Rapid response teams (RRTs) in top-performing hospitals for survival after cardiac arrest show distinct differences in structure and function from those at non-top-performing hospitals, a large qualitative study suggests.
"What we mainly found was that teams at top performing hospitals tended to have members that were dedicated, with little to no other competing clinical responsibilities, so they could be activated readily and respond to an emergency without delay," explained Saket Girotra, MD, SM, University of Iowa, Iowa City, in an interview with theheart.org | Medscape Cardiology.
"We also found several patterns where rapid response teams collaborated quite closely with bedside nurses, not just during a rapid response, but actually also in anticipation of a rapid response, and the bedside nurses felt trusted and empowered to call for a rapid response."
Their findings were published online July 29 in JAMA Internal Medicine.
RRTs are considered a key strategy for the prevention and management of in-hospital cardiac arrest (IHCA), which affect more than 200,000 patients annually in the United States.
RRTs are composed of health professionals with expertise in critical care and are called to evaluate patients with clinical deterioration that may lead to cardiac arrest, initiate life-saving treatments, and transfer patients to higher levels of care, such as the intensive care unit.
"In a sense, RRTs are activated to address any unexpected decline in a patient's condition, an idea that makes good sense," said Girotra. "But when you look at published literature on RRTs, the evidence is mixed, with some studies suggesting benefit, but many not."
Most acute care hospitals in the United States have RRTs, which can cost up to $1 million over a 5-year period at a medium-sized hospital.
Girotra's team, which included cofirst authors Kimberly Dukes, PhD, and Jacinda L. Bunch, PhD, RN, both also from the University of Iowa, sought to evaluate differences between top- and non-top-performing RRTs to see if differences in team structure and function would explain differential effects seen in benefit.
Differences in structure and function between top- and non-top-performing hospitals fell into four principal domains:
Team design and composition. Top-performing hospitals tended to have dedicated RRTs without other clinical responsibilities and were staffed with experienced individuals. Lower performers often had RRT members with competing responsibilities or high staff turnover.
Surveillance of at-risk patients. RRT personnel in top-performing hospitals engaged proactively in surveillance of at-risk patients. Non-top-performers RRTs engaged less actively with bedside nursing staff before a rapid response was called.
Empowerment of bedside nurses to activate a rapid response. Top-performers empowered nurses to call for a rapid response without fear of negative consequences.
Collaboration between RRTs and bedside nurses during and after a rapid response. Bottom-performing hospitals tended to "take over" patient care, whereas top-performing hospitals collaborated closely.
"As an example, in some of the top-performing hospitals, RRT team members would go to the individual units and basically ask the nurses, 'Who are your sickest patients and maybe we can keep an eye on them, or do you have any questions or concerns about particular patients and can we help troubleshoot things?'" said Girotra.
For Michael DeVita, MD, Harlem Hospital, New York, who has been a leader in the development of RRTs since 1998, these findings support his experiences with well-functioning RRTs.
"There is a sense that comes across very clearly that there are important differences in culture, differences in education, differences in support, which is why those of us in the field usually talk about rapid response systems, not teams, because it's not only the people on the team, but also those who call for help, the administrative support, and others who enable the teams to thrive," said DeVita.
The interview content used for this qualitative analysis came from another RRT study, called Hospital Enhancement of Resuscitation Outcomes for In-hospital Cardiac Arrest (HEROIC), which is focused on resuscitation practices at American hospitals.
HEROIC investigators conducted semistructured interviews with 158 hospital staff members from nine hospitals, five of which were deemed top performing and the other four, non-top-performing. Almost half of those interviewed were nurses in clinical roles (45.6%); the others were physicians (17.1%), other clinical staff (17.1%), and administrators (20.3%).
"The main focus of the HEROIC study was on resuscitation teams, but they also collected rich data around rapid response teams…. We wanted to utilize that content to better understand the strategies employed by different rapid response teams at the best hospitals," said Girotra.
He added that qualitative research is a well-established method to understand complex health system interventions and has been applied widely to identify best practices for other conditions, such as door-to-balloon times for ST-segment elevation myocardial infarction.
Participants were identified as "key informants" and asked questions to elicit information about the care of patients before, during, and after an IHCA, but they were also asked about hospital-wide prevention efforts for IHCA, including the use of RRTs, and possible areas needing improvement. This information was then coded by researchers who were blinded to whether a site was a top- or non-top-performing hospital.
Risk-adjusted survival rates varied from 81.7% to 97.3% in the top-performing category. In the non-top-performing group, one hospital was deemed moderate-performing and had a risk-adjusted survival rate of 56.1%. The three hospitals judged to be low-performing had survival rates that ranged from 2.9% to 12.9%.
Hospitals were classified as top-performing or non-top performing on the basis of risk-adjusted survival rates for IHCA, according to data from the Get With the Guidelines-Resuscitation, a national IHCA quality improvement program.
This may seem a counterintuitive approach, because the purpose of RRTs is to prevent IHCA and not necessarily to improve IHCA survival. About this, the authors explained that "the use of survival as a measure was based on the premise that hospitals that excel in IHCA management also excel at other aspects of care on the IHCA spectrum (i.e., IHCA prevention)." Also, data on IHCA incidence is not available in the GWTG-Resuscitation database.
DeVita wasn't bothered by how the authors picked their top-performing hospitals.
"Cardiac arrest and rapid response events are very tightly linked. Almost everybody — 85 plus percent of patients who have a cardiac arrest — pass through a time interval that would meet rapid response criteria, so 85% of these events should have had a rapid response call or at least met the criteria and there wasn't a call, so I don't think it's unreasonable to use a cardiac arrest database as your source material," DeVita said.
The study was funded by a grant from the National Institutes of Health. Girotra is supported by a career development award from the National Heart, Lung, and Blood Institute and a Department of Veterans Affairs Health Services Research and Development Service pilot grant. DeVita reported no conflict of interest.
JAMA Intern Med. Published online July 29, 2019. Full text
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