Page 17
of hospital staff regarding the rapid-response process. Table 2. Reasons for Failure to Rescue. Monitoring technology is used only in the intensive care unit or step-down units. Hospital-ward monitoring is only intermittent (vital-sign measurements). Intervals between measurements can easily be 8 hours or longer. Regular visits by a hospital-ward nurse vary in frequency and duration. Visits by a unit doctor may occur only once a day. When vital signs are measured, they are sometimes incomplete. When vital signs are abnormal, there may be no specific criteria for activating a higher-level intervention. Individual judgment is applied to a crucial decision. Individual judgment varies in accuracy according to training, experience, professional attitude, working environment, hierarchical position, and previous responses to alerts. If an alert is issued, the activation process goes through a long chain of command (e.g., nurse to charge nurse, charge nurse to intern, intern to resident, resident to fellow, fellow to attending physician). Each step in the chain is associated with individual judgment and delays. In surgical wards, doctors are sometimes physically unavailable because they are performing operations. Modern hospitals provide care for patients with complex disorders and coexisting conditions, and unexpected clinical deterioration may occur while nurses and doctors are busy with other tasks. 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. T h e n e w e ngl a nd j o u r na l o f m e dic i n e 142 n engl j med 365;2 nejm.org july 14, 2011 The key characteristic of rapid-response teams is that they are activated when a patient fulfills predefined criteria. Many organizations print mnemonic cards to promote use of the criteria (Fig. 1). Calls for the rapid-response team bypass traditional unit-based, hierarchical, and stepwise lessto-more-skilled approaches to care. The team responds rapidly (within minutes) to the call and delivers critical care equipment and expertise to the patient’s bedside1 (see the Supplementary Appendix, available with the full text of this article at NEJM.org). The team may or may not be joined by the patient’s primary caregivers, as designated by the facility. Response-Triggering Criteria The efferent limb is triggered by identified “calling criteria,” based on derangements in vital signs. In addition, many organizations include a “staff worried” criterion to permit activation of the rapidresponse team in the case of a patient who is considered to need an escalation in care. In some institutions, family members can activate the system. In the United Kingdom, many hospitals use calling criteria based on the Modified Early Warning System,38 in which scores for vital signs are added to obtain a total score. In some American centers10 and most Australian centers,6 the presence of any one abnormality is sufficient for activation (Fig. 1). Multiparameter weighted scoring systems may be time-consuming or inaccurately calculated.38 Simple calling criteria may be less sensitive and specific, but they predict an increased risk of death and appear to promote response activation.23,28,31 Composition of the Responding Team The composition of the rapid-response team is tailored to the institution’s goals, the team’s aims, the severity of illness in the patients it assesses, and institutional resources. Typically, in larger hospitals, the team includes at least one critical care physician or fellow (the so-called medical emergency team).39 In the United States, there are rapid-response teams led by nurses or respiratory therapists40 and physician-led medical emergency teams.10 In Australia,6 New Zealand, and Scandinavia, the typical model is the medical emergency team.39 The few nonrandomized, before-and-after studies at single centers that reported improved patient outcomes have involved medical emergency teams.12 However, no studies have compared the benefit of medical emergency teams with that of nonphysician-led rapid-response teams. The apparently superior benefits of medical emergency