Because use of RRT is now so widespread, it has become difficult to produce high-quality, randomized controlled trials, and that causes apprehension in those who advocate for a more rigorously studied and evidence-based intervention. Patient monitoring systems Early clinician recognition of signs of patient deterioration is critical to reducing the risk of preventable death and other adverse events. While RRTs have been widely implemented, their success depends on recognizing a deteriorating patient before serious harm has occurred. Patient monitoring system (PMS) is an umbrella term for electronic systems that scan patient data (e.g. vital signs and other variables) for signs of deterioration and alert a clinician if certain criteria are met. These systems can decrease the time from the onset of deterioration to the initiation of treatment, increasing the potential for better patient outcomes. While the training and clinical reasoning of staff cannot be discounted, PMSs can provide a valuable counterpart and backstop to ensure that no deteriorating patients are missed. Patients who are at a high risk of deterioration are usually admitted to a critical care setting or a telemetry unit, where patient vital signs are continuously monitored (CM) and there is a low patient-to-nurse ratio. However, most hospital beds are outside of these intensive settings, and most patients are boarded in general medical and surgical wards. These units typically do not have continuous PMS, and rely on intermittent collection of patient vital signs on a predetermined schedule (e.g., every 4–6 hours) and on nursing activation of the RRT. A delay of several hours in recognizing a patient’s deterioration can lead to avoidable morbidity, ICU transfers, and mortality. This section will review patient monitoring systems that use CM devices (e.g., pulse oximetry monitors), as well as electronic monitoring of intermittent manually collected vital signs. Effect on process measures Although testing a PMS for its effect on outcome measures (e.g., mortality) is the ultimate goal of this PSP, it is also important to test whether the PMS improves processes of care for deteriorating patients. Seven of eight studies reported one or more process measures for PMSs, all of which took place in general medical/surgical units. Articles assessing an effect on process measures had a variety of study designs, with one randomized trial and six experimental studies of varying type. In addition, one systematic review addressed this topic. The most commonly reported process measure in the reviewed articles was the number of rescue events, including RRT calls or Code Blue calls (i.e., calls activated by healthcare professionals in the hospital when there is a patient in cardiac or respiratory arrest). It is unclear how to interpret this measure in relation to the PMS. A decrease in rescue events likely indicates that more deteriorating patients are discovered early and are stabilized by staff without needing to call the
RRT. It could also indicate that patients in decline are being missed. Ultimately, this process measure needs to be combined with outcome measures to understand its true effect. Other reported process measures were related to vital sign collection times. A systematic review and meta-analysis by Cardona-Morrell and colleagues reported that implementing a PMS with CM was not associated with a reduction in mortality (odds ratio [OR]=0.87, 95% CI 0.57–1.33), while PMS with IM was associated with a statistically significant but modest reduction in mortality (OR=0.78, 95% CI 0.61–0.99). 27 This may seem counterintuitive, but the authors note that studies included in the meta-analysis were heterogeneous and most were observational. They conclude that more studies are needed of both CM and IM systems before drawing a definitive conclusion. Four other studies not included in that systematic review found no impact on mortality. Several studies noted that a generally low mortality rate before and during their studies made it unlikely that they could detect a significant change without a large increase in the sample size. Study authors did not indicate many unintended negative consequences as a result of implementing a PMS to detect patient deterioration. Some expressed hypothetical concern raised of over- testing and over-treating patients, but no studies measured outcomes to test these. If the PMS has a low predictive value, patients who are not deteriorating could receive unnecessary treatment or be transferred to a higher level of care as a result. However, this risk can be mitigated by ensuring the use of a highly predictive system. Positive consequences were mentioned by several authors. The tracking and display of patient vitals gave nurses and other clinicians a sense of increased knowledge about their patients. It also allowed the RRT and other primary team members to take a proactive approach to patient care, rather than relying solely on nursing staff activating an RRT call. Authors also noted that when nurses did call for an RRT, the system allowed them to communicate their concerns about a patient with objective, quantifiable data. Other potential benefits included nurses spending more time on patient- centered tasks and less time on vital sign collection, and reduced reliance on RRTs. The latter is supported by several studies that found a decrease in rescue events after PMS implementation. Implementing a PMS can be difficult technologically, financially, and in terms of workflow changes for staff. The studies we reviewed identified factors that facilitate PMS implementation, as well as barriers to successful PMS implementation. A PMS will be effective only if it is both sensitive and specific, to engender clinician trust and reduce false-positive alerts. When a PMS identifies a deteriorating patient, clinicians who can respond need to be quickly notified. Study authors disagreed on the best method for communicating this need to clinicians. Some favored auditory and visual alerts, and others preferred a non-interruptive dashboard at both the bedside and a central station to reduce potential alert fatigue.
Good communication between the bedside clinicians and the RRT was also cited as a facilitator, as well as staff who are well trained and have strong clinical reasoning. Finally, in relation to cost, several PMS systems are now available as electronic health record add-on modules or as standalone systems, sparing hospitals the cost of designing, building, and testing a system. The nonspecific nature of patient deterioration makes achieving a highly predictive system difficult. Therefore, it is important for clinicians/ administrators to test system performance and adjust variable thresholds to best balance speed, sensitivity, and specificity for their setting. For example, some settings may be willing to accept a lower sensitivity to reduce alarm fatigue. A poorly-designed system that is difficult to use can be a barrier. However, even in a well-designed system, staff need to understand the potential value of the PMS, be trained to use it correctly, understand the alerts/indicators it generates, and know how to respond quickly (calling the RRT or activating a Code Blue). A PMS will improve outcomes only if accompanied by comprehensive procedures for escalation, RRT activation, and audit and feedback to staff. Some PMSs that require manual input of vital signs into the electronic health record can actually delay vital sign recording and recognition of patient deterioration. Insufficient computers to input data and the practice of busy staff taking vital signs but delaying entry of the data were cited as barriers. Finally, the cost of designing, implementing, and storing data for a PMS can be prohibitive for smaller facilities. Rapid response teams Brought to widespread attention by the 2005 Institute for Healthcare Improvement’s 100,000 Lives Campaign, the RRT was developed in response to a growing body of evidence that revealed deficienciesin responding to rapid clinical decline in the inpatient setting. A key principle underlying RRTs is that early intervention can prevent avoidable morbidity and mortality in the non-intensive care hospital setting. RRTs have since been widely implemented across the globe. RRTs act as the efferent limb of the RRS and include the clinical care team that responds to the afferent limb’s calls. This team is typically multidisciplinary, and consists of a nurse, a physician, and a respiratory therapist, although team composition may vary slightly depending on institution policy and guidelines. The RRT assesses patient disposition, which can result in transfer of the patient to the ICU, return of care back to the primary medical team, or revision of the treatment plan. Of the three meta-analyses that reported the impact of RRS implementation on overall hospital mortality, two found significant decreases in mortality rates. 28,29 Chan et al., using 15 adult and pediatric studies with considerable heterogeneity found no difference in overall hospital mortality. 30
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