Critical Care

, 19:254 | Cite as

Rapid response systems: a systematic review and meta-analysis

Open Access
Research

Abstract

Introduction

Although rapid response system teams have been widely adopted by many health systems, their effectiveness in reducing hospital mortality is uncertain. We conducted a meta-analysis to examine the impact of rapid response teams on hospital mortality and cardiopulmonary arrest.

Method

We conducted a systematic review of studies published from January 1, 1990, through 31 December 2013, using PubMed, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and the Cochrane Library. We included studies that reported data on the primary outcomes of ICU and in-hospital mortality or cardiopulmonary arrests.

Results

Twenty-nine eligible studies were identified. The studies were analysed in groups based on adult and paediatric trials that were further sub-grouped on methodological design. There were 5 studies that were considered either cluster randomized control trial, controlled before after or interrupted time series. The remaining studies were before and after studies without a contemporaneous control. The implementation of RRS has been associated with an overall reduction in hospital mortality in both the adult (RR 0.87, 95 % CI 0.81–0.95, p<0.001) and paediatric (RR=0.82 95 % CI 0.76–0.89) in-patient population. There was substantial heterogeneity in both populations. The rapid response system team was also associated with a reduction in cardiopulmonary arrests in adults (RR 0.65, 95 % CI 0.61–0.70, p<0.001) and paediatric (RR=0.64 95 % CI 0.55–0.74) patients.

Conclusion

Rapid response systems were associated with a reduction in hospital mortality and cardiopulmonary arrest. Meta-regression did not identify the presence of a physician in the rapid response system to be significantly associated with a mortality reduction.

Keywords

Publication Bias Risk Ratio Hospital Mortality Medical Emergency Team Cluster Randomize Control Trial 

Abbreviations

CI

confidence interval

CINAHL

Cumulative Index to Nursing and Allied Health Literature

CRCT

cluster randomized control trial

ICC

intracluster correlation coefficient

NICE

National Institute of Clinical Excellence

NOS

Newcastle Ottawa Scale

RR

risk ratio

RRS

rapid response system

Introduction

Many ward patients may deteriorate to the point of unexpected ICU admission or even cardiac arrest and death. About one-half of the serious adverse events are deemed to be preventable [1]. Patients often show some signs of physiological deterioration for several hours (median 6 hours) before cardiac arrest [2, 3]. Theoretically, this would appear to be sufficient time to deliver interventions that would alter the trajectory of deterioration. This ‘failure to rescue’ is the context in which rapid response systems (RRSs) have been introduced [4].

Most RRS trials have used similar criteria for activation of the team. These include various thresholds for respiratory rate, heart rate, blood pressure and mental state as well as the ‘staff worried’ criterion [5]. Unfortunately, the determination of respiratory rate and mental state on the wards is error prone and vital signs are unlikely to be measured more frequently than five times per day outside the ICU [6, 7, 8]. Variations in activation potentially influence the effectiveness of RRSs. Non-activation and delays in activation may be associated with harm and too liberal activation may cause system fatigue [9, 10, 11]. Consequently, the time spent implementing and maintaining the concept of a RRS and the rate of RRS activation may be a contributory factor to its success.

The RRS team is usually multidisciplinary in nature and tailored to meet the institutional needs and resources. In this respect there is some variation in the constitution of a RRS. In the UK the RRS team may be nurse led, and in the USA nurse or respiratory therapists may lead [12, 13]. In Australia, New Zealand and Scandinavia, a physician-led RRS is favoured [5, 14]. The optimal composition of a RRS team is unknown and may depend upon organizational structure.

Organizations such as the Institute for Healthcare Improvement, the 2009 Joint Commission’s National Patient Safety Goal in the USA, the National Institute of Clinical Excellence (NICE) in the UK as well as numerous other organizations have driven the implementation of RRS teams [15, 16]. Despite high face validity, the effectiveness of RRS teams in reducing hospital mortality remains controversial. A high-quality meta-analysis in 2010 did not find evidence of RRS teams reducing hospital mortality in adults [17]. A more recent review by Winters et al. [18] included studies of varying methodological quality and design, with inconsistent findings across outcomes. Both analyses aggregated studies of varying methodology and quality, further limiting the interpretation of the results [18].

Accordingly, a systematic review and meta-regression was undertaken to assess the effect of the RRS on hospital mortality and cardiopulmonary arrest outside the ICU and to evaluate the potential relationship between the number of RRS team activations per 1000 admissions, the presence of a physician in the RRS team and the duration of the implementation phase and the effectiveness of RRS teams.

Methods

A systematic review of studies published between 1 January 1990 and 31 December 2013 was conducted in accordance with published guidelines [19, 20]. We used the PubMed, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and Cochrane Register of Controlled trials databases. Additionally, a hand search of bibliographies of key publications was performed. Search terms included ‘rapid response team’, medical emergency team’ and ‘critical care outreach’. Details of the electronic search are described in Fig. 1 with additional information provided in the supplementary appendix.

Study eligibility criteria and selection

The inclusion criteria for this meta-analysis was that studies had to be a study that described the effect of RRS teams in a population of hospital in-patients that included a comparison between a control cohort and intervention cohort, and provided quantitative data about mortality rates or cardiopulmonary arrests. There was no country restriction but only English language studies were included.

A total of 2935 abstracts were identified by the search strategy. The titles and abstracts were independently assessed for eligibility by two investigators (RM and IR). Eight hundred and eighty-one duplicate studies were removed and a further 1994 studies were removed because they were not relevant or did not report sufficient data (Fig. 1). In cases with multiple articles with overlapping data from the same population, we included data from the most comprehensive study and excluded the other studies [21, 22, 23, 24].
Fig. 1

Literature search flow diagram

Data extraction process

Two reviewers independently, using a standardized format, extracted the data. For each study the following data elements were extracted: year of study, type of study design (randomized controlled trial (RCT), before–after, interrupted time series), type of hospital, number of centres, type of RRS, types of interventions, period pre and post implementation, demographics, number of activations per 1000 admissions, effect on do-not-resuscitate orders, non-ICU cardiopulmonary arrest, hospital mortality, ICU admissions as well as study quality indicators. Authors were contacted for additional data as required.

Risk of bias in individual studies

Reviewers worked independently to assess study quality. The Newcastle Ottawa Scale (NOS) was used for assessing non-randomized studies [25]. The NOS uses a star system to evaluate the selection of study groups, the comparability of groups and the ascertainment of either the exposure or outcome of interest. The interrupted time series, controlled before–after and cluster randomized studies were evaluated using the criteria recommended by the Cochrane Effective Practice and Organisation of Care Group [26]. This included recruitment bias, baseline imbalance, loss of clusters, incorrect analysis or selective outcome reporting. To explore variability in study results (heterogeneity) we specified the following hypotheses a priori. We hypothesized that effect size may differ according to the number of activations per 1000 admissions, the duration of implementation in months and the presence of a physician on the team. The proposed standardized method to report the dose of RRS teams is activations per 1000 patient admissions [27].

Data analysis

The primary outcome was hospital mortality. The secondary outcomes were non-ICU cardiopulmonary arrest and ICU admission rates. The meta-analyses were performed by computing the risk ratio (RR) using a random effects model. The random effects model provides more conservative estimates of treatment effects in the face of heterogeneity. The analysis was performed in subgroups of adults and paediatrics with further subgroups by study design (cluster randomized control trial (CRCT), interrupted time series and controlled before–after versus before–after studies with no contemporaneous controls and observational studies). Quantitative analysis was performed using an intention-to-treat analysis, and the RR and 95 % confidence intervals (CIs) were calculated [28]. We used the method proposed by Higgins et al. [29] to measure inconsistency between study results, reported as the I 2 statistic as well as the 95 % CI. Publication bias was evaluated using the contour funnel plot asymmetry and the Harbord modification of the Egger test [30, 31]. We performed both analyses because graphical evaluation can be subjective. Factors other than publication bias can cause asymmetry in the funnel plot. These include factors such as study quality or true study heterogeneity.

A meta-regression was undertaken to explore the association between treatment effect and study characteristics [32]. These predefined factors included the number of activations per 1000 admissions, the presence of a physician in the RRS team and the time period for implementation.

The study by Hillman et al. [5] was a cluster randomized trial. The approach recommended by the Cochrane Collaboration to approximate the effective sample size is to divide by the design effect [20]. The design effect is calculated as:
$$ \mathrm{Design}\ \mathrm{effect} = 1 + \left(M\hbox{--}\ 1\right) \times \mathrm{I}\mathrm{C}\mathrm{C} $$

where M is the average cluster size and ICC is the intracluster correlation coefficient. The ICC compares the variance within clusters with the variance between clusters. Mathematically this is the between-cluster variability divided by the sum of the within-cluster and between-cluster variabilities. An ICC value of 0 gives a design effect of 1. This value indicates that individuals within a cluster have no similarity and there is no adjustment for sample size. An ICC of 1 indicates that all individuals within a cluster are identical and the sample size is the number of clusters. Larger cluster sizes are associated with smaller ICC values. In the study by Hillman et al. [5], the number of clusters was 23 and the ICC used was 0.02.

The study by Priestley et al. [12] was described as a step wedge CRCT. This involves a sequential roll-out of and intervention to clusters over a number of time periods [33]. The order in which clusters receive the intervention is random. The measurement of data from all clusters and at each step is a key feature that distinguishes the step wedge design from a classic cluster RCT [33, 34]. This trial did not measure at each step and is actually reported more like a cluster RCT [34]. We therefore calculated the design effect according to the procedure recommended by the Cochrane Collaboration [20].

Sensitivity analyses were pre-specified. The treatment effect was reported using a cumulative meta-analysis method fixed-effects model and a graphical augmentation to the funnel plot to assess the impact of a new study on the existing meta-analysis. An influence analysis was performed in which the pooled estimates are computed omitting one study at a time. Additionally a sensitivity analysis was conducted using an ICC of 0.01 and of 0.05 to establish whether this qualitatively changed results. The details of this analysis are included in Additional file 1. The analysis was performed using STATA statistical software (version 12.0; Statacorp, College Station, TX, USA) and Revman (version 5.1; Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration).

Results

A total of 29 publications were included in the analysis (Fig. 1). No unpublished studies were obtained.

Study characteristics

The RRS studies had an effective sample size of 2,160,213 patients (1,107,492 in the intervention group and 1,108,380 in the control group) (Table 1). Nineteen studies (65.5 %) reported physicians as part of the RRS team for 24 hours per day and 7 days per week, two studies only had physician presence for office hours Monday to Friday, seven studies had no physician presence and one study did not report on the composition of the team. All of the studies have been published since 2000 and 13 studies have been published after 2008 (the end date for systematic review by Chan et al. [17]). Twenty-five studies were single centre. Twenty-one studies were conducted in academic hospitals, seven in community hospitals and one study used multiple sites that included both academic and community hospitals. The characteristics of the RRS intervention are described in Table 2. The number of RRS team activations per 1000 admissions was reported in 23 studies and varied substantially across studies. The mean and 95 % CI for the adult and paediatric activations per 1000 admissions were 16.3 (9.0–23.7) and 16.8 (6.0–27.6), respectively. About 33 % (95 % CI 23–43 %) of referrals were admitted to the ICU immediately after a RRS team consultation and 9.7 % (95 % CI 4.5–14.9 %) acquired a new designation of do not attempt resuscitation.
Table 1

Characteristics of included studies

ID

Author

Country

Year

Study design

Number and type of sites and population

Type of team

1

Al-Qahtani et al. [40]

Saudi Arabia

2013

Before/after without contemporaneous controls

1/academic/adult

1 ICU doctor

1 ICU nurse

1 ward nurse

1 respiratory therapist

2

Baxter et al. [41]

Canada

2008

Before/after without contemporaneous controls

2/community/adult

1 ICU doctor

1 ICU nurse

1 respiratory therapist

3

Beitler et al. [42]

USA

2011

Before/after without contemporaneous controls

1/academic/adult

Medical doctor

ICU nurse

Respiratory therapist

Patient transporter

4

Bellomo et al. [22]

Australia

2004

Before/after study without contemporaneous controls

1/academic/adult

1 ICU doctor

1 Nurse

5

Bristow et al. [43]

Australia

2000

Controlled before/after

3/community/adult

1 ICU doctor

1 general medicine doctor

1 nurse

6

Buist et al. [44]

Australia

2002

Before/after without contemporaneous controls

1/academic/adult

2 doctors

1 ICU nurse

7

Campello et al. [45]

Portugal

2009

Before/after without contemporaneous controls

1/community/adult

1 ICU doctor

1 nurse

8

Chan et al. [13]

USA

2008

Before/after without contemporaneous controls

1/academic/adult

2 ICU nurses

1 respiratory therapist

9

Dacey et al. [46]

USA

2007

Before/after without contemporaneous controls

1/community/adult

1 ICU or hospitalist doctor

1 ICU nurse

1 respiratory therapist

1 physician assistant

10

De Vita et al. [47]

USA

2004

Before/after study without contemporaneous controls

1/academic/adult

1 ICU doctor

1 anaesthetist

2 physician

2 ICU nurse

1 ward nurse

11

Hayani et al. [48]

Canada

2011

Before/after without contemporaneous controls

1/academic/adult

1 ICU doctor

1 ICU nurse

1 respiratory therapist

12

Hillman et al. [5]

Australia

2004

Cluster RCT

23/mixed/adult

ICU or ED doctor

ICU or ED nurse

13

Howell et al. [49]

USA

2012

Interrupted time series

1/academic/adult

Ward doctor

2 nurses

1 respiratory therapist

14

Jones et al. [50]

Australia

2005

Before/after without contemporaneous controls

1/academic/adult

ICU doctor

ICU nurse

15

Kenward et al. [51]

UK

2004

Before/after study without contemporaneous controls

1/community/adult

NR

16

Konrad et al. [14]

Sweden

2010

Before/after without contemporaneous controls

1/academic/adult

1 ICU doctor

1 ward doctor

1 ICU nurse

1 ward nurse

17

Lim et al. [52]

South Korea

2011

Before/after without contemporaneous controls

1/academic/adult

1 ICU doctor

1 ICU nurse

1 respiratory therapist

18

Priestley et al. [12]

UK

2004

Step wedge cluster RCT

1/community/adult

2 nurses

19

Santamaria et al. [53]

Australia

2010

Before/after without contemporaneous controls

1/academic/adult

1 ICU doctor

1 general medicine doctor

1 ICU nurse

20

Shah et al. [54]

USA

2011

Before/after without contemporaneous controls

2/academic/adult

1 ICU nurse 1 respiratory therapist

21

Simmes et al. [55]

The Netherlands

2012

Before/after without contemporaneous controls

1/academic/adult

1 ICU physician

1 ICU nurse

22

Brilli et al. [56]

USA

2007

Before/after without contemporaneous controls

1/academic/paediatric

1 ICU doctor

1 nurse

1 respiratory therapist

23

Hanson et al. [57]

USA

2010

Interrupted time series

1/academic/paediatric

1 PICU doctor

1 nurse

1 respiratory therapist

24

Anwar ul Haque et al. [58]

Pakistan

2010

Before/after without contemporaneous controls

1/academic/paediatric

1 ICU doctor

25

Hunt et al. [59]

USA

2008

Before/after without contemporaneous controls

1/academic/paediatric

3 PICU doctors

1 PICU nurse

1 PICU respiratory therapist

26

Kotsakis et al. [60]

Canada

2011

Prospective before/after without contemporaneous controls

4/academic/paediatric

1 doctor (PICU daytime ICU night-time)

1 PICU nurse

1 respiratory therapist

27

Sharek et al. [61]

USA

2007

Before/after without contemporaneous controls

1/academic/paediatric

1 PICU doctor

1 PICU or cardiac nurse

1 respiratory therapist

28

Tibbals and Kinney [23]

Australia

2009

Before/after without contemporaneous controls

1/academic/paediatric

1 ICU doctor

1 ED doctor

1 general medicine doctor

1 ICU nurse

29

Zenker et al. [62]

USA

2007

Before/after without contemporaneous controls

1/academic/paediatric

1 doctor

1 PICU nurse

1 respiratory therapist

ED emergency department, NR not reported, PICU paediatric intensive care unit, RCT randomized controlled trial

Table 2

Characteristics of rapid response system implementation and interventions

ID

Author

Calls per 1000 admissions

DNAR (%)

Control period/implementation period/intervention period (months)

ICU disposition (%)

Types of interventions (%)

Study definition of cardiac arrest and mortality

1

Al-Qahtani et al. [40]

18.2

9.3

24/0/36

40.2

Intubation 4

Non-ICU cardiopulmonary arrests, hospital mortality, including patients with DNAR designation

NIV 8

IV fluids 48

Diuretics 13

Vasoactive infusions 5

2

Baxter et al. [41]

40.3

8

24/12/12

27

Intubation 5

All cases of arrest Hospital-wide deaths, patients with DNAR designation included

NIV 6

IV fluids 32

Diuretics 10

Vasopressors 8

3

Beitler et al. [42]

10.8

11.2

36/0/36

43.4

NR

Non-ICU cardiopulmonary arrests, hospital mortality, patients with DNAR designation included

4

Bellomo et al. [22]

4.7

10

4/14/4

18.2

Intubation 3

All cardiac arrests, hospital mortality, patients with DNAR designation included

NIV 9

IV fluids 18

Diuretics 11

Vasopressors 5

5

Bristow et al. [43]

NR

NR

NR/NR/6

NR

NR

All cardiac arrests, hospital mortality, patients with DNAR designation included

6

Buist et al. [44]

6.7

10.5

12/24/12

10.5

NR

All cardiac arrests, hospital mortality, patients with DNAR designation included

7

Campello et al. [45]

7.8

NR

12/0/48

NR

NR

All cardiac arrests, hospital mortality, patients with DNAR designation included

8

Chan et al. [13]

15.1

2.1

20/4/20

41.2

Intubation 7

Hospital-wide cardiopulmonary arrest and mortality with DNAR designation included

NIV 11

IV fluids 16

Diuretics 7

Vasopressors 1

9

Dacey et al. [46]

20.1

10

4/1/12

24

Intubation 11

All cardiac arrests, and hospital mortality with DNAR designation included

NIV 10

IV fluids 32

10

De Vita et al. [47]

25.8

NR

60/0/20

 

NR

Hospital-wide cardiopulmonary arrest mortality not reported

11

Hayani et al. [48]

NR

NR

60/0/36

NR

NR

Mortality at 100 days after transplant

12

Hillman et al. [5]

8.7

8

2/4/6

30

NR

Non-ICU cardiopulmonary arrest Cardiac arrest and non-ICU mortality with DNAR designation excluded

13

Howell et al. [49]

53

NR

22/6/31

20

NR

Hospital mortality with DNAR designation excluded

14

Jones et al. [50]

25.2

NR

12/14/50

NR

NR

All cardiac arrests, and hospital mortality with DNAR designation included

15

Kenward et al. [51]

53

25

12/0/12

20

Intubation 23

All cardiac arrests, and hospital mortality with DNAR designation included

IV fluids 25

16

Konrad et al. [14]

2.5

26

60/3/24

27

NR

All cardiac arrests, and hospital mortality DNAR designation included

17

Lim et al. [52]

NR

NR

6/6/6

NR

NR

All cardiac arrests, and hospital mortality including DNAR designation

18

Priestley et al. [12]

NR

NR

0/0/8

NR

NR

Cardiac arrest NR; hospital mortality including DNAR designation

19

Santamaria et al. [53]

8.7

NR

30/3/18

NR

NR

All cardiac arrest and hospital mortality including DNAR designation included

20

Shah et al. [54]

26.7

7

9/6/27

50

NR

All cardiac arrest and hospital mortality with DNAR designation included

21

Simmes et al. [55]

56

NR

12/3/25

53

NR

All cardiac arrest and hospital mortality with DNAR designation excluded

23

Hanson et al. [57]

NR

NR

24/10/12

57

NR

Non-ICU cardiac arrest and hospital mortality with DNAR designation included

24

Anwar ul Haque et al. [58]

21

NR

10/0/9

39

Intubation 18

All cardiac arrest and hospital mortality with DNAR designation included

25

Hunt et al. [59]

11.9

NR

12/0/12

NR

NR

Non-ICU cardiac arrest, hospital mortality NR

26

Kotsakis et al. [60]

44.2

NR

24/9/24

30

NR

All cardiac arrest and hospital mortality with DNAR designation included

27

Sharek et al. [61]

19.7

0.7

54/2/19

57

Intubation 0.7

Non-ICU cardiac arrest and hospital mortality with DNAR designation included

IV fluids 16

Vasopressors 4

28

Tibballs and Kinney [23]

5.1

NR

41/3/48

47

Intubation 8

All cardiac arrest and hospital mortality with DNAR designation included

NIV 7

IV fluids 23

Vasopressors 4

29

Zenker et al. [62]

12.8

NR

23/0/12

36

Intubation 7

All cardiac arrest and hospital mortality with DNAR designation included

NIV 6

IV fluids

Vasopressors 2

IV intravenous fluids, DNAR do not attempt resuscitation, NIV non-invasive ventilation, NR not reported

Risk of bias within studies

Two investigators (RM and IR) assessed study quality independently. The risk of bias for each study is presented in Tables 3, 4 and 5. The Newcastle Ottawa Quality Assessment Scale was used to evaluate the before–after studies without contemporaneous controls [35]. The interrupted time series, controlled before–after and cluster randomized studies were evaluated using the criteria recommended by the Cochrane Effective Practice and Organisation of Care Group [26]. This included recruitment bias, baseline imbalance, loss of clusters, incorrect analysis or selective outcome reporting.
Table 3

Risk of bias table for cluster randomized control trials and controlled before–after trials

Study

Allocation sequence generation

Allocation concealment

Baseline comparability

Complete outcome data

Outcome variables assessed blindly

Protection from contamination

Selective outcome reporting

Free from other biases

Bristow et al. [42]

High risk

High risk

Low risk

Low risk

Low risk

Low risk

Low risk

Low risk

Priestley et al. [12]

High risk

High risk

High risk

High risk

Unclear

Unclear

High risk

Low risk

Hillman et al. [5]

Low risk

Low risk

Low risk

Low risk

Low risk

Low risk

Low risk

Low risk

Table 4

Risk of bias table using the Newcastle Ottawa Quality Assessment Scale for cohort studies

Study

Selection

Comparability

Outcome

 

Representativeness of exposed cohort

Selection of non-exposed cohort

Ascertainment of exposure

Outcome of interest was not present at the start of the study

Comparability of cohorts on the basis of design or analysis

Assessment of outcome

Was follow-up long enough for the events to occur?

Adequacy of follow-up cohorts

Al-Qahtani et al. [40]

*

*

*

*

 

*

*

*

Baxter et al. [41]

*

*

*

*

 

*

*

*

Beitler et al. [42]

  

*

*

 

*

*

*

Bellomo et al. [22]

*

*

*

*

*

*

*

*

Buist et al. [44]

*

*

 

*

*

*

*

 

Campello et al. [45]

*

 

*

*

 

*

*

*

Dacey et al. [46]

*

*

*

*

*

*

  

DeVita et al. [47]

*

*

*

*

   

*

Hayani et al. [48]

  

*

*

 

*

*

 

Jones et al. [50]

*

*

*

*

 

*

*

 

Kenward et al. [51]

*

*

*

*

*

*

*

 

Konrad et al. [14]

*

*

*

*

*

*

*

*

Lim et al. [52]

*

*

*

*

 

*

 

*

Santamaria et al. [53]

*

*

*

*

*

*

*

*

Shah et al. [54]

*

*

*

*

*

*

*

*

Simmes et al. [55]

  

*

*

 

*

  

Brilli et al. [56]

*

*

*

*

*

*

*

*

Anwar ul Haque et al. [58]

 

*

 

*

 

*

*

 

Hunt et al. [59]

*

*

*

*

 

*

*

*

Kotsakis et al. [60]

   

*

*

 

*

*

Sharek et al. [61]

*

*

*

*

*

*

*

*

Tibballs and Kinney [23]

*

*

 

*

 

*

*

*

Zenker et al. [62]

 

*

 

*

 

*

*

*

Table 5

Risk of bias table for interrupted time series studies

Study

Was the intervention independent of other changes?

Was the shape of the intervention effect pre-specified?

Was the intervention unlikely to affect data collection?

Was knowledge of the allocated interventions adequately prevented during the study?

Were incomplete outcome data adequately addressed?

Was the study free from selective outcome reporting?

Was the study free from other risks of bias?

Howell et al. [49]

Low risk

Low risk

Low risk

Low risk

Low risk

Low risk

Low risk

Hanson et al. [57]

Low risk

Unclear risk

Low risk

Low risk

Low risk

Low risk

Low risk

In general terms, the number of stars denotes study quality. A study can earn one star for each component of ‘Selection’, ‘Outcome’ and ‘Comparability’. Representativeness is awarded a star if the cohort is truly or somewhat representative of the population of interest. A star is awarded for selection of the non-exposed cohort, if it is drawn from the same population as the exposed cohort. Exposure is satisfactorily ascertained if data were acquired from secure records. A maximum of two stars can be given for ‘Comparability’. Either the exposed or non-exposed were matched in design or confounders adjusted in analysis. A maximum of three stars can be given for ‘Outcome’. Assessment of outcome is awarded a star if the outcomes were assessed by independent or blind assessment, confirmation of records by reference to secure records or record linkage. The adequacy of the duration of follow-up should be awarded a star if it was long enough for the outcomes to occur. Completeness of follow-up was considered adequate if losses were not related to the exposure or the outcome and was sufficiently low to be unlikely to introduce bias.

Syntheses of results Primary outcome

Hospital mortality

The implementation of RRS in the adult population has been associated with an overall reduction in hospital mortality (RR 0.87, 95 % CI 0.81–0.95, p <0.001) (Fig. 2). There was evidence of considerable heterogeneity (I 2 = 86 %, p <0.001). The treatment effect in the cluster randomized trials, controlled before–after and interrupted time series studies was RR 0.91 (95 % CI 0.85–0.97) with less heterogeneity (I 2 = 3 %). In the paediatric population, RRS also showed a reduction in mortality (RR 0.82, 95 % CI 0.76–0.89) with significant heterogeneity (I 2 = 78 %) (Fig. 3). There was only one study in the cluster randomized control study, controlled before–after and interrupted time series subgroup so no subgroup analysis based on study design could be performed.
Fig. 2

Forest plot of the effect of rapid response system teams on hospital mortality in adult in-patients. Weights are calculated from random-effects analysis. CBA controlled before–after, CCO critical care outreach, CI confidence interval, ITS interrupted time series, RCT randomized controlled trial

Fig. 3

Forest plot of the effect of rapid response system teams on hospital mortality in paediatric in-patients. Weights are calculated from random-effects analysis. CBA controlled before–after, CI confidence interval, ITS interrupted time series, RCT randomized controlled trial

Secondary outcomes

Cardiopulmonary arrests

The implementation of RRS in the adult population has been associated with an overall reduction in cardiopulmonary arrests (RR 0.65, 95 % CI 0.61–0.70, p <0.001) with substantial heterogeneity (I 2 = 70 %, p <0.001) (Figure S1 in Additional file 1). The treatment effect in the cluster randomized trials, controlled before–after and interrupted time series studies subgroup was RR 0.74 (95 % CI 0.56–0.98) with less heterogeneity (I 2 = 0 %). In the paediatric population, RRS also showed a reduction in cardiopulmonary arrests (RR = 0.64, 95 % CI 0.55–0.74) with minimal heterogeneity (I 2 = 7 %) (Figure S2 in Additional file 1).

ICU admissions

Only 10 of the adult studies reported the effect of RRS teams on the number ICU admissions. The implementation of RRS in the adult population has not been associated with a significant effect on the number of ICU admissions (RR 0.90, 95 % CI 0.70–1.16, p = 0.43). None of the paediatric studies reported the effect of RRS teams on the number of ICU admissions.

Assessment of publication bias

Publication bias refers to the phenomenon in which studies with less favourable results are less likely to be published than those with favourable results. Funnel plots appear asymmetric because of systematic suppression of studies. There are many factors other than publication bias that may explain funnel plot asymmetry, such as differential study quality or small study effects. A contour-enhanced funnel plot aims to disentangle these causes of funnel plot asymmetry. Generally, the level of statistical significance may drive publication bias, with studies that do not reach the perceived milestones of significance (e.g. p <0.05) less likely to be published. A contour-enhanced funnel plot overlays the contours of statistical significance on a funnel plot. This provides a novel method to assess whether the studies that exist are areas of statistical significance or whether there are areas where studies are missing that correspond to areas of low statistical significance. If studies are missing in areas of low statistical significance, then there may be publication bias. If studies are perceived to be missing, then publication bias is less likely. The contour-enhanced funnel plot was asymmetric but the perceived missing studies were in areas of high statistical significance, making publication bias a less likely cause of funnel asymmetry (Fig. 4).
Fig. 4

Contour-enhanced funnel plot. If studies appear to be missing in areas of low statistical significance, then it is possible that the asymmetry is due to publication bias. Conversely, if the area in which studies are perceived to be missing are of high statistical significance, then publication bias is a less likely cause of the funnel asymmetry

The Harbord modification of the Egger test was used to assess funnel plot asymmetry. The estimated intercept was −0.207 with a standard error of 0.897 and a p value of 0.819. This result suggests little evidence for small study effects.

Assessment of heterogeneity

A meta-regression was performed to explore the heterogeneity between studies. The covariates used were the number of activations per 1000 admissions, the duration of implementation in months and the presence of a physician in the RRS team. The model was adjusted for multiplicity using the Monte-Carlo permutation test for meta-regression. There was no significant relationship between any of the covariates (activation dose (p = 0.112), implementation time (p = 0.999) or physician presence (p = 0.992)) and hospital mortality. The model accounted for 18 % of the observed heterogeneity. The residual 82 % heterogeneity was probably due to persisting between study effects.

Sensitivity analysis

Assumptions about the effects of clustering were explored using an ICC of 0 and of 0.01 (Figures S3 and S4 in Additional file 1). Neither of these assumptions changed the treatment effect and is included in the supplementary data. A sensitivity analysis was performed by systematically omitting individual studies to establish the influence on outcome (Figure S5 in Additional file 1). This showed that there was no study whose removal would materially change the pooled estimate of hospital mortality. A cumulative meta-analysis was performed in which the cumulative evidence at the time of each study is calculated (Figure S6 in Additional file 1). This analysis showed that the effect estimate has been consistent over time. A further analysis examined the potential impact a new study would have on the existing meta-analysis, providing an indication of the robustness of the results to the addition of new evidence. The graph shows that all studies lie in the region with a beneficial treatment effect, which dominates the graph (Figure S7 in Additional file 1). This result suggests that the meta-analysis is relatively robust to the addition of a single new trial.

Discussion

In a systematic review and meta-analysis of 29 studies we found that a RRS team was associated with a reduction in hospital mortality in both adult and paediatric hospital populations. Our study reveals a striking degree of variation in how RRS teams were constituted, delivered and evaluated. The term ‘rapid response system’ may refer to rapid response teams, medical emergency teams or critical care outreach teams. Critical care outreach teams have the functionality of rapid response teams together with a surveillance function as well as ICU discharge follow-up.

A number of findings merit further discussion. There was a high degree of between-study heterogeneity in the included studies. The analysis included studies with different methodologies and could account for this observation. The adult CRCTs, controlled before–after and interrupted time series studies showed minimal heterogeneity (I 2 = 3 %), compared with observational and before–after studies without a contemporaneous control (I 2 = 88 %). This may be due to a small number of studies in the former subgroup.

This study did not find any dose–response relationship between the duration of the implementation phase, the presence of a physician on the team or the number of activations per 1000 and hospital mortality. These covariates were chosen because of pre-existing favourable reports [4]. Previous reports have suggested that a longer duration of implementation may lead to higher levels of support and engagement with the RRS [4, 36].

The optimal composition of the RRS team is uncertain. Two previous single-centre reports did not show the benefits of intensivist-led teams compared with registrar or resident-led teams [37, 38]. The majority of RRS interventions did not require the presence of a physician (fluids, oxygen and diuretics). Decisions around end-of-life planning may require physician involvement but would not necessarily manifest as changes in hospital mortality, although they could affect the number of cardiopulmonary resuscitation codes on the wards. It is possible that the presence of a physician in the team may have a differential effect in university hospitals compared with community hospitals, but there are insufficient data to establish this.

An increase in RRS team activations per 1000 admissions had previously been associated with reduction in cardiac arrest [39]. We were unable to show a significant relationship between RRS team activation and hospital mortality. This may suggest that the mechanism by which RSS teams reduce mortality is not through reductions in cardiac arrest. Very sensitive calling criteria may overactivate the RSS team, causing system fatigue with no tangible benefit. A final caveat is that the interpretation of meta-regression should always be undertaken cautiously. Meta-regression has limitations: the small number of studies, correlation between covariates and unmeasured characteristics, differences in the relationships that occur at a patient level and that may not be detected at a study level, and the tendency of regression to the mean.

The effect on the RRS team on the ICU workflow is important. The study was not able to show any effect on overall numbers of ICU admissions.

This study has several limitations. The vast majority of studies were observational studies without a contemporaneous control. Whilst there are several guidelines for the reporting of these studies, valuable information was often missing. The subgroup analysis did not find any significant difference in treatment effect in the different study methodologies. The outcomes of studies were reported variably. Some studies reported all hospital mortality and others reported only non-DNAR designated hospital mortality We used all hospital mortality reported because this offers the most conservative estimate of treatment. The major strength of our study is that the treatment effect has been consistent over time, is not influenced by any single study, and is robust to assumptions about clustering and to a further study being conducted.

Conclusion

This study found that RRS teams associate with a reduction in hospital mortality and cardiac arrest. These findings did not show any significant publication bias. A sensitivity analysis showed that the study findings were robust to addition of a new study. We were unable to show any benefit from the presence of a physician on the RRS team, the duration of implementation or the number of activations. Whilst RRS teams are very much part of the landscape in many health systems, further work is needed to understand the specific factors that are likely to mitigate their effectiveness in given operational contexts.

Key messages

  • RRS teams are effective in reducing hospital mortality in both adult and paediatric in-patients.

  • RRS teams also reduce hospital cardiac arrest.

  • The vast majority of rapid response interventions do not require a physician and the presence of a physician was not associated with improved outcomes.

Notes

Supplementary material

13054_2015_973_MOESM1_ESM.docx (844 kb)
Additional file 1: Figure S1. Showing a forest plot of the effect of rapid response system teams on adult cardiac arrest, Figure S2. showing a forest plot of the effect of rapid response system teams on paediatric cardiac arrest, Figure S3. showing a forest plot of the effect of rapid response system teams on hospital mortality in adult in-patients using an ICC of 0.01, Figure S4. showing a forest plot of the effect of rapid response system teams on hospital mortality in adult in-patients using an ICC of 0, Figure S5. showing the influence of removing one study at a time on the pooled effect, Figure S6. showing the cumulative influence of study on meta-analysis of hospital mortality, and Figure S7. showing contours for areas in which new studies would have to lie for the pooled result to achieve significance at 5 %.

References

  1. 1.
    Neale G, Woloshynowych M, Vincent C. Exploring the causes of adverse events in NHS hospital practice. J R Soc Med. 2001;94:322–30.PubMedCentralPubMedGoogle Scholar
  2. 2.
    Buist MD, Jarmolowski E, Burton PR, Bernard SA, Waxman BP, Anderson J. Recognising clinical instability in hospital patients before cardiac arrest or unplanned admission to intensive care. A pilot study in a tertiary-care hospital. Med J Aust. 1999;171:22–5.PubMedGoogle Scholar
  3. 3.
    Franklin C, Mathew J. Developing strategies to prevent inhospital cardiac arrest: analyzing responses of physicians and nurses in the hours before the event. Crit Care Med. 1994;22:244–7.PubMedCrossRefGoogle Scholar
  4. 4.
    Jones DA, DeVita MA, Bellomo R. Rapid-response teams. N Engl J Med. 2011;365:139–46.PubMedCrossRefGoogle Scholar
  5. 5.
    Hillman K, Chen J, Cretikos M, Bellomo R, Brown D, Doig G, et al. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet. 2005;365:2091–7.PubMedCrossRefGoogle Scholar
  6. 6.
    Laurila JV, Pitkala KH, Strandberg TE, Tilvis RS. Detection and documentation of dementia and delirium in acute geriatric wards. Gen Hosp Psychiatry. 2004;26:31–5.PubMedCrossRefGoogle Scholar
  7. 7.
    Buist M, Bernard S, Nguyen TV, Moore G, Anderson J. Association between clinically abnormal observations and subsequent in-hospital mortality: a prospective study. Resuscitation. 2004;62:137–41.PubMedCrossRefGoogle Scholar
  8. 8.
    Smith GB, Prytherch DR, Schmidt P, Featherstone PI, Knight D, Clements G, et al. Hospital-wide physiological surveillance—a new approach to the early identification and management of the sick patient. Resuscitation. 2006;71:19–28.PubMedCrossRefGoogle Scholar
  9. 9.
    Downey AW, Quach JL, Haase M, Haase-Fielitz A, Jones D, Bellomo R. Characteristics and outcomes of patients receiving a medical emergency team review for acute change in conscious state or arrhythmias. Crit Care Med. 2008;36:477–81.PubMedCrossRefGoogle Scholar
  10. 10.
    Chen J, Bellomo R, Flabouris A, Hillman K, Finfer S. Centre MSIftS and Group ACT. The relationship between early emergency team calls and serious adverse events. Crit Care Med. 2009;37:148–53.PubMedCrossRefGoogle Scholar
  11. 11.
    Cretikos M, Chen J, Hillman K, Bellomo R, Finfer S, Flabouris A, et al. The objective medical emergency team activation criteria: a case–control study. Resuscitation. 2007;73:62–72.PubMedCrossRefGoogle Scholar
  12. 12.
    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;30:1398–404.PubMedCrossRefGoogle Scholar
  13. 13.
    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;300:2506–13.PubMedCrossRefGoogle Scholar
  14. 14.
    Konrad D, Jaderling 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;36:100–6.PubMedCrossRefGoogle Scholar
  15. 15.
    The Joint Commission announces the 2009 National Patient Safety Goals and requirements. Jt Comm Perspect. 2008;28:1, 11–5Google Scholar
  16. 16.
    Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD. The 100,000 lives campaign: setting a goal and a deadline for improving health care quality. JAMA. 2006;295:324–7.PubMedCrossRefGoogle Scholar
  17. 17.
    Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Rapid response teams: a systematic review and meta-analysis. Arch Intern Med. 2010;170:18–26.PubMedCrossRefGoogle Scholar
  18. 18.
    Winters BD, Weaver SJ, Pfoh ER, Yang T, Pham JC, Dy SM. Rapid-response systems as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158:417–25.PubMedCrossRefGoogle Scholar
  19. 19.
    Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009;339:b2700.PubMedCentralPubMedCrossRefGoogle Scholar
  20. 20.
    Higgins JPT, Green S, editors. Cochrane handbook for systematic reviews of interventions. Version 5.1.0 (updated March 2011). Oxford, UK: The Cochrane Collaboration;2011Google Scholar
  21. 21.
    Bellomo R, Goldsmith D, Uchino S, Buckmaster J, Hart GK, Opdam H, et al. A prospective before-and-after trial of a medical emergency team. Med J Aust. 2003;179:283–7.PubMedGoogle Scholar
  22. 22.
    Bellomo R, Goldsmith D, Uchino S, Buckmaster J, Hart G, Opdam H, et al. Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med. 2004;32:916–21.PubMedCrossRefGoogle Scholar
  23. 23.
    Tibballs J, Kinney S. Reduction of hospital mortality and of preventable cardiac arrest and death on introduction of a pediatric medical emergency team. Pediatr Crit Care Med. 2009;10:306–12.PubMedCrossRefGoogle Scholar
  24. 24.
    Tibballs J, Kinney S, Duke T, Oakley E, Hennessy M. Reduction of paediatric in-patient cardiac arrest and death with a medical emergency team: preliminary results. Arch Dis Child. 2005;90:1148–52.PubMedCentralPubMedCrossRefGoogle Scholar
  25. 25.
    Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010;25:603–5.PubMedCrossRefGoogle Scholar
  26. 26.
    Effective Practice and Organisation of Care (EPOC). EPOC Resources for review authors. Oslo: Norwegian Knowledge Centre for the Health Services; 2015. Available at: http://epoc.cochrane.org/epocspecific-resources-review-authors.
  27. 27.
    Devita MA, Bellomo R, Hillman K, Kellum J, Rotondi A, Teres D, et al. Findings of the first consensus conference on medical emergency teams. Crit Care Med. 2006;34:2463–78.PubMedCrossRefGoogle Scholar
  28. 28.
    Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med. 2009;6, e1000100.PubMedCentralPubMedCrossRefGoogle Scholar
  29. 29.
    Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327:557–60.PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    Harbord RM, Egger M, Sterne JA. A modified test for small-study effects in meta-analyses of controlled trials with binary endpoints. Stat Med. 2006;25:3443–57.PubMedCrossRefGoogle Scholar
  31. 31.
    Palmer TM, Peters JL, Sutton AJ, Moreno GG. Contour-enhanced funnel plots for meta-analysis. Stata J. 2008;8:242–54.Google Scholar
  32. 32.
    Harbord RM, Higgins JPT. Meta-regression in Stata. Stata J. 2008;8:493–519.Google Scholar
  33. 33.
    Woertman W, de Hoop E, Moerbeek M, Zuidema SU, Gerritsen DL, Teerenstra S. Stepped wedge designs could reduce the required sample size in cluster randomized trials. J Clin Epidemiol. 2013;66:752–8.PubMedCrossRefGoogle Scholar
  34. 34.
    de Hoop E, Woertman W, Teerenstra S. The stepped wedge cluster randomized trial always requires fewer clusters but not always fewer measurements, that is, participants than a parallel cluster randomized trial in a cross-sectional design. In reply J Clin Epidemiol. 2013;66:1428.CrossRefGoogle Scholar
  35. 35.
    Hartling L, Milne A, Hamm MP, Vandermeer B, Ansari M, Tsertsvadze A, et al. Testing the Newcastle Ottawa Scale showed low reliability between individual reviewers. J Clin Epidemiol. 2013;66:982–93.PubMedCrossRefGoogle Scholar
  36. 36.
    DeVita MA, Bellomo R, Hillman K. Introduction to the rapid response systems series. Jt Comm J Qual Patient Saf. 2006;32:359–60.PubMedGoogle Scholar
  37. 37.
    Morris DS, Schweickert W, Holena D, Handzel R, Sims C, Pascual JL, et al. Differences in outcomes between ICU attending and senior resident physician led medical emergency team responses. Resuscitation. 2012;83:1434–7.PubMedCentralPubMedCrossRefGoogle Scholar
  38. 38.
    Karvellas CJ, de Souza IA, Gibney RT, Bagshaw SM. Association between implementation of an intensivist-led medical emergency team and mortality. BMJ Qual Saf. 2012;21:152–9.PubMedCrossRefGoogle Scholar
  39. 39.
    Jones D, Bellomo R, DeVita MA. Effectiveness of the medical emergency team: the importance of dose. Crit Care. 2009;13:313.PubMedCentralPubMedCrossRefGoogle Scholar
  40. 40.
    Al-Qahtani S, Al-Dorzi HM, Tamim HM, Hussain S, Fong L, Taher S, et al. Impact of an intensivist-led multidisciplinary extended rapid response team on hospital-wide cardiopulmonary arrests and mortality. Crit Care Med. 2013;41:506–17.PubMedCrossRefGoogle Scholar
  41. 41.
    Baxter AD, Cardinal P, Hooper J, Patel R. Medical emergency teams at The Ottawa Hospital: the first two years. Can J Anaesth. 2008;55:223–31.PubMedCrossRefGoogle Scholar
  42. 42.
    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:R269.PubMedCentralPubMedCrossRefGoogle Scholar
  43. 43.
    Bristow PJ, Hillman KM, Chey T, Daffurn K, Jacques TC, Norman SL, et al. Rates of in-hospital arrests, deaths and intensive care admissions: the effect of a medical emergency team. Med J Aust. 2000;173:236–40.PubMedGoogle Scholar
  44. 44.
    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;324:387–90.PubMedCentralPubMedCrossRefGoogle Scholar
  45. 45.
    Campello G, Granja C, Carvalho F, Dias C, Azevedo LF, Costa-Pereira A. Immediate and long-term impact of medical emergency teams on cardiac arrest prevalence and mortality: a plea for periodic basic life-support training programs. Crit Care Med. 2009;37:3054–61.PubMedCrossRefGoogle Scholar
  46. 46.
    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;35:2076–82.PubMedCrossRefGoogle Scholar
  47. 47.
    DeVita MA, Braithwaite RS, Mahidhara R, Stuart S, Foraida M, Simmons RL, et al. Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Qual Saf Health Care. 2004;13:251–4.PubMedCentralPubMedCrossRefGoogle Scholar
  48. 48.
    Hayani O, Al-Beihany A, Zarychanski R, Chou A, Kharaba A, Baxter A, et al. Impact of critical care outreach on hematopoietic stem cell transplant recipients: a cohort study. Bone Marrow Transplant. 2011;46:1138–44.PubMedCrossRefGoogle Scholar
  49. 49.
    Howell MD, Ngo L, Folcarelli P, Yang J, Mottley L, Marcantonio ER, et al. Sustained effectiveness of a primary-team-based rapid response system. Crit Care Med. 2012;40:2562–8.PubMedCentralPubMedCrossRefGoogle Scholar
  50. 50.
    Jones D, Opdam H, Egi M, Goldsmith D, Bates S, Gutteridge G, et al. Long-term effect of a medical emergency team on mortality in a teaching hospital. Resuscitation. 2007;74:235–41.PubMedCrossRefGoogle Scholar
  51. 51.
    Kenward G, Castle N, Hodgetts T, Shaikh L. Evaluation of a medical emergency team one year after implementation. Resuscitation. 2004;61:257–63.PubMedCrossRefGoogle Scholar
  52. 52.
    Lim SY, Park SY, Park HK, Kim M, Park HY, Lee B, et al. Early impact of medical emergency team implementation in a country with limited medical resources: a before-and-after study. J Crit Care. 2011;26:373–8.PubMedCrossRefGoogle Scholar
  53. 53.
    Santamaria J, Tobin A, Holmes J. Changing cardiac arrest and hospital mortality rates through a medical emergency team takes time and constant review. Crit Care Med. 2010;38:445–50.PubMedCrossRefGoogle Scholar
  54. 54.
    Shah SK, Cardenas Jr VJ, Kuo YF, Sharma G. Rapid response team in an academic institution: does it make a difference? Chest. 2011;139:1361–7.PubMedCrossRefGoogle Scholar
  55. 55.
    Simmes FM, Schoonhoven L, Mintjes J, Fikkers BG, van der Hoeven JG. Incidence of cardiac arrests and unexpected deaths in surgical patients before and after implementation of a rapid response system. Annals Intensive Care. 2012;2:20.CrossRefGoogle Scholar
  56. 56.
    Brilli RJ, Gibson R, Luria JW, Wheeler TA, Shaw J, Linam M, et al. Implementation of a medical emergency team in a large pediatric teaching hospital prevents respiratory and cardiopulmonary arrests outside the intensive care unit. Pediatr Crit Care Med. 2007;8:236–46. quiz 247.PubMedCrossRefGoogle Scholar
  57. 57.
    Hanson CC, Randolph GD, Erickson JA, Mayer CM, Bruckel JT, Harris BD, et al. A reduction in cardiac arrests and duration of clinical instability after implementation of a paediatric rapid response system. Postgrad Med J. 2010;86:314–8.PubMedCrossRefGoogle Scholar
  58. 58.
    Haque A u, Saleem AF, Zaidi S, Haider SR. Experience of pediatric rapid response team in a tertiary care hospital in Pakistan. Indian J Pediatr. 2010;77:273–6.CrossRefGoogle Scholar
  59. 59.
    Hunt EA, Zimmer KP, Rinke ML, Shilkofski NA, Matlin C, Garger C, et al. Transition from a traditional code team to a medical emergency team and categorization of cardiopulmonary arrests in a children's center. Arch Pediatr Adolesc Med. 2008;162:117–22.PubMedCrossRefGoogle Scholar
  60. 60.
    Kotsakis A, Lobos AT, Parshuram C, Gilleland J, Gaiteiro R, Mohseni-Bod H, et al. Implementation of a multicenter rapid response system in pediatric academic hospitals is effective. Pediatrics. 2011;128:72–8.PubMedCrossRefGoogle Scholar
  61. 61.
    Sharek PJ, Parast LM, Leong K, Coombs J, Earnest K, Sullivan J, et al. Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a children’s hospital. JAMA. 2007;298:2267–74.PubMedCrossRefGoogle Scholar
  62. 62.
    Zenker P, Schlesinger A, Hauck M, Spencer S, Hellmich T, Finkelstein M, et al. Implementation and impact of a rapid response team in a children’s hospital. Jt Comm J Qual Patient Saf. 2007;33:418–25.PubMedGoogle Scholar

Copyright information

© Maharaj et al. 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors and Affiliations

  • Ritesh Maharaj
    • 1
    • 2
    • 3
  • Ivan Raffaele
    • 2
  • Julia Wendon
    • 1
    • 2
  1. 1.Kings College LondonLondonUK
  2. 2.Department of Critical Care MedicineKing’s College Hospital NHS Foundation TrustLondonUK
  3. 3.Department of Critical Care MedicineKings College LondonLondonUK

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