Outcomes following changing from a two-tiered to a three-tiered hospital rapid response system
The Concord Medical Emergency Team (MET) 2 Study InvestigatorsA A full list of study authors is available as Supplementary Material to this paper.
B Corresponding author. Winston Cheung, Concord Repatriation General Hospital, Hospital Road, Concord, NSW 2139, Australia. Email: winston.cheung@health.nsw.gov.au
Australian Health Review 43(2) 178-187 https://doi.org/10.1071/AH17105
Submitted: 18 April 2017 Accepted: 28 September 2017 Published: 16 November 2017
Abstract
Objectives The aim of the present study was to determine whether changing a hospital rapid response system (RRS) from a two-tiered to a three-tiered model can reduce disruption to normal hospital routines while maintaining the same overall patient outcomes.
Methods Staff at an Australian teaching hospital attending medical emergency team and cardiac arrest (MET/CA) calls were interviewed after the RRS was changed from a two-tiered to three-tiered model, and the results were compared with a study using the same methods conducted before the change. The main outcome measures were changes in: (1) the incident rate resulting from staff leaving normal duties to attend MET/CA calls; (2) the cardiac arrest rate, (3) unplanned intensive care unit (ICU) admission rates; and (4) hospital mortality.
Results We completed 1337 structured interviews (overall response rate 65.2%). The rate of incidents occurring as a result of staff leaving normal duties to attend MET/CA calls fell from 213.7 to 161.3 incidents per 1000 MET/CA call participant attendances (P < 0.001), but the rate of cardiac arrest and unplanned ICU admissions did not change significantly. Hospital mortality was confounded by the opening of a new palliative care ward.
Conclusion A three-tiered RRS may reduce disruption to normal hospital routines while maintaining the same overall patient outcomes.
What is known about the topic? RRS calls result in significant disruption to normal hospital routines because staff can be called away from normal duties to attend. The best staffing model for an RRS is currently unknown.
What does this paper add? The present study demonstrates, for the first time, that changing a hospital RRS from a two-tiered to a three-tiered model can reduce the rate of incidents reported by staff caused by leaving normal duties to attend RRS calls while maintaining the same overall patient outcomes.
What are the implications for practitioners? Hospitals could potentially reduce disruption to normal hospital routines, without compromising patient care, by changing to a three-tiered RRS.
Additional keywords: cardiopulmonary resuscitation, critical care, emergencies, heart arrest, hospital rapid response team, intensive care units.
References
[1] Lee A, Bishop G, Hillman KM, Daffurn K. The medical emergency team. Anaesth Intensive Care 1995; 23 183–6.| 1:CAS:528:DyaK2MXot1amsrc%3D&md5=f425cde0ba20fbaeccda9be45775d319CAS |
[2] Berwick DM, Calkins DR, McCannon CJ, Kacknarth AD. The 100 000 Lives Campaign. Setting a goal and a deadline for improving health care quality. JAMA 2006; 295 324–7.
| The 100 000 Lives Campaign. Setting a goal and a deadline for improving health care quality.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BD28XlsVentQ%3D%3D&md5=803b03abf3f5271ca3fadce0c1331341CAS |
[3] Goldhill DR, Worthington L, Mulcahy A, Tarling M, Sumner A. The patient-at-risk team: identifying and managing serious ill ward patients. Anaesthesia 1999; 54 853–60.
| The patient-at-risk team: identifying and managing serious ill ward patients.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK1MzovFCltg%3D%3D&md5=f7070a5b68d3ef51aa2113f45c314a16CAS |
[4] Garcea G, Thomasset S, McClelland L, Leslie A, Berry DP. Impact of a critical care outreach team on critical care readmissions and mortality. Acta Anaesthesiol Scand 2004; 48 1096–100.
| Impact of a critical care outreach team on critical care readmissions and mortality.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD2cvksFejuw%3D%3D&md5=0a0d7e2e4d5d90ee24c440a310cbe02fCAS |
[5] Jones DA, DeVita MA, Bellomo R. Rapid-response teams. N Engl J Med 2011; 365 139–46.
| Rapid-response teams.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BC3MXptFGnurc%3D&md5=dc739cef1a5931275e39f3c8019fce03CAS |
[6] The Concord Medical Emergency Team (MET) Incidents Study Investigators Cheung W, Sahai V, Mann-Farrar J, Skylas K, Uy J, Doyle B, Addis C, Brannelly A, Bui KT, Cain LE, Clarke L, Cavalletto A, Faruque MO, Fick M, Ho R, Jacobs R, Kuruvilla NA, Leadbeater ES, Lim JS, Mackey A, Mahananda D, Martin H, Pilz LN, Russo RR, Schiemer A, Shen NY, So N, Spiker C, Tangirala N, Taylor A, Thanakrishnan G, Vogelzang B, Waite M, Zhao CY, Zheng L, Zhong G. Incidents resulting from staff leaving normal duties to attend medical emergency team calls. Med J Aust 2014; 201 528–31.
| Incidents resulting from staff leaving normal duties to attend medical emergency team calls.Crossref | GoogleScholarGoogle Scholar |
[7] NSW Health – Clinical Excellence Commission. Between the flags: keeping patients safe. October 2008. Available at: http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0006/258153/btf-the-way-forward-2008.pdf [verified 26 October 2017].
[8] NSW Health. Recognition and management of patients who are clinically deteriorating. Policy directive PD2013_049. 2013. Available at: http://www1.health.nsw.gov.au/PDS/pages/doc.aspx?dn=PD2013_049 [verified April 2014].
[9] Health NSW. Incident management policy. Policy directive PD2014_004. 2014. Available at: http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2014_004.pdf [accessed August 2016].
[10] American Association for Public Opinion Research. Standard definitions: final dispositions of case codes and outcome rates for surveys, 7th edition. 2011. Available at:https://www.esomar.org/uploads/public/knowledge-and-standards/codes-and-guidelines/ESOMAR_Standard-Definitions-Final-Dispositions-of-Case-Codes-and-Outcome-Rates-for-Surveys.pdf [verified 26 October 2017].
[11] Bevan C, Officer C, Crameri J, Palmer C, Babl FE. Reducing “Cry wolf” – changing trauma team activation at a pediatric trauma centre. J Trauma 2009; 66 698–702.
| Reducing “Cry wolf” – changing trauma team activation at a pediatric trauma centre.Crossref | GoogleScholarGoogle Scholar |
[12] Frost SA, Chapman A, Aneman A, Chen J, Parr MJ, Hillman K. Hospital outcomes associated with introduction of a two-tiered response to the deteriorating patient. Crit Care Resusc 2015; 17 77–82.
[13] Rehn M, Lossius HM, Tjosevik KE, Vetrhus M, Østebø O, Eken T, Rogaland Trauma System Study Collaborating Group Efficacy of a two-tiered trauma team activation protocol in a Norwegian trauma centre. Br J Surg 2012; 99 199–208.
| Efficacy of a two-tiered trauma team activation protocol in a Norwegian trauma centre.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BC387itlegtg%3D%3D&md5=6f6140ec30c71803c61c36094f24ac8eCAS |
[14] Kouzminova N, Shatney C, Palm E, McCullough M, Sherck J. The efficacy of a two-tiered trauma activation system at a Level I trauma center. J Trauma 2009; 67 829–33.
| The efficacy of a two-tiered trauma activation system at a Level I trauma center.Crossref | GoogleScholarGoogle Scholar |
[15] Jenkins P, Rogers J, Kehoe A, Smith JE. An evaluation of the use of a two-tiered trauma team activation system in a UK major trauma centre. Emerg Med J 2015; 32 364–7.
| An evaluation of the use of a two-tiered trauma team activation system in a UK major trauma centre.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BC2crnslSguw%3D%3D&md5=b517f88f2a5b50e936322b63b6385d2eCAS |
