Are rapid response teams simply a bandage on a bigger problem?

The Institute for Healthcare Improvement is promoting the development of rapid response teams as part of its 100,000 Lives Campaign. Data show these teams can decrease the mortality rate associated with non-ICU cardiac arrest by intervening in the care of the patient who is clinically deteriorating on the medical floor.

The underlying theory that has been borne out in the literature is that a patient who suffers a cardiac arrest on the medical floor is likely to experience a "window" of six to eight hours (1) beforehand where there are measurable aberrations in vital signs or mental status that presage the occurrence of arrest that can be modified by intervention.

There is also evidence that the incidence of cardiac arrest and the mortality associated with this catastrophic event can be improved (2) by implementing rapid response teams as well. The data seem to hold up consistently, with the exception of a study done in Australia (3) that failed to show a significant improvement in either incidence or mortality.

On the surface, the concept of rapid response teams is well supported, but it begs certain questions that must be thoroughly investigated and satisfactorily answered before relying on the teams to improve the safety of our inpatient population.

The first question is, simply, "Why are presumably stable patients admitted to our medical floors arresting in the first place?"

A look at acuity over time of our inpatients clearly shows a trend upward. (4) Not long ago the catch phrase among medical futurists was that acute care hospitals would "soon be nothing but ICUs" since more stable patients would no longer be admitted but, rather, treated on an outpatient basis. Are patients not stable enough for the medical floor with its current staffing ratios and q 4 hour vital sign routine?

There is clearly a difference in acuity between the typical medical admission and the person admitted to the ICU, but is the difference becoming so subtle as to escape our detection?

A retrospective review of all patients who suffer a cardiac arrest on the medical floor must be conducted by all health care institutions to make sure the admission criteria are still relevant.

It is very important to study this patient population to determine easily recognizable predictors of cardiac arrest. A source of good data would be to collect unanticipated transfers to ICU to look for early signs of instability. Could it be that the staffing of our medical floors is too lean under normal circumstances and stretched beyond the ability to render safe care when stressed by peak census?

The medical staff plays an important role in assessing the acuity of a patient on admission, deciding what level of care to admit to, outlining a diagnostic and treatment plan, assessing progress and charting a course for safe discharge.

Is there a difference in the care rendered by a voluntary medical staff compared to a hospitalist service? There is literature to suggest that there is. (6)

The basic advantage of the rapid response team is that it compensates for missed signs of slow patient deterioration, inability of a nurse to reach a physician to report changing vital signs in a timely manner and calls forth expertise heretofore unavailable to help assess the cause of deterioration and develop a plan to correct the problem.

Another question to consider is whether the common model of voluntary medical staff structure predisposes to care that is not adequate given the level of acuity we are seeing today.

Can a 10- to 15-minute visit on rounds once a day possibly be adequate? The availability of hospitalists is a great nurse satisfier due to their availability. Most hospitalists see inpatients more than once a day as the acuity of the inpatient population may now require.

To gauge the value of inpatient specialists who are on the floors all day would be to prospectively collect data for both the hospitalists and the voluntary medical staff on:

* The need to call rapid response teams

* Cause of the call

* The clinical outcome

* Need to transfer

If there is indeed a difference, it might be time to revisit the structure of the medical staff caring for inpatients. We may be staffing nurses and other health care workers around an inadequate physician presence on the medical floors.

There are times, as we can all attest, that the unavailability of a physician in his office to answer a nurse's call from the floor completely paralyzes the care process for long periods of time.

Yet another question to consider is whether the present credentialing criteria for the privilege to care for inpatients need to be revisited. There are well-established volume criteria for certain procedures. (5)

We should have clear data that relate the volume of admissions a primary care physician cares for and his quality profile. Is there an inverse relationship between the number of rapid response team calls to the medical floor and an attending physician's overall volume?

We monitor so-called ambulatory sensitive diagnosis admission rates as a barometer of the adequacy and quality of primary care services (7) as well as the availability of primary care services in a given area. The lower the rate, the better the quality of outpatient primary care.

Presumably, the successful primary care physician would visit hospitalized patients less and less as he becomes more and more successful in practicing preventive medicine and early detection of certain illnesses.

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Should a primary care physician with one admission in the last quarter be recredentialed to care for any patient with any illness who walks into the emergency department even if that illness is within his traditional scope of practice?

We are, on the one hand, being told by such organizations as the Leapfrog Group that volume matters, but we interpret that selectively as is convenient and as best fits our traditional credentialing criteria.

Perhaps with physicians who have higher inpatient volumes (or with dedicated inpatient specialists), better choices will be made on admission that will mitigate the risk of cardiac arrest on the medical floor.

Robert M. Pickoff, MD, MMM, is chief medical officer of Hunterdon Healthcare System in Flemington, N.J. He can be reached at [e-mail]

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References

1. Schein RM, Hazday N, Pena M, and others. "Clinical antecedents to in-hospital cardiopulmonary arrest." Chest. 98 (6):1388-92 Dec. 1990.

2. 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 (7334): 387-90, Feb 16, 2002.

3. Hillman K, Chen J, Cretikos M, Bellomo R, Brown D, Doig G, Finfer S, Flabouris "Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial." Lancet. June 18-24, 365(9477):2091-7, June 18-24, 2005.

4. Goldfarb MG, Coffey RM. "Change in the Medicare case-mix index in the 1980s and the effect of the prospective payment system." Health Serv Res. 27(3):385-415, Aug. 1992.

5. Williams SV, Nash DB, Goldfarb N. "Differences in mortality from coronary artery bypass graft surgery at five teaching hospitals." JAMA. 266 (6):810-5, Aug. 14, 1991.

6. Halpert AP, Pearson SD, Le Wine HE, and others. "The impact of an inpatient physician program on quality, utilization, and satisfaction." Am J Manag Care 2000, 6(5) 549-55, May 2000.

7. Bindman, Andrew B. "Study of Ambulatory Care Sensitive Diagnoses as a monitor of primary access, 1993: [CALIFORNIA] [Computer file]. ICPSR version. San Francisco, CA: University of California [producer], 1993. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 1998.

By Robert M. Pickoff, MD, MMM