Medical Emergency Systems/ Rapid Response Teams for adult in-hospital patients: EIT 6309 TF SR

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The Task Force members and authors declare no conflict of interest.

CoSTR Citation

Allan KA, Yeung, J, Flaim B, Aves T, Olejarz M, Cheng A, Kishibe T, Greif R on behalf of the International Liaison Committee on Resuscitation from rom the Education Implementation Teams Task Force (EIT). Medical Emergency Systems/ Rapid Response Teams for adult in-hospital patients. Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Education, Implementation and Teams Task Force, November 1 2024. Available from: http://ilcor.org

Methodological Preamble and Link to Published Systematic Review

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with an ILCOR systematic review originally published in 2015 with evidence tables originally created by Frengley and Mancini, and later updated by K Allan and J Yeung with additional involvement of EIT Task force members (Cheng A, Greif R) and clinical content experts (Aves T, Flaim B, Olejarz M, Kishibe T). These data were taken into account when formulating the Treatment Recommendations.

Patients admitted to hospital with serious health issues are at risk of deterioration that can lead to cardiac arrest. Frequently, these patients will exhibit signs and symptoms of deterioration for hours or days before cardiac arrest.(1) A Rapid Response System is a program designed to evaluate patients early in their clinical deterioration to prevent serious adverse events in hospitalized individuals.(2) A successful Rapid Response System can be defined as a hospital-wide framework that ensures monitoring, detection of patient deterioration, and a tailored response for patients on the ward, which may involve a Rapid Response Team (RRT) or Medical Emergency Team (MET).(3) There is uncertainty if these system are effective in improving patient outcomes after cardiac arrest and patient survival or reducing the number of cardiac arrests.

Systematic Review

Publication in progress

PICOST

PROSPERO Registration CRDXXX – Submitted to Prospero, awaiting registration number

Consensus on Science

There was high heterogeneity among studies. The overall certainty of evidence was rated as very low to low for all outcomes, primarily due to a serious risk of bias and imprecision. The individual studies were all at a serious to critical risk of bias. Because of this and a high degree of heterogeneity, no meta-analyses could be performed and we have conducted a narrative synthesis of the findings.

For the critical outcome of hospital discharge with favourable neurological outcome, we did not find any study.

For the critical outcome of survival to hospital discharge, we found low-quality evidence (downgraded for risk of bias and imprecision) in 8 non randomized studies. (4-11) None of these studies demonstrated a statistically significant improvement in survival to discharge.

In addition to the above studies, 1 study showed no statistically significant difference in survival between pre and post RRS implementation 30 days post cardiac arrest. (12)

1 study showed an increase in long term survival post-surgery in hip fracture patients. The median survival time after hip fracture surgery was 71.8 months in the pre-RRS group and 75.0 months in the post-RRS group (p = 0.008). (13)

1 study that looked at the impact of a standardized RRS on clinical outcomes of female patients did not observe a statistically significant difference in IHCA survival to discharge overall, however, there was a statistically significant increase in survival to discharge for females aged 18-34 years old. (14)

For the critical outcome of in-hospital incidence of cardiac arrest, we found low-quality evidence (downgraded for risk of bias and imprecision) from 3 RCTs (15-17) and very low quality evidence (downgraded for risk of bias, inconsistency and imprecision) from 56 non-RCTs.

All 3 RCTS (15-17) showed no statistically significant improvement in the incidence of IHCA. Of the 56 observational studies, 39 showed statistically significant improvement after implementation of a RRS, while 17 showed no statistically significant improvement.

For the 3 RCTS (15-17), Jeddian 2016 reported that after implementation of RRS, the proportion of patients receiving cardiopulmonary resuscitation decreased from 4.86% to 3.61% (unadjusted OR, 0.73; 95% CI, 0.64-0.85). However, this result became more uncertain after adjusting for clustering and time effects (adjusted OR, 1.00; 95% CI, 0.69-1.48).(16) Piquette 2005 reported cardiac arrest incidence without RRS as 1.64 per 1000 patients versus with RRS 1.31 per 1000 patients p=0.306; differences 95% CI -0.264 (-2.449 to 1.921).(17) Haegdorens 2018 reported no difference between cardiac arrest rates (1.3 vs 1.0/1000, OR 0.71, 95% CI 0.33–1.52) with or without RRS. (15)

Of the 56 non randomized studies (4, 6-12, 14, 18-64), 25 studies with no adjustment demonstrated significant improvement in cardiac arrest rates after the introduction of a Rapid Response System (4, 6, 7, 12, 19-24, 31, 39, 41, 43-45, 50, 52-56, 58, 62, 63) (4, 7, 19-25, 32, 39, 41, 49, 50, 52-54, 58, 62, 63)

20 studies without adjustment showed significant improvement in cardiac arrest rates after the introduction of a Rapid Response System. (4, 7, 19-25, 32, 39, 41, 49, 50, 52-54, 58, 62, 63)

10 studies without adjustment demonstrated no significant improvement in cardiac arrest rates after the introduction of a Rapid Response System. (8, 11, 18, 34, 37, 38, 46, 48, 59, 64)

14 studies with adjustment demonstrated significant improvement in cardiac arrest rates after the introduction of a Rapid Response System. (6, 12, 29, 31, 35, 36, 42-45, 47, 51, 55, 56)

5 studies with adjustment showed no significant improvement in cardiac arrest rates after the introduction of a Rapid Response System. (9, 10, 40, 60, 61)

3 studies with adjustment demonstrated significant improvement in cardiac arrest rates after the introduction of a RRS both before and after adjustment. (27, 30, 33)

1 study with contemporaneous controls demonstrated no significant improvement in cardiac arrest rates after the introduction of a RRS both before and after adjustment. (26);

1 study with adjustment demonstrated significant improvement before adjustment for whole of hospital and non–intensive care unit (ICU) cardiac arrest rates, but only for non-ICU cardiac arrest rates after adjustment. (28)

1 before-after study that presented “after” unadjusted data for cardiac arrest in 3 separate time bands demonstrated significant improvement in time bands 2 and 3. (65)

The heterogeneous nature of the studies prevents pooling of data. However, there is reduced incidence of cardiac arrest in those hospitals that introduce a Rapid Response System, and a dose-response effect, with higher-intensity systems (e.g. higher Rapid Response System activation rates, senior medical staff on RRT) being more effective.

Treatment Recommendations

We suggest that hospitals consider the introduction of rapid response system (rapid response team/medical emergency team) to reduce the incidence of IHCA (weak recommendation, low-quality evidence).

Justification and Evidence to Decision Framework Highlights

In making these recommendations, the EIT Task Force considered the following:

• The task force emphasizes the importance of outcomes such as preventing in-hospital cardiac arrests and enhancing survival rates to hospital discharge, despite the considerable costs associated with these systems. Numerous healthcare institutions globally have effectively adopted rapid response systems. (66).
• The Institute for Healthcare Improvement (IHI) (http://www.ihi.org/Topics/Rapi...) and various national patient safety programs advocate for the use of rapid response systems to improve patient safety.
• Up to 33% of rapid response team activations involve patients nearing the end of life. Rapid response systems may also play a significant role in end-of-life care management and in mitigating medical errors. (67, 68)
• Implementing an effective rapid response system requires thoughtful integration of key components. Strong afferent (detection and activation) and efferent limbs (response by the RRS/MET team) should be supported by robust administrative and quality improvement measures. (69)
• Adequate investment in resources is crucial, which includes:

(a) comprehensive staff training on recognizing signs of patient decline;

(b) consistent and appropriate monitoring of vital signs;

(c) clear protocols such as alert systems or early warning scores to facilitate early detection; (d) a standardized, tiered clinical response structure; and

(e) a systematic approach to responding to assistance calls.

However, the best practices for patient monitoring and how to implement these components are still unclear. (70, 71)

• Monitoring the performance of rapid response systems is essential, and data should be utilized as part of a continuous quality improvement strategy. Healthcare organizations should follow the “Recommended Guidelines for Monitoring, Reporting, and Conducting Research on Medical Emergency Team, Outreach, and Rapid Response Systems: An Utstein-Style Scientific Statement” to gather meaningful data and enhance system effectiveness and clinical outcomes. (72)

Knowledge Gaps

• There is limited evidence regarding long-term survival with positive neurological outcomes with the application of RRT/MET.
• The role of technology in enhancing rapid response systems (e.g. use of remote monitoring, wearable devices) is unclear
• The essential components of the “afferent limb” in a rapid response system needs to be determined (e.g. which vital signs, clinical observations, laboratory parameters should be monitored, and what is the optimal frequency for these assessments).
• Which is an effective education program to improve the recognition of patient deterioration.
• The most effective mechanism for escalating assistance, and how do conventional escalation methods compare to automated electronic escalation work needs further investigation.
• The ideal composition of the “efferent limb,” or the response team needs to be defined.
• The primary reasons behind ‘failure to rescue’ scenarios or the underuse of rapid response systems needs to be clarified.
• The cost-effectiveness of rapid response systems in practice is unclear.

ETD summary table: EIT 6309 MET RRT Et D Table

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