Tuesday, November 27, 2007

Rapid Response Teams: Still Wondering After Allllllllll These Years

Bob Wachter blogged about Rapid Response Teams (RRT's) today. His observations about this often misunderstood hospital safety intervention are quite helpful.

Click here for my thoughts on this.
Bob Wachter blogged about Rapid Response Teams (RRT's) today. His observations about this often misunderstood hospital safety intervention are quite helpful.

RRT's are teams of personnel that can be summoned when a hospital patient isn't critically ill but is starting to just look bad. Dr. Wachter describes them as a Code Blue team in drag. I choose to think of them as a Code Blue team minus the adrenalin. Nurses are more willing to call them than call a Code Blue team because they're smaller and just...not as big a deal.

He is quite right that the empirical evidence supporting RRT's is lacking. Some relatively small studies (see here and here) did show benefit in terms of reduced mortality but these were not well "controlled" and their results can be easily refuted. The one large, multi-center trial, the Australian MERIT trial, failed to demonstrate benefit.

As Dr Wachter reports, the Institute of Healthcare Improvement (IHI) was so wedded to the RRT concept, that they elected to promote it as a national standard. Clearly, they were disturbed by the less then stellar performances RRT's exhibited in the MERIT trial and felt compelled to publish a specific critique of that study.

This critique struck me as quite reasonable. They noted that both the control and RRT groups demonstrated a reduction in mortality during the study period. IHI suggested that this could be explained by noting that in Australia, RRT's were already being adopted in various incarnations throughout the country. This probably tended to make the control and study groups look more alike and therefore lowered the likelihood of demonstrating a difference.

The IHI also made the point that the actual implementation of the RRT's in the study groups may have been suboptimal (and gave examples of this). Had the study groups RRT's been better executed, again, true benefits may well have been realized.

Arguments were also made that the hospitals studied were largely academic institutions and as such, the results may not have been generalizable. Likewise, they raised arguments that the study as a whole may have been too small and may not have had the statistical power to show a true difference.

For myself, I tend to think that there is some benefit to these programs even if the proof is hard to arrive at. The key, I think, is appropriate implementation.

I've seen situations where the RRT begins to look very much like a Code Blue team. This doesn't strike me as cost-effective. Too many people, too many doctors, too big a deal. I much prefer simpler concepts such as the version that Dr. Wachter eventually organized in his institution which seems to mainly be run by ICU nurses and respiratory technicians used to assessing very ill patients.

That such teams can be helpful in the event of a "pre-emergency" makes sense to me. In the second study I cited above, there is a very interesting table that documents the types of interventions the RRT's used. The leaders of the hit parade were:
  1. Nasopharyngeal suctioning with additional oxygen
  2. A simple IV fluid bolus
  3. A dose of IV Frusemide (the diuretic Lasix for those of us on this side of the Atlantic)
  4. Noninvasive positive pressure ventilation by mask
  5. Nebulizer treatments
  6. Temporary manual ventilation
  7. Trach tub suctioning
  8. IV Glyceryl trinitrate drip (which I had to look up to convince myself was just good ol' nitroglycerin)
With the exception of 8. and possibly 4. (which has some subtleties to it that can cause damage), these are all simple and relatively harmless interventions whose decision to initiate can easily be made by an experienced nurse. We're not talking major stuff here; just some simple things that can make all the difference in the world to a patient that's not quite critical but whose condition is worsening.

It's hard to argue with the utility of such an approach. I agree with Dr. Wachter that (at least given what we "know" at this time), individual institutions should be allowed to decide for themselves and later assess how well they work and whether they should be continued.

One additional point. I've heard a number of hospital nursing directors say that RRT's are a very useful nursing recruitment tool. It seems quite clear that nurses are very happy with RRT's and probably see them as helping to alleviate the anxiety of taking care of potentially deteriorating patients.

That has to be good!

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Blogger L.B. said...

I think the RRT's are a good idea if properly organized. Sometimes just a fresh set of eyes can be helpful.

November 27, 2007 7:06 PM  

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