Evaluating implementation of a rapid response team: considering alternative outcome measures

Abstract

Objective: Determine the prolonged effect of rapid response team (RRT) implementation on failure to rescue (FTR).

Design: Longitudinal study of institutional performance with control charts and Bayesian change point (BCP) analysis.

Setting: Two academic hospitals in Midwest, USA.

Participants: All inpatients discharged between 1 September 2005 and 31 December 2010.

Intervention: Implementation of an RRT serving the Mayo Clinic Rochester system was phased in for all inpatient services beginning in September 2006 and was completed in February 2008.

Main outcome measure: Modified version of the AHRQ FTR measure, which identifies hospital mortalities among medical and surgical patients with specified in-hospital complications.

Results: A decrease in FTR, as well as an increase in the unplanned ICU transfer rate, occurred in the second-year post-RRT implementation coinciding with an increase in RRT calls per month. No significant decreases were observed pre- and post-implementation for cardiopulmonary resuscitation events or overall mortality. A significant decrease in mortality among non-ICU discharges was identified by control charts, although this finding was not detected by BCP or pre- vs. post-analyses.

Conclusions: Reduction in the FTR rate was associated with a substantial increase in the number of RRT calls. Effects of RRT may not be seen until RRT calls reach a sufficient threshold. FTR rate may be better at capturing the effect of RRT implementation than the rate of cardiac arrests. These results support prior reports that short-term studies may underestimate the impact of RRT systems, and support the need for ongoing monitoring and assessment of outcomes to facilitate best resource utilization.

Keywords: failure to rescue; longitudinal evaluation; quality indicators; quality measures; rapid response team.

Figure 1

Monthly FTR rate control chart and monthly RRT calls. The FTR rate is presented with a control chart with limits based on the first 20 monthly data points. New control limits starting in March 2009 were set based on the control chart rule of eight consecutive data points below the process mean. Numbers of calls per month for the RRT are overlaid beginning with the start of RRT implementation in September 2006. Implementation was completed in February 2008.

Figure 2

BCP analysis of FTR rate. The bottom panel of this figure shows the estimated probabilities that a change point occurred. For example, there is a probability of 0.6 on 2/2009 that a change occurred as also evidenced by the drop in posterior means in the top panel of the figure. The BCP ‘bumps’ at June (2007) and February (2009) are mirrored by apparent changes in the FTR line as shown in Fig. 1.

Figure 3

Monthly Unplanned ICU transfer control chart and monthly RRT calls. The rate of unplanned ICU transfers per 1000 floor days is presented with a control chart with an initial process mean based on the first 20 monthly data points. New control limits starting in June 2009 were set based on the control chart rule of eight consecutive data points above the initial process mean. Numbers of calls per month for the RRT are overlaid beginning with the start of RRT implementation in September 2006. Implementation was completed in February 2008.

Figure 4

Monthly resuscitation events control chart. The rate of resuscitation events per 1000 discharges is presented with a control chart with an initial process mean based on the first 20 monthly data points. There was no evidence for a change in rate or control limits. Start of RRT implementation began in September 2006 and was completed in February 2008.

Figure 5

Monthly percent of discharges with a death outside the ICU. The mortality percentage for deaths outside the ICU is presented with a control chart with an initial process mean based on the first 20 monthly data points. New control limits starting in June 2009 were set based on the control chart rule of eight consecutive data points below the initial process mean. Start of RRT implementation began in September 2006 and was completed in February 2008.