Adding rapid response team to children's hospital reduces risk of death, cardiac arrests

A children’s hospital that added a rapid response medical team for patients not in the intensive care unit saw an 18 percent decrease in the death rate, and about a 70 percent decline in the rate of cardiac and respiratory arrests, according to a study in the November 21 issue of JAMA.

Introduction of a rapid response team (RRT; medical emergency team) has been shown to decrease death and cardiopulmonary arrests outside of the intensive care unit (ICU) in adult inpatients, according to background information in the article. An RRT is a multidisciplinary team frequently consisting of ICU-trained personnel who are available 24 hours per day, 7 days per week for evaluation of patients not in the ICU who develop signs or symptoms of clinical deterioration.

“The RRT intervention was developed in response to research that revealed adult patients on general medical and surgical hospital units often have evidence of physiological deterioration several hours before cardiopulmonary arrest, and that after a cardiac arrest occurred, survival rates were poor. Given that there appears to be a window of opportunity to identify and proactively treat ‘prearrest’ adult inpatients effectively, the Institute for Healthcare Improvement recommended RRTs be implemented nationwide in an effort to decrease inpatient mortality rates,” the authors write. Limited data exist evaluating the effectiveness of RRT implementation in pediatric inpatients.

Paul J. Sharek, M.D., M.P.H., of Stanford University School of Medicine, Palo Alto, Calif., and colleagues evaluated whether RRT implementation was associated with decreases in hospital-wide mortality rates and code rates (respiratory and cardiopulmonary arrests) outside of the ICU in pediatric inpatients at a 264-bed academic children’s hospital. Pediatric inpatients who spent at least one day on a medical or surgical ward between January 2001 and March 2007 were included. A total of 22,037 patient admissions were evaluated pre-intervention (before September 1, 2005), and 7,257 patient admissions were evaluated post-intervention (on or after September 1, 2005).

A significant decrease of 18 percent occurred in the hospital-wide mortality rate after implementation of the RRT. The rate of codes outside of the ICU setting per 1,000 eligible admissions declined by 71.7 percent, with pre-intervention and post-intervention rates of 2.45 vs. 0.69, respectively. The rate of codes outside of the ICU per 1,000 eligible patient-days decreased by 71.2 percent after RRT implementation.

The RRT intervention, using statistical modeling, was associated with a decrease of 0.178 deaths per 100 discharges or 1.78 deaths per 1,000 discharges. During the 19-month post-intervention period, the RRT intervention is estimated to have resulted in 33 lives saved at this hospital.

“Implementation of an RRT in our free-standing, quaternary care academic children’s hospital was associated with statistically significant reductions in hospital-wide mortality rates and code rates outside of the ICU setting. These reductions cannot be explained by differences in patient characteristics or severity of illness between the control and post-intervention populations,” the authors write.

“The potential implications of these findings on national mortality rates for children are dramatic. Future research should focus on replicating these findings in other pediatric inpatient settings, including settings where children are treated in predominantly adult-focused hospitals, developing efficient methods for implementing RRTs, and evaluating the cost-effectiveness of this intervention.”

(JAMA. 2007;298(19):2267-2274. Available pre-embargo to the media at www.jamamedia.org)

Editor’s Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

In an accompanying editorial, Jeffrey E. Nowak, M.D., and Richard J. Brilli, M.D., of the University of Cincinnati College of Medicine, comment on the findings of Sharek and colleagues.

“The data on RRT outcomes in pediatric hospitals are increasing and thus far suggest benefit. Sharek et al have provided the most persuasive data to date regarding the efficacy of pediatric RRTs – a mortality benefit. Nonetheless, the challenge remains to collect rigorous and comparable data, whether beneficial effects are demonstrated or not, so the optimal approach for RRTs in pediatrics can be determined.”

(JAMA. 2007;298(19):2311-2312. Available pre-embargo to the media at www.jamamedia.org)

Editor’s Note: Please see the article for additional information, including financial disclosures, funding and support, etc.