Quick Reactions
Problem: Patients die without obvious warning signs Proposal: Rapid-response teams to evaluate any deterioration in a patient's condition Possible lives saved: 60,000
The 100K campaign is pinning much of its hopes on specialized teams that can rush to the bedside when a nurse or other caregiver is worried about a patient but there's no obvious crisis. One or more vital signs might have teetered out of the usual range, or the patient suddenly seems confused or delirious. Sometimes the warning signs might be more subtle, a collection of small changes that only an observant nurse would pick up and fret over--slight pallor, sweaty hands, an unfocused stare. Enough to be concerned.
The point of the roving squads is that most hospitalized patients who have an unexpected heart attack or other potentially fatal event send up some kind of early flag. Their breathing or their pulse rate might speed up or slow down considerably, for example. These telltale signs usually extend over a period of several hours or more before there's an emergency--which by then is likely to result in death. If a nurse could pick up the troublesome indications and summon a team skilled at recognizing and treating patients who may be about to decline, many of those deaths could be avoided.
The teams were pioneered in the late 1980s in Australia, where they are called medical emergency teams, or MET s. They are credited with pushing down the number of unanticipated cardiac arrests and hospitals' overall death rate. At Dandenong Hospital, a teaching center in Australia, cardiac arrests fell by half, and the death rate in patients who had an arrest fell from 77 percent to 55 percent.
Now some U.S. hospitals are using or investigating the teams, but the concept is still a bold one for most places. By making it part of the 100K initiative (where the team is called a rapid-response team, or RRT), Donald Berwick hopes to give the idea a boost. It is symptomatic of his self-proclaimed impatience. "That's where Don and IHI went furthest out on a limb," says Robert Wachter. He considers the evidence supporting the use of RRT s "decent," but hardly overwhelming. Yet Berwick's influence is so strong, says Wachter, that his backing of RRT s is just shy of the hospital accrediting commission calling for them.
There's little doubt that hospitals will come at RRT s in very different ways. At all hospitals, nurses are free to call the team for no reason other than worry. "We've had patients with silent MI s," says Susan Abramson, a nurse in Hackensack's orthopedic unit, describing myocardial infarctions, or heart attacks, that lack such classic symptoms as crushing chest pain. "They are sweaty, gray. You just know."
But Hackensack nurses also can consider a list of clinical criteria for blood pressure, heart rate, and other vital signs. McLeod nurses have nothing beyond concern to guide them. "I do think it would be better if we had numbers to go by," says Terri Whitfield, a veteran nurse on a medical floor. "It's vague." Even so, she likes the RRT concept. "It's a wonderful idea, especially on the night shift," she says. "You know you're not alone--there's always help."
Bumps ahead. "It took us about six years before we got the system quite right and tuned up," cautions Ken Hillman, professor of intensive care at Australia's University of New South Wales in Sydney and one of the prime movers in spreading the idea in that country. A sign of bumps that still remain even in Australia came to light last month.
A study led by Hillman himself, published in the Lancet, showed no difference in unexpected deaths, heart attacks, and other key indicators between one group of Australian hospitals with MET s and another group without. He now suspects that the four-month training period at the MET hospitals wasn't long enough. A possible tip-off was that the teams weren't called nearly as often as they were at hospitals with a longer history. And that suggests that hospitals elsewhere should introduce the teams carefully and patiently.
This story appears in the July 18, 2005 print edition of U.S. News & World Report.
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