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absence of respiratory effort, unresponsive Low blood pressure, rapid heart rate, respiratory distress, altered consciousness Typical conditions that the team assesses and treats Cardiac arrest, respiratory arrest, airway obstruction Sepsis, pulmonary edema, arrhythmias, respiratory failure Typical team composition Anesthesia fellow, ICU fellow, internalmedicine house staff, ICU nurse ICU fellow, ICU nurse, respiratory therapist, internal-medicine house staff Typical call rate (no./1000 admissions) 0.5–5 20–40 Typical in-hospital mortality (%) 70–90 0–20 * ICU denotes intensive care unit. The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITY OF PITTSBURGH on May 30, 2012. For personal use only. No other uses without permission. Copyright © 2011 Massachusetts Medical Society. All rights reserved. current concepts n engl j med 365;2 nejm.org july 14, 2011 141 Pr inciples Under ly ing R a pid - R esponse S ys tems Goal 16 of the Joint Commission’s 2009 National Patient Safety Goals is to improve the identification of and response to clinical deterioration in hospital-ward patients. The goal states that organizations should select “a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening.”34 Rapid-response systems seek to address this goal.1 An important principle underlying rapid-response systems (and all critical illness care) is that early intervention can improve patient outcomes.35,36 Even within a mature rapid-response system, delayed activation of the responding team is associated with increased mortality.32 A logical sequence of events underlies the rationale for rapid-response systems. In particular, the system aims to “take critical care expertise to the patient before, rather than after, multiple organ failure or cardiac arrest develops.”37 Litvak and Pronovost5 have suggested that assessment by a rapid-response team is needed when the patient is triaged incorrectly and sent to the hospital ward rather than the ICU or a monitored area. In addition, patients may require an assessment by the rapid-response team if they have received inadequate care or if clinical deterioration occurs despite adequate care. In response to such observations, some form of rapid-response system is being implemented by hospitals throughout North America. The spread of such systems has been markedly augmented by their inclusion in the 3700 U.S. hospitals participating in the Institute for Healthcare Improvement’s 5 Million Lives Campaign (www.ihi.org/ ihi/programs/campaign). In Canada and Scandinavian countries, implementation of rapid-response systems is also increasing rapidly. Their cost-effectiveness and effect on patient outcomes, however, remain to be determined. Componen t s of the R a pid - R esponse S ys tem Although most of the literature has focused on the responding team, the rapid-response system is a coherent and integrated system of care that has four components.1 The first component, the system’s afferent limb, is designed to identify clinical deterioration in patients and trigger a response. This component includes the criteria for calling the rapid-response team, the means of assessing these calls, the personnel who trigger system activation, and the mechanism of activation. The second component, the efferent limb, is the response, which includes both the personnel and the equipment brought to the patient. Patient safety and quality improvement constitute the third component, which provides a feedback loop by collecting and analyzing data from events and improving prevention and response. This component reviews data on calls for the rapid-response team and their outcomes in order to develop strategies that prevent clinical deterioration meeting the criteria for a rapid response and that optimize the outcomes for patients who undergo assessment by the rapid response team. The fourth component, which is the administrative or governance component,1 coordinates resources to facilitate improved care, overseeing the appointment of responding-team staff and the purchase of equipment and coordinating the education