Rapid Response Systems: Rapid Response Teams and Medical Emergency Teams

Chapter 110


Rapid Response Systems


Rapid Response Teams and Medical Emergency Teams



In 2008, the Joint Commission (JC, formerly named the Joint Commission for the Accreditation of Healthcare Organizations, or JCAHO) stipulated that all hospitals in the United States had to implement a system to improve recognition and response to changes in a patient’s condition. Its intent was to ensure that all hospital staff members have a suitable method to directly request assistance from specially trained individuals when a patient’s condition appeared to be worsening. This represented a significant departure from well-established norms, particularly in teaching hospitals, where the standard of care was for nurses to contact interns initially and information was then passed up the hierarchical chain of command as needed.


In 1999, the Institute of Medicine published To Err Is Human, a landmark report which found that a large number of deaths in hospitalized patients were preventable and resulted from negligence, lack of communication, or lack of adequate safety mechanisms. Furthermore, it is now accepted that most cardiac arrests in hospitalized patients are preceded by physiologic changes for hours to days prior to the acute event. The fundamental concept underlying rapid response and medical emergency teams is that timely recognition and intervention by appropriately trained personnel will impact the incidence of cardiac arrest and mortality. In this sense, these teams are meant to serve as the hospital’s “911” system to immediately and quickly mobilize resources for patients with acute physiologic deterioration.



Terms and Definitions


One of the goals of the first consensus conference on medical emergency teams was to unify terms used to describe these teams. A rapid response team (RRT) does not include a prescribing individual, such as a physician or advanced practitioner. These teams often are led by a nurse and may include a respiratory therapist. An RRT quickly evaluates a patient, initiates basic interventions based on standing orders or protocols, and contacts a physician or advanced practitioner, but cannot initiate advanced therapies. Medical emergency teams (METs) have the capability to prescribe new therapies and are frequently led by a physician from the intensive care unit (ICU) or emergency department. Other team members may include ICU-trained nurses, respiratory therapists, and pharmacists. Rapid response system (RRS) describes the overall infrastructure through which RRTs and METs function (Figure 110.1). The RRS includes an afferent arm, which detects signs of impending physiologic deterioration; an efferent arm (RRT or MET) and any needed resources to render treatment; and an administrative arm, which oversees the system and detects trends or recurrent events. The administrative arm collects and analyzes data related to causes of patient deterioration, optimizes methods for the early detection of patient deterioration, and ensures that adequate resources are immediately available to intervene as needed.




Building the Team


Teams can be designed as “ramp up” or “ramp down.” Ramp-up teams are usually RRTs and consist of a nurse and/or a respiratory therapist. These personnel are the first to respond to a patient’s bedside, assess the patient, and determine what additional resources, if any, are needed. A ramp-up team requires few dedicated resources, and may be most beneficial in places where the call volume and the likelihood for urgent intervention are low. Such places include ambulatory care centers, such as hospital-based clinics and outpatient areas. Ramp-down teams are usually METs and are meant to be an extension of the ICU itself. All personnel respond initially, and those deemed unnecessary are released once the patient has been evaluated. A ramp-down team incurs no delay between the patient assessment and administration of therapy. However, ramp-down teams are very resource intensive and because of their size may foster an air of alarm in the hospital personnel, patient’s family, or the patient. These teams may be best suited to areas where the call volume and the need for urgent intervention are high, such as high acuity non-ICU hospital wards.


To optimize the efficacy of the RRS, it is imperative that a review of serious adverse events and cardiac arrest precede team planning. Designed in this way, the RRS can increase patient safety in areas where improvement is needed without impeding well-functioning aspects of the hospital. All hospital staff must then be educated on the role and function of the RRS, a process that usually takes 3 to 6 months. Shortly after implementation, the RRS leadership should solicit feedback from hospital staff and adjust the team to maintain a spirit of cooperation and mutual respect. Obstacles to RRS implementation are discussed later in the chapter.


No optimal criteria for activation of MET/RRT exist. Although many scoring systems have been validated to predict in-hospital mortality or outcomes in the ICU, such as the Acute Physiology and Chronic Health Evaluation (APACHE) and the Simplified Acute Physiology Score (SAPS), none have been validated as triage tools for the bedside assessment of ward patients. The Modified Early Warning Score (MEWS) (Table 110.1) has been validated as a tool to predict the need for ICU admission and mortality in hospitalized patients. Scores of 4 or more are associated with increased mortality and admission to the ICU with a demonstrated sensitivity of 75% and specificity of 83%. Although criteria for activation of the MET/RRT are most often based on physiologic signs, it is imperative to emphasize the importance of medical staff discretion in activating the team (Box 110.1). Since 2009, the JC has stipulated that patients and families also have a means to quickly solicit help from hospital health care providers if the patient or a family member perceives a significant, acute change in the patient’s medical condition.



BOX 110.1   Criteria for Activation of the Medical Emergency Team at the Hospital of the University of Pennsylvania

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Jul 7, 2016 | Posted by in CRITICAL CARE | Comments Off on Rapid Response Systems: Rapid Response Teams and Medical Emergency Teams

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