Medical emergency teams (METs), which are also known as rapid response teams, comprise groups of health care professionals who respond to high acuity cases in an effort to decrease the risk of further patient deterioration. An important principle underlying rapid response systems is that early intervention can improve patient outcomes [
We have previously shown that there is a significant delay between patient deterioration and ICU consultation for critically ill patients on our medical wards [
Our study was conducted at a university-affiliated 350-bed acute care teaching hospital in Montreal, Quebec. The hospital has a 22-bed ICU and a 10-bed cardiac care unit (CCU). There are no step-down or high-care units within the hospital.
The CTU is a 48-bed unit with a nursing ratio of 5 : 1 during the day (7:00 h–23:00 h) and 7 : 1 during nights (23:00 h–7:00 h) which receives 70 patients per month with a median length of stay of 6 days. The CTU is not capable of providing vasoactive agents, noninvasive ventilation, or IV insulin; though resuscitative measures are commenced on the CTU in “code blue” scenarios, patients must ultimately be transferred to the ICU or the CCU in order to receive the aforementioned therapeutic interventions.
The medical team responsible for patient care on our CTU is comprised of 1 attending staff, 4 senior residents (third-year and second-year trainees), 6 junior residents (first-year trainees), and 4 third-year medical students. Trainees would have completed a minimum of eighteen weeks of acute care medicine (ICU, CCU, and emergency medicine rotations) before assuming a senior resident role. At the end of their eighteen weeks of acute care medicine, trainees are expected to recognize the unstable patient, to initiate resuscitative measures (including fluids and vasoactive agents), to identify indications for advanced ventilatory aids (noninvasive and invasive ventilation), and to be comfortable with the intubation of the airway and central venous catheterization.
CTU physician manpower availability varies depending on day of the week and time of day. On weekend days and statutory holidays, the medical staff is decreased to 1 attending staff, 2 senior residents, and 2 junior residents or medical students. On both weekday and weekend nights (20:00 h–8:00 h), there is 1 senior resident and 2 junior residents or medical students in house on call for the CTU.
We embarked upon a six-month educational project between January 2011 and June 2011 in order to promote awareness of the observed delays in the recognition of and response to critically ill patients on our CTU. Our initial findings were presented at both medical grand rounds and nursing rounds. Attending staff, senior and junior medical house staff, nursing directors, and bedside nurses working on the medical CTU were targeted for an educational program during the six months prior to project implementation. Rounds were conducted with small groups of bedside nurses and physicians with the following goals: (1) to explain the rationale behind the project, (2) to explain anticipated project goals, (3) to attribute the role of primary activator (afferent limb) to the nursing staff, (4) to attribute the role of primary responder (efferent limb) to the senior residents, (5) to review the criteria for system activation, (6) to explore methods of call documentation, and (7) to answer questions and to address potential concerns surrounding system activation. Posters listing system activation criteria and contact numbers were designed and placed in both nursing and physician work areas (Appendix
The afferent limb of our response system, or activation component, was comprised of the CTU bedside nursing staff. As our nurses have already been trained to call for medical assistance when patient concerns arise, we elaborated a set of seven clearly ascribed calling criteria to improve early recognition of deteriorating patients.
Criteria utilized for system activation included the following: Temperature < 35.5°C or > 39.5°C. Systolic blood pressure < 100 mmHg or >200 mmHg. Respiratory rate/min < 10 or >30. Pulse rate/min < 40 or >120. Urine output of < 500 mL over 24 hours. Decreased or altered level of consciousness. Serious concern (see Figure
The efferent limb, or response component, was comprised of the CTU senior medical resident. The senior resident was contacted by the nursing staff directly via a portable phone when a patient met any one of the aforementioned system activation criteria. The senior thus served as the first-responder for patient evaluation and resuscitation. The senior, in turn, had the capability to call for medical team assistance and critical care support when deemed necessary (see Figure
System activation criteria.
Afferent and efferent limb definition.
Our system was instituted on July 1, 2011, with data collected and reviewed until June 30, 2012. Outcomes were compared to data prospectively collected prior to initiation of the educational project (January 2010–December 2010). Our major endpoints included time from decompensation to first intervention, ICU transfer rates, and rate of code blue calls. Code blue rates on the CTU were compared with hospital-wide (excluding medical CTUs) code blue rates to account for any secular trends. The time to intervention was defined as the time from which the nursing staff noted vital signs meeting system activation criteria to the time the senior resident assessed the patient in question and subsequently (1) prescribed a treatment or (2) ordered urgent investigations or (3) called for a consultation from critical care services or (4) called a code blue.
A system activation call record spreadsheet was designed for nurses to enter patient name, hospital number, date and time of call, and reason for system activation. A similar spreadsheet was designed for senior residents to track the aforementioned data to improve accuracy. Additional data recorded by seniors included age and gender of the patient for which the call was placed, the patient’s admission diagnosis, the cause or working hypothesis of his or her deterioration, poor prognostic features, time of first intervention, time of consult to critical care services (if applicable), and time of transfer to a critical care unit (if applicable). Poor prognostic factors were defined as advanced dementia and/or being a resident of a nursing home or long-term care facility, advanced cardiac and/or respiratory disease (NYHA III or IV congestive heart failure, nonrevascularizable coronary artery disease, or chronic obstructive pulmonary disease of MRC Dyspnea scale score 4 or 5), or active malignancy.
The study group reviewed all entries on a weekly basis and noted the time from patient decompensation to the time of symptom recognition and system activation. In addition, the study group reviewed all admissions to the hospital’s critical care units (ICU and CCU) from the medical wards on a weekly basis between July 1, 2011, and June 30, 2012, to discern if all transfers were preceded by system activation.
Precise activation times were confirmed via retrospective chart review. Afferent limb activation times were confirmed through verification of nursing notes and by cross-checking vital sign records in our computerized patient database. Times of intervention were confirmed through revision of senior call notes and through cross-checking of dates and times of prescriptions and/or orders, investigations, or consultations. When several therapeutic measures were initiated concurrently, the earliest documented time (prescription, note, or consultation) was considered the time of therapy initiation. Additionally, times to critical care admission were confirmed via critical care service admission notes, completed by both nursing staff and ICU residents on call. When time of critical care service admission notes were unavailable, times of critical care admissions were verified using electronic records. Code blue rates, mortality rates, and ICU transfer rates were obtained through hospital databases.
Furthermore, we examined overall nursing satisfaction with the project. Upon reaching the 6-month mark, surveys were distributed to the nursing staff to better elucidate the benefits and pitfalls of the project (see Appendix
All significance testing was two-tailed and significance level was set at 0.05. Means with standard deviations and medians with interquartile ranges were used where appropriate. ICU admission rates and code blue rates were compared using incident rate ratios and Poisson regression. All statistical analyses were performed using STATA (v13).
Activation of the new ward-based system occurred for 82 patients. The mean age of patients for which calls were placed was 70.4 years (SD: 15.6). There was a slight male predominance, with 57% of patients being male (
The admission diagnoses of the patients for which calls were placed were varied, with the majority of patients admitted for respiratory pathology (
Baseline characteristics, call records, and outcomes.
| 82 |
Male (%) | 47 (57) |
Age (years), mean (SD) | 70.4 (15.6) |
Admission diagnosis by category | |
(i) Respiratory (%) | 27 (33) |
(ii) Malignancy (%) | 16 (21) |
(iii) Infectious disease (%) | 10 (12) |
(iv) Cardiac (%) | 10 (12) |
(v) Gastrointestinal (%) | 8 (9) |
(vi) Other (%) | 11 (13) |
Total calls (mean per week) | 95 (1.8) |
(i) Daytime calls (8:00 h–18:00 h) (%) | 38 (40) |
| |
Activation triggers, call characteristics | |
(i) Blood pressure (%) | 17 (18) |
(ii) Heart rate (%) | 7 (7) |
(iii) Respiratory rate (%) | 17 (18) |
(iv) Change in mental status (%) | 20 (21) |
(v) Serious concern (%) | 23 (24) |
(vi) Multiple or unknown (%) | 11 (12) |
| |
Initial intervention after system activation | |
(i) Critical care consultation (%) | 32 (44) |
(ii) Initiation of pharmacotherapy oxygen therapy (%) | 40 (42) |
(iii) STAT imaging (%) | 4 (4) |
(iv) Clinical procedures (intubation, central line, and ABG) (%) | 11 (12) |
(v) Information not available | 8 (8) |
| |
Patients with poor prognostic factors ( | 52 |
(i) Advanced dementia or long-term care facility (% total) | 8 (9) |
(ii) Advanced cardiac or respiratory disease (% total) | 22 (27) |
(iii) Active malignancy (% total) | 22 (27) |
Before intervention | After intervention | | |
---|---|---|---|
Time from decompensation to intervention (min) (IQR) | 204 (1–10) | 5 (0.6–12.4) | <0.001 |
ICU admissions (per 1000 patient days) | 4.8 | 3.3 | 0.04 |
APACE II scores (mean) (CI 95%) | 28.4 (26.3–30.5) | 25.2 (23.0–27.5) | 0.04 |
CTU code blue rates (per 1000 patient days) | 2.2 | 1.2 | 0.02 |
Hospital-wide code blue rates (per 1000 patient days) | 1.2 | 1.1 | 0.56 |
CTU mortality (%) | 10.1 | 10.9 | 0.64 |
30-day ICU mortality (%) | 29.3 | 34.5 | 0.53 |
A total of 95 calls were placed for 82 patients during the study period, averaging 1.8 calls per week. Thirty-eight calls were placed during regular day-time working hours (defined from 8:00 h to 18:00 h), and 57 calls were placed at night (defined from 18:01 h to 7:59 h). Data surrounding precise time of system activation was missing for 7 patients. The majority of calls were placed for serious concern (24%,
The median time from decompensation to initial intervention or ICU consultation was 5 min (IQR 1–10) during the implementation period, compared to 3.4 hours (IQR 0.6–12.4) before project implementation (
We observed a reduction in the number of ICU admissions from the CTU, with an admission rate of 4.8/1000 patient days (
Code Blue rates on the CTU fell, with a decrease from 2.2/1000 patient days (
Mortality rates for patients admitted to the CTU did not change as a result of our intervention. During the control period, mortality was 10.1% (
Of the 82 patients for which calls were placed, a total of 52 were identified as having poor prognostic factors, including advanced dementia or being a permanent resident of a nursing home or of a long-term care facility (9%,
Of the 82 patients for which calls were placed, a total of 72 had requested Level of Care (LOC) 1, indicating provision of all potential life-saving measures and transfer to a monitored care unit (ICU or CCU). After system activation, a total of 8 patients (11%) underwent changes in their level of intervention, with change from LOC 1 to LOC 3 and decision to continue care without transfer to a monitored setting.
In total, 20 members of the nursing team (
Of the nurses surveyed, 70% (
Our study demonstrated that a ward-based response system consisting of the bedside nurse acting as the afferent limb and the senior resident as the efferent limb can decrease code blue rates and ICU transfer rates. The time to intervention after deterioration was also shortened. In contrast, we did not demonstrate a decrease in overall mortality or 30-day mortality after ICU transfer.
The ideal composition of rapid response teams remains unknown [
In contrast to Howell et al.’s system, in which the MET was comprised of the patient’s primary nurse, the floor’s senior nurse (nurse educator or specialty), the patient’s primary house officer or licensed independent practitioner, and a respiratory therapist in the case of respiratory criteria activation, our local ward-based system was substantially smaller, comprising only the patient’s primary bedside nurse (afferent limb) and the CTU senior resident (efferent limb). Nonetheless, our study demonstrated that this system consisting of the bedside nurse acting as the afferent limb and the senior resident as the efferent limb can decrease code blue rates and ICU transfer rates. The time to intervention after deterioration was also shortened.
Despite the decrease in APACHE II score from 28.4 to 25.2 among patients admitted to ICU after system implementation, which would suggest a potential decrease in the predicted risk of death from approximately 64% to 55%, we did not demonstrate a decrease in overall mortality or 30-day mortality after ICU transfer. Although some studies have shown a decrease in 30-day ICU mortality [
Overall mortality rates on the CTU did not decrease with the implementation of the local response system. Rapid response teams have not consistently shown a decrease in overall mortality [
Our results are relevant to both clinicians and administrators. The structure of our system allows for care-giver continuity and preserves educational opportunities by allowing residents to directly participate in the management of critically ill patients. Our system requires no additional clinical staffing and thus no additional funding, which could prove extremely advantageous in schemes where both human and economic resources for rapid response team creation are limited. In addition, our system’s activation does not automatically disrupt the day-to-day activities of nursing, respiratory therapy, and intensive care workers. Furthermore, not all hospitals have access to trained nurse practitioners.
Our study reflects the trend toward rapid response teams implementing DNRs and modifying levels of intervention. In our study, levels of care were changed for 11% of the patients (
Additionally, the role of the MET in end-of-life care was recently explored in work by Jones et al. [
The major limitation of our study is that it is a single-center study which involves senior residents who have had adequate critical care exposure. Nonetheless, the level of critical care exposure of our senior internal medicine residents reflects that of their colleagues trained in internal medicine at other Canadian university-affiliated institutions. Prior to the implementation of a similar ward-based response system at other centers, one would need to consider the level of critical care training of the efferent limb, as well as the acute care exposure and competence of the nursing staff, the availability and willingness of the health care team to embark upon a similar project, and the ease of access to the critical care environment.
Our local ward-based response system succeeded in achieving a significant reduction from the time of patient decompensation to initial intervention without necessitating additional usage of financial or human resources. Our system achieved a reduction in code blue rates on our CTU and led to an overall decrease in the number of transfers of CTU patients to the ICU. Our system is novel in that it is centered on a ward resident-based efferent limb, it requires no additional human or economic resources for implementation, and it lends itself to continuity of patient care. Expansion of our system to other centers is required to further appreciate the magnitude and generalizability of these results.
See Figure
Sample poster: system activation criteria.
See Figure
Sample of nursing survey.
The authors declare that there is no conflict of interests regarding the publication of this manuscript.