Early Warning and Rapid Response Systems

Introduction

Rapid response teams arose out of the realization that inpatients are at risk for serious adverse events that were usually preceded by physiologic signs of instability that were not always recognized by ward staff. ^, These teams have evolved over time since the concept appeared in the medical literature in the 1990s. These teams of responders vary in composition, but most have critical care experience and training and were developed in an effort to reduce hospital mortality by responding to, or preventing, serious adverse events.

Failure to rescue was originally defined as the death of a patient after developing a treatable condition, but has been refined to include these adverse events that could have been prevented or limited in severity by timely intervention or escalation of care. This has become an important safety indicator that attempts to measure a hospital’s ability to recognize and manage complications. In 2008 the Joint Commission established Patient Safety Goal #16 to improve recognition and response to changes in a patient’s condition. This has provided momentum to the international movement to develop and refine rapid response systems. Since their genesis, these teams have experienced a gradual transition from a primarily reactive response to a more proactive, early recognition model that utilizes early warning scoring systems, incorporating physiologic variables and trends to identify patients earlier in the process of deterioration.

The Rapid Response System

The term “rapid response system” describes the hospital-wide approach to recognition and treatment of a patient who is deteriorating. The major components are the afferent limb, the efferent limb, administrative (which oversees day-to-day function of the RRT), and audit and quality improvement.

The afferent limb describes the triggering mechanism for the activation of the rapid response team. A wide range of criteria for activation currently exists worldwide, ranging from complex early warning scoring systems to vital sign trends, specific cutoff points for individual vital signs (single parameter systems), and the instincts of the bedside nurse that “something is not right” (staff worried criterion). Experts feel that some objective criteria should be utilized, allowing standardization and education of staff, but that subjective reasons for escalating should not be deemphasized as this provides opportunities to intervene in patients for whom the objective criteria are unmet or not applicable. There is no set of calling criteria considered all-inclusive, as patient populations vary in their baseline physiology. In addition, there may be a need to customize calling criteria because of the variability in the expertise of the responders and availability of intensive care unit (ICU) beds, as well as other systems and processes for clinical deterioration. Experts have proposed a set of clinical indicators that suggest the need for ICU admission, which can easily be adapted into a hospital’s ICU admission criteria (see Table 38.1 ).

Not all patients who demonstrate one or more of these indicators will require ICU admission, but at the very least, timely evaluation and intervention should be considered, and the patient should be closely monitored for further deterioration. For the afferent limb to be effective, this triggering mechanism should not only be utilized by the bedside nurse but also be available to other caregivers and even to family members who recognize deterioration.

The efferent limb refers to the responding team, including the members and the equipment they carry. As will be described, the composition of the team varies between institutions and situation but typically follows one of the following models ( Table 38.2 ). The response should be available and timely all hours of the day, and there should be no negative consequences for activations considered unnecessary by the responding team. These team members are typically experienced high-acuity providers with critical care experience. They should project calm reassurance and the ability to diagnose and initiate treatment, and possess the authority to transfer to a higher level of care as needed.

Leadership and management of the rapid response system are essential to maintain an environment of patient safety. This key element should oversee team member selection and competency verification, sustained education of hospital staff, purchase and maintenance of equipment, collection and analysis of data from team activations, and communication of these data to hospital leadership to ensure patient safety and quality improvement. Rapid response systems will be limited in their effectiveness or may even fail if these critical elements are not addressed in an ongoing way, and success is impossible to achieve without hospital leadership support.

The administrative and quality improvement component is key in the collection and analysis of data, to allow feedback and appropriate allocation of resources. When coupled with hospital administrative support, this allows the team to improve function over time and to adapt to new challenges.