WASHINGTON — It was 8 a.m., and a nurse at Kaiser Permanente's Santa Clara (Calif.) Medical Center was puzzled about a patient who had been admitted for a small bowel obstruction. Everything seemed fine, but the patient was hypotensive. What should be done?
The nurse decided to call the hospital's rapid response team (RRT). Belinda Chu, R.N., the RRT nurse, considered possible causes for the low blood pressure. She concluded that the nasogastric tube that had been inserted to suction the patient's stomach could cause a high amount of fluid loss from the stomach, leading to an imbalance of fluids and electrolytes.
Ms. Chu recommended that the physician order more fluids to be given to the patient, but 2 hours later the patient was still extremely hypotensive. The physician agreed that the patient needed to be transferred to a higher-care unit for closer monitoring.
This is one example of the work of early-intervention teams. Such teams, which are available 24 hours a day, 7 days a week, vary in makeup, Dr. Andrew Auerbach of the University of California, San Francisco, said at the annual meeting of the Society of Hospital Medicine. The teams also go by different names:
▸ Medical emergency teams (METs). For these, “think of 'code team' in your head,” Dr. Auerbach said. “They can prescribe medications, they probably have airway management skills, and they can get vascular access easily. The term we use is 'ICU at the bedside.'” METs are typically led by intensivist physicians.
▸ RRTs. These teams, on the other hand, “have some but not all of the METs' abilities,” Dr. Auerbach continued. “They begin basic care, and they have the ability to call in other resources, but there's not necessarily a physician at the bedside and not generally an intensivist at the bedside. Instead, they choose to ramp up care as conditions dictate.”
▸ Critical care outreach (CCO) teams. Similar to RRTs, these provide active surveillance to recent ICU discharges in addition to doing RRT functions, he said.
Training requirements for nonphysician members of all of these teams vary, but Advanced Cardiac Life Support and Pediatric Advanced Life Support seem to be minimal requirements for all teams.
Criteria for activating the teams differ from one hospital to another, but in general, hospital staff members or anyone else in the room with the patient are encouraged to call the team after noticing any of the following: abnormal vital signs, a change in symptoms, a change in mental status, a perceived risk of harm or imminent deterioration, or a feeling that something is “just not right,” Dr. Auerbach said.
Team members are usually contacted via overhead speaker or by pager. “The [teams] tend to be underutilized even if the clinical criteria and triggering process is extraordinarily simple, so the systems can be there, but you have to really encourage people … to use it,” Dr. Auerbach said.
Once the team arrives at the bedside, he emphasized, “there should not be any negative feedback that this was an inappropriate call, or you were weak, and why couldn't you do this yourself. You should just reinforce that triggering the [team] was in fact appropriate and say, 'I'm glad to be here. How can I help?'”
Once activated, the team makes an initial diagnosis and starts appropriate interventions. The team should be able to make transfer decisions on its own and have access to the intensive care unit, Dr. Auerbach said.
Dr. Auerbach was part of a group of physicians who participated in a consensus conference on early-intervention systems held last year in Pittsburgh. The attendees discussed development of outcomes measures and criteria for using teams. The results of the conference are expected appear soon in a peer-reviewed journal, he said.
Gauging the Impact
Studies of early-intervention systems are mixed on the question of whether they improve the quality of care, said Dr. Kaveh Shojania of the department of medicine at the University of Ottawa (Ontario).
“There have been about eight before-and-after studies, most of which show pretty dramatic benefits,” but there have been major methodologic problems with some of them, Dr. Shojania said at the meeting. A large randomized, controlled trial in Australia found the teams to be of no benefit, but there are questions about that study's methodology as well, he added.
Hospitals that have implemented the teams have had varying results. At the University of Pittsburgh Medical Center, it used to be that if the patient decompensated, “you would get on the horn to the ICU or the critical care attending physician” and send the patient to the ICU. “That was how we took care of 'I'm a little bit worried' situations,” explained Dr. David J. McAdams of the University of Pittsburgh.