In hospitals across the nation, rapid response teams (RRTs) are the buzz. These mobile intensive care teams, which often comprise an ICU nurse, a respiratory therapist, and a nurse practitioner or a physician, respond immediately to the concerns of bedside nurses when patients’ conditions may be deteriorating. Their goal is to collaborate with bedside nurses and give prompt critical interventions to head off further deterioration and cardiac arrest.

The Institute for Healthcare Improvement’s (IHI) 100,000 Lives Campaign has promoted RRTs as an effective intervention to reduce cardiac arrests and overall mortality rates, and the RRT concept is considered a patient safety goal by the Joint Commission on Accreditation of Healthcare Organizations.

But is there enough evidence to justify an across-the-board implementation of RRTs? That’s the question posed by Bradford D. Winters, MD, PhD, and his coauthors in the article “Rapid Response Teams — Walk, Don’t Run,” published in the Oct. 4, 2006, issue of the Journal of the American Medical Association (JAMA).

The article is a review of the literature that examines outcomes and whether studies support the RRT concept. Winters and his coauthors conclude that RRTs are only one option hospitals can use to prevent patient deterioration and that the current push to make RRTs ubiquitous or mandatory is not supported by data.

“It’s too early and the data are too weak to drive RRTs forward as mandatory or as a standard of care,” says Winters. “RRTs are worthy of investigation, absolutely, but they also need to be evaluated in comparison to other modalities of intervention that may improve patient care. Medicine needs to be guided by gathering the best evidence possible and making decisions based on that.”

Observational vs. randomized data

Winters says that most of the data collected about RRTs come from observational studies and that randomized studies would provide stronger evidence. To date, only two randomized RRT-related studies have been published. Although one randomized single-institution study did find a significant reduction in mortality at hospitals that instituted RRTs, a larger multi-center (23-hospital) study, the MERIT Study, did not show a statistically significant mortality and cardiac arrest rate improvement or a reduction in unanticipated ICU admissions.

In its statement in response to the JAMA article, IHI interpreted the MERIT Study results as inconclusive. Although IHI acknowledges that data gathered from randomized trials usually are more powerful than data gathered during observational studies, the organization contends that it is a mistake to disregard observational study data. The IHI points to at least two observational studies in which RRTs reduced overall in-hospital mortality rates by as much as 30% to 40%. In another three studies, RRTs reduced the in-hospital cardiac arrest rate by 20% to 70%, according to the IHI.

“While we absolutely support evidence-based medicine, our feeling is that the observational and anecdotal data and accumulated reports from hospitals give us a lot of confidence in proceeding with the RRT intervention,” says Joe McCannon, vice president of IHI and manager of the 100,000 Lives Campaign. “There is not an evidence base to say that RRTs are not efficacious or not effective.”

Who benefits most?

Winters contends that he has nothing against RRTs. In fact, the facility at which he works, Johns Hopkins University School of Medicine in Baltimore, Md., initiated a pilot RRT program this fall. Nevertheless, he says hospitals should consider other interventions that often go overlooked to identify and rescue deteriorating patients. Such interventions may include monitoring systems on medical/surgical units, employing dedicated hospitalists and intensivists, and improving nurse-to-patient ratios.

“Unless you have nurses at the bedside who have the time to recognize that the patient is having a deterioration, an RRT doesn’t necessarily mean you can improve outcomes,” says Winters.

Winters believes that RRTs may be of most benefit to smaller hospitals; on the other hand, smaller hospitals are likely have fewer resources and staff members who are available to participate on a team. He cautions hospitals against relying on RRTs if they would divert staff members from their other responsibilities. He recommends that teams be built upon multiple layers of staff so someone is always available to respond. Teams should have a call-back system in place to ensure that help arrives, he adds.

“RRTs may not be a one-size-fits-all solution,” says Winters. “They may be perfect for some hospitals, while having hospitalists may be the better solution for others. A hospitalist may be able to head off problems sooner than an RRT.”

McCannon agrees there are additional effective approaches for detecting early patient deterioration but says, “We will continue to press ahead with RRTs. For many hospitals in the campaign, this has been a transformational intervention that has created excitement and energy. We’ve also heard from a lot of the hospitals that say the presence of an RRT has been very popular among nursing staff. RRTs have created learning opportunities that I hope will increase the competence of floor nursing staff and other members of the care team so that, in time, perhaps they won’t have to call the RRT as often.”

A pediatric RRT in action

The RRT at Yale-New Haven Hospital in New Haven, Conn., was initiated in January 2006 to provide urgent and emergent care to patients on the hospital’s medical units. The team consists of a critical care-trained RN, a physician, and a respiratory therapist. The team is deployed as soon as unit staff notes a trigger such as a drop in blood pressure or simply has a hunch that a patient is deteriorating.

It is still early in the implementation process, and data have not yet been compiled to assess the team’s success. A trend showing a decrease in the number of cardiac arrests, which began before RRT implementation, is continuing, however.

“We’re not sure if we have enough data yet to say if this is truly related to the RRT,” says Marie Devlin, RN, BA, patient service manager for the surgical ICU care unit and a member of the adult RRT committee. She notes that when the hospital implemented a physician/hospitalist team several years ago, patient mortality decreased at that time, as well.

Devlin believes RRTs may be of greatest benefit for the patients whose conditions fall in the “gray zone” — those who are not in imminent danger of cardiopulmonary arrest but whose deteriorating conditions may require prompt intervention.

“Some of the benefits of RRTs may not be as black and white as a decrease in mortality,” Devlin says. “We are starting to see our patients being rescued faster and an impressive change in the number of patients who get moved into the ICU faster. We are also seeing a decreased length of stay in the ICU and in the hospital for this population.”

Devlin says that RRTs also increase floor nurses’ communication and critical-care thinking skills through additional in-house education and team collaboration. “We would like to see the RRT get put out of business in five to six years,” she says. “Ultimately, the goal is to have good communication and good early recognition of triggers that mean the patient is getting into trouble.”

Yale-New Haven Hospital also has developed a pediatric RRT. Before this team’s implementation, pediatric ICU physicians often responded to calls for someone to assess children whose conditions were questionable.

“Nurses always like another set of eyes to see pediatric patients,” says Sue Reynolds, RN, MAHSM, clinical manager of the pediatric ICU and a member of the pediatric critical care response team. “We have just formalized the process.”

The Yale-New Haven pediatrics staff looks forward to improving the pediatric urgent response system by allowing parents to activate the RRT. “Parents are very savvy,” says Devlin. “They know if their children need a higher level of care.”