The rapid response team: patient characteristics and resource implications

Patients admitted to modern hospitals often have multiple co-morbidities and complex management issues. Studies in 1990s and early 2000s showed that patients suffered serious adverse events (SAEs) that were often not related to illness they presented to hospital with 1-11. These studies used various definitions for a SAE and found that such events occur in up to 17% of hospital admissions. Other studies revealed that prior to the development of the SAE there were warning signs that manifested as changes in a patients vital signs 11-20. In many instances, ward staff did not recognize this instability and the response and escalation of care was not commensurate to the degree of patient instability. In some cases, deterioration would continue until the patient suffered a cardiac arrest, where upon the hospital cardiac arrest team was activated 13,17,21. Multiple studies have shown that once a patient has a cardiac arrest in hospital, their risk of dying during that hospital admission is approximately 80% 22. In response to these observations, many hospitals have implemented specialised teams called Rapid Response Teams (RRT) 23. Such teams are activated when a patient shows signs of physiological instability which manifest as derangements in their vital signs, and the RRT reviews the patient before cardiac arrest and irreversible deterioration occurs. The first section of this thesis provides an overview of the RRT concepts, and presents three articles that investigate the resource implications of this model of care in Australia. The first article is a review which outlines the concepts and principles of Rapid Response Teams from the global perspective 23. The second article describes the uptake and timing of implementation of such services into hospitals in Australia and New Zealand, particularly in relation to related published literature 24. The third article describes the staff that comprise such teams, as well as the level of funding of such teams in Australia 25. The second section of the thesis, contains five articles that examine the epidemiology of patients who are reviewed by the RRT. The first two articles present original research that describes the role of the RRT in end of life care (EOLC) for hospitalised patients. The first presents the findings of a seven hospital multi-national 518 patient prospective observational study which revealed that almost one-third of RRT calls were associated with end of life care issues 26. The second article presents the findings of a retrospective observational study of 35 adult Australian hospitals which assessed the mortality of more than 4.9 million hospital admissions and 99,000 RRT calls 27. It revealed that the mortality of patients subject to RRT review was 24.3%, and that the RRT reviewed 21.7% of all of the patients who died during the study period. The third article summarises all known literature reporting on the role of the RRT in EOLC of hospitalised patients and discusses the potential advantages and disadvantages of this approach 28. The fourth article is a seven hospital prospective observational study that examines the timing of RRT activations in relation to the date of hospital admission, as well as over a 24hr period 29. The fifth article in this section summarises the known literature describing the epidemiology of the adult RRT patient in Australia, and proposes three models for summarising RRT syndromes 30. The third section of the thesis presents two articles that argue that earlier detection of deteriorating hospitalised patients may be important in improving patient outcome. The first of these summarises the historic and chronological approach to detection and treatment of deteriorating hospitalised patients and the evolution from cardiac arrest to RRT responses 31. It then presents information related to the Australian Commission on Safety and Quality in Healthcare National consensus statement on essential elements for recognising and responding to clinical deterioration 31. The final article highlights that there is no universally accepted definition of patient deterioration 32. It summarises four models for defining clinical deterioration and the utility of each. It emphasizes that there is a need to develop multiple-variable models for deteriorating ward patients similar to those for ICU patients in order to assist clinician education and real time patient stratification to guide quality improvement initiatives that prevent and improve the response to clinical deterioration. In the fourth section of the thesis, the major findings from the 10 articles of the thesis are summarised and further strategies for the improvement of care of deteriorating patients are proposed.