Effectiveness of rapid response teams in reducing intrahospital cardiac arrests and deaths: a systematic review and meta-analysis

Rocha, Hermano Alexandre Lima; Alcântara, Antônia Célia de Castro; Rocha, Sabrina Gabriele Maia Oliveira; Toscano, Cristiana Maria

doi:10.5935/0103-507X.20180049

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REVIEW ARTICLE • Rev. bras. ter. intensiva 30 (3) • Jul-Sept 2018 • https://doi.org/10.5935/0103-507X.20180049 copy

Effectiveness of rapid response teams in reducing intrahospital cardiac arrests and deaths: a systematic review and meta-analysis

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To evaluate the effectiveness of rapid response teams using early identification of clinical deterioration in reducing the occurrence of in-hospital mortality and cardiorespiratory arrest.

Data sources:

The MEDLINE, LILACS, Cochrane Library, Center for Reviews and Dissemination databases were searched.

Study selection:

We included studies that evaluated the effectiveness of rapid response teams in adult hospital units, published in English, Portuguese, or Spanish, from 2000 to 2016; systematic reviews, clinical trials, cohort studies, and prepost ecological studies were eligible for inclusion. The quality of studies was independently assessed by two researchers using the Newcastle-Ottawa, modified Jadad, and Assessment of Multiple Systematic Reviews scales.

Data extractions:

The results were synthesized and tabulated. When risk measures were reported by the authors of the included studies, we estimated effectiveness as 1-RR or 1-OR. In pre-post studies, we estimated effectiveness as the percent decrease in rates following the intervention.

Results:

Overall, 278 studies were identified, 256 of which were excluded after abstract evaluation, and two of which were excluded after full text evaluation. In the meta-analysis of the studies reporting mortality data, we calculated a risk ratio of 0.85 (95%CI 0.76 - 0.94); and for studies reporting cardiac arrest data the estimated risk ratio was 0.65 (95%CI 0.49 - 0.87). Evidence was assessed as low quality due to the high heterogeneity and risk of bias in primary studies.

Conclusion:

We conclude that rapid response teams may reduce in-hospital mortality and cardiac arrests, although the quality of evidence for both outcomes is low.

Keywords:
Patient care team; Rapid response teams; Mortality; Heart arrest; Quality of health care; Systematic review

Databases	List of terms
MEDLINE (Pubmed)	#1 ("Hospital Rapid Response Team"[Mesh]) AND "Hospital Mortality"[Mesh] #2 ("Hospital Rapid Response Team"[Mesh]) AND "Heart Arrest"[Mesh]
Cochrane Library	(tw:("rapid response team")) AND (tw:("mortality hospital")) (tw:("rapid response team")) AND (tw:("cardiac arrest"))
Centre for Reviews and Dissemination	"rapid response team" AND “mortality” "rapid response team" AND “cardiac arrest”
LILACS	(rapid response team) or "RAPID RESPONSE TEAM" [Palavras] and (mortality) or "MORTALITY, HOSPITAL" [Palavras] (rapid response team) or "RAPID RESPONSE TEAM" [Palavras] and "PARADA CARDIO-RESPIRATORIA" [Palavras]

Article	Checklist	Final conclusion in the scale
McGaughey et al.⁽²³23 McGaughey J, Alderdice F, Fowler R, Kapila A, Mayhew A, Moutray M. Outreach and Early Warning Systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards. Cochrane Database Syst Rev. 2007;(3):CD005529.⁾	AMSTAR	All items were yes
Chan et al.⁽²⁴24 Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Rapid response teams: a systematic review and meta-analysis. Arch Intern Med. 2010;170(1):18-26.⁾	AMSTAR	No explicit question does not present the record of meta-analysis
Maharaj et al.⁽²⁵25 Maharaj R, Raffaele I, Wendon J. Rapid response systems: a systematic review and meta-analysis. Crit Care. 2015;19:254.⁾	AMSTAR	All items were yes
Salvatierra et al.⁽²⁶26 Salvatierra G, Bindler RC, Corbett C, Roll J, Daratha KB. Rapid response team implementation and in-hospital mortality. Crit Care Med. 2014;42(9):2001-6.⁾	Jadad	8 points (inappropriate concealment)
Ludikhuize et al.⁽²⁹29 Ludikhuize J, Brunsveld-Reinders AH, Dijkgraaf MG, Smorenburg SM, de Rooij SE, Adams R, de Maaijer PF, Fikkers BG, Tangkau P, de Jonge E; Cost and Outcomes of Medical Emergency Teams Study Group. Outcomes Associated With the Nationwide Introduction of Rapid Response Systems in The Netherlands. Crit Care Med. 2015;43(12):2544-51.⁾	NOS	7 stars (poor comparability)
Buist et al.⁽³⁴34 Buist MD, Moore GE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study. BMJ. 2002;324(7334):387-9.⁾	Jadad	6 points (inappropriate concealment)
DeVita et al.⁽³⁵35 DeVita MA, Braithwaite RS, Mahidhara R, Stuart S, Foraida M, Simmons RL; Medical Emergency Response Improvement Team (MERIT). Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Qual Saf Health Care. 2004;13(4):251-4.⁾	NOS	7 stars (poor comparability)
Priestley et al.⁽³⁶36 Priestley G, Watson W, Rashidian A, Mozley C, Russell D, Wilson J, et al. Introducing Critical Care Outreach: a ward-randomised trial of phased introduction in a general hospital. Intensive Care Med. 2004;30(7):1398-404.⁾	Jadad	5 points (inappropriate randomization and concealment)
Jones et al.⁽³⁷37 Jones D, Bellomo R, Bates S, Warrillow S, Goldsmith D, Hart G, et al. Long term effect of a medical emergency team on cardiac arrests in a teaching hospital. Crit Care. 2005;9(6):R808-15.⁾	Jadad	6 points (inappropriate concealment)
Hillman et al.⁽³⁸38 Hillman K, Chen J, Cretikos M, Bellomo R, Brown D, Doig G, Finfer S, Flabouris A; MERIT study investigators. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet. 2005;365(9477):2091-7. Erratum in Lancet. 2005;366(9492):1164.⁾	Jadad	6 points (inappropriate concealment)
Dacey et al.⁽³⁹39 Dacey MJ, Mirza ER, Wilcox V, Doherty M, Mello J, Boyer A, et al. The effect of a rapid response team on major clinical outcome measures in a community hospital. Crit Care Med. 2007;35(9):2076-82.⁾	Jadad	8 points (inappropriate concealment)
Chan et al.⁽⁴⁰40 Chan PS, Khalid A, Longmore LS, Berg RA, Kosiborod M, Spertus JA. Hospital-wide code rates and mortality before and after implementation of a rapid response team. JAMA. 2008;300(21):2506-13.⁾	Jadad	8 points (inappropriate concealment)
Konrad et al.⁽⁴¹41 Konrad D, Jäderling G, Bell M, Granath F, Ekbom A, Martling CR. Reducing in-hospital cardiac arrests and hospital mortality by introducing a medical emergency team. Intensive Care Med. 2010;36(1):100-6.⁾	Jadad	8 points (inappropriate concealment)
Beitler et al.⁽⁴²42 Beitler JR, Link N, Bails DB, Hurdle K, Chong DH. Reduction in hospital-wide mortality after implementation of a rapid response team: a long-term cohort study. Crit Care. 2011;15(6):R269.⁾	NOS	7 stars (poor comparability)
Gonçales, et al.⁽⁴³43 Gonçales PD, Polessi JA, Bass LM, Santos GP, Yokota PK, Laselva CR, et al. Redução de paradas cardiorrespiratórias por times de resposta rápida. Einstein (São Paulo). 2012;10(4):442-8.⁾	Jadad	8 points (inappropriate concealment)

Studies	Study design/population	Outcome	Results	Study limitations	Effectiveness (%)	Quality of evidence
McGaughey et al.⁽²³23 McGaughey J, Alderdice F, Fowler R, Kapila A, Mayhew A, Moutray M. Outreach and Early Warning Systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards. Cochrane Database Syst Rev. 2007;(3):CD005529.⁾	Systematic review Studies published between 1996 and June 2006 Outcome: mortality Intervention: Introduction of early warning scores by RRT	Mortality	Reduction in mortality	Only two studies were examined; did not conduct economic analyses	Reduction in mortality	Moderate
Chan et al.⁽²⁴24 Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Rapid response teams: a systematic review and meta-analysis. Arch Intern Med. 2010;170(1):18-26.⁾	Systematic review and meta-analysis Studies published between 01 January 1950 and 31 November 2008 Outcome: mortality and cardiopulmonary arrest Intervention: Introduction of RRT	Mortality Cardiac arrest	RR 0.96 (95%CI 0.84 - 1.09) RR 0.66 (95%CI 0.54 - 0.80)	Did not analyze data at the individual level; academic centers were used in most studies reviewed	4% (95%CI -9 - 16) 0.34 (95%CI 0.20 - 0.46)	Moderate
Maharaj et al.⁽²⁵25 Maharaj R, Raffaele I, Wendon J. Rapid response systems: a systematic review and meta-analysis. Crit Care. 2015;19:254.⁾	Systematic review and meta-analysis Studies published between 01 January 1990 and 31 November 2013 Outcome: mortality and cardiopulmonary arrest Intervention: Introduction of RRT	Mortality Cardiac arrest	RR 0.87 (95%CI 0.81 - 0.95) (p < 0.001) RR 0.65 (95%CI 0.61 - 0.70) (p < 0.001)	Did not analyze data at the individual level	13% (95%CI 5 - 19) 35% (95%CI 30 - 39)	Moderate
Salvatierra et al.⁽²⁶26 Salvatierra G, Bindler RC, Corbett C, Roll J, Daratha KB. Rapid response team implementation and in-hospital mortality. Crit Care Med. 2014;42(9):2001-6.⁾	Before-after study Adult patients Intervention: Introduction of medical emergency teams in 10 hospitals in Washington over 31 months, 235344 patients Control: 235718 patients before intervention	Mortality	RR 0.76 (95%CI 0.72 - 0.80)	Used historical controls	24% (95%CI 20 - 28)	Low
Ludikhuize et al.⁽²⁹29 Ludikhuize J, Brunsveld-Reinders AH, Dijkgraaf MG, Smorenburg SM, de Rooij SE, Adams R, de Maaijer PF, Fikkers BG, Tangkau P, de Jonge E; Cost and Outcomes of Medical Emergency Teams Study Group. Outcomes Associated With the Nationwide Introduction of Rapid Response Systems in The Netherlands. Crit Care Med. 2015;43(12):2544-51.⁾	Before-after study Adult patients Intervention: The implementation of RRS was divided into two phases. First, the MEWS (Modified Early Warning Score) and the SBAR communication tools were administered; then after 7 months, RRTs were implemented in 12 Dutch hospitals, 29560 admissions Control: 28298 admissions	Mortality Cardiac arrest	OR 0.80 (95%CI 0.64 - 1.00) OR 0.60 (95%CI 0.39 - 0.93)	Used historical controls	20% (95%CI 0 - 36) 40% (95%CI 7 - 61)	Low
Buist et al.⁽³⁴34 Buist MD, Moore GE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study. BMJ. 2002;324(7334):387-9.⁾	Before-after study Adult patients in American hospitals with 300 beds Intervention: Introduction of rapid response teams Controls: historical, 19317 admissions	Cardiac arrest	OR 0.5 (95%CI 0.35 - 0.73)	Used historical controls	50% (95%CI 27 - 65)	Low
DeVita et al.⁽³⁵35 DeVita MA, Braithwaite RS, Mahidhara R, Stuart S, Foraida M, Simmons RL; Medical Emergency Response Improvement Team (MERIT). Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Qual Saf Health Care. 2004;13(4):251-4.⁾	Retrospective analysis of outcomes Adult patients in American hospitals with 622 beds Intervention: Introduction of objective criteria medical emergency team activation	Cardiac arrest	6.5 to 5.4/1000	Observational study; retrospective analysis with confounders that were difficult to control for	16%	Moderate
Priestley et al.⁽³⁶36 Priestley G, Watson W, Rashidian A, Mozley C, Russell D, Wilson J, et al. Introducing Critical Care Outreach: a ward-randomised trial of phased introduction in a general hospital. Intensive Care Med. 2004;30(7):1398-404.⁾	Clinical trial randomized by wards 16 wards in an 800-bed general hospital in England Outcome: mortality Intervention: Introduction of critical care service in wards	Mortality	OR 0.52 (95%CI 0.32 - 0.85)	Few hospitals participated; Hawthorne effect; contamination of controls; problems with data collection	48% (95%CI 15 - 68)	Moderate
Jones et al.⁽³⁷37 Jones D, Bellomo R, Bates S, Warrillow S, Goldsmith D, Hart G, et al. Long term effect of a medical emergency team on cardiac arrests in a teaching hospital. Crit Care. 2005;9(6):R808-15.⁾	Before-after study, analysis of three periods Adult patients in an Australian hospital with 400 beds Intervention: Introduction of medical emergency teams Controls: historical, 16246 admissions	Cardiac arrest	OR 0.47 (95%CI 0.35 - 0.62)	Used historical controls; not randomized or blinded; only one hospital was evaluated; cardiac arrest reduction mechanism was not revealed	53% (95%CI 38 - 65)	Low
Hillman et al.⁽³⁸38 Hillman K, Chen J, Cretikos M, Bellomo R, Brown D, Doig G, Finfer S, Flabouris A; MERIT study investigators. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet. 2005;365(9477):2091-7. Erratum in Lancet. 2005;366(9492):1164.⁾	Randomized trial Adult patients in 23 Australian hospitals Outcome: cardiopulmonary arrest and unexpected death Intervention: introduction of medical emergency teams Control: No introduction of medical emergency team	Mortality Cardiac arrest	OR 1.03 (95%CI 0.84 - 1.28) OR 0.94 (95%CI 0.79 - 1.13)	Variations found between hospitals were higher than was anticipated by the researchers	-3% (95%CI -28 - 16) 6% (95%CI -13 - 21)	Moderate
Dacey et al.⁽³⁹39 Dacey MJ, Mirza ER, Wilcox V, Doherty M, Mello J, Boyer A, et al. The effect of a rapid response team on major clinical outcome measures in a community hospital. Crit Care Med. 2007;35(9):2076-82.⁾	Before-after study Adult patients in American hospitals with 350 beds Intervention: Introduction of rapid response teams Controls: historical	Mortality Cardiac arrest	2.82 to 2.35/100 hospitalizations (p < 0.001) 7.6 to 3.0/1000 hospitalizations (p < 0.001)	Not randomized; Hawthorne effect	16% (p < 0.001) 60% (p < 0.001)	Low
Chan et al.⁽⁴⁰40 Chan PS, Khalid A, Longmore LS, Berg RA, Kosiborod M, Spertus JA. Hospital-wide code rates and mortality before and after implementation of a rapid response team. JAMA. 2008;300(21):2506-13.⁾	Prospective cohort Adult patients in an American hospital with 404 beds Intervention: Introduction of rapid response teams Controls: historical, 24193 admissions	Mortality	OR 0.95 (95%CI 0.81 - 1.11)	Used historical controls, but adjusted for temporal trends; weak statistical power to identify differences in mortality	5% (95%CI -11 - 19)	Low
Konrad et al.⁽⁴¹41 Konrad D, Jäderling G, Bell M, Granath F, Ekbom A, Martling CR. Reducing in-hospital cardiac arrests and hospital mortality by introducing a medical emergency team. Intensive Care Med. 2010;36(1):100-6.⁾	Before-after study Adult patients Intervention: Introduction of medical emergency teams, 73825 patients Control: 203892 patients before intervention	Mortality Cardiac arrest	OR 0.90 (95%CI 0.84 - 0.97) OR 0.74 (95%CI 0.55 - 0.98)	Used historical controls; delays in the team drive were not evaluated	10% (95%CI 3 - 16) 26% (95%CI 2 - 45)	Low
Beitler et al.⁽⁴²42 Beitler JR, Link N, Bails DB, Hurdle K, Chong DH. Reduction in hospital-wide mortality after implementation of a rapid response team: a long-term cohort study. Crit Care. 2011;15(6):R269.⁾	Prospective cohort Adult patients in American hospitals with 809 beds Intervention: Introduction of rapid response teams Controls: historical, 77021 patients	Mortality Cardiac arrest	RR 0.82 (95%CI 0.69 - 0.98) RR 0.49 (95%CI 0.39 - 0.61)	Used historical controls, but adjusted for temporal trends	18% (95%CI 2 - 31) 51% (95%CI 39 - 61)	Low
Gonçales et al.⁽⁴³43 Gonçales PD, Polessi JA, Bass LM, Santos GP, Yokota PK, Laselva CR, et al. Redução de paradas cardiorrespiratórias por times de resposta rápida. Einstein (São Paulo). 2012;10(4):442-8.⁾	Before-after study Adult patients in Brazilian hospitals with 477 beds Intervention: Introduction of medical emergency teams Control: patients attended over the 19 months before intervention	Mortality Cardiac arrest	14.34/1000 after intervention 16.27 before (p < 0.001) 1.69/1000 hospitalizations 3.54 before (p < 0.001)	Used historical controls; delays in the team drive were not evaluated	11% (p < 0.001) 52% (p < 0.001)	Low

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[1] Corresponding author: Hermano Alexandre Rocha, Centro Universitário Unichristus, Rua Adolfo Gurge, 113, Zip code: 60190-060 - Fortaleza (CE), Brazil, E-mail: hermano@ufc.br

Population	Adult patients admitted by all causes in hospital open units
Intervention	Rapid response team with early clinical deterioration identification systems
Comparison	Health services to patients in open units that do not use systems for early identification of clinical deterioration and without flow of triggering medical staff
Outcomes	Hospital mortality Cardiac arrest in open unit
Study design	Before-after ecological studies, clinical trials, cohort studies and meta-analyses