Issues and Trends in Rapid Response Systems

• 9/29/2009
• Author: Steven Berman
• Category: The Journal Blog
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The Journal has been running articles in Rapid Response Systems: The Stories, since this department premiered in July 2006. As Michael DeVita, the chief editor of the series then remarked (see article, attached), we launched the series “to provide a resource to those who are just getting started or are interested in advancing their programs already underway.” I encourage you, as he did then, to report your own experiences with rapid response systems, thereby contributing to a learning community. This week, Drs. Ajay D. Rao (Brigham and Women’s Hospital, Boston), Ken Hillman (University of New South Wales, Liverpool Hospital, Sydney, Australia), Anne Lippert (Danish Institute for Medical Simulation, Copenhagen), Andreas Hvarfner (Lund University Hospital, Sweden), and Rinaldo Bellomo (Austin Hospital, Victoria, Australia) join Dr. DeVita in providing a brief overview of the two-day 5th International Symposium on Rapid Response Systems and Medical Emergency Teams, which took place in scenic Copenhagen, in May 2009. We welcome your comments—and your own reports on using rapid response systems.

This year’s conference, which carried the theme, “Bridging The Gap Between Patient Needs And Resources,” reflected an exciting increase in the quality of the research reported. This was the first time that the conference, directed by Anne Lippert and Andreas Hvarfner, was held outside of North America, keeping with the intention to represent the international work being done in this field.

On Day 1, Michael DeVita “set the scene” by informing the audience as to the great headway that has been made in the growing field of rapid response systems (RRS) and medical emergency teams (METs), along with potential future pathways for research. Presentations then followed, organized by three separate tracks—Novice, Research, and Education. Highlights included a series of new sessions exploring the contribution of social sciences to effective METs. For example, Susan Scott (University of Missouri Health System, Columbia), reported on the success of a novel use of a RRS to provide support to the health case workers– physicians, nurses, therapists, students, volunteers, and so on—who are considered the so-called second victims of a patient crisis, often experiencing anxiety, stress, and even guilt when a patient decompensates or dies.

In another session, emphasis was placed on the afferent-efferent arms of the RRS model. The afferent arm focuses on the detection of the event, and the efferent arm refers to the team’s response to the event. Many studies have shown that implementation of an effective RRS involves optimizing both arms of the loop. This session provided the audience a reminder of the importance of the linking of the two arms.

In a session about the quality of research pertaining to RRS, Max Bell (Karolinska Institute) highlighted the need for better data collection and analysis in research. As RRSs move past the “why we do it” and “how to do it” and phase, more robust inquiry is needed as to what makes the system work and what models appear to be the most effective in which environments. 

On Day 2, in summarizing the previous day’s events, Rinaldo Bellomo commented the importance of education to developing RRSs. In addition, he spoke of how young the field was and the need for better ways to identify patients at risk of a deteriorating condition. This was followed by a panel debate with interactive audience voting on the question: “Should the patient themselves or relatives be allowed to activate the RRS?” The audience verdict was mixed, with those in favor of family activation stating that additional inputs to trigger the system will likely decrease the well-documented rate of failure to trigger a response. In addition, sociologically, it was felt that incorporating the family into the healing team was beneficial. Those opposed were concerned about the potential for overtriggering of responses. Another pro/con seminar addressed whether continuous vital sign monitoring should be offered to all patients in the hospital, as opposed to using only intermittent data collected by staff. Those in favor felt that continuous monitoring is needed to reliably detect all crisis events; those opposed were concerned about cost and false-positive alarm rates.

Day 2 included several sessions on pediatric RRSs. Some highlights include a presentation from the St James’ Hospital in Leeds (U.K.) on the need for a pediatric warning score.  Data shown included results from close to 14,000 encounters and the need for more clinical evaluation of the scoring system. The system is age based and was effective in predicting risk for in-hospital mortality.

In the afternoon, attendees had the privilege of listening to the three award-winning posters of the conference. The first presentation was from Dr. Catherine Jones (Wake Forest University Medical Center), “Mandatory Rapid Response Activation Improves Quality of Care.” This was followed by an excellent study from the pediatric world about “Pediatric Medical Emergency Teams Decrease Rate of Code Blue, PICU Readmissions, and PICU Mortality” from Afrothite Kotsakis (The Hospital for Sick Children, Toronto). The last presentation was an intriguing study by a team from the University of Pittsburgh Medical Center on possible prevention of patients found pulseless and apneic in the hospital.

In a concluding talk, “Where Are We Heading?”, Ken Hillman touched on the importance of in-house physicians and hospitalists and how their involvement will likely be contributory to future success of RRSs. He emphasized the changing role of the house staff in the modern setting of RRS and METs. As was noted in some breakout sessions later on, there is the concept that RRS and METs might take away from the learning experience of young physicians, along with duty hours implemented in the U.S. and on their way to being implemented in Europe. On the other hand, additional staff supervision might improve the learning experience during critical patient events while at the same time improve outcome. There are little data on these considerations as yet. In addition, he reminded the attendees about the value of reinvestigating age-old dogmatic monitoring methods that do not provide as valuable data as once thought with regards to medical emergencies. For example, an electrocardiogram is unlikely to predict an evolving crisis and can fail to detect respiratory, neurological, or circulatory events. (The conference returns to Pittsburgh in May 2010).