Kansas City, MO - So-called rapid-response teams, typically made up of ICU staff, have sprung up at hospitals hoping to improve survival in non-ICU patients showing signs of impending cardiopulmonary arrest—essentially preventing a "code blue" before it happens. But do they actually save lives? A new study, published in the December 3, 2008 issue of the Journal of the American Medical Association, says that the creation of a rapid-response team at St Luke's Hospital in Kansas City, MO had no impact on the number of hospital codes (cardiopulmonary arrests) or on hospitalwide mortality rates.

"This is by far the largest and longest study of a rapid-response team to date in the literature," first author on the study, Dr Paul S Chan (Mid America Heart Institute, Kansas City, MO), told heartwire. "This really argues for the fact that, since many hospitals are implementing these teams without any conclusive or consistent evidence to support their use, we need to go back to the drawing board and prove that they work."

The idea for rapid-response or "medical-emergency" teams, made up of ICU staff who could expedite the diagnosis and treatment of patients showing early signs of cardiac arrest (neurologic alterations, hypotension, tachycardia, etc), was pioneered in Australia and became one of the US Institute for Healthcare Improvement's cornerstone strategies in its "100 000 Lives Campaign" to prevent in-hospital deaths. As Chan et al note in their paper, hundreds of hospitals across the US have instituted rapid-response teams, despite a dearth of evidence supporting their effectiveness.

In their study, Chan et al report that the creation of a rapid-response team at St Luke's Hospital, fully instituted January 1, 2006 and studied until August 31, 2007, showed an improvement in unadjusted rates of hospitalwide codes and non-ICU codes. But after adjustment for patient demographics, case mix, and month-to-month variation, the implementation of a rapid-response team had no impact on the primary outcomes they were looking at—adjusted hospitalwide code rates and mortality—when compared with the period immediately preceding the creation of the team. Importantly, secondary analyses demonstrated that the lack of an effect of the rapid-response team could not be ascribed to underuse of appropriate interventions, suggesting that even when teams were doing everything they're supposed to do, mortality rates remained the same.

The only end point that was significantly reduced in the rapid-response-team era was the number of non-ICU codes per 1000 hospital admissions. But as the authors note in their paper, it's possible that non-ICU patients may have been transferred to the ICU by the rapid-response team and then died without formal code activation, since they were already the subject of specialized clinical attention.

Another possibility is that patients who survive a first rapid-response-team intervention or their loved ones might be more likely to consider a "do-not-resuscitate" (DNR) order; in fact, of the 70 patients who died despite a rapid-response-team activation, 46 of these were among patients who had obtained DNR status during or after the team's activation. In general, Chan added, "advance directives" are growing more common as the years go by, which may have diluted the impact of the rapid-response team.

This really argues for the fact that, since many hospitals are implementing these teams without any conclusive or consistent evidence to support their use, we need to go back to the drawing board and prove that they work.

Chan believes the study highlights the need for larger studies addressing not just codes but the "clinically meaningful" end point of mortality. Using a post hoc calculation, the investigators now believe that a study looking to detect a 5% reduction in mortality would need to have three times the number of patients to have adequate statistical power.

"We can't say from this study whether it's impossible to improve mortality in these patients, but we do know that there are very few things that actually improve fatality outcomes at a hospitalwide level, and if rapid-response teams are going to be one of those strategies, it is going to require a much larger sample size to show whether they actually improve long-term-mortality outcomes," he said.

Chan continued: "It's frustrating. There has certainly been a huge amount of excitement, energy, and interest applied to really making a difference in quality improvement, but what it gets down to is, how can we improve quality of care for patients in the in-hospital setting? I'm not sure this paper puts the question to rest as to whether rapid-response teams are effective or not. I think what we need to do is power a study or randomized trial that really takes a number of hospitals and follows them before and after a rapid-response team is implemented and over a long enough period of time to demonstrate whether there is a benefit before we can endorse them wholeheartedly."

Asked to comment on the findings for heartwire, Joe McCannon, vice president and a campaign manager at the Institute for Healthcare Improvement, acknowledged that different hospitals have had different levels of success with rapid-response teams.

"It is certainly the case that some facilities are challenged to introduce rapid-response teams and are unable to see their effects," he said. "Many others, however, have observed striking improvements through the introduction of the teams and through other early-detection strategies. . . . This is a study from one organization: we want to learn from this particular experience, but I think we'd also say that we still feel rapid-response teams and other early-detection strategies are important approaches for addressing failure to rescue."

McCannon also emphasized that the institute bases its recommendations on research and scientific publications. "If the evidence or experience were to suggest that we make a change to our advice to hospitals, we would do so. But we still believe that this intervention is an important one. If we know that patients are deteriorating, and we know the signs of their deterioration, we should find efficient and effective ways to avoid catastrophic cardiac and respiratory events before they happen. We're constantly learning more about different approaches and methods for doing that, but at this stage, we think the rapid-response teams and other early-detection strategies are important approaches."