PATIENT SURVEILLANCE AND RAPID RESPONSE TEAMS

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1 PATIENT SURVEILLANCE AND RAPID RESPONSE TEAMS EXECUTIVE SUMMARY Efforts to reduce in-hospital preventable harm and minimize failure to rescue events have led to widespread adoption of Rapid Response Teams (RRT). Despite advances in patient surveillance technology, the afferent limb of the RRT system remains a weak link. Many in-patient adverse events, including cardiopulmonary arrests, are preceded by prolonged periods of clinical instability, indicating that better patient surveillance could improve patient safety by providing earlier identification of patient deterioration. New patient surveillance technologies allow for more effective patient monitoring while potentially reducing alarm fatigue. Effective monitoring of respiration is a critical component of the afferent limb of RRTs that directly impacts patient morbidity and mortality. Strengthening the afferent limb of RRTs by implementing advanced patient surveillance technology might allow for RRTs to reach their true potential and directly reduce the incidence of preventable harm. Over the past two decades, the healthcare system has placed considerable attention on the concept of failure to rescue and the reduction of preventable harm in the hospital. Failure to rescue typically refers to the inability to recognize the early signs and symptoms of patient deterioration, or simply acting too late to prevent an in-hospital cardiopulmonary arrest. The concept of failure to rescue was first defined by Silber et al in 1992, as hospital death after adverse occurrences such as postsurgical complications. 1 Importantly, failure to rescue is a hospital-wide problem that is not necessarily confined to predefined at risk patients in intensive care. As discussed below, this problem can become especially apparent in lower acuity settings that are poorly equipped to detect rapid patient deterioration. Unfortunately, despite best efforts, preventable in-patient complications remain a significant problem. In fact, as seen in Table 1, the baseline incidence of in-hospital adverse event rates (in the absence of an RRT system) remains relatively high, and there is no clear evidence that the incidence of these events has changed markedly over the last decade Furthermore, in the 2011 HealthGrades Patient Safety in American Hospitals study, death among surgical inpatients with serious treatable complications was the most commonly occurring patient safety indicator, with an incidence rate of /1000 at-risk hospitalizations. 14 In an effort to reduce serious in-patient adverse events, the RRT (also known as medical emergency team, or MET) concept was widely implemented in the early 2000s with the intent to reduce delayed recognition of clinical decompensation in hospitalized patients. In 2006, the Institute for Healthcare Improvement made RRT implementation a key component of the 100,000 Lives Campaign to improve the quality of care in hospitals and reduce mortality rates. 15 In fact, it has been estimated that effective RRT implementation could contribute 66,000 lives saved in the 100,000

2 TABLE 1. REPORTED INCIDENCE OF ADVERSE EVENTS REFERENCE CODE BLUE (NON-ICU) UNPLANNED ICU TRANSFER MORTALITY PATIENT POPULATION Bapoje et al (2011) 34.0 Hospital-Wide Bellomo et al (2012) General Care Floor Brown et al (2014) Medical-Surgical Unit Buist et al (2002) Hospital-Wide Chan et al (2008) 6.1 a 32.2 Hospital-Wide Chan et al (2010) Meta-Analysis of 11 Adult Studies Chan et al (2010) Meta-Analysis of 5 Pediatric Studies Dacey et al (2007) 7.6 b Hospital-Wide DeVita et al (2004) 6.5 Hospital-Wide Hodgetts et al (2002) Hospital-Wide Jones et al (2005) 4.1 Hospital-Wide Reese et al (2015) 5.9 Children s Hospital Taenzer et al (2010) 5.6 c Postoperative Orthopedic Unit Pre-RRT implementation values reported as incidence per 1000 admissions (unless noted below); a Values for non-icu beds; b Value per 1000 discharges; c Value per 1000 patient days. Lives Saved Campaign. 16 The overarching goal of the RRT system is to prospectively identify deteriorating patients and alter the clinical course of these patients through rapid application of specialized care. 17 The foundation of the RRT concept is the evidence that up to 84% of in-hospital cardiopulmonary arrest events are preceded by prolonged periods of physiological and clinical instability. 10,18,19 Additionally, delayed ICU transfer of deteriorating patients is strongly associated with increased mortality, further supporting the importance of rapid identification and action with at-risk patients. 20 Thus, it is predicted that enhanced identification of patient deterioration combined with effective RRT response and intervention during this period of instability would reduce the incidence of arrests and improve outcomes. 21 While RRTs are typically hospital wide, their efficacy can become especially important in lower acuity settings such as the general care floor, where patient surveillance is typically suboptimal. The crucial components of the RRT system were first defined by DeVita et al in 2006, who described the importance of both the afferent crisis detection and response triggering side of the equation (i.e., patient surveillance) and the efferent response and intervention by the RRT. 22 As described below, there is growing concern that the afferent limb is the weak link of the system, especially in lower acuity settings with reduced patient surveillance capabilities. In practice, the RRT is a designated team of clinicians who can quickly respond to patient deterioration outside of the ICU. While RRT composition varies from institution to institution, RRTs typically include a mix of physicians, physician s assistants, critical care nurses, clinical nurse specialists, and respiratory therapists (Table 2). In order to be effective, the RRT needs to be available to respond to a call 24 hours a day, 7 days a week, within 15 minutes. 24 RRT activation criteria can vary from institution to institution and involve single- or multiple-parameter activation criteria, or aggregate weighted scoring systems, but typically include both objective and subjective measures, with a focus on acute changes in airway, breathing, circulation, oxygenation, and consciousness (Table 3). 9,25,26 EVIDENCE TO DATE Despite the widespread implementation of RRTs worldwide, there remains some controversy regarding the clinical impact of the RRT concept. Evidence supporting the use of RRTs includes that of Buist et al who showed that in a 300-bed teaching hospital, RRT implementation resulted in a 50% reduction odds ratio: 0.50; 95% CI: 0.35 to 0.73) in the incidence of unexpected cardiac arrest. The authors also found a significant reduction in patient mortality following RRT 2

3 TABLE 2. EXAMPLES OF RRT COMPOSITION Team Members PHYSICIAN-LED9 NON-PHYSICIAN-LED8 PRIMARY TEAM-LED23 Intensivist (leader) Critical care nurse Floor nurse Anesthesia Respiratory care Physician for chest compressions Physician for procedures Physician assistant (leader) Critical care nurse Respiratory care Intensivist (as needed) Hospitalist (as needed) Patient s primary resident (leader) Patient s primary nurse Senior nurse Respiratory care (as needed) Other providers (as needed) TABLE 3. EXAMPLES OF RRT ACTIVATION CRITERIA BELLOMO ET AL (2004) 25 DEVITA ET AL (2004) 9 HILLMAN ET AL (2005) 26 If one of the following is present: Staff member is worried about the patient Acute change in pulse rate to <40 or >130 bpm Acute change in SBP to <90 mmhg Acute change in RR to <8 or >30 breaths/min Acute change in pulse oximetry saturation to <90% despite oxygen administration Acute change in consciousness Acute change in urine output to <50 ml in 4 hours Respiratory RR <8 or >36 breaths/min New onset difficulty breathing New pulse oximetry reading <85% for more than 5 min Heart Rate <40 or >140 bpm with symptoms or any rate >160 bpm Blood Pressure SBP <80 or >200 mmhg or DBP >110 mmhg with symptoms Neurology Acute loss of consciousness New onset lethargy or Narcan use without immediate response Seizure (outside of seizure monitoring unit) Sudden loss of movement (or weakness) of face, arm, or leg Other Chest pain unresponsive to NTG or doctor unavailable Color change (patient/extremity): pale, dusky, gray, or blue Unexplained agitation for >10 min Suicide attempt Uncontrolled bleeding Airway If threatened Breathing Respiratory arrest RR <5 or >36 breaths/min Circulation Cardiac arrest Pulse rate <40 or >140 bpm SBP <90 mmhg Neurology Sudden fall in consciousness (fall in GCS of >2 points) Repeated or extended seizures Other Any patient a staff member is worried about that doesn t fit the above. Bpm = beats/minute, DBP = diastolic blood pressure; NTG = nitroglycerin; SBP = systolic blood pressure; RR = respiratory rate. In a selection of recent studies that have reported the incidence of specific RRT calling criteria, while there is variation across studies, there appears to be a slightly higher incidence of respiratory distress events (15% to 45% of calls) as compared to deteriorations in cardiovascular criteria such as blood pressure (12-24% of calls) and heart rate (10-28% of calls) (Figure 1). 6,

4 FIGURE 1. INCIDENCE OF COMMON RRT CALLING CRITERIA Percent of RRT Calls Blood Pressure Heart Rate Mental Status Oxygen Saturation Respiratory Rate or Respiratory Distress Abd et al (2011) Boniatti et al (2010) Chan et al (2008) Hatlem et al (2011) Thomas et al (2007) implementation (77% before, 55% after; p<0.001). In light of these data, the authors concluded in clinically unstable inpatients early intervention by a medical emergency team significantly reduces the incidence of and mortality from unexpected cardiac arrest in hospital. 5 DeVita et al conducted a retrospective analysis of 3269 MET responses and 1220 cardiopulmonary arrests over 6.8 years. 9 The authors showed an increase in MET responses from 13.7 to 25.8 per 1000 admissions (p<0.0001) after instituting objective MET activation criteria. Associated with this increase in MET activation was a 17% decrease in the incidence of cardiopulmonary arrests, from 6.5 to 5.4 per 1000 admissions (p=0.016). 9 In a 2004 study, Bellomo et al evaluated the effects of hospital-wide MET introduction on a number of factors, including serious adverse event rates, postsurgical mortality, and length of hospital stay. 25 Following MET implementation, the authors found that there was a significant decrease in the number of cases of respiratory failure (relative risk reduction, 79.1%; p<0.0001), stroke (78.2%; p=0.0026), severe sepsis (74.3%; p=0.0044), and acute renal failure requiring renal replacement therapy (88.5%; p<0.0001). Emergency intensive care unit admissions were also reduced (44.4%; p=0.001). Furthermore, MET introduction was associated with a significant decrease in the number of postoperative deaths (36.6%; p=0.0178), and the duration of hospital stay after major surgery decreased from a mean of 23.8 days to 19.8 days (p=0.0092). 25 In a pediatric setting, Tibballs et al showed that MET implementation reduced total hospital deaths from 4.38/1000 admissions pre-met to 2.87/1000 admissions post-met admissions (RR: 0.65 (95% CI: , p<0.0001)), reduced ward unexpected death from 13 (0.12/1000) to 6 (0.04/1000) (RR: 0.35 (95% CI: , p=0.03), and reduced preventable cardiac arrests from 17 (0.16/1000) to 10 (0.07/1000) (RR: 0.45 (95% CI: , p=0.04). Critics of the RRT concept point out that the majority of RRT studies to date have not been randomized and that most have utilized historical control groups. In fact, in one of the few randomized studies to date, Hillman et al found no significant differences in the incidence of cardiac arrest in patients without DNR orders, unplanned ICU admissions, and unexpected deaths in the general care wards of hospitals with and without MET adoption. 26 Similarly, in a 2008 prospective cohort study, Chan et al found no reduction in hospital-wide code rates (OR: 0.76 [95% CI: ]; p=0.06) and no difference in hospitalwide mortality between the pre-intervention and post-intervention periods (3.22 vs per 100 admissions; OR: 0.95 [95% CI: ]; p=0.52). 6 In a subsequent systematic review and meta-analysis, Chan et al identified mixed results. 7 More specifically, in this review of 18 studies encompassing nearly 1.3 million hospital 4

5 admissions, the implementation of an RRT in adults was associated with a 33.8% reduction in rates of cardiopulmonary arrest outside the ICU (RR: 0.66; 95% CI: ) but was not associated with lower hospital mortality rates (RR: 0.96; 95% CI: ). In children, implementation of an RRT was associated with a 37.7% reduction in rates of cardiopulmonary arrest outside the ICU (RR: 0.62; 95% CI: ) and a 21.4% reduction in hospital mortality rates (RR: 0.79; 95% CI: ). 7 Thus, despite a growing body of evidence supporting the efficacy of RRTs, additional controlled studies are needed to fully assess the clinical impact of RRTs. As discussed below, additional refinement of patient surveillance strategies to strengthen the afferent limb of the system might also improve RRT call outcomes and further support the widespread implementation of RRTs. ECONOMIC CONSIDERATIONS AND BENEFITS The implementation of an RRT system is not without cost to the hospital. Thus, a handful of studies have performed cost-benefit analyses in a variety of clinical settings. 8,30,32 In a children s hospital, Bonafide et al evaluated the cost of critical deterioration (CD) events (unplanned ICU transfers with mechanical ventilation or vasopressors as compared to ICU transfers without CD). The authors also performed a costbenefit analysis evaluating a number of MET compositions and staffing models on the annual reduction in CD events needed to offset MET costs. In this study, patients with CD cost $99,773 (95% CI: $69,431 to 130,116; p<0.001) more than ICU transfers without CD. In this study, annual MET operating costs ranged from $287,145 for a nurse and respiratory therapist team to $2,358,112 for a nurse, respiratory therapist, and ICU attending physician freestanding team. In base-case analysis, a nurse, respiratory therapist, and ICU fellow team with concurrent responsibilities cost $350,698 per year, a cost equivalent to a reduction of 3.5 CD events. The authors concluded that CD events were expensive, and that the costs of operating a MET could potentially be recouped with a modest reduction in CD events. The authors also concluded that hospitals reimbursed with bundled payments could achieve important financial savings by using a MET to reduce CD. 32 In a 2007 report, Thomas et al noted that in addition to the operational benefits of an RRT, there are financial benefits due to reducing unnecessary ICU transfers and the incidence of in-hospital cardiopulmonary arrests and other serious adverse events. 30 Using labor and cost accounting methods, these authors estimated that the potential annual savings due to an RRT were $171,480 based on reductions in code rates, reduced length of stay, and reduced ICU transfers. 30 Similarly, Dacey et al studied the effects of RRT implementation on rates of in-hospital cardiac arrest, ICU admissions, and mortality in a 350-bed community hospital. The authors found that the deployment of an RRT reduced cardiac arrests from 7.6/1,000 discharges per month to 3.0/1,000, reduced overall hospital mortality from 2.82 to 2.35%, and reduced unplanned ICU admissions from 45 to 29%. 8 These authors indicated that implementing the RRT system was associated with start-up costs of >$460,000 for the first year, including >$350,000 in new personnel costs, $50,000 in training expenses, and $60,000 in supplies. However, the authors noted that RRT implementation was predicted to result in approximately 94 cardiac arrests avoided per year, which, at a cost of $4,946 per arrest, would be estimated to save approximately $465,000 a year in excess costs. 8 ROOM FOR IMPROVEMENT Despite evidence supporting RRT systems, there remains room for improvement. In a 2007 study, Galhotra et al found evidence that the afferent limb of the system (i.e., identification of patient deterioration and MET activation) might be the weak link. More specifically, the authors found the most common circumstance of avoidable arrests included sudden critical illness in undermonitored patients and delays in initiating a MET response in monitored patients who met crisis criteria. 21 In a prospective study by Calzavacca et al, delayed MET activation was one of the strongest predictors of mortality and the authors concluded that strategies for avoiding delayed MET activation should be a priority for hospitals operating RRT systems. 33 Similarly, a consensus conference on the afferent limb of the RRT system reaffirmed that timely detection of patients who experience physiologic decompensation, as opposed to the timely response of the RRT team (efferent limb), remained a major weakness in the RRT system. 22 In 5

6 a 2011 review by Taenzer et al, the authors noted that until recently, approaches to reducing failure to rescue events have focused on improving the efferent response and that less attention has been paid to strategies for improving the afferent limb of the RRT system. In this review, the authors described the importance of patient surveillance monitoring based on continuous vital sign monitoring and its utility in early detection of physiologic deterioration, and noted that tremendous opportunities for improvement of patient safety and research exist in the emerging field of patient surveillance. 16 STRATEGIES TO IMPROVE PATIENT SURVEILLANCE Importantly, current patient surveillance strategies are often lacking in either design and/or execution. As noted above, lower acuity settings such as the general care floor are typically not designed for rapid detection of acute deterioration. Furthermore, acute respiratory compromise is one of the most common reasons for RRT activation, yet it is well established that respiration remains one of the most poorly documented physiological parameters To compound this issue, manual counting of respiration rate is notoriously unreliable and visual signs of hypoxia such as cyanosis are slow to manifest. Along these lines, Gordon and Beckett found that over a 14-night period, Standardized Early Warning Score (SEWS) documentation was incorrect in 79% of cases, with up to 5 errors per chart, including frequent omissions of respiration rate, temperature, and neurological status. 37 Effective detection of respiratory compromise is especially critical given the evidence that patients with respiratory compromise have up to a two-fold increase in mortality following delayed RRT activation. 38 Furthermore, in their 2011 study, Bapoje et al found that respiratory failure was the most common reason for unplanned ICU transfer, accounting for 27% of cases. 2 Given these concerns, recent studies highlighting advances in patient surveillance technology are described below. Taenzer et al studied the impact of pulse oximetry surveillance on the incidence of rescue events and ICU transfers for 11 months before and 10 months after implementation of the surveillance system in a 36-bed orthopedic unit. 13 In this analysis, the incidence of rescue events decreased from 3.4/1000 patients to 1.2/1000 patients (p=0.01) and the incidence of ICU transfers decreased from 5.6/1000 patients to 2.9/1000 patients (p=0.02). 13 Importantly, the patient acceptance rate of the technology was high (98.2%) and the alarm burden was low (average of 4 alarms per patient per day; alarm thresholds SpO 2 <80% and HR <50 or >140 bpm). The authors concluded that the implementation of universal surveillance with pulse oximetry was associated with a reduced need for patient rescue and ICU transfers. 13 In a controlled trial of electronic, automated vital sign monitoring in general hospital wards, Bellomo et al assessed the effects of automated monitoring on the frequency, type, and treatment of RRT calls, patient survival to discharge or to 90 days, the overall type and number of serious adverse events, and length of hospital stay. 3 The authors studied 9617 patients before implementation (control) and 8688 patients after implementation (intervention) of the vital sign monitors. Among RRT call patients, the intervention was associated with an increased proportion of calls secondary to abnormal respiratory vital signs (from 21 to 31%; p=0.029). Survival after RRT treatment and survival to hospital discharge or 90 days increased from 86 to 92% (p=0.04). The intervention was also associated with a decrease in mean length of stay. The authors concluded that the deployment of continuous, automated vital sign monitoring changed the identification, process of care and outcome of deteriorating patients, and the duration of hospital stay and that their findings suggest that electronic automated advisory vital signs monitoring holds promise as a tool to improve patient safety in general hospital wards. 3 In a 2014 study, Brown et al studied the effects of continuous heart rate and respiration rate monitoring on unplanned transfers and length of stay in a 33-bed medical-surgical unit vs. a sister control unit for a 9-month preimplementation period and 9-month postimplementation period. 4 The authors reviewed 7643 patient charts, including 2314 patients who had continuous monitoring and 5329 control patients. For this comparison, continuous monitoring resulted in a4: Significant reduction in average length of stay (3.6 vs. 4.0 days; p<0.05) Significant reduction in total ICU days (63.5 vs days; p=0.04) Significant reduction in the rate of code blue events (0.9/1000 vs. 6.3/1000 patients; p=0.02) 6

7 Also in 2014, Taenzer et al compared the accuracy and clinical value of manual oxygen saturation (SpO 2 ) charting vs. continuous automated oxygen saturation monitoring across 5 medical-surgical units at Dartmouth Hitchcock Medical Center. 39 The authors used bedside monitors to collect continuous (once per second) SpO 2 and heart rate readings, and compared these values to the manually charted vital signs recorded every 4 hours for 36 patients with adverse events and 176 control patients over a 24-month period. Analysis of these data indicated that intermittent, manual charting of oxygen saturation resulted in an inflation of SpO 2 values by approximately 6.5% (95% CI: 4.0 to 9.0%; p<0.001) in patients with prolonged desaturations (average SpO 2 <90% over 15 minutes), with differences in SpO 2 values for charted vs. continuous monitoring ranging from 1.9 to 14.2%. 39 The authors concluded that manual charting of SpO 2 did not reflect the true physiologic values when compared to continuous recorded values and that basing early warning scores on manually charted data might not be ideal. 39 The authors also noted the documentation of inaccurate and inflated SpO 2 levels in patient charts supports the call by the Anesthesia Patient Safety Foundation that Future technology developments may improve the ability to more effectively utilize continuous electronic monitoring of oxygenation and ventilation in the postoperative period. However, maintaining the status quo while awaiting newer technology is not acceptable. 39 alarm fatigue. In fact, the continued adoption of integrated smart alarms incorporating multiple physiological parameters at once might allow for more effective patient surveillance with fewer total alarms. Implementing these advances in surveillance technology, especially in lower acuity settings such as the general care floor, can directly strengthen the afferent limb of the RRT system and allow RRTs to reach their full promise. Enhancing the RRT concept with new technology thus has the potential to directly reduce the incidence of preventable harm and to favorably impact the lives of tens of thousands of patients per year in the United States alone. CONCLUSIONS Preventable in-patient complications remain one of the biggest patient safety issues worldwide. While there is increasing evidence that RRTs can reduce the incidence of serious adverse events, improvements are still needed, especially in the afferent limb of the system. In recent years, heightened attention has been placed on effective monitoring of respiration given the growing evidence that respiratory compromise is one of the most common causes of RRT activation and that it is also one of the most common causes of inhospital mortality. Despite this, respiration remains one of the most poorly monitored body systems. Continued advances in patient surveillance technology might allow for better detection of acute patient deterioration without detracting from patient comfort or contributing to additional 7

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