Rapid Response Systems in adults (EIT #638): Systematic Review

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

Yeung J, Scapigliati A, Hsieh M, Boulton A, Saviani M, Georgiou M, Schnaubelt S, Bray J, Bhanji F, Bigham B, Breckwoldt J, Cheng A, Duff J, Glerup Lauridsen K, Gilfoyle E, Iwami T, Lockey A, Ma M, Monsieurs K, Okamoto D, Pellegrino J, Finn J, Greif R on behalf of the EIT Task Force.

Rapid Response Systems in Adults Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Education, Implementation and Teams Task Force, 2020 January 4. Available from: http://ilcor.org

Methodological Preamble

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 Yeung and Scapigliati with additional involvement of clinical content experts (Lockey, Boulton, Saviani, Georgiou, Schnaubelt) from the Education Implementation Teams Task Force. These data were taken into account when formulating the Treatment Recommendations.

Unwell patients admitted to hospital are at risk of deterioration that may progress to cardiorespiratory arrest. Patients commonly show signs and symptoms of deterioration for hours or days before cardiorespiratory arrest {Andersen 2016 112}. Rapid response systems (RRS) are programs that are designed to improve the safety of hospitalized patients whose condition is deteriorating quickly {Maharaj 2015 254}. A successful RRS may be defined as a hospital-wide system that ensures observations, detection of deterioration, and tailored response to ward patients that may include rapid response team (RRT), also called medical emergency team (MET) {Winters 2013 417}. There is uncertainty as to whether these system are effective in improving patient outcomes e.g. improving patient survival, reducing number of cardiac arrests.

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 very serious risk of bias. 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.

PICOST

The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: Adults who are at risk of cardiac or respiratory arrest in hospital

Intervention: Rapid Response System (includes Rapid Response Team (RRT) or Medical Emergency Team MET))

Comparators: No Rapid Response System

Outcomes: Survival to hospital discharge with good neurological outcome; Survival to hospital discharge; In-hospital incidence of cardiac/respiratory arrest

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols) are excluded.

Timeframe: All years and all languages were included as long as there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols) were excluded. Literature search updated to 10 December 2019.

PROSPERO Registration CRD42019160097

Consensus on Science

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 have found low-quality evidence (downgraded for risk of bias and inconsistency) from 2 RCTs {Priestley 2004 1398; Hillman 2005 2091} and very-low-quality evidence (downgraded for risk of bias, inconsistency, and indirectness) from 35 non-RCTs.{Bristow 2000 236; Buist 2002 387; Bellomo 2003 283; Subbe 2003 797; Kenward 2004 257; Dacey 20072076; Baxter 2008 223; Chan 2008 2506; Rothschild 2008 417; Snyder 2009 834; Vazquez 2009 449; Konrad 2010 100; Lighthall 2010 679; Santamaria 2010 445; Beitler 2011 R269; Hayani 2011 1138; Jones 2011 83; Laurens 2011 707; Lim 2011 373; Moon 2011 150; Patel 2011 1455; Sarani 2011 415; Shah 20111361; Howell 20122562; Rothberg 2012 98; Scherr 2012 32; Simmes 2012 20; Al-Qahtani 2013 506; Chen 2014 167; Salvatierra 2014 2001, Kim 2017 e562; Al Rajhi 2016 478; Joshi 2017 369; Jung 2016 494; Oh 2018 1303; Davis 2016 352; Chen 2016 47}

Of the 2 RCTs, one demonstrated no significant difference between control hospitals (functioned as usual) and intervention hospitals (introduced a MET team) for both unadjusted (P=0.564; Diff, −0.093; 95% CI, −0.423 to 0.237) and adjusted (P=0.752; OR, 1.03; 95% CI, 0.84–1.28) survival.{Hillman 2005 2091} The other study demonstrated a significant difference between control wards and intervention wards (introduction of a critical care outreach service) with all patients (OR, 0.70; 95% CI, 0.50–0.97), and matched randomized patients (OR, 0.52; 95% CI, 0.32–0.85).{Priestley 2004 1398}

Of the 34 nonrandomized studies reporting mortality, no studies reported statistically significant worse outcomes for the intervention. For studies not reporting adjusted outcomes:

• 16 studies with no adjustment demonstrated no significant improvement {Subbe 2003 797; Kenward 2004 257; Baxter 2008 223; Rothschild 2008 417; Snyder 2009 834; Vazquez 2009 449; Hayani 2011 1138; Jones 2011 83; Lim 2011 373; Patel 2011 1455; Shah 2011 1361; Rothberg 2012 98; Scherr 2012 32; Simmes 2012 20; Al Rajhi 2016 478; Oh 2018 1303};
• 10 studies with no adjustment demonstrated significant improvement {Buist 2002 387; Bellomo 2003 283; Laurens 2011 707; Moon 2011 150; Al-Qahtani 2013 506; Kim 2017 e562, Joshi 2017 369, Jung 2016 494; Davis 2016 352; Chen 2106, 47};
• 1 study with no adjustment reported on rates, which improved with MET, but did not report on significance {Dacey 2007 2076};
• 1 study with no adjustment demonstrated significant improvement for medical patients but not surgical patients (combined significance not reported){Sarani 2011 415}

For studies reporting adjusted outcomes:

• 3 studies with adjustment demonstrated significant improvement both before and after adjustment {Konrad 2010 100; Beitler 2011 R269; Chen 2014 167};
• 3 studies with adjustment demonstrated significant improvement before adjustment but not after adjustment {Lighthall 2010 679; Salvatierra 2014 2001; {Todd 1998 364};
• 2 studies with adjustment demonstrated no significant improvement both before and after adjustment {Bristow 2000 236; Chan 2008 2506};
• 1 study that reported on both unexpected mortality and overall mortality showed significant improvement both before and after adjustment for unexpected mortality but no significant improvement both before and after adjustment for overall mortality {Santamaria 2010 445};
• 1 before-after study that presented “after” data for unexpected mortality in 3 separate time bands demonstrated significant improvement in time band 3 before adjustment and in time bands 2 and 3 after adjustment.{Howell 2012 2562}

The heterogeneous nature of the studies prevents pooling of data; however, there is a suggestion of improved hospital survival in those hospitals that introduce a RRS, and a suggestion of a dose-response effect, with higher-intensity systems (eg, higher RRS activation rates, senior medical staff on RRS teams) being more effective.

For the critical outcome of in-hospital incidence of cardiac arrest, we found low-quality evidence (downgraded for risk of bias and indirectness) from 1 RCT {Hillman 2005 2091} and very-low-quality evidence (downgraded for risk of bias, inconsistency, and indirectness) from 33 further non-RCTs.{Bristow 2000 236; Buist 2002 387; Bellomo 2003 283; Subbe 2003797; DeVita 2004 251; Kenward 2004 257; Dacey 20072076; Offner 2007 1223; Baxter 2008 223; Benson 2008 743; Rothschild 2008 417; Moldenhauer 2009 164; Vazquez 2009 449; Konrad 2010 100; Lighthall 2010 679; Santamaria 2010 445; Beitler 2011 R269; Laurens 2011 707; Lim 2011 373; Moon 2011 150; Sarani 2011 415; Shah 2011 1361; Rothberg 2012 98; Scherr 2012 32; Simmes 2012 20; Al-Qahtani 2013 506; Chen 2014 167; Ludikhuize 2015 2544; Oh 20181303; Chen 2106 47; Joshi 2017 369; Kim 2017 e562; Nishijima 2016 12}.

For the 1 RCT, {Hillman 2005, 2091} no significant difference between control hospitals and intervention hospitals, for both unadjusted (P=0.306; Diff, −0.208; 95% CI, −0.620 to 0.204) and adjusted (P=0.736; OR, 0.94; 95% CI, 0.79–1.13) analyses.

Of the 32 observational studies reporting on cardiac arrest rates:

• 17 studies with no adjustment demonstrated significant improvement in cardiac arrest rates after the introduction of a MET system {Bellomo 2003 283; Dacey 20072076; Offner 2007 1223; Baxter 2008 223; Benson 2008 743; Moldenhauer 2009 164; Konrad 2010 100; Lighthall 2010 679; Beitler 2011 R269; Laurens 2011 707; Moon 2011 150; Sarani 2011 415; Rothberg 2012 98; Al-Qahtani 2013 506; Ludikhuize 2015 2544; Oh 2018 1303; Chen 2106 47};
• 7 studies with no adjustment demonstrated no significant improvement in cardiac arrest rates after the introduction of a MET system {Kenward 2004 257; Rothschild 2008 417; Vazquez 2009 449; Lim 2011 373; Shah 2011 1361; Scherr 2012 32; Simmes 2012 20};
• 1 before-after study using an aggregated weighted scoring system (Modified Early Warning Score [MEWS]) reported significantly higher cardiac arrest rates in MEWS bands 3 to 4 after intervention, but not in MEWS bands 0 to 2 or 5 to 15, and overall cardiac arrest rate significance was not reported {Subbe 2003 797};
• 3 studies with adjustment demonstrated significant improvement in cardiac arrest rates after the introduction of a RRS both before and after adjustment {Buist 2002 387; DeVita 2004 251; Chen 2014167};
• 1 study with contemporaneous controls demonstrated no significant improvement in cardiac arrest rates after the introduction of a RRS both before and after adjustment {Bristow 2000 236};
• 1 study with contemporaneous controls demonstrated significant improvement in cardiac arrest rates after the introduction of a RRS both before and after adjustment {Chen 2014 167};
• 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 {Chan 2008 2506};
• 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. {Santamaria 2010 445}

The heterogeneous nature of the studies prevents pooling of data. However, there is a suggestion of a reduced incidence of cardiac arrest in those hospitals that introduce a RRS, and a suggestion of a dose-response effect, with higher-intensity systems (eg, higher RRS activation rates, senior medical staff on RRS teams) 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 and in-hospital mortality (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 places a high value on the outcomes—the prevention of in-hospital cardiac arrest and death—relative to the likely substantial cost of the system. Rapid response systems have been successfully implemented in many healthcare settings worldwide {Lyons 2018 191}.
• Rapid response system is recommended by Institute for Healthcare Improvement (http://www.ihi.org/Topics/RapidResponseTeams/Pages/default.aspx) and other national patient safety initiatives around the world.
• There may be a role for rapid response system in patients with end of life care {Jones 2013 616} and also in reduction of medical errors {Braithwaite 2004 255}.
• Careful consideration needs to be given to the elements of such system. Effective afferent (detection and activation) and efferent limbs (RRS/MET response) may need the support of administrative and quality improvement strategies {Olsen 2019, 75}.
• Adequate resources should be dedicated to such systems to include (a) staff education about the signs of patient deterioration; (b) appropriate and regular vital signs monitoring of patients; (c) clear guidance (e.g., alert systems or early warning scores) to assist staff in the early detection of patient deterioration; (d) a clear, uniform system of tiered clinical response; and (e) a clinical response to calls for assistance. The optimal method of patient monitoring and delivery of these components remains unclear {DeVita 2010 375, Mancini 2010 S539}.
• The performance of rapid response systems should be monitored and used as part of quality improvement program of healthcare organisations. The “Recommended Guidelines for Monitoring, Reporting, and Conducting Research on Medical Emergency Team, Outreach, and Rapid Response Systems: An Utstein-Style Scientific Statement” {Peberdy 2007 2481} should be used by hospitals to collect the most meaningful data to optimize system interventions and improve clinical outcomes.

Knowledge Gaps

• There is lack of evidence on long term survival with favorable neurological outcomes.
• What is the role of technology in rapid response systems (e.g. remote monitoring, wearable devices)?
• What are the ideal components of the “afferent limb” of a rapid response system, eg, which vital signs, observations, and/or laboratory parameters, and with what frequency?
• What are the ideal components of an education program in the recognition of a deteriorating patient?
• What is the ideal mechanism for escalation for assistance (eg, conventional escalation versus automated electronic escalation)?
• What is the ideal makeup of the efferent limb (the response team)?
• What are the causes of ‘failure to rescue’ or underutilisation of rapid response systems?
• What is the cost effectiveness of rapid response system?

Attachments

Evidence-to-Decision Table: EIT-638 RRS in adults TFSR

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