Rapid Response Team 'Acts as a Safety Valve,' Uncovers Problems

CHICAGO — The effect of rapid response teams on hard clinical outcomes remains unclear, but such teams do seem to have an important role at many hospitals, experts said at the annual meeting of the Society of Hospital Medicine.

At the University of California at San Francisco, the rapid response team (RRT) was hospitalist-led from 2005 to 2007, but it struggled with low utilization and had little effect, said Dr. Sumant Ranji, of the university's division of hospital medicine. The RRT was disbanded, but it came back in late 2007, this time staffed by critical care nurses and respiratory therapists. Today, the RRT is popular among nurses, serves as an important liaison between floors and the ICU, and has a major role in educating new nurses.

Available 24/7, 365 days a year, the RRT responds to emergencies, follows up on ICU discharges, and proactively rounds on the wards. In about 20% of cases, the patient is transferred to the ICU.

“What we've found is that the rapid response team acts as a safety valve” and provides a way to identify system problems such as inadequate bedside staffing, poor communication between staff, and staff with inadequate training or experience, Dr. Ranji said.

An RRT should not be used as a replacement for Code Blue, said copresenter Dr. Winthrop Whitcomb, a hospitalist at Mercy Medical Center in Springfield, Mass., and cofounder of the Society of Hospital Medicine. Led by critical care nurses, Mercy's RRT is called when there is an acute change in heart rate, respiratory rate, or oxygen saturation; an acute or symptomatic change in systolic blood pressure; significant bleeding; new or prolonged seizures; unresolved chest pain; or other concerns.

After educating staff in early 2005, Mercy rolled out the RRT to all inpatient units and expanded the team to cover the entire hospital after just 7 months. The RRT includes nurses, ICU nurses, respiratory therapists, nursing supervisors, a hospitalist at night, and an intensivist during the day.

Despite receiving written educational materials about seeking assistance, after 12 months, not a single patient or family had called a rapid response at Mercy, he said.

Two other obstacles are criticism of staff members for calling the RRT and failure to have a plan for post-RRT care. A hospitalist involved in an RRT encounter must hand off care to the attending physician of record, Dr. Whitcomb said.

Billing for an RRT encounter can include critical care codes, if the encounter qualifies, or subsequent care codes, if the bill denotes a new diagnosis or an exacerbation of an existing one.

Mercy handles about a dozen rapid response calls per month, with two-thirds originating outside the ICU. A review of 449 RRT encounters showed that 45% of patients remained in their room, while 18% were transferred to the ICU. Unadjusted mortality rates for 2004–2008 were “pretty flat” at about 2.5%–3%, Dr. Whitcomb said.

In a systematic review of 13 RRT studies, Dr. Ranji and his associates reported reductions in inpatient mortality and cardiac arrest rates in 11 before-and-after studies. In the lone randomized controlled trial, however, mortality declined in the control group to a similar extent as in the observational studies (J. Hosp. Med. 2007;2:422–32).

The authors had no conflicts of interest.