What is the primary purpose of a rapid response team or medical emergency team

1Division of Allergy and Respiratory Diseases, Department of Internal Medicine, Soonchunhyang University Hospital, Seoul, Korea

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Sang-Bum Hong

2Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

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Disclaimer

1Division of Allergy and Respiratory Diseases, Department of Internal Medicine, Soonchunhyang University Hospital, Seoul, Korea

2Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

Corresponding author Sang-Bum Hong Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel: +82-2-3010-3130 Fax: +82-2-3010-6968 E-mail: rk.luoes.cma@gnohbs

Received 2019 May 12; Revised 2019 May 17; Accepted 2019 May 20.

Copyright © 2019 The Korean Society of Critical Care Medicine

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

The inpatient treatment process is becoming more and more complicated with advanced treatments, aging of the patient population, and multiple comorbidities. During the process, patients often experience unexpected deterioration, about half of which might be preventable. Early identification of patient deterioration and the proper response are priorities in most healthcare facilities. A rapid response system (RRS) is a safety net to identify antecedents of these adverse events and to respond in a timely manner. The RRS has become an essential part of the medical system worldwide, supported by all major quality improvement organizations. An RRS consists of a trigger system and response team and needs constant assessment and process improvement. Although the effectiveness and cost-benefit of RRS remain controversial, according to previous studies, it may be beneficial by decreasing in-hospital cardiac arrest and mortality. Since the first implementation of RRS in Korea in 2008, it has been developed in over 15 medical centers and continues to expand. Recent accreditation standards and an RRS pilot program by the Korean government will promote the proliferation of RRSs in Korea.

Keywords: hospital medical emergency team, hospital rapid response team, patient safety

INTRODUCTION

It is well known that approximately 10% of patients admitted to hospital experience unexpected serious adverse events []. A rapid response system (RRS) is a patient safety strategy that prevents cardiac arrests or deaths by providing immediate and timely interventions when patients unexpectedly deteriorate [,]. Delayed or inappropriate medical management in these patients may result in an increased risk of death or disability. An RRS aims to improve the safety of hospital-ward patients. Although the effectiveness of RRSs is controversial [,], several before-and-after studies have shown a reduction in cardiac arrest and hospital mortality [-]. Starting in the United States and Australia, this system has become an essential part of patient safety and has been adopted worldwide. Last year, the Korea Institute for Healthcare Accreditation distributed its third edition revised accreditation standards, and it recommended all acute care hospitals implement an RRS. In addition, in May 2019, the Korean Health Insurance Review and Assessment Service and the Ministry of Health and Welfare started a rapid response system pilot program. This article reviews the concept of the RRS; its requirements; and its past, present, and future in Korea.

RAPID RESPONSE SYSTEM

Patient Safety Issues

Admitted patients experience unexpected adverse events in about 10% of cases, 7.3% of which could be fatal. Although not all unexpected adverse events are preventable or predictable, 30% to 83% are so [,,]. Approximately 80% of in-hospital cardiorespiratory arrest showed at least one abnormal sign such as blood pressure, heart rate, respiratory rate, body temperature, or change in consciousness within 8 hours before the event [-]. This suggests that there is an opportunity for intervention before patient condition worsens. However, these antecedents can go unrecognized in general wards. In most hospitals, continuous monitoring of vital signs is usually available only in the intensive care unit (ICU). The number of physician rounds for ward-patients is one to two times a day. The interval between measurements of vital signs is usually 8 hours or longer. Respiratory rate and mental state should be measured under direct observation, which is prone to error [,]. Even if there is a warning sign, it may not be recognized or properly alerted depending on personal experience, attitude, work environment, and position of the responding nurse or the doctor. As there is a long chain of command to activate—from nurse to intern or resident, from resident to fellow, fellow to attending physician—an alert may be delayed in each step [].

In the surgical ward, doctors are not readily available because they might be in the operating room. Even if the patient’s warning signs are recognized and reported in a timely manner, it can be difficult to provide appropriate monitoring, intervention, or treatment because of the limited medical resources available in general wards. The Surviving Sepsis Campaign emphasizes early recognition and treatment. Accordingly, the current guideline combines 3- and 6-hour bundles into a “1-hour bundle” to emphasize immediate resuscitation and management []. Considering this, the current conventional medical system might be inadequate for proper early response.

Components of RRS

An RRS is composed of doctors and nurses who specialize in intensive care medicine to cope with patients at risk. An RRS consists of an afferent limb, efferent limb, patient safety, quality improvement with feedback from data analysis, and administrative components including education of staff [], as shown in Figure 1. The afferent limb is a way to detect patient deterioration []. A nurse or a ward-physician can contact the responding team according to “calling criteria.” Alternatively, using scores such as the modified Early Warning Score (MEWS), patients at risk can be actively screened [,]. As under-recognition of monitored abnormal values leads to delay in activation, a surveillance system using a scoring system like MEWS (Table 1) [] or the National Early Warning Score (NEWS) 2: standardising the assessment of acute-illness severity in the NHS.

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