Rapid response systems: a systematic review and meta-analysis

Ritesh Maharaj, Ivan Raffaele, Julia Wendon, Ritesh Maharaj, Ivan Raffaele, Julia Wendon

Abstract

Introduction: Although rapid response system teams have been widely adopted by many health systems, their effectiveness in reducing hospital mortality is uncertain. We conducted a meta-analysis to examine the impact of rapid response teams on hospital mortality and cardiopulmonary arrest.

Method: We conducted a systematic review of studies published from January 1, 1990, through 31 December 2013, using PubMed, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and the Cochrane Library. We included studies that reported data on the primary outcomes of ICU and in-hospital mortality or cardiopulmonary arrests.

Results: Twenty-nine eligible studies were identified. The studies were analysed in groups based on adult and paediatric trials that were further sub-grouped on methodological design. There were 5 studies that were considered either cluster randomized control trial, controlled before after or interrupted time series. The remaining studies were before and after studies without a contemporaneous control. The implementation of RRS has been associated with an overall reduction in hospital mortality in both the adult (RR 0.87, 95 % CI 0.81-0.95, p<0.001) and paediatric (RR=0.82 95 % CI 0.76-0.89) in-patient population. There was substantial heterogeneity in both populations. The rapid response system team was also associated with a reduction in cardiopulmonary arrests in adults (RR 0.65, 95 % CI 0.61-0.70, p<0.001) and paediatric (RR=0.64 95 % CI 0.55-0.74) patients.

Conclusion: Rapid response systems were associated with a reduction in hospital mortality and cardiopulmonary arrest. Meta-regression did not identify the presence of a physician in the rapid response system to be significantly associated with a mortality reduction.

Figures

Fig. 1
Fig. 1
Literature search flow diagram
Fig. 2
Fig. 2
Forest plot of the effect of rapid response system teams on hospital mortality in adult in-patients. Weights are calculated from random-effects analysis. CBA controlled before–after, CCO critical care outreach, CI confidence interval, ITS interrupted time series, RCT randomized controlled trial
Fig. 3
Fig. 3
Forest plot of the effect of rapid response system teams on hospital mortality in paediatric in-patients. Weights are calculated from random-effects analysis. CBA controlled before–after, CI confidence interval, ITS interrupted time series, RCT randomized controlled trial
Fig. 4
Fig. 4
Contour-enhanced funnel plot. If studies appear to be missing in areas of low statistical significance, then it is possible that the asymmetry is due to publication bias. Conversely, if the area in which studies are perceived to be missing are of high statistical significance, then publication bias is a less likely cause of the funnel asymmetry

References

    1. Neale G, Woloshynowych M, Vincent C. Exploring the causes of adverse events in NHS hospital practice. J R Soc Med. 2001;94:322–30.
    1. Buist MD, Jarmolowski E, Burton PR, Bernard SA, Waxman BP, Anderson J. Recognising clinical instability in hospital patients before cardiac arrest or unplanned admission to intensive care. A pilot study in a tertiary-care hospital. Med J Aust. 1999;171:22–5.
    1. Franklin C, Mathew J. Developing strategies to prevent inhospital cardiac arrest: analyzing responses of physicians and nurses in the hours before the event. Crit Care Med. 1994;22:244–7. doi: 10.1097/00003246-199402000-00014.
    1. Jones DA, DeVita MA, Bellomo R. Rapid-response teams. N Engl J Med. 2011;365:139–46. doi: 10.1056/NEJMra0910926.
    1. Hillman K, Chen J, Cretikos M, Bellomo R, Brown D, Doig G, et al. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet. 2005;365:2091–7. doi: 10.1016/S0140-6736(05)66733-5.
    1. Laurila JV, Pitkala KH, Strandberg TE, Tilvis RS. Detection and documentation of dementia and delirium in acute geriatric wards. Gen Hosp Psychiatry. 2004;26:31–5. doi: 10.1016/j.genhosppsych.2003.08.003.
    1. Buist M, Bernard S, Nguyen TV, Moore G, Anderson J. Association between clinically abnormal observations and subsequent in-hospital mortality: a prospective study. Resuscitation. 2004;62:137–41. doi: 10.1016/j.resuscitation.2004.03.005.
    1. Smith GB, Prytherch DR, Schmidt P, Featherstone PI, Knight D, Clements G, et al. Hospital-wide physiological surveillance—a new approach to the early identification and management of the sick patient. Resuscitation. 2006;71:19–28. doi: 10.1016/j.resuscitation.2006.03.008.
    1. Downey AW, Quach JL, Haase M, Haase-Fielitz A, Jones D, Bellomo R. Characteristics and outcomes of patients receiving a medical emergency team review for acute change in conscious state or arrhythmias. Crit Care Med. 2008;36:477–81. doi: 10.1097/01.CCM.0000300277.41113.46.
    1. Chen J, Bellomo R, Flabouris A, Hillman K, Finfer S. Centre MSIftS and Group ACT. The relationship between early emergency team calls and serious adverse events. Crit Care Med. 2009;37:148–53. doi: 10.1097/CCM.0b013e3181928ce3.
    1. Cretikos M, Chen J, Hillman K, Bellomo R, Finfer S, Flabouris A, et al. The objective medical emergency team activation criteria: a case–control study. Resuscitation. 2007;73:62–72. doi: 10.1016/j.resuscitation.2006.08.020.
    1. Priestley G, Watson W, Rashidian A, Mozley C, Russell D, Wilson J, et al. Introducing Critical Care Outreach: a ward-randomised trial of phased introduction in a general hospital. Intensive Care Med. 2004;30:1398–404. doi: 10.1007/s00134-004-2268-7.
    1. Chan PS, Khalid A, Longmore LS, Berg RA, Kosiborod M, Spertus JA. Hospital-wide code rates and mortality before and after implementation of a rapid response team. JAMA. 2008;300:2506–13. doi: 10.1001/jama.2008.715.
    1. Konrad D, Jaderling G, Bell M, Granath F, Ekbom A, Martling CR. Reducing in-hospital cardiac arrests and hospital mortality by introducing a medical emergency team. Intensive Care Med. 2010;36:100–6. doi: 10.1007/s00134-009-1634-x.
    1. The Joint Commission announces the 2009 National Patient Safety Goals and requirements. Jt Comm Perspect. 2008;28:1, 11–5
    1. Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD. The 100,000 lives campaign: setting a goal and a deadline for improving health care quality. JAMA. 2006;295:324–7. doi: 10.1001/jama.295.3.324.
    1. Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Rapid response teams: a systematic review and meta-analysis. Arch Intern Med. 2010;170:18–26. doi: 10.1001/archinternmed.2009.424.
    1. Winters BD, Weaver SJ, Pfoh ER, Yang T, Pham JC, Dy SM. Rapid-response systems as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158:417–25. doi: 10.7326/0003-4819-158-5-201303051-00009.
    1. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009;339:b2700. doi: 10.1136/bmj.b2700.
    1. Higgins JPT, Green S, editors. Cochrane handbook for systematic reviews of interventions. Version 5.1.0 (updated March 2011). Oxford, UK: The Cochrane Collaboration;2011
    1. Bellomo R, Goldsmith D, Uchino S, Buckmaster J, Hart GK, Opdam H, et al. A prospective before-and-after trial of a medical emergency team. Med J Aust. 2003;179:283–7.
    1. Bellomo R, Goldsmith D, Uchino S, Buckmaster J, Hart G, Opdam H, et al. Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med. 2004;32:916–21. doi: 10.1097/01.CCM.0000119428.02968.9E.
    1. Tibballs J, Kinney S. Reduction of hospital mortality and of preventable cardiac arrest and death on introduction of a pediatric medical emergency team. Pediatr Crit Care Med. 2009;10:306–12. doi: 10.1097/PCC.0b013e318198b02c.
    1. Tibballs J, Kinney S, Duke T, Oakley E, Hennessy M. Reduction of paediatric in-patient cardiac arrest and death with a medical emergency team: preliminary results. Arch Dis Child. 2005;90:1148–52. doi: 10.1136/adc.2004.069401.
    1. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010;25:603–5. doi: 10.1007/s10654-010-9491-z.
    1. Effective Practice and Organisation of Care (EPOC). EPOC Resources for review authors. Oslo: Norwegian Knowledge Centre for the Health Services; 2015. Available at: .
    1. Devita MA, Bellomo R, Hillman K, Kellum J, Rotondi A, Teres D, et al. Findings of the first consensus conference on medical emergency teams. Crit Care Med. 2006;34:2463–78. doi: 10.1097/01.CCM.0000235743.38172.6E.
    1. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med. 2009;6 doi: 10.1371/journal.pmed.1000100.
    1. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327:557–60. doi: 10.1136/bmj.327.7414.557.
    1. Harbord RM, Egger M, Sterne JA. A modified test for small-study effects in meta-analyses of controlled trials with binary endpoints. Stat Med. 2006;25:3443–57. doi: 10.1002/sim.2380.
    1. Palmer TM, Peters JL, Sutton AJ, Moreno GG. Contour-enhanced funnel plots for meta-analysis. Stata J. 2008;8:242–54.
    1. Harbord RM, Higgins JPT. Meta-regression in Stata. Stata J. 2008;8:493–519.
    1. Woertman W, de Hoop E, Moerbeek M, Zuidema SU, Gerritsen DL, Teerenstra S. Stepped wedge designs could reduce the required sample size in cluster randomized trials. J Clin Epidemiol. 2013;66:752–8. doi: 10.1016/j.jclinepi.2013.01.009.
    1. de Hoop E, Woertman W, Teerenstra S. The stepped wedge cluster randomized trial always requires fewer clusters but not always fewer measurements, that is, participants than a parallel cluster randomized trial in a cross-sectional design. In reply. J Clin Epidemiol. 2013;66:1428. doi: 10.1016/j.jclinepi.2013.07.008.
    1. Hartling L, Milne A, Hamm MP, Vandermeer B, Ansari M, Tsertsvadze A, et al. Testing the Newcastle Ottawa Scale showed low reliability between individual reviewers. J Clin Epidemiol. 2013;66:982–93. doi: 10.1016/j.jclinepi.2013.03.003.
    1. DeVita MA, Bellomo R, Hillman K. Introduction to the rapid response systems series. Jt Comm J Qual Patient Saf. 2006;32:359–60.
    1. Morris DS, Schweickert W, Holena D, Handzel R, Sims C, Pascual JL, et al. Differences in outcomes between ICU attending and senior resident physician led medical emergency team responses. Resuscitation. 2012;83:1434–7. doi: 10.1016/j.resuscitation.2012.07.017.
    1. Karvellas CJ, de Souza IA, Gibney RT, Bagshaw SM. Association between implementation of an intensivist-led medical emergency team and mortality. BMJ Qual Saf. 2012;21:152–9. doi: 10.1136/bmjqs-2011-000393.
    1. Jones D, Bellomo R, DeVita MA. Effectiveness of the medical emergency team: the importance of dose. Crit Care. 2009;13:313. doi: 10.1186/cc7996.
    1. Al-Qahtani S, Al-Dorzi HM, Tamim HM, Hussain S, Fong L, Taher S, et al. Impact of an intensivist-led multidisciplinary extended rapid response team on hospital-wide cardiopulmonary arrests and mortality. Crit Care Med. 2013;41:506–17. doi: 10.1097/CCM.0b013e318271440b.
    1. Baxter AD, Cardinal P, Hooper J, Patel R. Medical emergency teams at The Ottawa Hospital: the first two years. Can J Anaesth. 2008;55:223–31. doi: 10.1007/BF03021506.
    1. Beitler JR, Link N, Bails DB, Hurdle K, Chong DH. Reduction in hospital-wide mortality after implementation of a rapid response team: a long-term cohort study. Crit Care. 2011;15:R269. doi: 10.1186/cc10547.
    1. Bristow PJ, Hillman KM, Chey T, Daffurn K, Jacques TC, Norman SL, et al. Rates of in-hospital arrests, deaths and intensive care admissions: the effect of a medical emergency team. Med J Aust. 2000;173:236–40.
    1. Buist MD, Moore GE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study. BMJ. 2002;324:387–90. doi: 10.1136/bmj.324.7334.387.
    1. Campello G, Granja C, Carvalho F, Dias C, Azevedo LF, Costa-Pereira A. Immediate and long-term impact of medical emergency teams on cardiac arrest prevalence and mortality: a plea for periodic basic life-support training programs. Crit Care Med. 2009;37:3054–61. doi: 10.1097/CCM.0b013e3181b02183.
    1. Dacey MJ, Mirza ER, Wilcox V, Doherty M, Mello J, Boyer A, et al. The effect of a rapid response team on major clinical outcome measures in a community hospital. Crit Care Med. 2007;35:2076–82. doi: 10.1097/.
    1. DeVita MA, Braithwaite RS, Mahidhara R, Stuart S, Foraida M, Simmons RL, et al. Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Qual Saf Health Care. 2004;13:251–4. doi: 10.1136/qshc.2003.006585.
    1. Hayani O, Al-Beihany A, Zarychanski R, Chou A, Kharaba A, Baxter A, et al. Impact of critical care outreach on hematopoietic stem cell transplant recipients: a cohort study. Bone Marrow Transplant. 2011;46:1138–44. doi: 10.1038/bmt.2010.248.
    1. Howell MD, Ngo L, Folcarelli P, Yang J, Mottley L, Marcantonio ER, et al. Sustained effectiveness of a primary-team-based rapid response system. Crit Care Med. 2012;40:2562–8. doi: 10.1097/CCM.0b013e318259007b.
    1. Jones D, Opdam H, Egi M, Goldsmith D, Bates S, Gutteridge G, et al. Long-term effect of a medical emergency team on mortality in a teaching hospital. Resuscitation. 2007;74:235–41. doi: 10.1016/j.resuscitation.2006.12.007.
    1. Kenward G, Castle N, Hodgetts T, Shaikh L. Evaluation of a medical emergency team one year after implementation. Resuscitation. 2004;61:257–63. doi: 10.1016/j.resuscitation.2004.01.021.
    1. Lim SY, Park SY, Park HK, Kim M, Park HY, Lee B, et al. Early impact of medical emergency team implementation in a country with limited medical resources: a before-and-after study. J Crit Care. 2011;26:373–8. doi: 10.1016/j.jcrc.2010.08.019.
    1. Santamaria J, Tobin A, Holmes J. Changing cardiac arrest and hospital mortality rates through a medical emergency team takes time and constant review. Crit Care Med. 2010;38:445–50. doi: 10.1097/CCM.0b013e3181cb0ff1.
    1. Shah SK, Cardenas VJ, Jr, Kuo YF, Sharma G. Rapid response team in an academic institution: does it make a difference? Chest. 2011;139:1361–7. doi: 10.1378/chest.10-0556.
    1. Simmes FM, Schoonhoven L, Mintjes J, Fikkers BG, van der Hoeven JG. Incidence of cardiac arrests and unexpected deaths in surgical patients before and after implementation of a rapid response system. Annals Intensive Care. 2012;2:20. doi: 10.1186/2110-5820-2-20.
    1. Brilli RJ, Gibson R, Luria JW, Wheeler TA, Shaw J, Linam M, et al. Implementation of a medical emergency team in a large pediatric teaching hospital prevents respiratory and cardiopulmonary arrests outside the intensive care unit. Pediatr Crit Care Med. 2007;8:236–46. doi: 10.1097/01.PCC.0000262947.72442.EA.
    1. Hanson CC, Randolph GD, Erickson JA, Mayer CM, Bruckel JT, Harris BD, et al. A reduction in cardiac arrests and duration of clinical instability after implementation of a paediatric rapid response system. Postgrad Med J. 2010;86:314–8. doi: 10.1136/qshc.2007.026054.
    1. Haque A u, Saleem AF, Zaidi S, Haider SR. Experience of pediatric rapid response team in a tertiary care hospital in Pakistan. Indian J Pediatr. 2010;77:273–6. doi: 10.1007/s12098-010-0032-2.
    1. Hunt EA, Zimmer KP, Rinke ML, Shilkofski NA, Matlin C, Garger C, et al. Transition from a traditional code team to a medical emergency team and categorization of cardiopulmonary arrests in a children's center. Arch Pediatr Adolesc Med. 2008;162:117–22. doi: 10.1001/archpediatrics.2007.33.
    1. Kotsakis A, Lobos AT, Parshuram C, Gilleland J, Gaiteiro R, Mohseni-Bod H, et al. Implementation of a multicenter rapid response system in pediatric academic hospitals is effective. Pediatrics. 2011;128:72–8. doi: 10.1542/peds.2010-0756.
    1. Sharek PJ, Parast LM, Leong K, Coombs J, Earnest K, Sullivan J, et al. Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a children’s hospital. JAMA. 2007;298:2267–74. doi: 10.1001/jama.298.19.2267.
    1. Zenker P, Schlesinger A, Hauck M, Spencer S, Hellmich T, Finkelstein M, et al. Implementation and impact of a rapid response team in a children’s hospital. Jt Comm J Qual Patient Saf. 2007;33:418–25.

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