January, 2017 - SUPPORT Summary of a systematic review | print this article |

Do rapid-response systems improve clinical outcomes?

Rapid-response systems were created to improve recognition of and response to deterioration of hospitalized patients, with the goal of reducing the incidence of cardiorespiratory arrest and hospital mortality. A rapid-response system consists of providers who immediately assess and treat unstable patients. Examples include medical emergency teams and rapid response teams. Preliminary evidence of improvements in patient outcomes led to widespread utilization of rapid response systems.

 Key messages

  • Rapid response systems for hospitalised adults may slightly reduce hospital mortality and cardiopulmonary arrests outside of intensive care units; and may lead to little or no difference in admissions to intensive care units.

  • Rapid-response systems for hospitalised children may slightly reduce cardiopulmonary arrests outside of intensive care units, and the effects on hospital mortality and admissions to intensive care units are uncertain.

  • None of the included studies were conducted in a low income country.

 

 

Background

Hospitalized patients often experience unrecognized deterioration that may progress to cardiorespiratory arrest. Rapid-response systems, which were created to improve recognition of and response to deterioration of hospitalized patients, generally have three components:

1) Criteria and a system for notifying and activating the response team. These usually include vital signs (single-trigger criteria or aggregated and weighted early warning scoring) or general concern expressed by a clinician or family member.

2) A response team that generally uses a physician (trained in intensive care); rapid-response teams, which do not include a physician; or critical care outreach teams, which follow up on patients discharged from the intensive care unit but also respond to all ward patients.

3) An administrative and quality improvement component that collects and analyses event data, coordinates resources, and ensures improvement or maintenance over time.

 



About the systematic review underlying this summary

Review objectives: To assess the effect of the rapid response system on hospital mortality and cardiopulmonary arrest outside the intensive care unit.
Type of What the review authors searched for What the review authors found
Study designs & interventions Comparisons between a control cohort and intervention (rapid response system) cohort that provided quantitative data about mortality rates or cardiopulmonary arrests.
29 studies met the inclusion criteria: cluster-randomised trials (2), interrupted time series studies (2), controlled before-after study (1), and before-after studies with no contemporaneous control group (24)
Participants Hospitalised patients
Hospitalised adults (21 studies) and children (8)
Settings Hospitals
Academic teaching hospitals (22) and community hospitals (6) in the USA (11), Australia (7), Canada (3), the UK (2), Pakistan, Portugal, Saudi Arabia, South Korea, Sweden, the Netherlands (1 each)
Outcomes Hospital mortality (primary outcome); non-intensive care unit cardiopulmonary arrest, and intensive care unit admissions (secondary outcomes) Hospital mortality (27 studies), cardiopulmonary arrests (26), intensive care unit admissions (10)
Date of most recent search: December 2013

Limitations: This is a well-conducted systematic review with only minor limitations.

Maharaj R, Raffaele I, Wendon J. Rapid response systems: a systematic review and meta-analysis. Crit Care 2015; 19:254.

Maharaj R, Raffaele I, Wendon J. Rapid response systems: a systematic review and meta-analysis. Crit Care 2015; 19:254.

Summary of findings

1) Adults

 Twenty one studies were included in the systematic review that reported the effects of rapid-response systems for hospitalised adults. Twenty studies reported hospital mortality, 18 reported cardiopulmonary arrests, and 10 reported intensive care unit admissions for hospitalised adults. Most (16) of the studies were uncontrolled before-after studies with a high risk of bias. There was variation in the size of the effects observed in different studies. Neither the duration of the service or having a doctor present was associated with the size of the effect.

 For hospitalised adults:

  • Rapid-response systems may slightly reduce hospital mor-tality. The certainty of this evidence is low.

  • Rapid-response systems may slightly reduce cardiopulmo-nary arrests outside of intensive care units. The certainty of this evidence is low.

  • Rapid-response systems may lead to little or no difference in admissions to intensive care units. The certainty of this evi-dence is low.

 

Rapid-response systems for hospitalised adults

People:  Hospitalised adults
Settings
:  Hospitals
Intervention
: Rapid-response system (RSP)
Comparison
: No rapid response system
Outcomes Types of studies Illustrative comparative risks Relative effect
(95% CI)
Certainty of the evidence
(GRADE)
Without RSP With RSP
Hospital Mortality RCT, CBA, ITS
Before-after studies

19 per 1000

admissions


19 per 1000

admissions

18 per 1000

(16 to 19)


17 per 1000

(16 to 18)

 

 

RR 0.91

(0.85 to 0.97)


RR 0.88

(0.81 to 0.95)

 

 

Low
Cardiopulmonary arrest outside the ICU

 

RCT, CBA, ITS


Before-after studies


4 per 1000

admissions


3 per 1000

admissions

3 per 1000

(2 to 4)


2 per 1000

(2 to 2)

RR 0.74

(0.56 to 0.98)


RR 0.62

(0.54 to 0.98)

Low
ICU admissions All studies

5 per 1000

admissions

4 per 1000

(2 to 5)

RR 0.90

(0.70 to 1.16)

Low 

RCT: randomised trial CBA: controlled before-after study ITS: interrupted time series study ICU: intensive care unit

95% CI: 95% confidence interval RR: Risk ratio

GRADE: GRADE Working Group grades of evidence (see above and last page)

2) Children

Eight studies were included in the systematic review that reported the effects of rapid-response systems for children. Seven studies reported hospital mortality, eight reported cardiopulmonary arrests, and none reported intensive care unit admissions for hospitalised children. Most (7) of the studies were uncontrolled before after studies with a high risk of bias.

For hospitalised children:

  • The effect of rapid-response systems on hospital mortality is uncertain. The certainty of this evidence is very low.
  • Rapid-response systems may slightly reduce cardiopulmonary arrests outside of intensive care units. The certainty of this evidence is low.
  • The effect of rapid-response systems on admissions to intensive care units is uncertain. No studies reported this outcome.

Rapid-response systems for hospitalised children

People:  Hospitalised children
Settings
:  Hospitals
Intervention
: Rapid-response system (RSP)
Comparison
: No rapid response system
Outcomes Types of studies Illustrative comparative risks Relative effect
(95% CI)
Certainty of the evidence
(GRADE)
Without RSP With RSP
Hospital Mortality RCT, CBA, ITS
Before-after studies

96 per 10,000

admissions


75 per 1000

admissions

73 per 10,000

(51 to 105)


60 per 10,000

(47 to 75)

 

 

RR 0.76

(0.53 to 1.09)

 


RR 0.80

(0.63 to 1.00)

 

 

Very Low
Cardiopulmonary arrest outside the ICU

 

RCT, CBA, ITS


Before-after studies


10 per 10,000

admissions


23 per 10,000

admissions

4 per 10,000

(1 to 17)


15 per 10,000

(12 to 18)

RR 0.35

(0.08 to 1.59)


RR 0.64

(0.53 to 0.77)

Low
ICU admissions No studies -

-

- -

 

 

 

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY
None of the included studies were conducted in a low-income country.
When assessing the transferability of these findings to low-income countries the availability of resources and the capacity of hospital systems to implement rapid-response services needs to be considered.
EQUITY
There was no information in the included studies regarding effects of the interventions on disadvantaged populations.

Resources needed for rapid response systems may be less available in disadvantaged settings.

 

  • The interventions could increase inequity if they are effective and are not applied or adapted to hospitals serving disadvantaged populations.

 


ECONOMIC CONSIDERATIONS
None of the included studies assessed costs associated with rapid-response systems.
Local costings should be undertaken, including the costs of training, support, personnel, equipment and supplies.
MONITORING & EVALUATION

There is low certainty evidence about the effects of rapid response systems.


  • It is uncertain how best to design and implement a rapid response system.

 


More rigorous studies (randomised trials or interrupted time series studies) are needed to determine the effects and the cost-effectiveness of rapid-response systems prior to scaling up their use in low-income countries.

 

  • Further studies should focus on identifying which patient populations are at high risk and should compare different rapid-response models.

 


*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm

 

Additional information

Related literature

Solomon RS, Corwin GS, Barclay DC, et al. Effectiveness of rapid response teams on rates of in-hospital cardiopulmonary arrest and mortality: a systematic review and meta-analysis. J Hosp Med 2016; 11:438-45.

 

Alam N, Hobbelink EL, van Tienhoven AJet al. The impact of the use of the Early Warning Score (EWS) on patient outcomes: a systematic review. Resuscitation 2014; 85:587-94.

 

Smith ME, Chiovaro JC, O'Neil M, et al. Early warning system scores for clinical deterioration in hospitalized patients: a systematic review. Ann Am Thor Soc 2014; 11:1454-65.

 

McNeill G, Bryden D. Do either early warning systems or emergency response teams improve hospital patient survival? A systematic review. Resuscitation 2013; 84:1652-67.

 

Winters BD, Weaver SJ, Pfoh ER, et al. Rapid-response systems as a patient safety strategy: a systematic review. Ann Intern Med 2013; 158:417-25.

 

Chan PS, Jain R, Nallmothu BK, et al. Rapid response teams: a systematic review and meta-analysis. Arch Intern Med 2010; 170:18-26.

 

Ranji SR, Auerbach AD, Hurd CJ, et al. Effects of rapid response systems on clini-cal outcomes: systematic review and meta-analysis. J Hosp Med 2007; 2:422-32.

 

McGaughey J, Alderdice F, Fowler R, et al. Outreach and early warning systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards. Cochrane Database Syst Rev 2007; 3:CD005529.

 

This summary was prepared by

Agustín Ciapponi, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

An earlier version of this summary based on another review (Ranji 2007) was peer reviewed by Sumant

Ranji, Sameer Pathan, and Newton Opiyo.

 

This review should be cited as

Maharaj R, Raffaele I, Wendon J. Rapid response systems: a systematic review and meta-analysis. Crit Care 2015; 19:254.

 

The summary should be cited as

Ciapponi A. Do rapid-response systems improve clinical outcomes? A SUPPORT Summary of a systematic review. January 2017. www.supportsummaries.org

 

Keywords

evidence-informed health policy, evidence-based, systematic review, health sys-tems research, health care, low and middle-income countries, developing coun-tries, primary health care, rapid-response systems, medical emergency team, mortality, cardiac arrest and outcomes

 

 

 

 

 

 



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