Rapid response team composition effects on outcomes for adult hospitalised patients: A systematic review.

BACKGROUND: Utilisation of a rapid response team (RRT) in a hospital setting has been documented in the literature. RRTs were formed to intervene quickly when the hospitalised patient first shows signs of deterioration. The purpose was to prevent failure to rescue, leading to intensive care unit transfers, cardiac arrest and mortality. To date, however, there is a lack of evidence to support the effectiveness of this intervention. The focused question, subsequent systematic review and data analysis are presented.

OBJECTIVE: To synthesise the best available research evidence on the impact of rapid response team composition on cardiopulmonary arrest outside the intensive care unit (ICU), unplanned transfers to ICU, in-hospital mortality, length of hospital stay in hospitalised non-ICU adult medical-surgical patients and staff satisfaction.

SEARCH STRATEGY: Published and unpublished literature were searched. The databases searched for studies from 1989 to 2010 were CINAHL, EMBASE, Google Scholar, Mednar, New York Academy of Medicine, Proquest and PubMed. Reference lists of included studies were hand searched. Initial keywords searched were rapid response team, rapid response system, medical emergency team, medical emergency system and team composition.

INCLUSION CRITERIA: The studies included in the systematic review were randomized controlled trials (RCTs). In absence of sufficient RCTs, quasi-experimental studies, cohort studies, observational and control trials without randomization were included. Types of participants were adults (18 years and older) hospitalised in an acute care setting, not requiring the specialized care and management of an ICU. Hospitalised paediatric patients, ICU patients, hospice or palliative care patients were excluded.

CRITICAL APPRAISAL, DATA COLLECTION AND ANALYSIS: JBI MAStARI Critical Appraisal Tools were used for the methodological assessment of identified studies. Data were collected specifically related to RRT intervention, study methods and design, randomization, length of intervention, data collection points and inclusion criteria. Significant variables of interest included in the data collection were team composition, cardiopulmonary arrest outside the ICU, unplanned transfers to the ICU, in-hospital mortality, length of hospital stay and staff satisfaction. Data were extracted and analysed using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). The findings were presented in narrative form as statistical meta-analysis was not possible.

MAIN RESULTS: A total of 26 articles were included. The types of studies included in this systematic review were one cluster randomized control trial and one controlled trial without randomization. The remaining 24 studies were quasi-experimental cohort control design with two being retrospective studies and 22 prospective before-and-after intervention studies. Of those included, 10 were physician led, 13 were critical care registered nurse led and three nurse practitioner led. No association was found between team composition and patient outcomes.

CONCLUSIONS: This systematic review found no correlation between team composition and patient outcomes. Teams that were mature, dedicated, made rounds and required mandatory activation had statistically significant results. These teams were more effective in decreasing cardiopulmonary arrest outside of the ICU, unplanned ICU transfer, in-hospital mortality, length of hospital stay and increased staff satisfaction.

IMPLICATIONS FOR PRACTICE: RRT activation was either mandatory or voluntary. Mandatory activation directed the RRT to be called if specific predetermined criteria were observed. Voluntary activation of the team was at the discretion of the staff regardless of guidelines. In these instances, concerns were reported about initiating "inappropriate" activation. Dedicated RRTs making proactive rounds and educating staff led to improved outcomes and staff satisfaction.

IMPLICATIONS FOR RESEARCH: Short study periods after team implementation may not accurately reflect the effectiveness of the RRT. Evidence points to significant results with team maturation. Further research should be directed toward more rigorous studies on team maturation, mandatory versus voluntary team activations, use of dedicated teams making rounds and staff satisfaction.