Rapid Response System (RRS)

Acute deterioration is often time-critical, arising over minutes or hours rather than days or weeks. These may lead to medical emergencies. including unplanned admission to the intensive care unit (ICU), in-hospital cardiac arrest and death [1–4].  When occur, the risk of death is greater than 80 percent after in-hospital cardiopulmonary resuscitation (CPR) for cardiac arrest as indicated in several studies [5, 6].

Life threatening emergencies and events do not happen without warning. Several studies indicate that almost all critical inpatient events are preceded by warning signs for an average of 6–8 hours. [2,7,8]. In multicentre, prospective cohorts, clinical antecedents, such as a change in vital signs, are present in the majority of patients (60 to 70 percent) before in-hospital cardiac arrest occurs [3, 7] and such severe changes in vital signs were found to be associated with a 6.8-fold increase in mortality (95% CI 2.7-17.1) [9]. Simultaneously, studies in the US, Canada, Australia, and the UK[1-12] estimate that adverse events occur in 10% of hospitalized patients with a mortality rate of 5–8%,[8,9].

Unfortunately, as many as 50-70% of these adverse events are judged to be preventable. [8, 13] Of the avoidable cases, 35 percent had a delay in nursing staff communicating with the physician, and 29 percent had a delay in the physician responding to the nurse's request [13].

Another important factor affecting patient outcome in hospitals is Delay in ICU transfer for the critically ill in the wards, which is not uncommon [14] and leads to higher mortality when patient transfer to higher levels of care is delayed [15, 16]. In addition, some critically ill patients are either inappropriately admitted to the general ward, rather than to the ICU, from the emergency department or decompensate rapidly shortly after admission. Therefore, these patients' outcome would improve if they were identified and transferred earlier to the required higher level of care to facilitate timely interventions and treatment.

For those hospitalized patients experiencing clinical deterioration outside the intensive care unit (ICU), a mismatch between an acute increase in a patient's needs and available resources occur [17]. Recognizing these patients early, represent a window of opportunity in which to rescue deteriorating patients before irreversible morbidity or mortality occurs. This concept of “rescue" for the hospitalized patient has led to the development of rapid response systems (RRS) designed to identify and respond to deteriorating patients by moving critical personnel, diagnostics, and interventions to the bedside. In 2004, the Institute for Healthcare Improvement (IHI) began its “100,000 Lives Campaign," which called for all United States hospitals to deploy rapid response teams [18]. Subsequently, the Joint Commission mandated that United States hospitals should establish RRSs as part of the 2008 National Patient Safety Goals [19] Most recently, the 2015 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care continue to recommend RRSs, especially in general care wards [20].

Rapid response systems (RRS) are put in place to improve the safety of hospitalized patients whose condition is deteriorating quickly by identifying them by timely notification upon early signs of deterioration, bring the expertise (team of responders) capable of providing critical care resources and interventions at the patient's current location to the patients in timely manner, rapid intervention by the response team, and ongoing evaluation of the system's performance and hospital-wide processes of care leading to Preventing deterioration leading to life threatening events, prompt therapy and resuscitation as needed and transfer to higher level of care while promoting education and higher patient safety culture.

Generally, RRS are multidisciplinary and comprised of four limbs: 1) an afferent limb, which is the calling criteria and the method of activation, 2) an efferent limb, which is the Rapid Response Team (RRT) itself, 3) an administrative limb, which is responsible for the day-to-day running of the RRS and 4) the quality improvement and governance limb which addresses system and clinical factors contributing to deterioration [17].

In the majority of the studies, the introduction of a RRS resulted in an overall reduced rate of unexpected cardiac arrest outside ICU, unscheduled critical care admissions and hospital mortality [21-25] such as 46% reduction in cardiac arrest rates; a 54% reduction in cardiac arrest related mortality rates; a 19% reduction in hospital mortality; a 35% decrease in failure to rescue rates [26]. Similarly, delay in activation of the RRS for decompensating patients is independently associated with increased mortality [27].

Implementation of an RRS was associated with a significant decrease in hospital mortality (relative risk [RR]= 0.88, 95% confidence interval [CI]: 0.83-0.93, I(2) = 86%, 3,478,952 admissions) and a significant decrease in the number of non-ICU cardiac arrests (RR = 0.62, 95% CI: 0.55-0.69, I(2) = 71%, 3,045,273 admissions) [25,28].

In Saudi Arabia, there is published literature regarding the impact of RRS application. The hospital mortality rate dropped from 7.8 to 2.8 per 1000 hospital admission and Hospital cardiopulmonary arrest rate has dropped from 10.53 per 1000 hospital admissions to 2.58[28]. In another local study involving more than 1000 rapid response activation over a year of study period, there was low mortality rates in those RRS were activated for and have identified the risk factors higher age (>70 years). While low oxygen saturation and level of consciousness were the higher criteria for transfer to the ICU [29].

Therefore, the aim of this national priority is to establish high quality RRT service for in-patients in the Saudi hospitals which will improve patient safety, decrease in-hospital serious events and death by ensure timely evaluation/intervention for the critical ill in-patients outside the critical care areas by bringing the expertise to the in-patient bedside in timely manner.

Objectives:

1.Establish rapid response system in hospitals across Saudi Arabia.

2. Facilitate early intervention and stabilization to prevent clinical deterioration of any critically ill in-patient prior to cardiopulmonary arrest or other potentially life-threatening event.

3. Decrease the number of preventable cardiopulmonary arrest that occurs outside the ICU.

4. To facilitate timely and appropriate ICU admissions.

5. Encourage end-of-life discussions and decision-making with primary health care providers to avoid unnecessary ICU admission of terminally ill patients.

6. Encourage continued call to RRT by responding promptly and using every patient encounter as an opportunity to facilitate shared learning as well as promoting an improved culture of care.

7. Establish quality measures and ongoing audits to improve the service provided by the RRS to enhance patient safety culture. 

RRS.1. The hospital has a rapid response program.

RRS.1.1. The hospital has a rapid response committee chaired by a qualified ICU consultant physician, meets regularly, and reports directly to the CEO.

RRS.1.2. The rapid response committee membership includes relevant stakeholders, including critical care, nursing, pharmacy, respiratory care, and quality and patient safety.

RRS.1.3. The rapid response committee collects, analyses, evaluates, and disseminates rapid response-specific measures benchmarked with internal and external data.

RRS.1.4. Required rapid response KPIs include: rates of activation per 1000 hospital admissions, response times, percentage transfer to ICU, transfer time, decision-to-intervention time, patient outcome(s), CPR rates with and without rapid response activation, and clinician documentation compliance.

RRS.1.5. The rapid response committee findings are incorporated into the hospital's quality and patient safety programs and are disseminated at the relevant departmental meetings with action plans for continual performance improvement.

Explanations:

Engagement of senior leadership in hospital is an essential role to assure successful implementation and continuity of rapid response team. This shows an explicit organization commitment to improve care delivery and improve outcome measures within hospitals. The involvement of leadership and establishment of a committee send a clear message to hospital staff about nature and usefulness of such team in the day-to-day clinical work. The major role of the committee is to oversee all activities related to establishing, implementing and measuring effectiveness and outcome. This will help in facilitating all recommendation modifications reflected by the KPI and quality improvement projects. The committee establishment will ensure availability of required equipment/supplies, continuous formal training and education of hospital staff and accurate monitoring of the related documentation process in the hospital. 

RRS.2. The hospital has a rapid response team (RRT).

RRS.2.1. The hospital has a policy and processes for standardized rapid response activation criteria at all times, with defined response time frames for all RRT members (within 15 minutes or less) and termination criteria.

RRS.2.2. The hospital outlines the qualifications, roles, responsibilities of the RRT, comprised at a minimum with ICU physicians, ICU nurses, and RTs.

RRS.2.3. The hospital outlines the roles and responsibilities of the patient's primary nurse, most responsible physician, and the patient's 'on duty' physician.

RRS.2.4. Rapid response activation is simple, standardized, easily accessible, and recognized by all relevant staff via an overhead loudspeaker or standardized electronic system.

RRS.2.5. The hospital's rapid response system's activation criteria are based on age and condition-appropriate early warning signs (EWS, Pediatric-PEWS, Neonatal- NEWS, and Maternal -MEWS) inclusive of parameters for all vital signs as well as mental status, urine output, oxygenation requirements, and other relevant evidenced-based criteria.

RRS.2.6. The hospital's staff and RRT identify sepsis early through evidence-based sepsis early warning signs (SEWS), including qSOFA and/or SIRS.

RRS.2.7. The hospital's RRT identifies stroke, ACS/MI, and VTE early through evidence-based screening and assessment.

RRS.2.8. Any staff can activate the rapid response/RRT in any patient location in the hospital, even if the patient does not meet the EWS criteria, based solely on staff's concern or clinical judgement without any negative consequences or retaliation.

Explanations:

Typically, the afferent limb of Rapid response system is a protocolised process where a call for activation is based on the detection of physiological abnormality from the routine patient vital signs taken by in-patient nursing staff or qualitative criteria such as staff or family concern which may be of particular importance in the paediatric setting with parents detecting subtle change in a child's condition. Emergency medication should be readily available to the RRS team for immediate use as needed and important medication to be prepared and delivered by different faster route than regular inpatient medication.

RRS.3. The hospital has policies, processes, and standardized documentation specific to rapid response.

RRS.3.1. Members of the patient's primary team document the rapid response activation in the patient's medical record, including the activation reason, signs, time, and RRT team response time on a designated rapid response form.

RRS.3.2. The RRT communicates with the primary care team about their concerns for the patient, activation, and co-develops a documented management plan including assessments, treatments, medications, interventions, and disposition status and time on a designated rapid response form.

RRS.3.3. The RRT assesses, diagnoses, and stabilizes clinical situations, including stroke ACS/MI, and VTE, per standards of care and regulations, initiating emergency care and transfer to a higher level of care, as indicated.

RRS.3.4. The RRT assesses, diagnoses, and stabilizes sepsis per standards of care and, as indicated, indicated the Hour-1 Sepsis Bundle, emergency care, and transfer to a higher level of care.

RRS.3.5. The hospital has a policy and processes for standardized and timely medication ordering, dispensing, and administration for rapid response cases.

RRS.3.6. The hospital has a policy and processes for the management and continuity of care of rapid response cases that remain in the general ward, with defined time frames by the RRT and primary nurse and physician team.

RRS.3.7. The RRT's responding physician has the authority to transfer the patient to a higher level of care and ensures clinical stability and patient monitoring during transport.

RRS.3.8. The RRT participates in end-of-life discussions, decision-making with the primary team, patient and family, and has the authority to independently refer the patient and or family to the EOLC team, as indicated.

Explanations:

Efferent limb of rapid response system is the responding team to the RRS activation. Once arrived to the bedside within the target time, handover from the primary team nurse and physician should be taken. Communication tool could be chosen as SBAR. To minimize potential clinical inefficiencies, fragmented patient care and sub-optimal handover, the care plan should be discussed with the primary team especially if the patient is to be kept in the ward. In the case of patients with terminal illness, the RRS team discuss goals of care with the treating team to avoid unnecessary ICU admission or chest compression for those who wouldn't benefit from it due to flutily.

Standardized RRS form facilitate comprehensive assessment and close follow up along with feasible way to facilitate auditing, quality review, and communication between the stakeholders.  

RRS.4. The hospital has specific awareness and training for staff, patients, and families.

RRS.4.1. All hospital healthcare providers and staff receive education and training for rapid response activation, their roles, responsibilities, and awareness of no retaliation policies for activation.

RRS.4.2. All patients and families are educated on admission and ongoing about the hospital's rapid response system and their role and responsibilities related to patient deterioration.

RRS.4.3. The RRT members have specific qualifications, including valid advanced life support for all ages served.

RRS.4.4. The RRT members have specific initial and ongoing education, training courses, and as applicable, simulations and competencies for the initial management of common scenarios and emergencies encountered, including stroke, sepsis, ACS/MI and VTE, effective communication, conflict resolution, and EOLC.

RRS.4.5. The rapid response activation criteria are easily accessible and universally distributed to hospital staff, patients, and families based on the target populations.

Explanations:

Because of the wide variety of skills, knowledge and behaviour required to train a staff in the elements of RRS assessment, management and team management and leadership, there is a need to use a variety of training techniques. The structure of teaching should include both theoretical and practical components.

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