Research DIMENSION Rapid Response Team Effectiveness Stephanie C. Butner, BSN, RN The purpose of this integrated review of the literature was to summarize the evidence surrounding the effectiveness of rapid response teams. Studies included in this review were written within the last 10 years, in English, and examined the effectiveness of having a rapid response team. Pediatric studies were excluded from this review. There was a reduction in all cardiac arrests found in 60% of the studies reviewed as well as a reduction in mortality associated with cardiac arrests. Keywords: Cardiac arrest prevention, Medical emergency teams, Rapid response teams [DIMENS CRIT CARE NURS. 2011;30(4):201/205] A code blue rings out over the hospital intercom. In every RRT have developed a protocol for when to call the hospital, a code blue or cardiac arrest team will respond team. These may include but are not limited to (1) a and attempt to save the patient’s life. What led up to this change in vital signs, (2) low or elevated heart rate, situation? Could this code blue have been prevented? (3) low or elevated blood pressure, (4) difficulty breath- Some cardiac arrests are unpreventable and occur with no ing, (5) low oxygen saturation despite increasing oxygen warning signs. However, Offner et al1 submit that 70% delivery, (6) change in level of consciousness, (7) re- of adverse outcomes related to medical management are peated or prolonged seizures, (8) or when the nurse just preventable. How does a hospital attempt to prevent feels something is wrong, a nurse’s intuition so to speak. these deaths? Many hospitals have implemented a rapid So when the medical/surgical nurse calls and alerts the response team (RRT) as their answer to this question. RRT to a situation, it is able to bring critical-care ex- However, some hospitals have yet to implement an RRT. pertise to the patient’s bedside no matter where the pa- The purpose of this integrated review of the literature tient may be in the hospital. was to summarize the evidence surrounding the effective- ness of RRTs. METHODS Rapid response teams are composed of professionals The literature search for this integrated review was done who are educated in critical care. Some institutions use using the following electronic databases: CINAHL, the term medical emergency team (MET). The profes- PubMed, and EBSCO host. Jolley and colleagues2 stated sionals vary from institution to institution, but are the first RRT was initiated in 1995; however, the search generally critical-care nurses, physicians, and/or respira- was limited to studies published within the last 10 years tory therapists, although some institutions use only so that more recent research would be reviewed. Other nurses, whereas some institutions use a multidisciplinary inclusion criteria used were that the articles needed team. Regardless of the skill mix or name of the team, to be written in English and needed to examine the the focus of the RRT is on preventing a potentially lethal effectiveness and/or receptiveness of RRTs. Pediatric situation.2 Most hospitals that have implemented an studies were excluded in this review. DOI: 10.1097/DCC.0b013e31821b7eab July/August 2011 201 Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Rapid Response Team Effectiveness (P G .001). In addition, there was a reduction in non-ICU However, the search was limited code rates. The non-ICU code rates dropped from 6.08 per to studies published within 1000 admissions to 3.08 per 1000 admissions (P G .001). the last 10 years. They also examined the number of deaths after a cardiac arrest before and after implementation of the RRT. There was a slight reduction in the number of deaths following a cardiac arrest; however, it was not statistically significant.4 FINDINGS Another group of researchers studied the relationship All of the research articles reviewed for this study were between early emergency team calls and the incidence of based on the implementation of an RRT. They all presented a serious adverse event.5 Their definition of a serious ad- outcomes based on mortality, cardiac arrest rates outside verse event included cardiac arrests, deaths, or unplanned the intensive care unit (ICU), overall cardiac arrest rates, admissions to the ICU. This study used a post hoc analysis and unexpected cardiac arrest rates. One study reviewed did of a randomized control trial conducted with control hos- not examine these factors, but instead implemented an RRT pitals not using an RRT compared with hospitals that used to improve the care and survival rates of patients in whom an RRT. They examined 23 hospitals and collected data sepsis is suspected. on 741 744 patient admissions over a 12-month period. Jolley and colleagues2 researched the implementation Their findings showed a 10% increase in early emergency of an RRT at a 488-bed level I trauma and academic team (RRT) calls, which resulted in a reduction in un- medical center. They collected data 12 months prior to expected cardiac arrests by 1.99 per 10 000 hospital ad- and 12 months after the implementation of the RRT. The missions, a reduction in unexpected deaths by 0.94 per sample included all inpatient units, excluding ICUs. Their 10 000 admissions, and a reduction in all cardiac arrests RRT consisted of a critical-care nurse and a respiratory by 2.21 per 10 000 admissions. Furthermore, they found therapist. The RRT responded to 76 calls during the a reduction in the total number of deaths per 1000 ad- 12-month period. The variables were the number of missions in the RRT hospitals when compared with pre- codes called outside the ICU and the resulting mortality. intervention. They found no significant relationship They reported a 21% decrease in codes called outside between early RRT calls and unplanned ICU admissions.5 the ICU after the RRT was implemented (P =.262).2 Del Giorno and colleagues6 conducted a pilot study However, the overall hospital mortality rate stayed the that implemented an RRT with the goal to reduce hospital same despite the introduction of the RRT. mortality rates at a large teaching hospital. Their RRT Bader and colleagues3 reviewed the data before and consisted of 2 critical-care nurses per shift with backup after RRT implementation at a 304-bed acute-care hospi- from physicians, respiratory therapists, and house super- tal. They collected data 12 months prior to and 12 months visors when needed. The sample included 1335 RRT con- after the introduction of the RRT. This hospital’s goal was sults and 207 patients discharged from the ICU. The results to decrease the high number of codes outside the ICU. This revealed a reduction in hospital mortality rate from 2.8% RRT consisted of all critical-care nurses, and the RRT re- to 2.4%.6 They did not review any other categories pre- sponded to an average of 338 calls per month throughout viously mentioned in other studies. the 12-month period. They examined cardiac arrests out- Offner and colleagues1 conducted research on the effec- side the ICU and the associated mortality rates. They found tiveness of RRTs to evaluate whether an RRT would reduce a reduction in non-ICU arrests from 36 per year to 17 per inpatient cardiac arrests. This research study was conducted year after implementation of the RRT. In addition, they at a level I trauma center. The RRT included an intensivist, had a 35% reduction in mortality associated with non- a critical-care nurse, and a respiratory therapist. Over the ICU cardiac arrests of 35% (P G .05).3 The overall mor- 10-month study period, the RRT was activated 76 times. tality rates at this hospital were not available for review. Findings were compared with the same 10-month period in Chan and colleagues4 studied the effects of the im- the year prior to the initiation of the RRT. They found a plementation of an RRT on hospital-wide cardiac arrest 50% reduction in cardiac arrests outside the ICU and in over- and mortality rates. This study was done at a 404-bed all inpatient cardiac arrests (P = .02). In addition, overall tertiary-care hospital including all adult patients who had inpatient cardiac arrests decreased from 4.4 T 2.4 per 10 been admitted for at least 1 day on any inpatient unit. The 000 patient-days to 1.4 T 0.8 per 10 000 patient-days (P G RRT in this study consisted of 2 critical-care nurses and 1 .001).1 They did not review mortality rates in this study. respiratory therapist on every shift. The RRT responded One group of researchers conducted a study to de- to 376 calls during the 19-month period it was in use. A termine the effect of RRTs on in-hospital arrests, total decrease in hospital-wide code rates from 11.20 per 1000 and unplanned ICU admissions, and hospital mortal- admissions to 7.53 per 1000 admissions was reported ity.7 The study was conducted at a 350-bed nonteaching 202 Dimensions of Critical Care Nursing Vol. 30 / No. 4 Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Rapid Response Team Effectiveness community hospital. Data were collected 4 months prior to statistically significant difference found in the amount of and 12 months after the introduction of the RRT. Their deaths or cardiac arrests among the 3 different hospitals. team consisted of a critical-care nurse, a respiratory ther- However, the authors felt their results were possibly the apist, and a physician assistant. The RRT responded to a result of underutilization of the team as they were expecting total of 334 calls during the study period of 12 months.