The Role of Dentists in Rapid Response Teams for Disasters

Study Objectives: Every year 33,000 people suffer an IHCA with an initial shockable rhythm in the US. Rapid Response Teams may increase time to defibrillation and are not associated with lower in-hospital mortality. We sought to describe characteristics of sudden IHCAs with a shockable initial rhythm in a system with mature Rapid Response and Code Blue teams, in particular, time to defibrillation. Methods: Retrospective chart review at a large, urban teaching hospital with mature Rapid Response and Code Blue teams. Adults in whom a “Code Blue” was called with confirmed cardiac arrest between Jan 2017 and Mar 2018 were included. Codes with incomplete data or that occurred in the ED or ICU were excluded. The “Code Blue” team consists of 1-3 Nurse Responders, a nursing supervisor, a respiratory therapist, Anesthesiology, a critical care resident, and a surgical resident. Each ward has a defibrillator and standardized code cart. Trained and supervised research assistants used a standardized data collection tool to extract demographic information, comorbidities and event related data from code sheets, history and physical, progress notes, discharge and death summaries. Events were categorized by initial rhythm as shockable or non-shockable. Time to defibrillation was defined as the interval from reported time of initial recognition of cardiac arrest to the reported time of first attempted defibrillation. Fisher’s exact testing was used to test for statistical significance. Results: A total of 183 “Code Blues” met criteria. Demographics: 71% black; mean age 65; and 46% women. Fifty-five (30%) survived to hospital discharge. Forty (21.3%) had an initial shockable rhythm of whom 21 (52.5%) survived to hospital discharge. Of the 40 patients that had an initial shockable rhythm, 36 were defibrillated. Median time to defibrillation was 2 minutes [IQR = 1-4]. Of those defibrillated within 2 minutes, survival was 64% vs 33% (P = 0.102) among those defibrillated in > 2 minutes. Of the 143 patients that had a nonshockable initial rhythm, 34 (23.8%) survived to hospital discharge. Conclusion: In a system with mature Rapid Response and Code Blue teams, time to defibrillation among IHCA patients with a shockable initial rhythm is 2 minutes.

Simulation Testing of Pediatric Rapid Response Teams: Can Simulation Be Used to Determine the Best Team Structure?

Rationale: Studies show that there is a 34.6% increase in in-hospital mortality in patients who have more than one rapid response compared to those who have a single rapid response. Reasons for this remains unclear but highlights an important area for further research as the potential to reduce mortality risk is significant. Our multidisciplinary team sought to identify trends among patients experiencing multiple rapids at a large quaternary care academic hospital to focus an intervention that would improve patient safety and outcomes by ensuring appropriate disposition after the rapid response. Methods: We conducted a retrospective chart review of 100 adult patients admitted from August 2023 through June 2024 who had two or more rapid responses in 24 hours. Data collected included: reasons for rapid, duration of rapid, time elapsed between the first and second rapid, whether the medical intensive care unit (MICU) was notified after the second rapid (as per protocol), and patient disposition after the second rapid. Additionally, interviews were held with rapid response nursing team and MICU fellows to further evaluate gaps in the process. Results: 91% of patients had two rapid responses within the 24-hour period while the remaining 9% had up to five. Most rapids occurred outside of shift change (6-8AM/PM). Median time between the first and second rapid was 467 min. The top three reasons for rapid response were hypotension, hypoxia, and encephalopathy. 54% of patients remained on the regular nursing floor after the second rapid with 19% of those patients having an in-hospital mortality. Overall documentation of the rapids was inconsistent between responding providers and many cases had missing or incomplete documentation. Discussion: Best practices for assessing patients with multiple rapids are unknown. Several themes were identified in our initial data collection and interviews which included clarity of documentation from responding team (provider) and communication between the rapid response team and the MICU. Based on this initial data, our team developed: 1. Standardized documentation templates for each clinician role (rapid response team, primary team, MICU fellow) emphasizing working diagnosis and plan of care. 2. Standardized communication scripts between rapid response and MICU team for evaluation. Some of these interventions have already been deployed and will plan to have all interventions deployed by end of November 2024. Next steps include auditing charts from rapid response cases biweekly to ensure adequate documentation and identify further areas of improvement.

Descriptive cross-sectional, internet-based survey. Cohort of preidentified clinicians involved in their hospital's adult rapid response system across the United States. Clinicians who had been identified by study team members using personal and professional contacts over a 7-month period from June 2018 to December 2018. An 80-item survey was developed by the investigators. It sought information on the afferent (identification and notification of providers) and efferent (response of providers to patient) limbs of the rapid response system, as well as management of patients post in-hospital cardiac arrest. One-hundred fourteen surveys were distributed. Of these, 109 (96%) were completed. Six were duplicates and were excluded, leaving a total of 103 surveys from 103 hospitals in 30 states. Seventy-six percent of hospitals were academic, 30% were large hospitals (> 750 inpatient beds), and 58% had large ICUs (> 50 ICU beds). We found wide variation in the structure and function in both the afferent and efferent limbs of the rapid response system. The majority of hospitals had a rapid response team and a cardiac arrest team. Most rapid response teams contained a provider, a critical care nurse, and a respiratory therapist. In hospitals with training programs in internal medicine, anesthesia, emergency medicine, or critical care, 45% of rapid response teams and 75% of cardiac arrest teams were led by trainees, with inconsistent attending presence. Targeted temperature management and coronary catheterization were widely used post in-hospital cardiac arrest, but indications varied considerably. We have demonstrated substantial variation in the structure and function of rapid response systems as well as in management of patients during and after in-hospital cardiac arrest.

BackgroundPrevious studies have reported that the quality of cardiopulmonary resuscitation (CPR) is closely associated with patient outcomes. The aim of this study was to compare patient CPR outcomes across resident, emergency medicine, and rapid response teams.MethodsThe records of patients who underwent CPR at the Seoul National University Bundang Hospital from January 1, 2013 to December 31, 2016 were analyzed retrospectively. Return of spontaneous circulation, 10- and 30-day survival, and live discharge after return of spontaneous circulation were compared across patients treated by the three CPR teams.ResultsOf the 1145 CPR cases, 444 (39%) were conducted by the resident team, 431 (38%) by the rapid response team, and 270 (23%) by the emergency medicine team. The adjusted odds ratios for the return of spontaneous circulation and subsequent 10-day survival among patients who received CPR from the resident team compared to the rapid response team were 0.59 (P = 0.001) and 0.71 (P = 0.037), respectively. There were no significant differences in the 30-day survival and rate of live discharge between patients who received CPR from the rapid response and resident teams; likewise, no significant differences were observed between patients who received CPR from the emergency medicine and rapid response teams.ConclusionsPatients receiving CPR from the rapid response team may have higher 10-day survival and return of spontaneous circulation rates than those who receive CPR from the resident team. However, our results are limited by the differences in approach, time of CPR, and room settings between teams.

BackgroundCardiopulmonary arrest may result in high mortality rate in hospitals where the rapid response team is not implemented. A rapid response system can recognize patients at high risk of cardiopulmonary arrest and provide the needed medical management to prevent further deterioration. The rapid response system has shown a dramatic reduction in mortality rate and cardiopulmonary arrest.ObjectiveTo evaluate the effectiveness of the rapid response team (RRT) implementation in reducing the mortality rate, number of cardiopulmonary arrests, and number of ICU admission.DesignA pre- and post-rapid response team system implementation.SettingFour tertiary private hospitals in Saudi Arabia.PatientsA total of 154,869 patients in the 3-year before rapid response system period (January 2010 to December 2012) and a total of 466,161 during the 2.5-year post-RRT implementation period (January 2014 to June 2016).ResultsResults indicated that ward nurses activated RRT more often than physicians (1104 activations [69%] vs. 499 activations [31%]), with cardiovascular and respiratory abnormalities being the most common triggers. Serious concern about the patient condition by the ward staff was the trigger for 181 (11.29%) activations. The RRT provided a variety of diagnostic and therapeutic interventions. Most patients cared for by RRT were admitted to ICU 1103 (68.81%), and the rest 500 (31.19%) were managed in the ward. After the implementation of the RRT project, the hospital mortality rate dropped from 7.8 to 2.8 per 1000 hospital admission. Hospital cardiopulmonary arrest rate has dropped from 10.53 per 1000 hospital admissions to 2.58. Rapid response team implementation also facilitated end-of-life care discussions.ConclusionImplementation of the RRT project has shown a dramatic reduction in the total ICU admissions, average ICU occupancy rate, total hospital mortality, and total ICU mortality. These findings reinforce the evidence that RRT implementation is effective in reducing hospital mortality and cardiopulmonary arrest rates in addition to other outcomes related to healthcare quality.

Improving Obstetric Rapid Response Teams: Multidisciplinary Simulation Training Using the Plan‐Do‐Study‐Act Cycle

Component analyses for effectiveness of compressions and ventilations in bystander cardiopulmonary resuscitation

Association of early emergency calls before patient collapse with survival from out-of-hospital cardiac arrests

Simulation has been used to analyse teamwork, find areas of deficiency, and to improve team performance in several different industries. Recently, simulation has been used to assess the skills of medical emergency teams (MET) and rapid response teams (RRT), as well as a tool to improve team performance. In this chapter we will describe a few examples of industries that have successfully used simulation as a key component for team training as a template for medical professionals to follow and expand upon, and then discuss how lessons learned have been and may be applied to MET and RRT.

Background: Prior studies have shown that hospitals with exceptional survival for in-hospital cardiac arrest (IHCA) also excel at preventing IHCA—a key function of rapid response team (RRT). However, little is known about how RRTs differ across sites. We used qualitative methods to evaluate organizational and contextual factors of RRTs that may be linked to hospital performance on IHCA survival. Methods: We selected 9 academically and geographically diverse hospitals in the AHA Get With The Guidelines Resuscitation registry based on risk standardized IHCA survival during 2012-2014 (top quartile: 5 hospitals; middle quartiles: 1 hospital; bottom quartile: 3 hospitals). During site visits, we conducted semi-structured interviews with key stakeholders regarding resuscitation care at their site. We conducted a directed content analysis focused on RRT roles and activities related to preventing IHCA. Results: A total of 158 interviews were conducted that included physicians (17.1%), nurses (45.6%), other clinical (17.1%), and administrative staff (20.3%). Differences in RRTs at top and bottom performing sites were noted in the following domains: team design and composition, engagement of RRT in surveillance of at-risk patients, empowerment of bedside nurses to activate RRT, and collaboration of RRT members with bedside nurses during and after a rapid response. Differences within each domain and representative quotes are included in the Table. Top performing hospitals tended to have RRTs staffed with members without other clinical responsibilities, often served as a resource for bedside nurses in preventing patient decline, and collaborated with them during and after a rapid response. Bedside nurses were empowered to activate RRTs based on their judgement and experience. In contrast, RRTs at bottom performing hospitals were staffed with members with competing clinical responsibilities, and were generally less engaged with bedside nurses. Moreover, nurses were concerned about potential consequences (e.g. fear of reprisal from physicians) in calling a rapid response. Conclusions: The design and implementation of RRTs differ markedly between top and bottom performing hospitals with regard to IHCA survival. Our findings provide unique insights into RRTs at hospitals with better IHCA outcomes.

To determine the relationship between implementation of rapid response teams and improved mortality rate using a large, uniform dataset from one state in the United States. This observational cohort study included 471,062 adult patients hospitalized between 2001 and 2009. Ten acute tertiary care hospitals in Washington State. Hospital abstract records on adult patients (18 years old or older) were examined (n = 471,062). Patients most likely to benefit from rapid response team interventions were included and other prognostic factors of severity of illness and comorbidities were controlled. Each participating hospital provided the implementation date of their rapid response team intervention. Mortality rates in 31 months before rapid response team implementation (pre-rapid response team time period) were compared with mortality rates in 31 months following rapid response team implementation (post-rapid response team time period). Implementation of a rapid response team within each acute tertiary care hospital. In-hospital mortality. Relative risk for in-hospital mortality improved in the post-rapid response team time period compared with the pre-rapid response team time period (relative risk = 0.76; 95% CI = 0.72-0.80; p < 0.001). In-hospital mortality improved in six of 10 acute tertiary care hospitals in the post-rapid response team time period when compared with the pre-rapid response team time period. Because of a long-term trend of decline in hospital mortality, these decreases could not be unambiguously attributed to rapid response team implementation. Further research should examine additional objective outcomes and optimal configuration of rapid response teams to maximize intervention effectiveness.

The effectiveness of rapid response teams remains controversial. However, many studied rapid response teams were not intensivist-led, had limited involvement beyond the initial activations, and did not provide post-ICU follow-up. The objective of this study was to examine the impact of implementing an intensivist-led multidisciplinary extended rapid response team on hospital-wide cardiopulmonary arrests and mortality. This was a pre-post rapid response team implementation study. : Tertiary care academic center in Saudi Arabia. A total of 98,391 patients in the 2-yr pre-rapid response team and 157,804 patients in the 3-yr post-rapid response team implementation were evaluated. The rapid response team was activated by any health care provider based on pre-defined criteria and a four-member intensivist-led multidisciplinary rapid response team responded to provide the necessary management and disposition. The rapid response team function was extended to provide follow-up until clinical stabilization. In addition, the rapid response team provided a mandatory post-ICU follow-up for a minimum of 48 hrs. The primary outcomes were cardiopulmonary arrests and mortality. After rapid response team implementation, non-ICU cardiopulmonary arrests decreased from 1.4 to 0.9 per 1,000 hospital admissions (relative risk, 0.68; 95% confidence interval, 0.53-0.86; p = 0.001) and total hospital mortality decreased from 22.5 to 20.2 per 1,000 hospital admissions (relative risk, 0.90; 95% confidence interval, 0.85-0.95; p < 0.0001). For patients who required admission to the ICU, there was a significant reduction in the Acute Physiology and Chronic Health Evaluation II scores after rapid response team implementation from 29.3 ± 9.3 to 26.9 ± 8.5 (p < 0.0001), with reduction in hospital mortality from 57.4% to 48.7% (relative risk, 0.85; 95% confidence interval, 0.78-0.92; p < 0.0001). Do-not-resuscitate orders for ward referrals increased from 0.7 to 1.7 per 1,000 hospital admissions (relative risk, 2.58; 95% confidence interval, 1.95-3.42; p < 0.0001) and decreased for patients admitted to ICU from the wards from 30.5% to 26.1% (relative risk, 0.86; 95% confidence interval, 0.74-0.99; p = 0.03). Additionally, ICU readmission rate decreased from 18.6 to 14.3 per 100 ICU alive discharges (relative risk, 0.77; 95% confidence interval, 0.66-0.89; p < 0.0001) and post-ICU hospital mortality from 18.2% to 14.8% (relative risk, 0.85; 95% confidence interval, 0.72-0.99; p = 0.04). The implementation of rapid response team was effective in reducing cardiopulmonary arrests and total hospital mortality for ward patients, improving the outcomes of patients who needed ICU admission and reduced readmissions and mortality of patients who were discharged from the ICU.

ObjectiveTo evaluate changes in the characteristics of in-hospital cardiac arrest after the implementation of a Rapid Response Team.MethodsThis was a prospective observational study of in-hospital cardiac arrest that occurred from January 2013 to December 2017. The exclusion criterion was in-hospital cardiac arrest in the intensive care unit, emergency room or operating room. The Rapid Response Team was implemented in July 2014 in the study hospital. Patients were classified into two groups: a Pre-Rapid Response Team (in-hospital cardiac arrest before Rapid Response Team implementation) and a Post-Rapid Response Team (in-hospital cardiac arrest after Rapid Response Team implementation). Patients were followed until hospital discharge or death.ResultsWe had a total of 308 cardiac arrests (64.6 ± 15.2 years, 60.3% men, 13.9% with initial shockable rhythm). There was a decrease from 4.2 to 2.5 in-hospital cardiac arrest/1000 admissions after implementation of the Rapid Response Team, and we had approximately 124 calls/1000 admissions. Pre-Rapid Response Team cardiac arrest was associated with more hypoxia (29.4 versus 14.3%; p = 0.006) and an altered respiratory rate (14.7 versus 4.2%; p = 0.004) compared with post-Rapid Response Team cardiac arrest. Cardiac arrest due to hypoxia was more common before Rapid Response Team implementation (61.2 versus 38.1%, p < 0.001). In multivariate analysis, return of spontaneous circulation was associated with shockable rhythm (OR 2.97; IC95% 1.04 - 8.43) and witnessed cardiac arrest (OR 2.52; IC95% 1.39 - 4.59) but not with Rapid Response Team implementation (OR 1.40; IC95% 0.70 - 2.81) or premonitory signs (OR 0.71; IC95% 0.39 - 1.28). In multivariate analysis, in-hospital mortality was associated with non-shockable rhythm (OR 5.34; IC95% 2.28 - 12.53) and age (OR 1.03; IC95% 1.01 - 1.05) but not with Rapid Response Team implementation (OR 0.89; IC95% 0.40 - 2.02).ConclusionEven though Rapid Response Team implementation is associated with a reduction in in-hospital cardiac arrest, it was not associated with the mortality of in-hospital cardiac arrest victims. A significant decrease in cardiac arrests due to respiratory causes was noted after Rapid Response Team implementation.

Despite wide implementation of rapid response teams (RRTs), no published data exist on RRT nurses' attitudes and barriers to the rapid response system (RRS). We piloted a 5-point Likert-type scale questionnaire among all Finnish university hospitals' RRT nurses with optional open-ended comments. The impact of more frequent RRT participation was further investigated. The response rate was 46% (n=176/379, 34%-93% between hospitals). The respondents median experience on a RRT was three years (0.8-5) and median participation was two (1-5) RRT activations per month. Over 90% of the RRT nurses felt that RRS prevented cardiac arrests and improved patient safety. Nurses with five or more RRT activations/month believed their critical care skills had improved through these duties (94% vs 71%, P=.001), considered their RRT work meaningful (94% vs 76%, P=.005) and wanted to continue as RRT nurses (91% vs 74%, P=.015) more often than nurses with less than five RRT activations/month. In addition to the infrequent RRT participation, further negative experiences with RRS among the RRT nurses included feeling overworked (68%) or undercompensated (94%) for the RRT duties and conflicts between RRT and ward doctors (25%). RRT nurses consider their work important and believe it fosters improved critical care skills; these beliefs are emphasized among those with more frequent RRT participation. Infrequent RRT participation, feeling overworked and/or undercompensated and conflicts between RRT and ward doctors may present barriers for successful RRS among RRT nurses.