It’s Been a Hard Day’s Night—What Determines Impact of Less Than 24/7 Rapid Response Systems?*

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Rapid response systems have been introduced in many hospitals in Australia, Europe, the United States, and Asia, with the aim of reducing cardiopulmonary arrests, avoidable intensive care admissions, and preventable harm. While the only multicenter, randomized controlled trial (1) showed no significant difference in adverse events between the intervention and control groups, there have now been a number of meta-analyses of published literature in authoritative journals demonstrating the sizeable benefits of RRS (2, 3).
At the same time, it is also true that the published interventional studies are highly heterogeneous. The Medical Emergency Teams: Hospital Outcomes in a Day (METHOD) (4) Study and the more recent METHOD16 Study (unpublished data) collected data from RRS in three continents. Teams were staffed by doctors, nurses, doctors and nurses, with or without physical therapists. Teams often operated out of intensive care, where members might have other duties, which they had to leave to attend calls to general floors. Other teams were exclusively devoted to supporting at risk and deteriorating patients on general wards. This model of team makes fast response times potentially more reliable and avoids conflicts of interest between caring for a highly unstable patient in intensive care or a deteriorating patient outside the unit. However, they require dedicated funding over and above the budget for the ICU, which may be one of the reasons that many hospitals only provide the service during some part of the working week. Part-time teams thus operate based on perceived times of increased need during nights and weekends or just during convenient office hours. Little is known on the differences in effectiveness of a 24/7 team versus a team that operates only during part of the week.
The article by Kim et al (5), in this issue of Critical Care Medicine, looks at ways to quantify what the effect of a part-time rapid response team might be. The team uses a state-of-the-art electronic blackboard with data from the electronic patient record to trigger reviews. But, due to funding restrictions, the Seoul National University Bundang Hospital Medical Alert First Responder (SAFER) team only operates a rapid response service from 7 AM to 10 PM on weekdays and from 7 AM to 12 PM on Saturdays. The team composition varies between weekdays and weekend days but has senior medical input throughout.
In a retrospective cohort study, 254 cardiopulmonary arrests occurred during an observation period of nearly 4 years before introduction of SAFER, whereas only 202 were reported in the 3 years after the introduction. Importantly, the decrease in ratio of cardiopulmonary arrests per 1,000 admissions was statistically significant, but in a subgroup analysis, the reduction was limited exclusively to arrests during the hours covered by the SAFER team.
What are the potential implications of this work?
The introduction of a RRS might follow the pattern of more conventional interventions in that only those patients exposed to the intervention benefit. This would suggest a negligible effect of introducing an RRS in terms of changing the overall safety culture of the hospital and staff behavior outside the team’s hours of operation (6, 7). Impact might depend on the overall dose of rapid response team inputs (8), and what the team actually does when it attends patients. Effects related to organizational culture might of course take more than three years to become apparent, and might require a program of staff education and quality improvement running alongside.
The conditions under which RRS staffing in the night would further decrease the rate of cardiopulmonary arrests are unclear: In some studies, half of patients who suffered deterioration during the night have already noticeable abnormalities during the day (9).

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