Expanding the Scope of the Rapid Response System

Published:September 13, 2017DOI:https://doi.org/10.1016/j.jcjq.2017.08.001
      While the medical emergency team was described in 1995,
      • Lee A.
      • et al.
      The medical emergency team.
      the rapid response system (RRS) was first described in 2006 as a system intended to detect critical deterioration anywhere in the hospital, trigger an alert, and deliver a planned response of appropriate equipment and personnel to prevent further deterioration and death.
      • DeVita M.A.
      • et al.
      Findings of the first consensus conference on medical emergency teams.
      These two actions—detection and response—were called the Afferent and Efferent Limbs of the RRS, respectively. There are two other limbs, one needed for oversight and direction of the process (Administrative Limb) and the other focused on improvement in both the RRS and the care of hospitalized patients (Quality Improvement Limb). It was postulated that all four limbs were necessary for a fully functional RRS that would improve safety in hospitals.
      • DeVita M.A.
      • et al.
      Findings of the first consensus conference on medical emergency teams.
      At the time, and for years after, most hospitals generally concentrated on detecting and managing deteriorating patients by using abnormalities in vital signs as triggers. Using the same principle of a four-armed process, other trigger-based applications of the RRS have since been reported. These applications have included obstetric crises
      • Gosman G.G.
      • et al.
      Introduction of an obstetric-specific medical emergency team for obstetric crises: implementation and experience.
      ; rapidly escalating, potentially violent encounters
      • Shearn D.
      • Rubulotta F.
      • DeVita M.A.
      Other efferent limb teams: crises that require specialized resources.
      ; “lost” patients
      • Shearn D.
      • Rubulotta F.
      • DeVita M.A.
      Other efferent limb teams: crises that require specialized resources.
      ; hospital employees suffering from the emotional impact following errors or the burden of care they are delivering
      • Scott S.D.
      • et al.
      Caring for our own: deploying a systemwide second victim rapid response team.
      ; and identification and treatment of patients with stroke,
      • Alberts M.J.
      • et al.
      Acute stroke team: results of a national survey.
      acute myocardial infarction,
      • Shearn D.
      • Rubulotta F.
      • DeVita M.A.
      Other efferent limb teams: crises that require specialized resources.
      and sepsis.
      • Funk D.
      • Sebat F.
      • Kumar A.
      A systems approach to the early recognition and rapid administration of best practice therapy in sepsis and septic shock.
      The common theme among these RRS applications is the acuity of the situation and the necessity for a planned, rapid, rehearsed, and coordinated response to minimize further harm. Nonemergency applications exist, as well, such as admission-discharge-transfer teams.
      • Joyce C.
      • et al.
      Transfer admission discharge teams keep things moving.
      These teams, which are responsible for rapidly processing patients into and out of the hospital, thereby relieving ward nurses from doing the work piecemeal, are now becoming ubiquitous.
      In 2015 Mark and colleagues reported the development of an RRS focused on the “difficult airway.”
      • Mark L.J.
      • et al.
      Difficult airway response team: a novel quality improvement program for managing hospital-wide airway emergencies.
      They recognized patient harms resulting from delayed or uncoordinated care in patients whose airway management was life threatening. Just a few minutes of delay could be the difference between life and death. Their work demonstrated a decrease in the number of patient injuries following implementation of a process to provide care that included appropriate personnel and equipment. The response was based on defined triggers and was rehearsed and coordinated, qualifying it as a type of RRS. This is a system to be emulated at all acute care hospitals. In this issue of The Joint Commission Journal on Quality and Patient Safety, Atkins and colleagues describe how they have refined this process and created an RRS–based approach for developing and implementing an airway rapid response (ARR) team.
      • Atkins J.H.
      • et al.
      An airway rapid response system: implementation and utilization in a large academic trauma center.
      This approach, which was prompted by identification of a series of care events requiring improvement and led to the leadership team's initiation of a number of interventions, is one that any hospital can follow. Atkins et al. map out the approach according to the RRS nomenclature to make it easier to see how each piece fits into the whole. They created system triggers, defined the equipment and team, as well as how the team is notified, and the expected response activities. Finally, they describe their outcomes, thereby providing a benchmark for comparison. This article should help others promote, design, and implement similar systems in their own hospitals. It highlights the lesson that the success of any organizationwide system requires planning, equipment resources, personnel, and teamwork.
      As the Atkins et al. article demonstrates, the basic concept of the RRS—which is focused on the needs of individual patients and brings an interdisciplinary team that may circumvent the usual silo-based care—is now being used for an increasingly diverse set of problems. For example, in a hospital without such a team approach for a patient with a difficult airway, help from different “silos” of care must be brought together in an uncoordinated, inefficient fashion. The bedside clinician might, for example, request the assistance of a respiratory therapist, a nurse, an anesthesiologist, and, then, a technician to bring a bronchoscope or other specialized equipment to be used, or a surgeon to perform a tracheostomy. Each additional person necessitates a new page or phone call and adds to a slowly increasing response that takes time and is uncoordinated. The RRS often uses the same resources, but in a more planned and coordinated manner that is more efficient and effective. The needed clinicians, equipment, triggers, and call system are all planned in advance, and the activities may occur in parallel (that is, at the same time) instead of in series (that is, one after the other). Delays at critical moments may cost lives, and the system to deliver effective care the fastest is likely to be the safest.
      One may expect that the trend to reorganize care using the concept of RRSs will increasingly continue to expand and take hold, bringing planned and focused team responses to a myriad of patient problems, which cross the usual strict boundaries that operate in hospital. The kind of problem-based hospital process design that Atkins et al. describe may replace the traditional hierarchical and siloed departmental or professional structures. Reworking the hospital in this way is ultimately inevitable as hospitals around the world strive to become high reliability organizations—that is, organizations striving to reduce failures and aiming for perfection. The ongoing work to prevent errors must be accompanied by a system for preventing harm when error, or unexpected or rare unpreventable events, do occur (as they must). This will become even more of a challenge as the population of hospital patients becomes older, and increasingly with multiple chronic diseases. The RRS provides a template for a problem-based interdisciplinary approach for rapid detection and rapid-response care, which can and should be applied broadly: both to address more critical and complex patient problems, and across more types of health care organizations (such as skilled nursing, long term acute care, and rehabilitation centers).

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      Biography

      Michael DeVita, MD, is Director, Critical Care, Harlem Hospital Center, New York City; President, International Society for Rapid Response Systems, London; Associate Medical Director, LiveOnNY, New York City; and Member, Editorial Advisory Board, The Joint Commission Journal on Quality and Patient Safety.

      Biography

      Kenneth M. Hillman, MB, is Professor, Intensive Care Medicine, University of New South Wales, and Foundation Director, Simpson Centre for Health Services Research, Sydney.