ICU without Borders: We Reached out and MET them

Abstract

Rapid response systems and MET teams are now recognised as integral components of patient safety measures in health care. While their roles have continued to evolve over the last two decades, most healthcare systems have adopted a model of ICU-led MET teams. We review the current role of ICU-led MET teams within the healthcare ecosystem, including their scope, structure, governance, and contribution to system-wide quality and safety approaches. We also explore the increasing input of rapid response systems into areas of health care not within the traditional remit of intensive care medicine, from end-of- life decision-making to clinical governance, and the increasing reliance of ward-based teams on support from their colleagues in ICU to provide safe, high-quality patient-centric care in modern healthcare systems.

1. Introduction

Data from many health systems worldwide suggest that 15–20% of hospitalised patients develop serious adverse events [1, 2]. Up to 80% of these adverse events are preceded by physiological and biochemical derangements that can occur over hours and sometimes days [3, 4, 5]. Furthermore, many adverse events leading to significant deterioration, including unplanned admissions to intensive care unit (ICU), in-hospital cardiac arrest, and unexpected death, may be due to delays or deficiencies in medical management prior to deterioration, meaning that the majority of these may be preventable [1, 2, 6].

Efforts to minimise harm from such incidents and enhance patient safety during hospital admission have become a cornerstone of patient-centric care in healthcare systems worldwide. Beginning with dedicated cardiac arrest teams, solutions to this problem have been in evolution for over two decades now, and varying nomenclatures—Rapid Response Team (RRT), Critical Care Outreach Team (CCOT), and Medical Emergency Team (MET)—are in use in different parts of the world.

Patient deterioration itself is a complex phenomenon and the nature and trajectory of patient deterioration—whether due to natural trajectory of disease, or errors of omission or commission during medical management—is often dependent on the patient population being served by the health service.

Furthermore, there is considerable heterogeneity in personnel, resources, and equipment available to any health service, and this is reflected in the thresholds at which such emergency responses are triggered for patients, the personnel available to provide a meaningful response, and the nature of the response (interventions, outcomes and dispositions). Detailing every possible scenario is outside the scope of this chapter.

In the interests of uniform nomenclature, this chapter will refer to all physiologic deteriorations triggering a health system response as rapid response system (RRS) activations, the responding teams as Medical Emergency Teams (MET team), and primarily consider health services with access to intensive care (ICU) facilities.

2. We reached out and MET

General hospital wards are not staffed or equipped to provide intensive observations and treatments available in critical care areas such as ICU, high dependency units (HDU), emergency departments (ED), or operating theatres (OR). The intent behind rapid-response systems is to identify and respond to patients outside the critical care environment who are at risk of progressing to a serious adverse event such as cardiac arrest, unanticipated ICU admission, or death [7].

2.1 Why have we MET?

Nearly 90% of patients who needed RRS activation were also reviewed by the home teams in the 24 hours preceding this [7]. Interestingly, patients receiving only a home team review prior to RRS were likelier to have higher mortality than if they had a recent ICU review or had recently been discharged from a critical care area [7]. There was little influence of availability of the home team on the likelihood of patients triggering RRS, as evidenced by the day (weekday versus weekend) or time (business hours versus after hours), or on disposition of patients by the MET teams [8, 9].

MET teams and RRS represent an intuitively simple concept: When a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to the bedside to immediately assess and treat the patient with the goal of preventing ICU transfer, cardiac arrest, or death. This is a step forward from “cardiac arrest” or “Code Blue” teams, which can only be summoned after cardiopulmonary arrest occurs, with accompanying high mortality and morbidity. MET teams, on the other hand, intervene during the critical period of deterioration on patients in general medical and surgical wards [10].

RRS have become integral to the culture of patient safety in healthcare services across the world. The National Health Service (NHS) in UK has been at the forefront of safety culture in health care. The Royal College of Physicians developed the National Early Warning Score (NEWS) to standardise identification of patients at risk of deterioration in hospital. The Australian Commission on Safety and Quality in Health Care (ACSQHC) determines the National Safety and Quality Health Service Standards (NSQHSS) that all Australian health services must meet for accreditation, of which Standard 8 (“Recognising and Responding to Acute Deterioration Standard”) aims to ensure that a person’s acute deterioration is recognised promptly and appropriate action is taken [11]. In the United States, the Joint Commission Centre for Transforming Healthcare, which also focuses on accreditation of healthcare organisations, has incorporated RRS into the National Patient Safety Goals [12]. The worldwide movement has coalesced into the International Society for Rapid Response Systems (ISRRS), a forum where medical, nursing, managerial, and administrative expertise is shared to improve detection and prevention of patient deterioration, with the goal of improving patient safety in hospitals [13].

2.2 Who have we MET?

MET teams respond to RRS activations in patients admitted to a hospital’s non-critical care areas. Thus, the patient population encountered in RRS is reflective of the inpatient population, which can vary between health services.

Physiologic thresholds for RRS activation, too, are reflective of the variations in populations of inpatients. An interesting result has been guidance received by ward teams when recording physiologic observations of their patients using (usually colour-coded) “track and trigger” charts (electronic or paper-based), prompting ward nursing staff to activate RRS as per local protocol (e.g. “Between the Flags” observation charts used in New South Wales and “Observation Recording Charts” used in Victoria, Australia) once critical physiologic thresholds are breached. Electronic records further facilitate calculation of early warning scores such as the National Early Warning Score, version 2 (NEWS2) in the National Health Service (NHS) Trusts in UK, the Modified Early Warning Score (MEWS), and the Canadian Hamilton Early Warning Score (HEWS).

Track and trigger charts have further been refined for specific patient subsets, e.g. The age-specific Victorian Children’s Tool for Observation and Response (VicTOR) charts introduced by the Royal Children’s Hospital in Melbourne, Australia, to record paediatric vital signs and the Maternity Observations Recording Chart (M-ORC) widely used in Victoria, Australia, to detect deterioration in obstetric patients.

Patients needing RRS activation represent a very small fraction of patients admitted to hospital. However, they represent disproportionately higher resource use, with increased length of stay, high likelihood of unplanned ICU interventions, and greater odds of poorer (death or ongoing care) outcomes (OR 5.5) compared to patients admitted to hospital with similar diagnoses. Hospital mortality increases significantly after the age of 50 and rises rapidly for every decade in age [8, 14]. In-hospital mortality rates as high as 15% (for patients with no limitations on therapy) to 50% (for patients with limitations on care) have been quoted [15].

2.3 What is different now we have MET?

While initial smaller studies [16, 17] indicated that introduction of RRS and MET teams could reduce incidence of unexpected cardiac arrests and hospital mortality, larger multicentre studies like MERIT [18] and subsequent systematic reviews have failed to corroborate this effect [19, 20].

Rapid response systems have come to exemplify the tension between those arguing for swift implementation of conceptually attractive patient safety interventions supported by anecdotal evidence of benefit and those advocating a more rigorous, evidence-based, and inevitably slower, approach [10].

Despite failure to demonstrate direct reduction in unexpected hospital mortality, “before and after” studies support the notion that RRS is of benefit through improvements in multiple surrogate measures—respiratory failure, stroke, severe, sepsis, acute renal failure needing renal replacement, unplanned ICU admissions, perioperative deaths, and postoperative LOS in hospital [21]. There has also been a sustained and progressive reduction in the number of in-hospital cardiac arrests [22], which, in themselves, are a major cause of unexpected in-hospital mortality.

While the MERIT study and multiple subsequent studies [8, 18, 23, 24, 25] did demonstrate a significant increase in RRS activations in every health service where such systems have been introduced, one of the significant benefits has been a marked increase in support and uptake by nursing staff. The advantages from this cultural change within the healthcare system are difficult to quantify, but sustained focus on patient safety through early detection and escalation of patient deterioration can only be considered beneficial [25, 26].

About 20% RRS calls occur in patients with pre-existing end-of-life issues and another 10% identify end-of-life issues at the MET [15]. It is unclear whether identification of patients at end-of-life or with significant deterioration at end-of-life through RRS has made any material difference to care delivery at end-of-life [9].

2.4 How soon should we have MET?

About a quarter of RRS activations occur within 24 hours of admission to hospital [27, 28]. ED patients admitted with respiratory conditions, myocardial infarction, or sepsis are at modestly increased risk for unplanned ICU transfer. While they may benefit from better triage from the ED, earlier intervention, or closer monitoring to prevent acute decompensation [29], decisions to discharge from ED to the ward are often made under time constraints based on clinical acumen alone rather than evidence-based guidelines [30]. While these may reflect suboptimal triage before ward transfer, the associated mortality is low [8, 28].

In contrast, RRS activations later in the course of the hospital admission are associated with high mortality [28]. Having the first RRS activation more than 24 hours of admission to hospital is an independent predictor of both increased hospital mortality and length of stay [8]. Initial RRS activation after 48 hours of hospital admission is associated with significantly higher risk of in hospital mortality (OR 1.47) compared to MET calls within 24 hours of admission [8]. Whether these represent disease progression, failure to respond to therapy, suboptimal end-of-life planning, or nosocomial complications is poorly understood.

2.5 We MET again!

Recurrent clinical deterioration and repeat medical emergency team activation are common and associated with increased risk of subsequent ICU admission, increased hospital length of stay, and increased hospital mortality. It may be possible to identify patients at risk of recurrent clinical deterioration following medical emergency team activation and target interventions to improve patient care [31].

These patients often represent substantial resource use for MET teams, are often frail, and have significant comorbidities. The greater the number of MET calls, the higher the levels of frailty and comorbidities (Figure 1) [14]. This may represent inadequate management of clinical problems in the ward or suboptimal end-of-life planning, as many have significant treatment limitations in place at the time of RRS activation.

Figure 1.

Box-and-whiskers plot of burden of comorbidities (Charlson score) and frailty (Clinical Frailty Score, CFS) in patients with multiple MET calls. Patients triggering more MET calls have higher comorbidity burden and frailty. (Reproduced with permission from: [14]).

Figures 2 and 3 [14] demonstrate that while poor outcomes (death or ongoing care) are relatively rare amongst hospital admissions, these outcomes are far likelier in the patients having MET calls. Compared to admissions not associated with RRS, having even one MET call during the admission significantly increases risk of poor outcomes (OR 3.3), while having more than one MET call increases risk of poor outcome substantially beyond this (OR 15.7). In general, having any MET call during an admission increases likelihood of poor outcome (OR 5.5) (Figure 4) [14].

Figure 2.

Death or need for ongoing care after hospital discharge is likelier in the population needing MET calls during the course of their hospital admission. (Reproduced with permission from: [14]).

Figure 3.

Likelihood of dying or needing ongoing care is higher in patients needing multiple MET calls than those needing a single MET call. (Reproduced with permission from: [14]).

Figure 4.

Patients needing a MET call are likelier to have a poor outcome (death or need for ongoing care) than those who do not (OR5.5). A single MET call increases likelihood of poor outcome (OR3.3) but multiple MET calls increase the risk much more (OR 15.7). (Reproduced with permission from: [14]).

MET teams generally triage patients without limitations on medical therapy well [32]. After the second MET call, if escalation of care does not occur, further RRS activations do not significantly change disposition from MET call or hospital outcome (Figures 4 and 5) [14].

Figure 5.

If escalation does not occur at the 2nd MET call, subsequent RRS calls do not change disposition or hospital outcomes. (Reproduced with permission from: [14]).

3. Anatomy of a MET system

The minimum standards for ICU-based RRS have been laid out by the College of Intensive Care Medicine of Australia and New Zealand (CICM) [33]. In conjunction with the Joint Position Statement with the Australian and New Zealand Intensive Care Society (ANZICS) [34], it lays the framework for RRS in Australia and New Zealand. Further jurisdictional regulatory requirements for health services, including governance and reporting structures, are laid out by state-wide bodies such as Safer Care Victoria [35] and the Clinical Excellence Commission in New South Wales.

The CICM-ANZICS position acknowledges that there is no clear evidence for the best model for RRS and suggests that the model employed by individual institutions must consider the resources available and the complexity and acuity of the patient mix. Whilst RRS must enhance the ability of all hospital staff to anticipate, identify, and manage patients at risk of deterioration, it may use variable combinations of ward and non-ward-based responders that best meet patient needs and ensure a continuum of patient care. Most hospitals adopt a multi-tiered response and collaborative decision-making between ICU and primary admitting or “home” teams is encouraged. RRS systems working in isolation from home teams are discouraged, as these may conceal underlying systemic contributors to patient deterioration such as staffing levels, inadequate training of ward staff, access to senior medical staff or clinical services, and culture issues resulting in premature or delayed transfer of patients from critical care areas like ED, ICU, and OR to the ward.

In most jurisdictions, RRS is multidisciplinary. It is useful to consider them as comprised of four limbs: (1) an afferent limb, which is the calling criteria and the method of activation, (2) an efferent limb, which is the rapid response team (RRT) itself, (3) an administrative limb, which is responsible for the day-to-day running of the RRS, and (4) the quality improvement and governance limb which addresses system and clinical factors contributing to deterioration.

3.1 The afferent limb

In Victoria, Australia, where RRS activation occurring every 15.9 minutes [35], there is high demand for MET team services.

The optimal set of calling criteria for RRS has not been definitively identified, and there is significant variability in practise between individual institutions, which opt for thresholds and systems to suit their patient populations and staffing. As a general principle, having excessively high thresholds for triggering RRS activations is potentially unsafe for the deteriorating patient and defeats the purpose of RRS activation. While modification of calling criteria, to account for chronic disease and individual patient needs, has also not been validated for safety, there is sound clinical rationale for the practise. It is recommended that modifications to calling criteria for individual patients should involve senior clinicians [34].

Staff involved in RRS are familiar with the A-B-C paradigm in resuscitation, and it may be helpful to consider RRS triggers in the same light, with thresholds individualised to health services to reflect capabilities and inpatient populations.

1. Airway: Impending or actual threat to airway is universally recognised as an emergency in every health system, and it is reasonable to activate RRS for immediate expert assessment and management by an RRS team with airway expertise and equipment.

   An occluded airway is frequently followed by cardiorespiratory arrest and is clear grounds for a Code Blue

2. Breathing: Tachypnoea (with or without significant increase in work of breathing) and bradypnea (with or without progressive decrease in respiratory effort) may or may not accompany hypoxia, signified by reduced oxygen saturations (detectable with ward-level monitoring devices like pulse oximeters) or increasing oxygen requirements.

   Respiratory distress is often a harbinger of physiologic compromise and comes with approximately doubling (OR 2.05) of risk of in-hospital mortality after MET call [8].

3. Circulation: Tachycardia, symptomatic bradycardia, and new arrhythmias are some of the commonest causes of RRS activation in most healthcare services.

   Chest pain in at-risk populations as a symptom of myocardial infarction, pulmonary embolus, or respiratory infection merits immediate attention.

   Hypotension has long been recognised as a marker of shock and is also a common trigger for MET calls. Hypertension with malignant symptoms is a significant cause for concern. Hypertension may be of high significance in specific populations like obstetric patients.

   Paradoxically, given the traditional focus on cardiovascular parameters for shock, recognition and familiarity with resuscitation protocols often leads to successful resuscitation from cardiovascular compromise prior to progressing to cardiac arrest [8].

4. Disability/altered neurology: Acute alterations in cognition and neurology may not just signify time critical emergencies like stroke or seizures, they may also be early signs of a diverse range of pathologies from sepsis to intoxication, substance withdrawal, delirium, and metabolic encephalopathy. Neurologic emergencies can approximately double (OR 1.83) risk of in-hospital mortality after MET call [8], and, given the diversity of precipitants, early escalation and senior clinician assessments available through RRS activation may be life-saving.

   Other/worry-Not every patient deterioration fits neatly into a system-specific paradigm reflected by abnormal vital signs for RRS activation. It has long been recognised that extreme worry by bedside clinical staff merits immediate senior medical review and is grounds for calling the MET team. Recent studies have tried to evaluate and quantify “Worry” in the context of physiologic deterioration of patients [36].

The influence of the indication for MET on in-hospital mortality at a university-linked metropolitan teaching hospital in Australia is shown in Figure 6 [8].

Figure 6.

Odds ratios of death due to various triggers for RRS. Higher chances of dying when the triggers for the RRS were respiratory distress or altered level of consciousness. (Reproduced with permission from: [8]).

3.2 The efferent limb

The efferent limb describes the responding clinician team and is often determined by the expertise immediately available. In Australasian hospitals with ICUs, it is common for ICU clinical staff to be members of the responding team. In centres without an ICU, the team may be led by either senior nurses, senior medical, or junior medical staff [34]. In North America, hospitalists are increasingly becoming an integral component of RRS, often leading the MET team [10]. The CICM document acknowledges that in hospitals with an ICU, the immediate availability of an ICU team to attend and initiate appropriate life-supportive measures on the ward represents the highest level of patient safety attainable, while recognising that other institution-specific system arrangements may also provide a level of patient safety [33].

The following aspects of the efferent limb are worth considering [33].

1. Staffing: Management of critically ill patients outside the ICU has increasingly become part of ICU core business and is a recognised part of core ICU training. A response time of less than 10 minutes would be typically expected from an ICU team in a large hospital.

   The MET team should be overseen at all times by a specialist in intensive care, immediately available for advice to the ICU RRS responders and to attend to the RRS call where specialist expertise is required.

   While units should ensure attendance of ICU medical staff to RRS calls, “Out of ICU Roles” must not compromise care of the patients within ICU. Trainees and non-specialist medical officers in both ICU and in the RRS teams must have adequate intensivist supervision available at all times.

   All ICU-based RRS should have at least one experienced ICU senior nurse available to attend RRS calls. Their attendance in RRS calls must not compromise nursing care of patients within the ICU.

   Hospitals averaging 2000 or more RRS calls per annum should roster an ICU medical officer and nurse separate to the main ICU treating team exclusively for RRS and have a separate specialist roster for RRS oversight.

   The “admitting” team is most familiar with the patient and holds primary responsibility for the patient. This team should have a designated medical officer who is immediately contactable for notification of RRS activation and for involvement in discussions with the ICU MET team members regarding appropriate patient management. Ideally, the afferent limb activation should also alert these doctors about the occurrence of the call in their patient so that they can attend the call in-person.

2. Education: The hospital should have a documented educational program for RRT members.

   The required skill set for ICU staff should focus on knowledge. Technical and non-technical skills and leadership skills should be taught, ideally in the context of immersive team training.

   Success of the RRS requires clinical teams from the RRS and the primary team to work in partnership to ensure timely review and continuity of clinical care. Such an approach has the greatest potential to enhance the skill set of members of each team and ensures that the RRS does not mask organisational problems in the patient’s management.

   Education should include the ward-based staff (who are responsible for initiating RRS calls) so both the afferent and efferent limbs of the RRS are effective.

   In hospitals admitting paediatric and obstetric patients, RRT members should undergo specific education in the management of paediatric, neonatal, and obstetric emergencies.

3. Operational requirements: An ICU-based RRS must meet any national criteria set out for such systems.

   An ICU specialist should be nominated as the clinical lead, with appropriate delegated responsibility from the hospital executive providing clinical governance and representing the RRS on relevant hospital committees (e.g. clinical quality, safety, and governance committee), with adequate support from hospital administrative staff employed for quality improvement.

   The clinical lead should meet regularly with nurses and doctors to ensure that the system is running effectively and to resolve problems with the responding team, if any.

   A prospective data collection and evaluation process must be in place and adequately resourced to provide timely and data-driven evaluation of performance that aims to improve the response and outcomes for deteriorating patients.

4. Equipment: The type and quantity of equipment and medications will vary with the type, size, and function of the RRS and must be appropriate to the workload of the MET team as judged by contemporary standards.

   There must be a regular system in place for replacement and checking the safety of equipment. Protocols and in-service training for medical and nursing staff need to be available for the use of all equipment, including steps to be taken in the event of malfunction. Portable equipment for mechanical ventilation and monitoring of ventilation, respiratory, and circulatory status must be available for RRS patient transports.

   Suggested equipment and medication lists for RRT can be found in the ANZICS and CICM Joint Position Statement on Rapid Response Systems in Australia and New Zealand and the Roles of Intensive Care [34]. Published data suggests RRS efferent limbs in ICU-based systems are good at risk stratification and triage of deteriorating inpatients [32].

3.3 Governance

The governance guidelines from Safer Care Victoria (SCV) [37] concur with CICM and ANZICS guidelines. There are similar principles embedded in other Australasian jurisdictions regarding the establishment of integrated systems, processes, leadership, and culture central to providing safe, effective, accountable, and person-centred care, underpinned by continuous improvement.

At a minimum, RRS must

• Demonstrate compliance with National Safety and Quality Health Service (NSQHS) Standard 8

• Have organisational-level recognition and response governance systems driven by medical lead/s (i.e. heads of unit or equivalent)

• Have clearly defined roles and responsibilities for those involved in the recognition and response system at both organisational and ward level

• Have clear expectations of attending clinician/team accountability within the recognition and response system

• Have clear rapid response escalation policy/policies

• Promote engagement of the attending clinician/team in the recognition and response escalation policies and procedures

• Define organisational clinical indicators for the recognition and response system

• Have a recognition and response system with audit and review processes in place

• Have specific timelines for recognition and response system data collection and data review

• NSQHS Standard 8 (deteriorating patient) committee and/or rapid response team operational lead undertaking risk review and identifies gaps for improvement.

Additional desirable features include

• Hospital executive sponsor to set expectations of engagement

• NSQHS Standard 8 (deteriorating patient) committee including a broad range of multidisciplinary staff

• Standardised process for goals of care/resuscitation planning, including promotion and assistance for patients/families/carers to undertake advanced care planning

• Statewide and national benchmarking of recognition and response systems

• Organisational commitment to recognition and response systems through specific key performance indicators (KPI)

• Support and resource governance staff and clinicians to improve the recognition and response system

• Putting contingency processes, involving attending clinicians/teams in place to guide management of multiple demands on the recognition and response system (e.g. more than one rapid response call occurring at one time)

• Local minimum recognition and response system training requirements

• Ensuring bedside clinicians have adequate assessment skills with regular training updates to maintain skill level

• Development of guidelines for the management of common deterioration syndromes

• Regular multidisciplinary education sessions addressing common deterioration syndromes aimed at bedside clinicians, specific to clinical area.

3.4 Quality and improvement

Communication and feedback between operational, governance, and quality improvement arms of the health service are key for successful implementation of site-specific improvement measures.

RRS involves personnel who do not usually work together assessing and managing the sickest inpatients, often in unfamiliar areas outside of critical care, in a time-critical fashion.

Communication between various elements of RRS, at bedside as well as organisation-wide, is critical for success. At a system level, minimum, communication should include

• Informing patients/families/carers on admission that there is a process for managing deterioration, including a consumer-triggered escalation process

• Open communication and documentation, regarding goals of care, occurs between the patient/family/carer and the attending clinician/team within 48 hours of admission

• Robust rapid response notification system, including notification of attending clinician/team

• Use of crisis management communication skills, such as closed-loop communication, shared mental model, recapping, and graded escalation when escalating and caring for a patient experiencing acute deterioration

• Development of attending clinician/team consultant notification guidelines for when a patient experiences acute deterioration

• Clear, accessible, and open communication with the patient/family/carer regarding patient deterioration and ongoing care from attending clinician/team

• Further review of goals of care, where appropriate, as soon as possible after acute deterioration.

Ideally, communication could also include

• Regular multidisciplinary education and training to support clinicians in the use of crisis management communication skills

  Open discussion and joint decision-making between patient/family/carer, attending clinician/team and rapid response team about ongoing care, especially after repeated RRS activations.

Tiered systems of individual and systemic communication then form the basis of a feedback loop between health consumers, admitting medical staff, ward nursing staff, ICU-based MET team personnel, and organisational staff including personnel in governance, quality improvement, and executive roles. At a bare minimum, the feedback process should

• Be a two-way process that occurs in a “just culture” and focuses on overall improvement of the recognition and response system

• Ensure bedside clinicians are satisfied with the call outcome and plan prior to completion of the RRS

• Ensure debriefing is available post rapid response calls as required

• Ensure clinicians attending the RRS can review performance and system functions, with the aim of system improvement

• Ensure consistent recognition and response system data collection, analysis, and reporting

• Be facilitated by Standard 8 committee/lead, with attending teams clinically reviewing their own rapid response calls to look for patterns and develop strategies for better clinical care

• Ensure individual units and/or wards review their own recognition and response data at morbidity and mortality meetings

• Ensure recognition and response system reports are made available to all clinicians (nursing and medical)

• Ensure feedback to attending clinicians/teams/wards includes recognition and response data and specific trends.

Ideally, feedback should

• Be multidisciplinary (including ward staff) at rapid response morbidity and mortality review sessions

• Involve the attending clinicians/teams involved in audit, review, and feedback of recognition and response systems

• Provide recognition and response system reports are made available to consumers in an accessible way

• Provide transparent, whole of organisation feedback that identifies trends across the health service (i.e. rapid response ground rounds, open access database)

• Have the ability to publicly report rapid response trends and patient outcomes to allow for benchmarking.

4. Conclusions

ICU-based MET teams have become the norm for RRS in hospitals that have ICU on site over the last couple of decades. Models using both ICU medical and nursing staff as primary responders have been successfully introduced.

The commonly accepted model consists of afferent (recognition and escalation at the ward/bedside), efferent (MET teams, often ICU-based, comprising skilled resuscitators with senior decision-making authority and with ability to access more specialised facilities, e.g. ICU), governance (general policy, procedure and oversight of RRS framework as well as jurisdiction and organisation-specific compliance roles), and quality improvement (data gathering, reporting, and benchmarking) arms.

With widespread introduction of RRS, identification and escalation of care to critical care teams at an earlier point in the trajectory of physiologic deterioration means that therapies can be instituted pre-emptively within the general ward setting and only a small proportion of inpatients who trigger an RRS then actually need ICU admission for further management. Measures of patient safety such as unplanned ICU admissions and unexpected cardiac arrests, with attendant high mortality and morbidity, have shown measurable reductions consistently as RRS has become widespread. RRS also provides opportunities to identify patients with significant disease progression, failures to respond to therapy, inadequacies in triage prior to ward transfer, and suboptimal end-of-life planning.

An unavoidable consequence has been the progressive engagement of ICU staff in the governance, organisation, and processes across the remainder of the hospital and in areas not within the traditional remit of ICU medicine. This is a significant change to both care delivery responsibilities and hospital culture. Like all major change, this comes with potential barriers due to entrenched practices and cultures within health systems and these need to be negotiated sensitively and appropriately for the RRS system to successfully provide the intended safety net to patient care in healthcare.

Acknowledgments

The author would like to gratefully acknowledge the work done by the ICU Liaison Nurse Team at Werribee Mercy Hospital for their assistance in data collection and entry and members of the Deteriorating Patient Committee, the organisational governance committee with oversight of the policy and procedure framework relating to NSQHS Standard 8, Mercy Health, Victoria.

Conflict of interest

The author declares no conflict of interest.

Notes/thanks/other declarations

No specific funding was received for this project.