HEALTH POLICY AND SYSTEMS

Rapid Response Teams: Is it Time to Reframe the Questions

of Rapid Response Team Measurement?
Gail G. Salvatierra, RN, PhD1 , Ruth C. Bindler, RN, PhD2 , & Kenn B. Daratha, PhD3,4
1 Assistant Professor, School of Nursing, California State University, San Marcos, CA, USA
2 Professor Emeritus, College of Nursing, Washington State University, Spokane, WA, USA
3 Associate Professor, Washington State University College of Nursing, Spokane, WA, USA
4 Affiliate Associate Professor, Washington State University Elson S. Floyd College of Medicine, Spokane, WA, USA

Key words Abstract

Medical emergency teams, nursepatient
relations, nursing care, organizational culture, Purpose: The purpose of this article is to present an overview of rapid
patient-centered care, rapid response system, response team (RRT) history in the United States, provide a review of prior
rapid response team RRT effectiveness research, and propose the reframing of four new questions
of RRT measurement that are designed to better understand RRTs in the
Correspondence
context of contemporary nursing practice as well as patient outcomes.
Dr. Gail G. Salvatierra, School of Nursing,
Organizing Construct: RRTs were adopted in the United States because of
California State University, San Marcos, 333 S.
Twin Oaks Valley Rd., San Marcos, CA 92096. their intuitive appeal, and despite a lack of evidence for their effectiveness.
E-mail: [email protected] Subsequent studies used mortality and cardiac arrest rates to measure whether
or not RRTs work. Few studies have thoroughly examined the effect of RRTs
Accepted August 4, 2016 on nurses and on nursing practice.
Methods: An extensive literature review provided the background. Suppo-
doi: 10.1111/jnu.12252
sitions and four critical, unanswered questions arising from the literature are
suggested.
Findings: The results of RRT effectiveness, which have focused on patient-
oriented outcomes, have been ambiguous, contradictory, and difficult to
interpret. Additionally, they have not taken into account the multiple ways
in which these teams have impacted nurses and nursing practice as well as
patient outcomes.
Conclusions: What happens in terms of RRT process and utilization is likely
to have a major impact on nurses and nursing care on general medical and
surgical wards. What that impact will be depends on what we can learn from
measuring with an expanded yardstick, in order to answer the question, Do
RRTs work?
Clinical Relevance: Evidence for the benefits of RRTs depends on proper
framing of questions relating to their effectiveness, including the multiple
ways RRTs contribute to nursing efficacy.

The scientist is not a person who gives the right answers, contradictory (Bellomo et al., 2003; Hillman et al., 2005;
hes one who asks the right questions. Lee, Bishop, Hillman, & Daffurn, 1995; Offner, Heit, &
Claude Levi-Strauss Roberts, 2007). It is clear that RRTs are very much a part
of the landscape of acute care hospitals today, represent-
For more than 20 years, we have been measuring ing an initiative that is here to stay. It is time to ask new
whether or not rapid response teams (RRTs) are effective questions that focus on how to obtain better value from
by asking, Do rapid response teams reduce hospital these teams instead of questioning their validity.
mortality and cardiac arrest rates? The answers, from This article utilizes our research and a literature review
numerous studies, have often been ambiguous and to launch us into asking more and different questions

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regarding RRTs. We will examine the RRT character- appeal of a MET was undeniable. How could pre-arrest
istics at 10 similarly functioning tertiary hospitals in intervention by a team of critical care specialists not yield
Washington State (Table 1) that were a part of a large better outcomes? It seemed so obvious that by the time
retrospective study of RRTs on hospital mortality, the the concept of RRTs was first introduced in the United
full results of which are reported elsewhere (Salvatierra, States, their implementation quickly led to rapid adop-
Bindler, Corbett, Roll, & Daratha, 2014). We will review tion despite conflicting clinical evidence. The Institute for
the history of RRT adoption in the United States, the Healthcare Improvement (IHI, 2009), The Joint Commis-
studies conducted to date on the effectiveness of RRTs sion (2009), and the Robert Wood Johnson Foundation
as measured primarily by survival criteria in one form (2005) were all early endorsers and enforcers. However,
or another. Finally, we will discuss the role of nurses in their support was based on a handful of uncontrolled
RRTs and the ways in which RRTs have an impact on studies, most of them from other countries with medical
nurses, patients, and patient families. delivery models that differed from those of the United
The current questions regarding RRT effectiveness that States. Within a relatively short time span, two thirds
focus on patient outcomes have not begun to gauge the of U.S. hospitals had an RRT in some form or another
effect of RRTs on nurses and on nursing practice, despite (Agency for Healthcare Research and Quality, 2013).
the fact that nurses are at the bedside more than any Retrospectively, researchers asked, Do RRTs save lives?
other member of the healthcare team. Additionally, it is The answers were, yes, no, and maybe. Some
the nurse who almost always is the one to activate the studies showed benefits, while others demonstrated no
RRT. Nurses are the major personnel that comprise RRTs benefits or yielded ambiguous results (Bellomo et al.,
in most facilities. Thus, we propose four new research 2003; Bristow et al., 2000; Buist et al., 2002; Chan et al.,
questions that are designed to better understand RRTs in 2008; Dacey et al., 2007; DeVita et al., 2004; Jolley,
the context of contemporary nursing practice as well as Bendyk, Holaday, Lombardozzi, & Harmon, 2007; Lee
patient outcomes. et al., 1995; Priestley et al., 2004; Salvatierra et al., 2014).
Until recently, attempts to resolve the literature gap
of RRT effectiveness with meta-analyses have also been
Background
inconclusive. Earlier meta-analyses showed no improve-
RRTs represent one of the more visible and significant ments in adult hospital mortality following implemen-
responses to the realization that some patients who tation of RRTs (Chan, Jain, Nallmothu, Berg, & Sasson,
should not die do die during hospitalization (Beaumont, 2010; Winters & Weaver, 2013). However, the two most
Luettel, & Thomson, 2008; Berwick, Calkins, McCannon, recently published meta-analysis found lower in-hospital
& Hackbarth, 2006). The first rapid response system was cardiac arrest and mortality rates after RRT implemen-
launched in Australia in the early 1990s; these physician- tation (Maharaj, Raffaele, & Wendon, 2015; Solomon,
led teams were known as the medical emergency team Corwin, Barclay, Quddusi, & Dannenberg, 2016).
(MET; Bellomo et al., 2003; Hillman et al., 2005; Lee In response to the ambiguities about RRT outcomes
et al., 1995). Prior to the introduction of the MET or that existed in the literature, we chose to examine
RRT, no option existed to provide the bedside nurse with in-hospital mortality rates from 10 similarly functioning
additional expertise, consultation, and intervention for large tertiary hospitals in Washington State. At the time
deteriorating patients. of the study, it was the largest of its kind (Salvatierra
Preceding RRT implementation in U.S. hospitals, when et al., 2014). Utilizing data from the Washington State
nurses at the bedside encountered a deteriorating patient Comprehensive Hospital Abstract Reporting System
they had three choices: call the patients physician, deal (CHARS) database, we observed the mortality rate for
with the patients decline using institutional resources 31 months prior to and following implementation of an
at hand, or if and when the decline worsened, call a RRT while controlling for a number of factors, including
code. There are problems with each of the three options: time, patient severity of illness, and other complexities
physicians can be slow to respond, or they may be of patient care (Salvatierra et al., 2014). Although we
inaccessible; most nursing units are not staffed to support found reduced in-hospital mortality in the post-RRT
care for deteriorating patients; and codes are reserved implementation period in 6 of the 10 acute tertiary care
for cardiopulmonary arrests (Goldhill, Worthington, & hospitals examined, after adjusting for the long-term
Mulcahy, 1999). trend of decline in hospital mortality, the improved
Motivated by studies showing distressingly poor out- outcomes could not be attributed directly to RRT imple-
comes for patients who experienced cardiopulmonary mentation (Salvatierra et al., 2014). Our study reflected
arrest, and armed with the knowledge that there are the difficulty that other researchers have had in finding
premonitory signs prior to the arrest event, the intuitive definitive evidence of RRT effectiveness.

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The Questions of RRT Measurement

Table 1. Select Rapid Response Team Characteristics Among Study Hospitals

Year RRT RRT calls/ Who can Goal for % annual

Hospital ID started Team members 1,000 discharges activate RRT Calling criteria Educational plan response (min) D/C 2009

C 2007 CCRN RT 35 Anyone Any Concern Formal mandatory classes 5 2.8

D 2006 CCRN, EDRN RT 263 Anyone Clinical & qualitative indicator Formal mandatory classes 5 4.7
E 2006 CCRN, EDRN RT 52 Anyone Clinical & qualitative indicator Formal mandatory classes 15 3.2
J 2006 CCRN, EDRN RT MD 17 Anyone Clinical & qualitative indicator Formal mandatory classes 5 2.5
K 2005 CCRN RT 222 Anyone MEWS Formal mandatory classes 10 2.7
L 2005 CCRN EDRN RT 16 Anyone Clinical & qualitative indicator Formal mandatory classes 15 5.7
B 2006 CCRN, EDRN RT 44 Anyone Clinical & qualitative indicator Formal mandatory classes 5 3.6
F 2004 CCRN, EDRN RT 40 Anyone MEWS Informal, non-mandatory classes 10 2.6
H 2004 Dedicated CCRN RT 80 Anyone Gut of bedside nurse a Informal classes 10 3.7
I 2005 CCRN, EDRN RT MD 33 Anyone Clinical & qualitative indicator Informal classes 5 3.0

Note. Shading indicates hospitals demonstrating reduction in risk of in-hospital mortality. Survey title: Timing and Processes Related to Implementation of Rapid Response Teams. CCRN = critical care
registered nurse; D/C = discharge; EDRN = emergency department registered nurse; MD = medical doctor; MEWS = modified early warning systems; RT = respiratory therapist. a Results copied verbatim
from survey.


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Salvatierra et al.
Salvatierra et al. The Questions of RRT Measurement

Table 1 provides information about the characteristics to provide families with a sense of autonomy and em-
of the RRTs at each of the 10 hospitals included in our powerment (Chen, Bellomo, Hillman, Flabouris, & Finfer,
study (Salvatierra et al., 2014). Of interest is that the six 2010). These factors have an impact on many aspects of
hospitals demonstrating reduced mortality rates had only the hospital ecosystem, yet several of these issues have
two process points in common: response time <15 min not been well measured as they relate to RRTs. Research
and a comprehensive, formal, and mandatory education should be designed to discover all of the facets of what
plan for RRT implementation. Team composition and RRTs do, outside the measurement of survival statistics.
type of activation criteria did not appear to have any Whether the intuition that RRTs have an important
relationship with the reported results. The concept of role to playin fact, several important rolesis not in
dose within the context of the RRT domain implies that question. What is in question is the way in which we
the greater the number of RRT calls (per 1,000 patients) have initially measured RRT success, because none of the
within a hospital, the better the outcomes that are previous measures have specifically assessed those roles.
associated with RRT. However, our study did not support Perhaps it is time to ask different questions in order to
the previously reported results that a higher RRT dose more clearly understand the ways in which these teams
is linked to improved outcomes and team composition influence nurses, nursing care, and patient outcomes.
(Jones, Bellomo & DeVita, 2009). In particular, having Instead of asking, Do RRTs reduce in-hospital mortality
a physician on the team did not seem to have any from cardiac arrest? maybe we should be askingand
influence on the outcome. researchingthe following four crucial questions.
The varying results regarding RRT effectiveness as
measured by in-hospital mortality and in-hospital cardiac
Question 1: What Are the Best Measures
arrests is hardly a surprise. RRTs are medically and
of the Benefits That RRTs Provide?
organizationally complex undertakings subject to sub-
stantial variations in their implementation, adoption, and Illness severity among hospitalized patients has
utilization within and between hospital cultures (Chan increased significantly over the past 20 years. This in-
et al., 2008, 2010; Maharaj et al., 2015; Salvatierra et al., creased patient acuity places a greater burden on existing
2014; Winters & Weaver, 2013). Furthermore, despite nursing resources (Jennings, 2012; Jones, DeVita, &
each hospitals standardized assessment for identifying Bellomo, 2011). Of course, not all patients who are
signs of deterioration, interinstitutional standardization deteriorating can be or should be rescued. Rather, for
in this area is lacking (DeVita, et al., 2006). Additionally, many deteriorating patients who have a terminal illness,
not all patients who are deteriorating can be saved; end-of-life care is needed. End-of-life care involves
in fact, implementing life-saving interventions at the establishing a plan of care that provides a clear and
terminal phase of a patients life can be painful and most valuable resource to provide safe care for acutely ill
often futile (Jones, Moran, Winters, & Welch, 2013). patients (Benin, Borgstrom, Jeng, Roumanis, & Horwitz,
2012; Cioffi, 2000; Donaldson, Shapiro, Scott, Foley, &
Spetz, 2009; Shapiro, Donaldson, & Scott, 2010).
What Do RRTs Really Do?
For a floor nurse, an RRT is situated below a code
The varying results of the multiple studies conducted but above being left on ones own with what a nurse
on RRTs should cause researchers to step back and con- perceives to be a deteriorating patient. While there
sider additional questions. The cumulative findings of is no official diagnosis, medical or nursing, for this
previous RRT studies suggest that RRT research should be patient doesnt seem right, nurses everywhere know
broadened to measure a far wider range of outcomes. It the condition exists and is often detectable (DeVita &
is now time to begin using a different measuring stick for Winters, 2014; Donaldson et al., 2009).
deciding whether or not RRTs work. We should consider Recognizing patient deterioration without having the
if we are missing key aspects of what RRTs really do. resources to effectively address patient decline is futile
Perhaps RRTs work in ways that contribute an indirect and frustrating. Having reliable backup not only facili-
benefit to the patient and nursing staff, in addition to tates escalation of care in a patient experiencing dete-
any direct effect. RRTs provide an option for higher-level rioration, but it may also decrease perceived workload
assistance that did not previously exist in the hospital and increase nurses satisfaction with their jobs. Nurses
setting. RRTs are positioned to assure and reassure the have described their satisfaction with RRTs in a vari-
nurses on the floor that they are not alone and do not ety of settings (Benin et al., 2012; Cioffi, 2000; DeVita
have to wait until someone is so compromised that the et al., 2006; DeVita & Winters, 2014; Donaldson et al.,
only choice is to call a code. The fact that in many facil- 2009; Salamonson, van Heere, Everett & Davidson, 2006;
ities, families can also activate the team has the potential Jones et al., 2006; Shapiro et al., 2010) and nursing care

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The Questions of RRT Measurement Salvatierra et al.

environments have been linked to better patient out- the skills of the RRTs and promotes the medical-surgical
comes and higher nurse satisfaction (Bagshaw et al., nurses early recognition of patient failure.
2010). RRTs have the potential to serve as a tool for helping
The existence of an RRT has the potential to improve nurses provide and deliver evidence-based treatment
nursing workflow, because nurses have an option for within the acute care environment. These teams should
higher-level assistance that did not previously exist in bring the latest evidence-based practice to the bedside,
the hospital setting. However, the effects that RRT role thus raising the knowledge and skill base of all nurses.
has on nursing workflow (process) and outcomes are not Several studies have identified the importance of hav-
well documented in the research literature. ing a well-defined triggering system or calling criteria by
RRTs enhance the importance of a floor nurses which nurses can base the decision to call the RRT. One
decisions and autonomy. Their very existence should of the frustrating aspects of the calling criteria relates to
encourage nurses to intervene earlier and more aggres- the inability of the different systems within the hospitals
sively, because now they have an option for doing so. to communicate with each other. For example, nurses
RRTs represent a patient-centered approach to care record patient vital signs into the nursing documentation
that depends on teamwork, collaboration, evidence- area, while laboratory results commonly populate a
based practice, and informaticskey elements in the different section of the electronic medical record (EMR);
Institute of Medicine (IOM) report (Institute for Health- rarely have these two sections communicated with one
care Improvement, 2009). The authors of the IOM report another. Recently the capability to access fully auto-
acknowledge the need for developing competencies mated, computerized data collection software that can
within new care delivery models. RRTs represent a analyze the triggers within different components of the
relatively new care delivery process whose effectiveness electronic medical records (EMR) has been suggested.
has the potential to be strengthened in almost every way, This capability would assist the bedside nurse and the
from standardization of calling criteria to the competen- RRT nurse in recognizing early clinical deterioration.
cies of team members. This makes the role of both the Ideally, RRTs should do more than just serve as a tool
RRT and the floor nurse more important, because they for helping nurses provide care and treatment to deteri-
are linked in a tight feedback loop in which neither suc- orating patients within the acute care setting. We should
ceeds without the success of the other. The best measures be measuring whether RRTs provide an opportunity to
of the benefits that RRTs provide include identifying and expand nursing skills and improve nursing confidence
measuring changes in the care delivery process, measur- through provision of education, application of evidence-
ing nurse satisfaction with RRTs, and establishing clear based practice, and improvement in documentation that
competencies. triggers RRT implementation.

Question 2: Do RRTs Provide an Opportunity Question 3: What Criteria for Membership

to Expand Nursing Skills and Improved Nursing and Training Should Exist for RRTs?
Confidence?
One area regarding the RRT staff that is not well
By definition, the RRT team is composed of people defined or described relates to team membership and
with a high level of specialty expertise. RRTs can be the skills required to be a team member. Possessing
composed of a variety of personnel; however, most in- excellent critical care skills does not translate to having
clude intensive care unit nurses. The clinical implications excellent teaching skills, yet both are essential in the
of the RRT from a nursing standpoint extend beyond RRT role. One hospital found that the most effective
just assisting in emergency situations. RRT nurses are RRT nurses were those who had excellent critical care
in a position to also provide education and support for clinical skills, as well as excellent communication and
nurses on best responses to specific clinical situations. collaboration skills while also being comfortable teaching
In this role, RRTs may serve as a mobile educational others (Aiken, Clarke, Sloane, Lake, & Cheney, 2008).
resource from which every nurse can learn, thus offering Another study found that delays in activation were a
another real-life venue for skill improvement as well as result of poor interactions between the responding RRT
bringing evidence-based practice to the bedside. From nurse and the medical-surgical nurse (Braaten, 2015).
demonstrating infrequently used or new techniques to Despite these findings related to the need for clinical
sharpening patient evaluation skills, every RRT call is expertise and communication skills, there is no standard-
a potential teachable moment. Continuing education ized training or training requirement for RRT nurses and
targeting the detectors, responders, and all persons other personnel. Improving the function of the RRT calls
involved in providing care has the potential to enhance for developing a standardized approach in the training

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Salvatierra et al. The Questions of RRT Measurement

and education of RRT members. Standardization of RRTs systems, and patient outcomes. What that impact will be
would provide a unified process for education, which depends on what we can learn from measuring RRT
would ensure that RRT members are not only critical effects with an expanded yardstick. This article has
care experts but also are strong communicators and suggested four new questions that will provide structure
collaborators (Caricati et al., 2016). Researchers should for research in order to answer the question, Do RRTs
design studies that answer the question of what criteria work?
for membership and training should exist for RRTs, and
measure the outcomes on care and staff satisfaction.
Clinical Resources
r Agency for Healthcare Research and Quality. Rapid
Question 4: Do RRTs Provide an Enhanced Level
of Patient and Family Empowerment and response systems: https://psnet.ahrq.gov/primers/
Satisfaction? primer/4/rapid-response-systems
r Institute for Healthcare Improvement. Rapid
Patient satisfaction is recognized as an important, response teams: http://www.ihi.org/topics/
quantified criterion for quality of care. Therefore, patient- rapidresponseteams/pages/default.aspx
or family-activated RRTs provide a means for patients and r Resuscitation Central. Rapid response and medical
their families to summon assistance if they feel the level emergency teams: http://www.resuscitationcentral.
of response by the floor or charge nurse is not satisfactory. com/documentation/rapid-response-medical-
In our large, multicenter study (Salvatierra et al., emergency-team/
2014), all 10 of the hospitals supported family-activated
RRT, which aligns with characteristics of patient- and
family-centered care. Most patients expect a high level
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