AAMC Reporter: April 2009

Rapid Response Teams Yield Mixed Results

In many hospitals nationwide, a new kind of health care provider team is taking hold. Known as rapid response teams (RRT), these groups work in concert with attending physicians to help prevent medical catastrophes and avoidable patient deaths.

At a glance, the idea would seem to have little downside. However, RRTs are generating lots of debate even as their popularity increases.

RRTs mainly consist of nurses, respiratory therapists, and physicians (including residents) who, when alerted, assemble within minutes to provide consultation and assistance for a deteriorating patient before early symptoms balloon into a crisis such as cardiac or respiratory arrest. Any member of the health care team and even family members have the authority to call the RRT. Teams are notified either by pager or intercom.

Previous studies indicate most patients exhibit symptoms of decline, such as altered mental status, chest pain, or an elevated or reduced heart rate or blood pressure reading, between six hours and eight hours before a cardiac arrest. Arguments for RRTs hold that if providers evaluate a patient at the initial signs of trouble, they can potentially prevent an avoidable death.

RRTs are a recommendation from the Institute for Healthcare Improvement (IHI) 100,000 Lives Campaign, a 2004 initiative to reduce the number of unnecessary deaths in the United States. The call for RRTs continued in the IHI's current 5 Million Lives Campaign. The institute said RRTs would improve patient treatment, communication between providers, and the identification of faltering patients. More than 3,000 teaching hospitals and health systems joined the IHI campaign, and to date 1,781 of these institutions pledged to and have created an RRT.

Through the Rapid Response System Collaborative in 2006, the AAMC and several academic medical centers supported implementing RRTs in teaching and community hospitals.

According to IHI RRT expert Kathy Duncan, R.N., hospitals with RRTs have experienced varying levels of success, but the IHI considers them effective because institutions reported a drop in preventable deaths. In addition, providers feel they offer an extra layer of support for the patient.

"For the most part, it's been very rewarding to the staff to know that with one phone call they can get colleagues to assess and help with a patient immediately," Duncan said. "In some places, if you eliminate the RRT, there would be mutiny. Nurses love them and are asking if hospitals have one before accepting jobs."

However, Robert M. Wachter, M.D., professor and chief of medical services at the University of California, San Francisco Medical Center, said the evidence supporting RRTs is anecdotal and too weak to warrant mandating more widespread implementation.

"Many places have RRTs, and many swear by them," Wachter said. "But they were rolled out with much fanfare and pressure to make them a national standard. At UCSF, we've not seen any real improvements due to our RRT, and it's simply not clear that it's worth putting so many resources into an intervention that isn't proven with hard evidence."

A 2006 Journal of the American Medical Association study mirrored Wachter's conclusion, asserting available evidence did not demonstrate RRT superiority over other patient safety and mortality rate improvement methods. However, study coauthor Bradford Winters, M.D., Ph.D., assistant professor of anesthesiology and critical care medicine, neurology, and surgery for Johns Hopkins Medicine, said RRTs have other benefits, including increasing education about early deterioration signs and fostering collaboration between various hospital providers.

Regardless of whether clinical evidence supports RRT use, some academic medical centers report the teams have positively affected their institution. Rosemary Gibson, M.S.N., C.N.S., RRT project manager at Cincinnati Children's Hospital Medical Center, said that preventable deaths outside the intensive care unit dropped 50 percent since the hospital introduced the team last year.

"I know the literature surrounding these teams is controversial, but I can't imagine not having one," she said. "We just can't argue with the data on our number of codes in the past year."

William Ford, M.D., program medical director for Cogent Healthcare, part of the Temple University Health System, said data collected on RRT calls have allowed staff to determine the situations that best lend themselves to an RRT response.

"We've been able to identify trends in behavior among failing patients," he said, "to see what strategies work and which ones don't and to pinpoint errors that can be prevented in the future."

Richard J. Brilli, M.D., chief medical officer of Nationwide Children's Hospital in Columbus, Ohio, supports RRTs. However, he said it is challenging to manage the job responsibilities of RRT members called away from their official duties and to ensure providers do not call the team unnecessarily. Meeting these challenges contributes to the financial burden that RRT implementation places on health care institutions.

Brilli added that hospitals and academic medical centers must work diligently to change the hierarchical structure that has historically existed in the relationship among doctors, nurses, and residents. Nurses and residents must feel free to call for extra support or for a consultation without fear of punishment.

Overall, as the use of RRTs advances, Wachter said they must be studied intensively to determine how best to use them before they are mandated as a national standard of care.

"RRTs are only part of the puzzle to reaching these patient safety goals," he said. "But I believe we need to employ tactics supported by the strongest evidence and work our way down the ladder. Right now, RRTs aren't at the top of the ladder."

—By Madeleine Evans, special to the Reporter