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Original Research: CRITICAL CARE |

Rapid Response Team in an Academic Institution: Does It Make a Difference? FREE TO VIEW

Shiwan K. Shah, DO; Victor J. Cardenas, Jr, MD; Yong-Fang Kuo, PhD; Gulshan Sharma, MD, MPH; MERIT Study Investigators for the Simpson Centre
Author and Funding Information

From the Departments of Internal Medicine and Pediatrics (Dr Shah), the Division of Pulmonary, Allergy, and Critical Care Medicine (Drs Cardenas and Sharma), and the Sealy Center on Aging, Department of Internal Medicine (Drs Kuo and Sharma), University of Texas Medical Branch, Galveston, TX.

Correspondence to: Gulshan Sharma, MD, MPH, Division of Pulmonary, Allergy, and Critical Care Medicine, 301 University Blvd, Galveston, TX 77555-0561; e-mail: gulshan.sharma@utmb.edu


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;139(6):1361-1367. doi:10.1378/chest.10-0556
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Background:  Although data remain contradictory, rapid response systems are implemented across US hospitals. We aimed to determine whether implementation of a rapid response team (RRT) in a tertiary academic hospital improved outcomes.

Methods:  Our hospital is a tertiary academic medical center with 24-h in-house resident coverage. We conducted a retrospective cohort study comparing 27 months after implementation of the RRT (April 1, 2006, to June 31, 2008) and 9 months before (January 1, 2005, to September 31, 2005). Outcomes included incidence of codes (cardiac and/or respiratory arrests), outcome of the codes, and overall hospital mortality.

Results:  We analyzed 16,244 nonobstetrics hospital admissions and 70,208 patient days in the control period and 45,145 nonobstetrics hospital admissions and 161,097 patient days after the RRT was implemented. The RRT was activated 1,206 times (7.7 calls per 1,000 patient days). There was no difference in the code rate (0.83 vs 0.98 per 1,000 patient days, P = .3). There was a modest but nonsustained improvement in nonobstetrics hospital mortality during the study period (2.40% vs 2.15%; P = .05), which could not be explained by the RRT effect on code rates. The mortality was 2.40% in the control group and 2.06%, 1.94%, and 2.46%, respectively, during the next three consecutive 9-month intervals.

Conclusions:  In our single-institution study involving an academic hospital with 24-h in-house coverage, we found that RRT implementation did not reduce code rates in the 27 months after intervention. Although there was a decrease in overall hospital mortality, this decrease was small, nonsustained, and not explained by the RRT effect on code rates.

Figures in this Article

Various regulatory agencies and health-care organizations have advocated implementing rapid response systems to circumvent poor outcomes in hospitalized patients and mitigate medical error. The Institute of Healthcare Improvement recommends implementing an early intervention plan for deteriorating patients, such as a rapid response system, as one of their six strategies for their 100,000 Lives Campaign. The Joint Commission states as goal 16 of their National Patient Safety Goals that hospitals should implement a plan to improve the recognition of and response to deteriorating patients.1 The outcomes of hospitalized patients who experience cardiopulmonary arrest remain dismal, and most of these patients have signs of physiologic deterioration in the hours before the event. Early recognition and rapid intervention during this “pre-arrest” period may prevent cardiopulmonary arrest and save lives.

A rapid response system consists of a multidisciplinary team, usually composed of an experienced nurse and a respiratory therapist and occasionally a physician. Such teams are called rapid response teams (RRTs) or medical emergency teams (METs). Although there are no definite differentiations between RRT and MET, the term RRT usually refers to a nurse-led team, whereas MET refers to a physician-led team.

Numerous cohort studies with historical design have shown rapid response systems are beneficial in reducing cardiopulmonary arrest rates and/or mortality in hospitalized patients.218 However, other studies, including the largest cluster randomization study the MERIT (Medical Emergency Response Improvement Team) trial, failed to confirm these results.1924 Two meta-analyses, by Winters et al20 and Ranji et al,19 found that rapid response systems reduced cardiac arrests and hospital mortality when examining the cohort studies only, but when the recent randomized controlled trials were included, no benefit was found. Chan et al,25 in a recent meta-analysis, found that although rapid response systems may reduce cardiopulmonary arrest rates, there was no effect on hospital mortality. Possible explanations include that rapid response systems may prevent cardiopulmonary arrest in patients who would otherwise survive, or they may have merely shifted those arrests from the floors to the ICU.25 Nevertheless, hospitals are widely implementing RRTs despite uncertainty about their effectiveness. Specifically, the need for RRTs in academic institutions with 24-h/7-d coverage by house staff and dedicated code teams is unclear. To examine the effect of RRT in an academic institution, we conducted a retrospective cohort study with historical controls at our institution.

The University of Texas Medical Branch (UTMB) in Galveston, Texas, is a tertiary care academic institution with three hospitals: a children’s hospital, John Sealy Hospital (adult inpatient services), and the Texas Department of Criminal Justice (TDCJ) hospital (inpatient hospital for state prison inmates). UTMB runs an active solid organ transplant program, including cardiac, lung, liver, and kidney transplantation. This study included patients in both adult inpatient settings (John Sealy and TDCJ hospitals). The institutional review board at UTMB approved the study and waived the requirement for informed consent.

As at most academic hospitals, UTMB has a code team. Composed of three senior internal medicine residents, an anesthesiology resident, two critical care nurses, and a respiratory therapist, it provides 24-h/7-d assistance for patients with cardiopulmonary arrest. After reviewing the composition of rapid response systems at different hospitals reported in the literature, the UTMB Resuscitation Committee formalized an RRT composed of an experienced critical care nurse and a respiratory therapist. The RRT provides 24-h/7-d assessment and treatment (when indicated) for all adult hospitalized patients. Implementation began October 1, 2005. The trigger points for activation were similar to those reported in the literature: respiratory rate > 24/min, oxygen saturation < 90%, heart rate > 130/min, systolic BP < 90 mm Hg, change in mental status, or a concerned staff member. Staff members on all inpatient facilities were educated on the triggers for RRT activation. After the initial pilot, the RRT was rolled out consecutively to serve the inpatient services at John Sealy and TDCJ hospitals between October 1, 2005, and March 31, 2006. Any concerned medical staff member could activate the RRT. At the time of this study, family members could not activate the RRT.

The study incorporated patients admitted January 1, 2005, to June 31, 2008. The baseline (preintervention) period was January 1, 2005, to September 30, 2005. The postintervention period was April 1, 2006, to June 31, 2008. Data during the postintervention period were divided into three 9-month intervals. We excluded patients admitted during the rollout period of October 1, 2005, to March 31, 2006 and those treated only in the ED, ICU, or the cardiac catheterization laboratory. In addition, we excluded any codes occurring in the operating room, EDs, cardiac catheterization laboratory, or ICUs.

We obtained data on reason for activation of the RRT, the site/service of activation, and the immediate disposition postactivation from the RRT activation sheet. The final outcome of the patients was obtained from the hospital discharge database. The primary outcome measure was the number of in-hospital codes and the code rates per 1,000 patient days outside of the ICU. Information on the total number of admissions and length of hospital stay during the study period was obtained from discharge database. A code was defined as the patient requiring chest compressions or emergent intubation (ie, cardiac arrest and/or respiratory arrest). Secondary outcomes were outcomes of the codes, number of unplanned ICU admissions, and overall hospital mortality. About one-third of admissions in our hospital were obstetrics/labor and delivery patients with a very low mortality; we excluded these in the calculation of overall hospital mortality, as done in previous studies.

Because all data were reported monthly, we examined the potential autocorrelations in time and seasonality effect by autoregressive integrated moving average models. In addition, possible linear trends preintervention and postintervention were tested by piecewise and discontinuity models. Overall, there was no evidence of autocorrelation, seasonality, or linear trend for either studies outcome: code rate or overall mortality. The trend in RRT activation was examined using autoregression model adjusted for the positive autocorrelation in time. A Poisson regression model was used to analyze the change in code rates and a logistic regression model was used to analyze the change in mortality during preintervention and postintervention periods. We performed all analysis using SAS, version 9.2 (SAS Institute; Cary, North Carolina).

A total of 231,305 patient days were included in the study period. Of these, 70,208 were in the preintervention period and 161,097 in the postintervention period. There were 16,244 admissions during the preintervention period and 45,145 admissions in the postintervention period. Case mix in the preintervention and postintervention periods was similar (1.50 ± 0.05 vs 1.51 ± 0.02, P = .36).

During the postintervention period (Fig 1), there were 1,206 RRT activations (7.7 activations per 1,000 patient days, 26.7 activations per 1,000 hospital admissions). The trend in number of RRT activations significantly increased over the 27-month period (P = .0225).

Figure Jump LinkFigure 1. Rapid response activation rates.Grahic Jump Location

Table 1 shows the triggers for RRT activation. The most common reason for RRT activation was an acute change in respiratory status (respiratory rate > 24/min, oxygen saturation < 90%, or threatened airway) followed by acute change in mental status.

Table Graphic Jump Location
Table 1 —Reason for RRT Activation

N = 1,206. HR = heart rate; RR = respiratory rate; RRT = rapid response team; SBP = systolic BP.

* 

Total % can be > 100% because a patient can have more than one reason for RRT activation.

As a result of the activation, 50% of patients were subsequently transferred to the ICU, another 8.7% were transferred to other locations (such as to a telemetry floor, catheterization laboratory, ED, or operating room), with the remainder staying at their initial location (Table 2). Of note, code status was changed in 34 (7%) patients who stayed at their initial location during RRT activation.

Table Graphic Jump Location
Table 2 —Immediate Disposition of Patients Evaluated by RRT

OR = operating room. See Table 1 legend for expansion of other abbreviation.

Figure 2 presents the codes per 1,000 patient-days during pre-RRT and postimplementation periods. In the preintervention phase, there were 58 codes (0.83 codes per 1,000 patient days, 3.59 codes per 1,000 hospital admissions) compared with 157 codes (0.98 per 1,000 patient days, 3.48 codes per 1,000 hospital admissions) in the postintervention phase (P = .30). This difference was not statistically significant. There was no difference in the outcomes of the codes, with a survival to discharge in 29% of preintervention and 33% of postintervention cases (P = .60). In the postintervention period, 50% of ICU admissions were unplanned. Overall in-hospital mortality was 2.40% in the preintervention period and 2.06%, 1.94%, 2.46% in the first, second, and third 9 months postintervention periods (P = .03, 0.01, 0.83, respectively) (Table 3).

Figure Jump LinkFigure 2. Code rates and hospital mortality.Grahic Jump Location
Table Graphic Jump Location
Table 3 —Pre- and Post-RRT In-Hospital Codes, Code Rates, Outcome of Codes, and Mortality

Early response systems are advocated by various regulatory agencies to improve patient outcomes. Studies have shown that patients experience hours of physiologic deterioration prior to cardiopulmonary arrest. Theoretically, an intervention during this time can improve patient outcomes. However, studies of rapid response systems have yielded contradictory results.

Our study showed that RRT implementation in a tertiary academic hospital with a preexisting 24-h/7-d code team did not meaningfully improve the number of codes or the outcome of the codes. There was a modest (approximately one-half of one percent), but nonsustained decrease in nonobstetric hospital mortality. The mechanism for reduced mortality with implementation of RRT is believed to be mediated via reduction in hospital cardiopulmonary arrest. There was a numerical increase in the code rate in the first two periods with a reduction in mortality rate. During the third period, there was a numerical decrease in the code rate, even as the mortality returned to baseline levels. Furthermore, this return to baseline mortality occurred even as RRT activation rates increased (Fig 1). Thus, the decrease in mortality cannot be plausibly explained by the effect of RRT on code rates. One possible reason for the mortality difference is a subtle change in the severity of illness during the postintervention period. Although there was no change in the case mix index, the case mix index, based on Medicare diagnostic related group codes, does not always reflect illness severity.26 Other possible reasons include secular trends and other quality-improvement initiatives.

However, despite no clear evidence of improvement in outcomes, RRT implementation did lead to an increase in the number of unplanned ICU admissions. These findings are consistent with the MERIT trial done in Australia21 and conclusions from two recent meta-analyses.19,20

Several factors may explain our results as well as the discrepancies in previous studies. First, the baseline code rates of the hospital prior to RRT implementation may have had an effect on the outcome.27 Institutions with higher baseline code rates will show larger improvements, whereas institutions with lower code rates will have smaller or no improvements. This is consistent with the ceiling effect phenomenon of an intervention. Everyone aims for zero codes, but this quest remains elusive. Our codes in the pre-RRT period were relatively low (0.83 per 1,000 patient days or 3.59 per 1,000 hospital admissions). Studies that reported a positive effect of RRTs had a baseline code rate between 2.4 and 7.6 codes per 1,000 hospital admissions, with five of the eight positive studies reporting such data having baseline code rates higher than our study.3,4,6,9,11,1416

Second, the denominator used to calculate the code rates, such as hospital admissions or patient days, could affect the conclusion. A patient is at risk for a code every day during the entire hospital stay. Studies using per 1,000 admissions as a denominator are more likely to show benefits of RRT then those using 1,000 patient days. With the exception of the study by Sharek et al7 in a pediatric population, all previous studies in the literature used 1,000 admissions as the denominator. We analyzed our data using per 1,000 patient days as well as per 1,000 admissions and were not able to show a difference in any of the predefined outcomes.

Prior studies have examined cardiopulmonary arrests in a non-ICU setting. Patients in the ICU during their hospital stay were not at risk for the specified outcome during their entire hospital stay. Relying solely on hospital admissions as a denominator could confound results because ICU patients will be included in the denominator but not in the numerator if they suffer a cardiac and/or respiratory arrest. In fact, the Institute for Healthcare Improvement recommends using patient days to determine code rates.28

Third, the dose of the intervention (ie, number of activations per month) can affect outcomes of an intervention. The RRT represents the efferent limb of the rapid response system. The afferent limb depends on the bedside nursing staff recognizing that a patient is in distress and activating the team. RRTs are often not activated in patients who meet criteria for activation.3,20 The overall rate of RRT calls in our study was 7.7 per 1,000 patient days, and 26.7 per 1,000 hospital admissions. Jones et al29 found that RRT usage between 25.8 and 56.4 calls per 1,000 admissions were associated with improved outcomes. Relatively low RRT activations in the setting of a low baseline code rate in our study population may partly explain the modest benefits. Future research should investigate the rate of minimal RRT activation needed to demonstrate effectiveness of the system.

Fourth, the composition of the RRT may affect outcomes. Most RRTs are built on local systems and availability of resources. Having a physician on the team can provide immediate assessment and early interventions, which may not be always possible in a nurse-led team. However, there are no data to support that a physician-led team is more effective than an experienced nurse-led team. In fact, in the MERIT trial, being led by a physician did not show any benefit.

Prior studies have not adequately addressed the effect of preexisting in-house code teams on RRT implementation. UTMB is a tertiary care academic institution with 24-h/7-d in-house resident coverage for hospitalized patients as well as a 24-h/7-d code team. If a nurse believes a patient is deteriorating, a physician is always available to evaluate the patient, which would decrease use of the RRT. This in turn may diminish the value of an RRT. Thus, our results may not be applicable to community hospitals without in-house physician coverage. However, this trend is receding because of increase employment of hospitalist physicians in most community settings.

Last, RRTs can potentially have negative effects. An RRT member may not know the patient as well as the primary team and thus can institute inappropriate or unnecessary therapy. This is more common if the RRT makes decisions without fully involving the primary team. If the RRT reduces the number of codes, tools such as simulations should be used regularly to ensure that trainees learn how to properly manage these events.30

Our study has several limitations. The historical control design makes it susceptible to secular trends. However, secular variations between the two groups would likely overestimate treatment effects19; thus, our modest results in face of increasing rates of RRT activation are probably not explained by secular variations. Similarly, the Hawthorne effect (the fact that a group is being studied alters the results) would not explain our results, as by the end of the third period the mortality is similar to pre-RRT period. Of note, our primary outcome included both cardiopulmonary arrests and pure respiratory arrests. Most previous studies, except for Chan et al22 and Sharek et al,7 included only those patients who had cardiopulmonary arrest. Last, other indirect benefits of RRT, such as patient and nursing satisfaction, were not studied. Despite our findings, our institutional RRT continues to meet Joint Commission requirements.

In summary, our study, in combination with previous studies and meta-analyses, suggests that it is premature to make RRT mandatory for all hospitals. The response to any intervention is heterogeneous. We acknowledge that any intervention may work or fail in a given setting, for a host of reasons. RRTs are expensive to implement and require significant dedicated workforce, potentially diverting finite resources away from other, more beneficial interventions, such as hiring additional nursing staff. Second, as noted by Winters et al,31 physicians are already skeptical about implementation of rapid response systems, and implementing an unproven intervention may diminish support for future quality improvement ideas that have better evidence for their support.27

Future studies should address the role of nurses’ education in assessing deteriorating patients, the nurse-to-patient ratios in non-ICU settings, and the role of automated patient monitoring systems, to delineate how better to implement RRTs. A study by Kho et al32 determined that the use of an automated scoring system, such as the modified early warning score, could improve the use of RRTs. Similarly, we need to examine the effect of RRT by type of hospital, presence of 24-h in-house physician coverage, and composition.

In our single-institution study involving an academic hospital with 24-h in-house coverage, we found that implementation of an RRT did not lead to a decrease in codes or a sustained plausible improvement in the overall hospital mortality. These results, in combination with recent randomized controlled trials, should encourage further research into factors that increase the effectiveness of RRTs.

Author Contributions:Dr Shah: contributed to the analysis of the data, drafting of the manuscript, and providing final approval of the version to be published.

Dr Cardenas: contributed to the design of the study, obtaining the data, analyzing the data, giving advice on the drafting of the manuscript, and providing final approval of the version to be published.

Dr Kuo: contributed to the design of the study, statistically analyzing the results, drafting of the manuscript, and providing final approval of the version to be published.

Dr Sharma: contributed to initiating the study, designing the study, obtaining the data, analyzing the data, drafting of the manuscript, and providing final approval of the version to be published.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: We thank Sarah Toombs-Smith, PhD, for her help in preparation of the manuscript. We also thank Keith Ozenberger, Odette Y. Comeau, RN, and Valerie Clover for their assistance with data collection, and all the members of the RRT, including the critical care nurses and respiratory therapists, for their dedication and commitment to patient care.

MERIT

Medical Emergency Response Improvement Team

MET

medical emergency team

RRT

rapid response team

TDCJ

Texas Department of Criminal Justice

UTMB

University of Texas Medical Branch

2008 National Patient Safety Goals Hospital Program2008 National Patient Safety Goals Hospital Program 2007; Joint Commission Web site.http://www.jointcommission.org/PatientSafety. Accessed June 1, 2010.
 
Jones D, George C, Hart GK, Bellomo R, Martin J. Introduction of medical emergency teams in Australia and New Zealand: a multi-centre study. Crit Care. 2008;122:R46. [CrossRef] [PubMed]
 
Bellomo R, Goldsmith D, Uchino S, et al. Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med. 2004;324:916-921. [CrossRef] [PubMed]
 
Buist M, Harrison J, Abaloz E, Van Dyke S. Six year audit of cardiac arrests and medical emergency team calls in an Australian outer metropolitan teaching hospital. BMJ. 2007;3357631:1210-1212. [CrossRef] [PubMed]
 
Priestley G, Watson W, Rashidian A, et al. Introducing Critical Care Outreach: a ward-randomised trial of phased introduction in a general hospital. Intensive Care Med. 2004;307:1398-1404. [CrossRef] [PubMed]
 
DeVita MA, Braithwaite RS, Mahidhara R, Stuart S, Foraida M, Simmons RL. Medical Emergency Response Improvement Team (MERIT) Medical Emergency Response Improvement Team (MERIT) Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Qual Saf Health Care. 2004;134:251-254. [CrossRef] [PubMed]
 
Sharek PJ, Parast LM, Leong K, et al. Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a Children’s Hospital. JAMA. 2007;29819:2267-2274. [CrossRef] [PubMed]
 
Chen J, Bellomo R, Flabouris A, Hillman K, Finfer S. MERIT Study Investigators for the Simpson Centre MERIT Study Investigators for the Simpson Centre ANZICS Clinical Trials Group ANZICS Clinical Trials Group The relationship between early emergency team calls and serious adverse events. Crit Care Med. 2009;371:148-153. [CrossRef] [PubMed]
 
Bristow PJ, Hillman KM, Chey T, et al. Rates of in-hospital arrests, deaths and intensive care admissions: the effect of a medical emergency team. Med J Aust. 2000;1735:236-240. [PubMed]
 
Bellomo R, Goldsmith D, Uchino S, et al. A prospective before-and-after trial of a medical emergency team. Med J Aust. 2003;1796:283-287. [PubMed]
 
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;3247334:387-390. [CrossRef] [PubMed]
 
Jones D, Egi M, Bellomo R, Goldsmith D. Effect of the medical emergency team on long-term mortality following major surgery. Crit Care. 2007;111:R12. [CrossRef] [PubMed]
 
Jones D, Opdam H, Egi M, et al. Long-term effect of a Medical Emergency Team on mortality in a teaching hospital. Resuscitation. 2007;742:235-241. [CrossRef] [PubMed]
 
Jones D, Bellomo R, Bates S, et al. Long term effect of a medical emergency team on cardiac arrests in a teaching hospital. Crit Care. 2005;96:R808-R815. [CrossRef] [PubMed]
 
Baxter AD, Cardinal P, Hooper J, Patel R. Medical emergency teams at The Ottawa Hospital: the first two years. Can J Anaesth. 2008;554:223-231. [CrossRef] [PubMed]
 
Dacey MJ, Mirza ER, Wilcox V, et al. The effect of a rapid response team on major clinical outcome measures in a community hospital. Crit Care Med. 2007;359:2076-2082. [CrossRef] [PubMed]
 
Brilli RJ, Gibson R, Luria JW, et al. Implementation of a medical emergency team in a large pediatric teaching hospital prevents respiratory and cardiopulmonary arrests outside the intensive care unit. Pediatr Crit Care Med. 2007;83:236-246 quiz 247.. [CrossRef] [PubMed]
 
Hunt EA, Zimmer KP, Rinke ML, et al. Transition from a traditional code team to a medical emergency team and categorization of cardiopulmonary arrests in a children’s center. Arch Pediatr Adolesc Med. 2008;1622:117-122. [CrossRef] [PubMed]
 
Ranji SR, Auerbach AD, Hurd CJ, O’Rourke K, Shojania KG. Effects of rapid response systems on clinical outcomes: systematic review and meta-analysis. J Hosp Med. 2007;26:422-432. [CrossRef] [PubMed]
 
Winters BD, Pham JC, Hunt EA, Guallar E, Berenholtz S, Pronovost PJ. Rapid response systems: a systematic review. Crit Care Med. 2007;355:1238-1243. [CrossRef] [PubMed]
 
Hillman K, Chen J, Cretikos M, et al; MERIT study investigators MERIT study investigators Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet. 2005;3659477:2091-2097. [CrossRef] [PubMed]
 
Chan PS, Khalid A, Longmore LS, Berg RA, Kosiborod M, Spertus JA. Hospital-wide code rates and mortality before and after implementation of a rapid response team. JAMA. 2008;30021:2506-2513. [CrossRef] [PubMed]
 
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Zenker P, Schlesinger A, Hauck M, et al. Implementation and impact of a rapid response team in a children’s hospital. Jt Comm J Qual Patient Saf. 2007;337:418-425. [PubMed]
 
Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Rapid response teams: a systematic review and meta-analysis. Arch Intern Med. 2010;1701:18-26. [CrossRef] [PubMed]
 
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Jones D, Bellomo R, DeVita MA. Effectiveness of the Medical Emergency Team: the importance of dose. Crit Care. 2009;135:313. [CrossRef] [PubMed]
 
Hunt EA, Patel S, Vera K, Shaffner DH, Pronovost PJ. Survey of pediatric resident experiences with resuscitation training and attendance at actual cardiopulmonary arrests. Pediatr Crit Care Med. 2009;101:96-105. [CrossRef] [PubMed]
 
Winters BD, Pham J, Pronovost PJ. Rapid response teams—walk, don’t run. JAMA. 2006;29613:1645-1647. [CrossRef] [PubMed]
 
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Figures

Figure Jump LinkFigure 1. Rapid response activation rates.Grahic Jump Location
Figure Jump LinkFigure 2. Code rates and hospital mortality.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 —Reason for RRT Activation

N = 1,206. HR = heart rate; RR = respiratory rate; RRT = rapid response team; SBP = systolic BP.

* 

Total % can be > 100% because a patient can have more than one reason for RRT activation.

Table Graphic Jump Location
Table 2 —Immediate Disposition of Patients Evaluated by RRT

OR = operating room. See Table 1 legend for expansion of other abbreviation.

Table Graphic Jump Location
Table 3 —Pre- and Post-RRT In-Hospital Codes, Code Rates, Outcome of Codes, and Mortality

References

2008 National Patient Safety Goals Hospital Program2008 National Patient Safety Goals Hospital Program 2007; Joint Commission Web site.http://www.jointcommission.org/PatientSafety. Accessed June 1, 2010.
 
Jones D, George C, Hart GK, Bellomo R, Martin J. Introduction of medical emergency teams in Australia and New Zealand: a multi-centre study. Crit Care. 2008;122:R46. [CrossRef] [PubMed]
 
Bellomo R, Goldsmith D, Uchino S, et al. Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med. 2004;324:916-921. [CrossRef] [PubMed]
 
Buist M, Harrison J, Abaloz E, Van Dyke S. Six year audit of cardiac arrests and medical emergency team calls in an Australian outer metropolitan teaching hospital. BMJ. 2007;3357631:1210-1212. [CrossRef] [PubMed]
 
Priestley G, Watson W, Rashidian A, et al. Introducing Critical Care Outreach: a ward-randomised trial of phased introduction in a general hospital. Intensive Care Med. 2004;307:1398-1404. [CrossRef] [PubMed]
 
DeVita MA, Braithwaite RS, Mahidhara R, Stuart S, Foraida M, Simmons RL. Medical Emergency Response Improvement Team (MERIT) Medical Emergency Response Improvement Team (MERIT) Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Qual Saf Health Care. 2004;134:251-254. [CrossRef] [PubMed]
 
Sharek PJ, Parast LM, Leong K, et al. Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a Children’s Hospital. JAMA. 2007;29819:2267-2274. [CrossRef] [PubMed]
 
Chen J, Bellomo R, Flabouris A, Hillman K, Finfer S. MERIT Study Investigators for the Simpson Centre MERIT Study Investigators for the Simpson Centre ANZICS Clinical Trials Group ANZICS Clinical Trials Group The relationship between early emergency team calls and serious adverse events. Crit Care Med. 2009;371:148-153. [CrossRef] [PubMed]
 
Bristow PJ, Hillman KM, Chey T, et al. Rates of in-hospital arrests, deaths and intensive care admissions: the effect of a medical emergency team. Med J Aust. 2000;1735:236-240. [PubMed]
 
Bellomo R, Goldsmith D, Uchino S, et al. A prospective before-and-after trial of a medical emergency team. Med J Aust. 2003;1796:283-287. [PubMed]
 
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;3247334:387-390. [CrossRef] [PubMed]
 
Jones D, Egi M, Bellomo R, Goldsmith D. Effect of the medical emergency team on long-term mortality following major surgery. Crit Care. 2007;111:R12. [CrossRef] [PubMed]
 
Jones D, Opdam H, Egi M, et al. Long-term effect of a Medical Emergency Team on mortality in a teaching hospital. Resuscitation. 2007;742:235-241. [CrossRef] [PubMed]
 
Jones D, Bellomo R, Bates S, et al. Long term effect of a medical emergency team on cardiac arrests in a teaching hospital. Crit Care. 2005;96:R808-R815. [CrossRef] [PubMed]
 
Baxter AD, Cardinal P, Hooper J, Patel R. Medical emergency teams at The Ottawa Hospital: the first two years. Can J Anaesth. 2008;554:223-231. [CrossRef] [PubMed]
 
Dacey MJ, Mirza ER, Wilcox V, et al. The effect of a rapid response team on major clinical outcome measures in a community hospital. Crit Care Med. 2007;359:2076-2082. [CrossRef] [PubMed]
 
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