mortality across a major metropolitan health network. Mortality benefits after the introduction of a MET system take time to become apparent.
Available from: John P Fletcher
- "Clinical audits, whilst valuable educational tools, are not without their limitations. Our study utilised a simple before and after design, which may be subject to methodological limitations. Confounding issues, such as the relative experience of the medical staff at the time of each audit were likely to be minimal given that the first cycle of data collection occurred mid-year when trainees would have had at least 6 months experience. "
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ABSTRACT: Venous thromboembolism (VTE) is a major health and financial burden. VTE impacts health outcomes in surgical and non-surgical patients. VTE prophylaxis is underutilized, particularly amongst high risk medical patients. We conducted a multicentre clinical audit to determine the extent to which appropriate VTE prophylaxis in acutely ill hospitalized medical patients could be improved via implementation of a multifaceted nurse facilitated educational program.
This multicentre clinical audit of 15 Australian hospitals was conducted in 2007-208. The program incorporated a baseline audit to determine the proportion of patients receiving appropriate VTE prophylaxis according to best practice recommendations issued by the Australian and New Zealand Working Party on the Management and Prevention of Venous Thromboembolism (ANZ-WP recommendations), followed by a 4-month education intervention program and a post intervention audit. The primary endpoint was to compare the proportion of patients being appropriately managed based on their risk profile between the two audits.
A total of 8774 patients (audit 1; 4399 and audit 2; 4375) were included in the study, most (82.2% audit 1; and 81.0% audit 2) were high risk based on ANZ-WP recommendations. At baseline 37.9% of high risk patients were receiving appropriate thromboprophylaxis. This increased to 54.1% in the post intervention audit (absolute improvement 16%; 95% confidence interval [CI] 11.7%, 20.5%). As a result of the nurse educator program, the likelihood of high risk patients being treated according to ANZ-WP recommendations increased significantly (OR 1.96; 1.62, 2.37).
Utilization of VTE prophylaxis amongst hospitalized medical patients can be significantly improved by implementation of a multifaceted educational program coordinated by a dedicated nurse practitioner.
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