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Dress for the Occasion
The Joint Commission Journal on Quality and Patient Safety Letter to the Editor
Dress for the Occasion
I
n his editorial on our article,1 Dr. Sirio correctly states with respect to rapid response systems (RRSs), “systemized methods must be employed, bringing to bear necessary resources, providing rapid diagnosis and applying primary and secondary treatments.”2(p. 162) Although the rationale behind the evolution of rapid response teams (RRTs) or (physician-led) medical emergency teams (METs) is intuitive, systematic reviews have demonstrated no significant benefit to RRSs.3–5 Dr. Sirio compares a team of providers led by a critical care physician to the tried and true old clothes of the Emperor. The composition of this team would ensure that “caregivers are likely to triage and treat the most important injuries first”1(p. 162) The underlying fallacy to this argument is that the literature does not support any “one set of clothing” for RRSs. In Ranji and colleagues’ systematic review of RRSs,3 the response arms of RRSs were heterogeneous,5 as they also were in published “positive” studies.1,6 Similarly, in the MERIT trial, another study with a wide variety of response arms, as the rate of activation of RRTs increased, the rate of unexpected deaths and cardiac arrests decreased.7 No studies to date have examined the relative effectiveness of different RRSs on clinical outcomes. Therefore, any perspectives on the adequacy or inadequacy of different types of RRSs or on the specific composition of an RRT are purely conjectural. However, with increasingly constrained resources, we must consider whether a whole team of providers, including a critical care physician, is truly needed for every manifestation of a potential future adverse inpatient event. In our own examination of failure to rescue at Denver Health Medical Center,8 the conditions that led to these events were within the scope of practice of our housestaff who provide care for both our non–ICU and ICU patients. Although Dr. Sirio wonders how “the clinical triggers program accounts for the need of a much more timely response than 15 minutes,”2(p. 162) RRTs were never designed to resuscitate patients in extremis. In fact, Kause and colleagues, who first called attention to the issue of unheeded antecedents to adverse patient outcomes, excluded antecedents that occurred within 15 minutes of the adverse event.9
June 2009
Although Dr. Sirio compares the response to signs of clinical instability in hospitalized patients to the “golden hour” of trauma care, the reality is that virtually no rapid response calls are for severe trauma. A more valid emergency department comparison to the rapid response paradigm would be the scores of patients who enter emergency departments with new hypoxemia, hemodynamic variations from baseline or mental status changes. A number of these patients would also experience adverse outcomes if not evaluated and treated promptly. However, unless the patient is in extremis, emergency department patients are seen in stepwise fashion by interns and residents. To date, no one has suggested that a team of providers, led by an emergency department or critical care attending, meet each “emergency” department patient to adhere to a “golden hour” of care. In this manner, we do not feel that the question is whether the Emperor needs new clothes, since, for this occasion, the proper attire has yet to be established. J
References 1. Moldenhauer K., et al.: Clinical triggers: An alternative to a rapid response team. Jt Comm J Qual Patient Saf 35:64–74, Mar. 2009. 2. Sirio C.A.: Clinical triggers or rapid response teams: Does the emperor need “new“clothes. Jt Comm J Qual Patient Saf 35:162–163, Mar. 2009. 3. Ranji S.R., et al.: Effects of rapid response systems on clinical outcomes: Review and meta-analyses. J Hosp Med 2:422–432, Nov. 2007. 4. Winters B.D., et al.: Rapid response systems: A systematic review. Crit Care Med 35:1238–1243, May 2007. 5. Hillman K.: Introduction of the medical emergency team (MET) system: A cluster-randomised controlled trial. Lancet 365:2091–2097, Jun. 2005. 6. Priestley G., et al.: Introducing Critical Care Outreach: A ward-randomised trial of phased introduction in a general hospital. Intensive Care Med 30:1398–1404, Jul. 2004. 7. Bellomo R., et al.: Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med 32:916–921, Apr. 2004. 8. Chen J., et al.: The relationship between early emergency team calls and serious adverse events. Crit Care Med 37:148–153, Jan. 2009. 9. Kause J., et al.: A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand and the United Kingdom: The ACAMEIA study. Resuscitation 62:275–282, Sep. 2004.
—Eugene S. Chu, M.D.; Kendra Moldenhauer, R.N., B.S.N.; Allison Sabel, M.D., Ph.D, M.P.H.; Philip S. Mehler, M.D. Denver Health Medical Center, Denver
Volume 35 Number 6
Copyright 2009 Joint Commission on Accreditation of Healthcare Organizations
295
Dress for the Occasion
I
n his editorial on our article,1 Dr. Sirio correctly states with respect to rapid response systems (RRSs), “systemized methods must be employed, bringing to bear necessary resources, providing rapid diagnosis and applying primary and secondary treatments.”2(p. 162) Although the rationale behind the evolution of rapid response teams (RRTs) or (physician-led) medical emergency teams (METs) is intuitive, systematic reviews have demonstrated no significant benefit to RRSs.3–5 Dr. Sirio compares a team of providers led by a critical care physician to the tried and true old clothes of the Emperor. The composition of this team would ensure that “caregivers are likely to triage and treat the most important injuries first”1(p. 162) The underlying fallacy to this argument is that the literature does not support any “one set of clothing” for RRSs. In Ranji and colleagues’ systematic review of RRSs,3 the response arms of RRSs were heterogeneous,5 as they also were in published “positive” studies.1,6 Similarly, in the MERIT trial, another study with a wide variety of response arms, as the rate of activation of RRTs increased, the rate of unexpected deaths and cardiac arrests decreased.7 No studies to date have examined the relative effectiveness of different RRSs on clinical outcomes. Therefore, any perspectives on the adequacy or inadequacy of different types of RRSs or on the specific composition of an RRT are purely conjectural. However, with increasingly constrained resources, we must consider whether a whole team of providers, including a critical care physician, is truly needed for every manifestation of a potential future adverse inpatient event. In our own examination of failure to rescue at Denver Health Medical Center,8 the conditions that led to these events were within the scope of practice of our housestaff who provide care for both our non–ICU and ICU patients. Although Dr. Sirio wonders how “the clinical triggers program accounts for the need of a much more timely response than 15 minutes,”2(p. 162) RRTs were never designed to resuscitate patients in extremis. In fact, Kause and colleagues, who first called attention to the issue of unheeded antecedents to adverse patient outcomes, excluded antecedents that occurred within 15 minutes of the adverse event.9
June 2009
Although Dr. Sirio compares the response to signs of clinical instability in hospitalized patients to the “golden hour” of trauma care, the reality is that virtually no rapid response calls are for severe trauma. A more valid emergency department comparison to the rapid response paradigm would be the scores of patients who enter emergency departments with new hypoxemia, hemodynamic variations from baseline or mental status changes. A number of these patients would also experience adverse outcomes if not evaluated and treated promptly. However, unless the patient is in extremis, emergency department patients are seen in stepwise fashion by interns and residents. To date, no one has suggested that a team of providers, led by an emergency department or critical care attending, meet each “emergency” department patient to adhere to a “golden hour” of care. In this manner, we do not feel that the question is whether the Emperor needs new clothes, since, for this occasion, the proper attire has yet to be established. J
References 1. Moldenhauer K., et al.: Clinical triggers: An alternative to a rapid response team. Jt Comm J Qual Patient Saf 35:64–74, Mar. 2009. 2. Sirio C.A.: Clinical triggers or rapid response teams: Does the emperor need “new“clothes. Jt Comm J Qual Patient Saf 35:162–163, Mar. 2009. 3. Ranji S.R., et al.: Effects of rapid response systems on clinical outcomes: Review and meta-analyses. J Hosp Med 2:422–432, Nov. 2007. 4. Winters B.D., et al.: Rapid response systems: A systematic review. Crit Care Med 35:1238–1243, May 2007. 5. Hillman K.: Introduction of the medical emergency team (MET) system: A cluster-randomised controlled trial. Lancet 365:2091–2097, Jun. 2005. 6. Priestley G., et al.: Introducing Critical Care Outreach: A ward-randomised trial of phased introduction in a general hospital. Intensive Care Med 30:1398–1404, Jul. 2004. 7. Bellomo R., et al.: Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med 32:916–921, Apr. 2004. 8. Chen J., et al.: The relationship between early emergency team calls and serious adverse events. Crit Care Med 37:148–153, Jan. 2009. 9. Kause J., et al.: A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand and the United Kingdom: The ACAMEIA study. Resuscitation 62:275–282, Sep. 2004.
—Eugene S. Chu, M.D.; Kendra Moldenhauer, R.N., B.S.N.; Allison Sabel, M.D., Ph.D, M.P.H.; Philip S. Mehler, M.D. Denver Health Medical Center, Denver
Volume 35 Number 6
Copyright 2009 Joint Commission on Accreditation of Healthcare Organizations
295