Page 109 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 12: Rapid Response Teams 77

Traditional code teams are activated when a patient suffers a cardiac
children admitted to paediatric intensive care units in England
and Wales: a retrospective cohort study. Lancet. 2010;376:698-704. arrest manifesting as a loss of circulation or respiration. In this chapter,
we discuss the concept of the Rapid Response Team (RRT), which is
• Raspé C, Rückert F, Metz D, et al. Inter-hospital transfer of activated when a patient develops less severe and earlier signs of insta-
ECMO-assisted patients with a portable miniaturized ECMO bility. We also describe the Rapid Response System (RRS), which is the
device: 4 years of experience. Perfusion. 2014; epub ahead PMID entire system used to support the team.
24743549.
• Singh JM, Macdonald RD, Ahghari M. Critical events during land- SERIOUS ADVERSE EVENTS ARE COMMON
based interfacility transport. Ann Emerg Med. 2014; epub ahead
PMID 24412668. IN HOSPITALIZED PATIENTS
• Stewart AM, McNay R, Thomas R, Mitchell AR. Early aero- Modern hospitals in developed countries care for patients of increas-
1
medical transfer after acute coronary syndromes. Emerg Med J. ing age, acuity, and complexity. Studies conducted in North America,
2011;28:325-327. Australia, New Zealand, and the United Kingdom suggest that such
• Warren J, Fromm RE, Orr RA, Rotello LC, Horst HM. American patients suffer adverse events in up to 20% of cases depending on the
College of Critical Care Medicine. Guidelines for the inter- and definition used and population assessed (Table 12-1).
2
intrahospital transport of critically ill patients. Crit Care Med. In 1964, Schimmel reported on the incidence of adverse events in a
2004;32:256-262. cohort of 1014 patients admitted over an 8-month period to a univer-
sity teaching hospital in the United States. Participating house officers
• Wiegersma JS, Droogh JM, Zijlstra JG, Fokkema J, Ligtenberg JJ. reported “every noxious response to medical care occurring among their
Quality of interhospital transport of the critically ill: impact of a patients.” The study found that 20% suffered iatrogenic injury, 6.7% of
Mobile Intensive Care Unit with a specialized retrieval team. Crit which were fatal. Subsequently, two large studies, one in New York and
3
Care. 2011;15:R75. the other in Utah and Colorado, estimated a much lower incidence
4
of adverse events of 2.9% to 3.7%. However, both of these studies defined
adverse events from a medicolegal perspective in an attempt to estimate
the incidence of medical negligence. In a different study assessing a
REFERENCES broader definition of medical error, Andrews and coworkers found
5
Complete references available online at www.mhprofessional.com/hall a 17.7% incidence of adverse events.
Four subsequent studies defined adverse events as “unintended injury
or complication resulting from medical management rather than the
underlying disease process.” These studies were conducted in multiple
countries worldwide including Australia, New Zealand, England,
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8
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CHAPTER Rapid Response Teams and Canada and enrolled more than 25,500 hospitalized patients
9
(Table 12-1). These studies reported an incidence of adverse events
12 Daryl Jones ranging from 7.5% to 16.6% and suggested that between 36.9% and
9
9
6
51% were preventable.
Rinaldo Bellomo
6
The above studies assess adverse events from the perspective of
iatrogenesis and negligence. Patients may suffer an adverse event that
does not fall into these categories. Bellomo and coworkers conducted
10
KEY POINTS a 4-month study of serious adverse events (SAEs) in 1125 patients
undergoing major surgery (defined as surgery requiring admission for
• Patients admitted to modern hospitals may develop serious more than 48 hours) at the Austin hospital. A dedicated research coor-
adverse events in up to 20% of admissions. In addition, hospital-
ized patients can deteriorate unexpectedly due to the development dinator assessed patient records for the presence of 11 predefined SAEs:
acute myocardial infarction, pulmonary embolism, acute pulmonary
of a new problem. edema, unscheduled tracheostomy, respiratory failure, cardiac arrest,
• In a high percentage of cases, deterioration is gradual in onset and cerebrovascular accident, severe sepsis, acute renal failure, emergency
is associated with the development of derangement in the patient’s ICU admission, and death. The study reported that 16.9% of patients
vital signs. suffered postoperative SAEs, and that 7.1% of patients died. Further,
• Many hospitals have introduced Rapid Response Teams (RRTs) to in those older than 75 years who underwent unscheduled surgery, the
review deteriorating patients when they develop derangements in mortality was 20%. 10
vital signs that fulfill predefined criteria.
• Evidence for the effectiveness of RRTs is conflicting, and the optimal SERIOUS ADVERSE EVENTS ARE PRECEDED
team composition and thresholds for activation remain undetermined. BY SIGNS OF INSTABILITY
A number of studies have assessed the clinical course and manage-
ment of patients in the hours leading up to SAEs and cardiac arrests
INTRODUCTION (Table 12-2). Some of these studies 11,12 have used an expert panel to
determine whether the cardiac arrest or iatrogenic arrest was avoidable
Modern hospitals treat patients with increasingly complex medical con- and whether it was associated with medical error. Such studies suggest
ditions. Despite advances in medical technology and the advent of new that approximately 60% of cardiac arrests were avoidable. Similarly, an
medicines and interventions, many patients admitted to hospitals suffer assessment of 100 consecutive emergency ICU admissions suggested
adverse events. The most studied of these events are unplanned admis- that 54% of patients received suboptimal care, and that suboptimal care
sions to the intensive care unit (ICU), unexpected hospital deaths, and was associated with increased mortality. 13
cardiac arrests. Other studies have shown that such events are preceded The major limitation of these studies is their retrospective design and
by the development of new problems or derangements in vital signs for lack of objective criteria for assigning preventability. Consistent with
several hours, and that the response to these problems by ward staff may this notion, Hayward and Hofer reported an analysis of 111 deaths in
14
be suboptimal. 7 Veteran hospitals in the United States, which suggested that previous

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