Rapid Response System

An RRS is a hospital-wide structure that provides a safety net for deteriorating patients who have a mismatch between their clinical needs and the local resources available to manage them.

Indications

Contraindications

Principles

RRS are demonstrated to:

  • ↓ Incidence of cardiac arrest calls
  • ↓ Hospital mortality
  • ↑ Number of patients prescribed treatment limitations
  • Have no clear effect on ICU admission numbers

One-third of RRS activations occur in patients with end-of-life issues.

Presence of an RRS is required for hospital accreditation, and there should be:

  • An institution-specific model, balanced by:
    • Resources availability
    • Patient complexity
    • Patient acuity
  • Afferent limb
    Calling criteria and method of activation. May use variety of responses:
    • Vital signs
      • Degree of abnormality
      • Aggregate scoring systems
    • Other observations
      e.g. Pain, urine output.
    • Family or staff concern
  • Efferent limb
    Response team. Considerations:
    • Team composition
      • Multi-disciplinary preferred
      • Nursing involvement essential
      • Nurse-led teams may be equivalent to medical-led teams
    • Graded escalation
      Pace of escalation balances resource use against missed deterioration.
    • Inclusion of primary team
  • Administrative limb
    Manages day-to-day running of the RRS.
  • Outcomes evaluation and QI limb
    Addresses QI and governance issues.

Early Warning Scores

In-hospital cardiac arrest is heralded by a deterioration in other physiological parameters in ~80% of cases. Early warning scores:

  • Are a system response to improve the needs-resources mismatch
  • Have a variety of formulations
    • Score based on single measurement outside of a “normal” range
    • Weighted score based on number and degree of abnormal measurements
      May be a better discriminator of outcome.

Modification to Calling Criteria

Modification of criteria is:

  • Required to prevent a system becoming over-sensitive
  • Necessary because scores do not adapt to individual variation and chronic disease states
    One size does not fit all.
  • Highly variable between institutions

Practice

The goals of an RRS team response should be to:

The RRS team is often ad-hoc, with unacquainted members, in an unfamiliar ward environment.

  1. Rapidly assess adequacy of airway, breathing, and circulation
  2. Establish or confirm a provisional diagnosis
  3. Ensure events of review are documented, including:
    • Diagnosis
    • Plan
    • Proposed investigations and interventions
    • Follow-up plan
  4. Communicate cause of deterioration
    • To next of kin
    • To parent unit
  5. Support ward staff
  6. Determining disposition

Complications

Key Studies

References

  1. CICM & ANZICS. IC-25 Joint Position Statement on Rapid Response Systems in Australia and New Zealand and the Roles of Intensive Care. 2016.
  2. Advanced Life Support Level 2 Third Australian Edition. Australian Resuscitation Council. 2016.