A/Prof Jack Chen MBBS PhD MBA(Exec)
Simpson Centre for Health Services Research
South Western Clinical School & Australia Institute of Health Innovation
The University of New South Wales
Do Rapid Response Teams save lives
– new emerging research evidences
Widespread of the concepts of RRS
2
The Joint Commission of the USA
Australian Commission on Safety and Quality in Health Care
“Between the Flags” (BTF) by Clinical Excellence Commission, NSW
Many many more
Controversies
3
“Rapid response teams--walk, don't run”
Winters BD, Pham J, Pronovost PJ. JAMA; 2006; 296: 1645-7.
“Run, but not walk !”
Hillman KM. Critical care medicine 2012;40:2712-3.
Confusing and conflicting messages from the
systematic reviews
4
Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Rapid response teams: A systematic
review and meta-analysis. Archives of Internal Medicine 2010;170:18-26.
Implementing a RRS reduce cardiac arrests in adult patients by 1/3 but had
no impact on overall hospital mortality
Winters BD, Weaver SJ, Pfoh ER, Yang T, Cuong J, Dy SM. Rapid-response
systems as a patient safety strategy: A systematic review. Annals of Internal
Medicine 2013;158:417-25.
In discussion: “Our update supports the previous conclusions, although the most
recent studies were more likely to show positive results.” p422.
In abstract: “Moderate strength evidence from a high-quality meta-analysis of 18
studies and 26 lower-quality before-and-after studies published after that meta-
analysis showed that RRSs are associated with reduced rates of cardiorespiratory arrest
outside of the intensive care unit and reduced mortality.”
How many inhopsital cardiopulmonary
arrests (IHCA) a year – 1 ?
5
We really don‟t know so far
Too many different definitions (more than 20+)
Too many different data collection methods
No population-based estimates
It is not a standard patient safety indicator
• Is it a cardiopulmonary arrest or a cardiac arrest ?
How many inhopsital cardiopulmonary arrests
(IHCA) a year – 2 ?
6
Most likely between 1-5 cardiac arrests per 1000 patient admissions
Conservatively: 200,000 in-hospital cardiac arrests in the USA ( the
American Heart Association Consensus paper, Circulation
2013;127:1538-63)
But there could be as high as 750,000 inhospital CPR conducted in the
USA per year
Have the rate of IHCA survival to hospital discharge
changed ?
7
There are exciting new technologies
Peak agencies in promoting resuscitation guidelines
Morrison LJ, Neumar RW, Zimmerman JL, et al. Strategies for improving survival after
in-hospital cardiac arrest in the United States: 2013 consensus recommendations: A
consensus statement from the American heart association. Circulation
2013;127:1538-63.
Most studies indicated that little has changed in terms of IHCA
surviving rate during the last several decades
A recent report in NEJM: crude increase in % IHCA surviving to
hospital discharge: 3.9%;(adjusted rate: 8.1%) between 2001-2009
(Girotra S, Nallamothu BK, Spertus JA, Li Y, Krumholz HM, Chan PS. Trends in survival
after in-hospital cardiac arrest. New England Journal of Medicine 2012;367:1912-
20.)
A population based study of the secular trends of cardiopulmonary
arrest and mortality and their association with rapid response
system expansion in NSW (2002-2009)
8
Aims:
To explore the associations between the expansion of RRS in NSW and the trends of
1) IHCA incidence rate: the number of IHCA divided by total number of admissions (including same-day admissions);
2) IHCA-related mortality: the number of deaths among those patients who suffered an IHCA divided by the total number of admissions;
3) Hospital mortality rate: the number of deaths divided by total number of hospital admissions;
4) Proportion of IHCA surviving to discharge: the number of patients who survived to hospital discharge divided by total number of IHCA patients;
5) One year post-discharge mortality of IHCA: the number of deaths within 1-year after discharge alive from hospital among IHCA patients
Aims:
9
Pre-arrest prevention versus post-arrest
treatment : which is the major
contributor to the lives saved?
Method -1
10
Patient outcomes and other related variables were derived from
the NSW Admitted Patient Data Collection (APDC) database
All admissions to the study hospitals were linked to the NSW
Registry of Births, Deaths, and Marriages (RBDM) through the
Centre of Health Record Linkage (CHeReL), NSW Ministry of
Health
Two state wide telephone-based surveys (one during the end of
2007 and one in May 2013) and one web-based survey (during
October to December 2012)
A RRS was defined as any system that had a clear objective in
identifying and responding to the deteriorating hospital in-patients
Method - 2
11
Death was defined as a patient documented as „deceased‟ within
the APDC database.
A cardiopulmonary arrest in the current study was derived from
the International Classification of Disease Version 10 (ICD 10-
AM, v5.0-v5.1) and defined as a state of pulselessness (I.46) or
cessation of breathing (R09.2 ) which required cardiac message,
defibrillation or any other cardiopulmonary resuscitations.
A patient coded as I.46 or R09.2 in any one of the 54 non-
principal diagnostic fields, but not coded for these as the principal
diagnostic field, was defined as having had a cardiopulmonary
arrest during the hospitalization
Method - 3
12
We only studies acute public hospitals (Peer group A – C)
Two children hospitals excluded
Only those older than 14 years patients were included (not for
pediatric patients)
Statistical Analysis
13
Crude and adjusted analysis of trends
Risk ratio rather than odds ratio derived through specifying a Poisson distribution and adjusted for cluster effect of the hospital
Elixhauser Index based methodology for the baseline risk groups
Charlson Index derived using recommended coding scheme for ICD-10
Risk-adjustment model include: year, age groups, sex, marital status, country of birth, socio-economic status, geological area of hospitals (urban versus rural) and major hospital peer groups.
Diagram 1: Data linkage and data verification process
14
16,046,272 de-identifying records received from CHeReL after the
vertical linkage with unique person key including 497 health care
facilities in NSW 2002-09
9,221,138 from 82 public acute hospitals in NSW
6,812,532 records removed from private and
other health care facilities such as residential
care facilities
12,597 duplicates removed as well as 5 records
were deemed invalid due to out of range of
admission and separation dates
9,221,138 records retained after one-to-one linkage
to RBDM database provided by the CHeReL
Table 1: The trends (2002-2009) of rates (per 1000 admissions)
of IHCA, IHCA-related mortality, hospital mortality, and % of IHCA
surviving to discharge, 1-yr post-discharge mortality after IHCA
15
2002 2003 2004 2005 2006 2007 2008 2009 P for
linear
trend
IHCA incidence(/1000
admissions) 3.72 3.34 2.97 2.71 2.51 2.46 2.12 1.85 <0.001
IHCA mortality (/1000
admissions) 2.71 2.42 2.10 1.91 1.81 1.76 1.47 1.26 <0.001
Hospital
mortality(/1000
admissions)
17.63 17.18 17.03 15.91 15.29 15.46 15.47 14.36 <0.001
IHCA surviving to
discharge (%) 27.2 27.6 29.1 29.6 27.9 28.4 30.8 32.3 0.002
1-yr post-discharge
mortality after IHCA
(%)
5.4 5.1 3.9 4.6 3.7 4.3 3.0 5.6 0.117
Figure 1 Risk-adjusted incidence rates of IHCA, IHCA-related mortality, hospital
mortality (per 1000 admissions), and % of hospitals having a RRS between 2002-
2009
16
17.63
16.92 16.57
15.69
14.81 14.81 14.63
13.58
3.72 3.31
2.94 2.68 2.49 2.42
2.08 1.79 2.71
2.38 2.06 1.90 1.79 1.71
1.44 1.22
31.7 34.2
39.0
43.9
47.6
58.5
64.6
74.4
0
10
20
30
40
50
60
70
80
0
2
4
6
8
10
12
14
16
18
20
2002 2003 2004 2005 2006 2007 2008 2009
%
o
f
R
R
S
Nu
mb
er
of
ev
en
ts p
er
1,00
0 ad
mis
sio
ns
Mortality IHCA
IHCA mortality % of RRS
Figure 2 Risk-adjusted % of IHCA surviving to hospital
discharge and 1-year post-discharge mortality after IHCA
17
27.2 27.7 29.1 29.4
28.0 28.6
30.2 31.3
5.4 5.0 3.9
4.5 3.6 4.2
3.0
5.5
0
5
10
15
20
25
30
35
2002 2003 2004 2005 2006 2007 2008 2009
%
% IHCA Survival to dishcharge 1yr post-dishcarge mortliaty after IHCA
Key findings: -1
18
Hospitals with a RRS more than doubled over this period .
Over the same time, there was also
a greater than 50% reduction in the incidence of IHCA;
a greater than 50% reduction in IHCA-related mortality;
a 23% overall reduction in hospital mortality;
a 4.1% increase in the proportion of IHCA patients who
survived to discharge.
However, there was no change in 1-year post-discharge
mortality among IHCA patients.
.
Key findings - 2
19
The adjusted rate reduction in IHCA-related mortality was
1.49 patients per 1000 admissions (2.71-1.22=1.49;
RR=0.45; p<0.001) and accounted for 36.8% of the
adjusted hospital mortality reduction (17.63-13.58=4.05 per
1000 admissions; RR=0.77; p<0.001).
The reduction in IHCA incidence and the increase in IHCA
survival accounted for 95% and 5% of the IHCA-related
mortality reduction, respectively (5%= 4.1% x 1.79/1.49)
Implications: Lives saved
20
Assuming a similar rate of uptake of RRS across other Australian states (8.6 million patients older than 14 years ),the number of estimated lives saved due to the reduction in annual IHCA related mortality would be over 12,800 in Australia in 2011-2012.
Greater than the total number of Australians who died of bowel cancer (3982), prostate cancer (3235), breast cancer (2864) and pancreatic cancer (2434) in 2012.
Assuming a 200,000/year IHCA incidence, with a 20% survival rate, 80,000 cardiac arrest associated deaths would potentially be prevented each year in the USA by a doubling in the implementation of RRS‟s.
Implications:
21
Prevention IHCA is the main contributor to the lives
saved (95% vs 5%)
No evidence of systematic mismanagement of
patients due to more NFR orders (i.e, consistent 5%
1-yr post-discharge mortality after IHCA)
A feasible, cheap way in tracking patient safety and
hospital performances
Four hospitals head-to-head comparison
22
The same study data
One MET versus three non-MET hospitals
MET hospital: Liverpool hospital, a large teaching hospital of the
University of New South Wales(UNSW) which had pioneered the
Medical Emergency Team (MET) system in 1990.
Three non-MET hospitals: three large hospitals (H1,H2,H3), also
belong to the same top principal referral group of hospitals as defined
by the NSW Health.
Each hospital situates within the metropolitan area of Sydney.
Hospitals H1 and H3 did not implement a RRS until 2009 and
hospital H2 formally started its RRS in January 2010.
Aims and methods
23
Primary outcomes: rates of IHCA, IHCA-related mortality,
hospital mortality
We specifically compared the primary outcomes between the
MET hospital and other non-MET hospitals at three different
stages:
1) the three outcomes (pooled between 2002-2008);
2) the changes of three outcomes between 2008 and 2009;
3) the three outcomes in 2009.
Figure 3: The rates of IHCA, IHCA-related mortality and hospital
mortality (per 1000 admissions) between 2002-2009
24
Liverpool hospital
H2
H1
H3
Pre-RRS Post-RRS
1011
1213
1415
1617
1819
Hos
pita
l mor
talit
y (p
er
1000
adm
issi
ons
)
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Hospital mortality
LIverpool hospital
H1
H2
H3 Pre-RRS Post-RRS
1.0
2.0
3.0
4.0
5.0
6.0
7.0
IHC
A r
ate
(per
100
0 ad
mis
sion
s)
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
IHCA rate
Liverpool hospital
H1
H2
H3Pre-RRS Post-RRS
1.0
2.0
3.0
4.0
5.0
IHC
A r
ela
ted
mor
talit
y (
per
100
0 ad
mis
sion
s)
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
IHCA related mortality
Table 2 The outcome differences between MET hospital and non-
RRS hospitals(2002-2008) and 2009, respectively
25
Outcome Non-
MET
MET
hospital
Crude RR
(95%CI) P Adjusted RR P
Year 2002 to 2008
IHCA incidence (/1000
admissions) 3.97 2.09
0.53 (0.49-
0.57) <0.001 0.48 (0.44 - 0.53) <0.001
IHCA related mortality (/1000
admissions) 2.72 1.62
0.60 (0.55 -
0.65) <0.001 0.60 (0.54 - 0.67) <0.001
Hospital mortality (/1000
admissions) 15.20 12.76
0.84 (0.81-
0.87) <0.001 0.94 (0.90 - 0.98) 0.002
Year 2009
IHCA incidence (/1000
admissions) 2.81 2.09
0.75 (0.62 -
0.90) 0.002 0.77(0.60 - 0.98) 0.037
IHCA-related mortality
(/1000 admissions) 1.87 1.56
0.83 (0.67 -
1.04) 0.101 0.93 (0.69 - 1.25) 0.617
Hospital mortality (/1000
admissions) 13.24 10.95
0.83(0.76 -
0.90) <0.001 0.93 (0.83 - 1.04) 0.224
Table 3 The rate ratio (2009/2008) between MET hospital and
Non-MET hospitals
26
Outcome Rates
(2009/2008)
Adjusted RR
(95%CI)
P values
Non-MET hospitals
IHCA incidence (/1000 admissions) 2.81/3.56
0.80 (0.70 - 0.91) 0.001
IHCA mortality (/1000 admissions) 1.87/2.35
0.80 (0.68 - 0.94) 0.006
Hospital mortality (/1000
admissions) 13.2/14.85
0.89 (0.84 - 0.95) <0.001
MET hospital
IHCA incidence (/1000 admissions) 2.09/1.98 1.05 (0.84 - 1.33)
0.655
IHCA mortality (/1000 admissions) 1.50/1.42 1.11 (0.85 - 1.45)
0.456
Hospital mortality (/1000
admissions) 10.95/11.07 1.00 (0.91 - 1.11)
0.923
The results
27
Between 2002-2008:
50% reduction in IHCA and 40% reduction in IHCA-
related mortality in the MET hospital compared to the
non-MET hospitals
Between 2008-2009:
the MET hospital did not have a before-after change
the non-MET hospitals had a 20% reduction in both
IHCA incidence and IHCA-related mortality
In 2009:
the MET hospital still had a lower IHCA incidence than
the non-MET hospitals
Conclusions:
28
The concurrent comparison (2002-2008) between the MET hospital and non-MET hospitals supported the notion that implementing a RRS improved patient safety and saved lives.
The significant reduction of IHCA and related mortality between 2008 and 2009 during implementing a RRS among all non-MET hospital demonstrated the feasibility and generalisabeility of such concept.
The gap between the non-MET hospitals and MET hospital in 2009 indicated that longer time may be needed to perfect such a complex system in hospitals.
Summary
29
Both our population-based study and the four hospitals
concurrent comparison study showed that implementing a
RRS was associated with significant lives saved
Despite the improvement in advanced resuscitation
technology and promulgation of the clinical guidelines,
prevention of IHCA is still the leading cause of the reduced
IHCA-related mortality
More efforts should be devoted to develop optimal
implementation strategies of a RRS and supporting self-
learning of hospitals through performance measures related to
IHCA
“Run, but not walk !”
30
Thank You !