Rapid response saves lives, but is it good medicine?
December 8, 2010 |  by Michael Anft

A patient, recently released from intensive care to the hospital’s main floor, gasps for breath. Her heart beats rapidly. A nurse recognizes that this patient is spiraling toward death. She notifies her supervisors to call in the hospital’s rapid response team of intensive-care specialists. The team, drawn from a cadre of physicians, nurses, and respiratory therapists already on the hospital’s ICU staff, stabilizes the patient, then returns to its regular duties.

That heroic drama, played out thousands of times each year in hospitals across the country, has been promoted as a prime example of how to improve the quality of patient care. But not everyone is enthusiastic about the recent explosion in the number of rapid response teams, or RRTs. In an article in the September 22 issue of the Journal of the American Medical Association, Peter Pronovost, professor of anesthesiology and critical care medicine at the School of Medicine, and Eugene Litvak, professor of health policy and management at the Harvard School of Public Health, argue that instead of being an example of better health care, use of RRTs points out shortcomings in basic patient care. The authors don’t question that the teams save lives. They do ask if patients would be better served by more appropriate monitoring, placement in the hospital, and treatment in the first place.

“There’s no doubt that patients can deteriorate in the hospital ward without being noticed early on,” says Pronovost, Med ’99 (PhD). “But what we ought to be doing instead of trumpeting the role of rapid response teams is advancing the science as to how we deal with those cases.”

Hospitals form RRTs to deal with patients who “crash”—exhibit life-threatening symptoms such as shortness of breath, very low or very high blood pressure, changes in mental status, or a rapid heartbeat. The team concept has been embraced by more than 3,000 hospitals since 2004, when the Institute for Healthcare Improvement (IHI), a nonprofit organization that promotes what it considers best medical practices, recommended using RRTs as part of its 100,000 Lives Campaign to reduce preventable hospital deaths. The 2004–2006 campaign enlisted some heavyweight participants, including the American Medical Association, the American Nursing Association, the Centers for Disease Control, the American Heart Association, and several large health care systems.

But Bradford D. Winters, medical director of the adult neurosciences rapid response team at Johns Hopkins Hospital, warns, “We have to make sure we don’t rob Peter to pay Paul. You don’t want to diminish care for the intensive care patients by calling away staff [for RRT duty].” Winters co-authored a study in 2006 that found that RRTs help to educate medical staffers in recognizing signs that a patient is going downhill. But his study also backed up Pronovost’s contention that evidence showing RRTs are better than other safety methods is sorely lacking. While patients can take a turn for the worse in any hospital unit, those who are in beds in the general ward often aren’t monitored enough to catch a crash early — hence the need for RRTs. “The nurses do fantastic work, but among the general hospital population, we’re not far from the days of Florence Nightingale,” Winters says. “We need better research as to what we should do to treat general ward patients better.”

In addition to improving how staffs track patients, Pronovost and Litvak say hospitals and researchers should take a hard look at how intensive-care beds are managed, with an eye toward finding ways to keep some patients in ICUs for longer. Winters suggests that investing in wireless monitors would go far in catching early signs of an impending crash. But Pronovost argues that hospitals have no financial incentives to spend the money on such machines, even though they save lives. Hospitals often are not reimbursed by insurance companies for use of such equipment, so there is little short-term bottom-line benefit. Pronovost’s worries about hospital finances run even deeper:

“One of the fears about health reform is that if we don’t reduce costs, we could see nurse staffing cut with the idea we could just form more RRTs instead.”

The two authors wrote the JAMA article in response to ongoing efforts by IHI to promote RRTs. Pronovost sees his effort as counterbalancing much of the health marketing that touts RRTs’ purported value. Organizations cite the lives saved by RRTs, he says, but don’t consider how many patients needed the teams because of errors made in assessing their conditions and because of short staffing at hospitals.

Donald Goldmann, senior vice president at IHI and a professor of pediatrics and public health at Harvard, says the group stands behind its campaign for RRTs and welcomes more research on the topic. “Hospitals should do more root-cause analysis to see whether some RRT response could be avoided,” he says. “I think [Pronovost] and I can agree that there are circumstances in which RRTs are appropriate.”

“Rapid response teams certainly have a place,” says Pronovost. “The question is how big of one.”