Assessment of Rapid Response Teams at Top-Performing Hospitals for In-Hospital Cardiac Arrest | Cardiology | JAMA Internal Medicine | JAMA Network
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Merchant  RM, Yang  L, Becker  LB,  et al; American Heart Association Get With The Guidelines–Resuscitation Investigators.  Incidence of treated cardiac arrest in hospitalized patients in the United States.  Crit Care Med. 2011;39(11):2401-2406. doi:10.1097/CCM.0b013e3182257459PubMedGoogle ScholarCrossref
Girotra  S, Nallamothu  BK, Spertus  JA, Li  Y, Krumholz  HM, Chan  PS; American Heart Association Get with the Guidelines–Resuscitation Investigators.  Trends in survival after in-hospital cardiac arrest.  N Engl J Med. 2012;367(20):1912-1920. doi:10.1056/NEJMoa1109148PubMedGoogle ScholarCrossref
Chan  PS, Krumholz  HM, Nichol  G, Nallamothu  BK; American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators.  Delayed time to defibrillation after in-hospital cardiac arrest.  N Engl J Med. 2008;358(1):9-17. doi:10.1056/NEJMoa0706467PubMedGoogle ScholarCrossref
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(3):324-327. doi:10.1001/jama.295.3.324PubMedGoogle ScholarCrossref
Devita  MA, Bellomo  R, Hillman  K,  et al.  Findings of the first consensus conference on medical emergency teams [published correction appears in Crit Care Med. 2006;34(12):3070].  Crit Care Med. 2006;34(9):2463-2478. doi:10.1097/01.CCM.0000235743.38172.6EPubMedGoogle ScholarCrossref
Agency for Healthcare Research and Quality. Rapid response systems. Accessed April 9, 2019.
Townsend  S. Making the business case for a rapid response system. In: DeVita  M, Hillman  K, Bellomo  R,  et al, eds.  Textbook of Rapid Response Systems: Concept and Implementation. 2nd ed. Cham, Switzerland: Springer;2017:125-136. doi:10.1007/978-3-319-39391-9_12
Bellomo  R, Goldsmith  D, Uchino  S,  et al.  A prospective before-and-after trial of a medical emergency team.  Med J Aust. 2003;179(6):283-287.PubMedGoogle ScholarCrossref
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(7334):387-390. doi:10.1136/bmj.324.7334.387PubMedGoogle ScholarCrossref
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(21):2506-2513. doi:10.1001/jama.2008.715PubMedGoogle ScholarCrossref
Hillman  K, Chen  J, Cretikos  M,  et al; MERIT study investigators.  Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial.  Lancet. 2005;365(9477):2091-2097. doi:10.1016/S0140-6736(05)66733-5PubMedGoogle ScholarCrossref
Chan  PS, Jain  R, Nallmothu  BK, Berg  RA, Sasson  C.  Rapid response teams: a systematic review and meta-analysis.  Arch Intern Med. 2010;170(1):18-26. doi:10.1001/archinternmed.2009.424PubMedGoogle ScholarCrossref
Maharaj  R, Raffaele  I, Wendon  J.  Rapid response systems: a systematic review and meta-analysis.  Crit Care. 2015;19:254. doi:10.1186/s13054-015-0973-yPubMedGoogle ScholarCrossref
Chan  PS, Krein  SL, Tang  F,  et al; American Heart Association’s Get With the Guidelines–Resuscitation Investigators.  Resuscitation practices associated with survival after in-hospital cardiac arrest: a nationwide survey.  JAMA Cardiol. 2016;1(2):189-197. doi:10.1001/jamacardio.2016.0073PubMedGoogle ScholarCrossref
Nallamothu  BK, Guetterman  TC, Harrod  M,  et al.  How do resuscitation teams at top-performing hospitals for in-hospital cardiac arrest succeed? a qualitative study.  Circulation. 2018;138(2):154-163. doi:10.1161/CIRCULATIONAHA.118.033674PubMedGoogle ScholarCrossref
Chen  LM, Nallamothu  BK, Spertus  JA, Li  Y, Chan  PS; American Heart Association’s Get With the Guidelines–Resuscitation (formerly the National Registry of Cardiopulmonary Resuscitation) Investigators.  Association between a hospital’s rate of cardiac arrest incidence and cardiac arrest survival.  JAMA Intern Med. 2013;173(13):1186-1195. doi:10.1001/jamainternmed.2013.1026PubMedGoogle ScholarCrossref
Chan  PS, Berg  RA, Spertus  JA,  et al; American Heart Association’s Get With the Guidelines–Resuscitation Investigators.  Risk-standardizing survival for in-hospital cardiac arrest to facilitate hospital comparisons.  J Am Coll Cardiol. 2013;62(7):601-609. doi:10.1016/j.jacc.2013.05.051PubMedGoogle ScholarCrossref
Terry  G. Doing thematic analysis. In: Lyons  E, Coyle  A, eds.  Analysing Qualitative Data in Psychology. 2nd ed. London, UK: Sage; 2016:104-118.
Creswell  J.  Qualitative Inquiry and Research Design: Choosing Among Five Approaches. Thousand Oaks, CA: Sage Publications Inc; 2012.
Kuckartz  U.  Qualitative Text Analysis: A Guide to Methods, Practice and Using Software. London, UK: Sage Publications Ltd; 2014. doi:10.4135/9781446288719
Curry  LA, Nembhard  IM, Bradley  EH.  Qualitative and mixed methods provide unique contributions to outcomes research.  Circulation. 2009;119(10):1442-1452. doi:10.1161/CIRCULATIONAHA.107.742775PubMedGoogle ScholarCrossref
American Hospital Association. AHA data products. Accessed June 24, 2019.
Chen  J, Bellomo  R, Flabouris  A, Hillman  K, Finfer  S; MERIT Study Investigators for the Simpson Centre; ANZICS Clinical Trials Group.  The relationship between early emergency team calls and serious adverse events.  Crit Care Med. 2009;37(1):148-153. doi:10.1097/CCM.0b013e3181928ce3PubMedGoogle ScholarCrossref
Chua  WL, See  MTA, Legio-Quigley  H, Jones  D, Tee  A, Liaw  SY.  Factors influencing the activation of the rapid response system for clinically deteriorating patients by frontline ward clinicians: a systematic review.  Int J Qual Health Care. 2017;29(8):981-998. doi:10.1093/intqhc/mzx149PubMedGoogle ScholarCrossref
Jones  D, Drennan  K, Hart  GK, Bellomo  R, Web  SA; ANZICS-CORE MET Dose Investigators.  Rapid response team composition, resourcing and calling criteria in Australia.  Resuscitation. 2012;83(5):563-567. doi:10.1016/j.resuscitation.2011.10.023PubMedGoogle ScholarCrossref
Spence Laschinger  HK, Read  E, Wilk  P, Finegan  J.  The influence of nursing unit empowerment and social capital on unit effectiveness and nurse perceptions of patient care quality.  J Nurs Adm. 2014;44(6):347-352. doi:10.1097/NNA.0000000000000080PubMedGoogle ScholarCrossref
Bradley  EH, Herrin  J, Wang  Y,  et al.  Strategies for reducing the door-to-balloon time in acute myocardial infarction.  N Engl J Med. 2006;355(22):2308-2320. doi:10.1056/NEJMsa063117PubMedGoogle ScholarCrossref
Goedhart  NS, van Oostveen  CJ, Vermeulen  H.  The effect of structural empowerment of nurses on quality outcomes in hospitals: a scoping review.  J Nurs Manag. 2017;25(3):194-206. doi:10.1111/jonm.12455PubMedGoogle ScholarCrossref
McHugh  MD, Rochman  MF, Sloane  DM,  et al; American Heart Association’s Get With The Guidelines–Resuscitation Investigators.  Better nurse staffing and nurse work environments associated with increased survival of in-hospital cardiac arrest patients.  Med Care. 2016;54(1):74-80. doi:10.1097/MLR.0000000000000456PubMedGoogle ScholarCrossref
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    Original Investigation
    July 29, 2019

    Assessment of Rapid Response Teams at Top-Performing Hospitals for In-Hospital Cardiac Arrest

    Author Affiliations
    • 1Institute of Clinical and Translational Science, University of Iowa, Iowa City
    • 2College of Nursing, University of Iowa, Iowa City
    • 3Department of Internal Medicine, University of Missouri–Kansas City
    • 4Division of Cardiology, Department of Internal Medicine, University of Missouri–Kansas City and Saint Luke’s Mid America Heart Institute, Kansas City
    • 5Department of Family Medicine, University of Michigan Medical School, Ann Arbor
    • 6Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
    • 7Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
    • 8Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City
    • 9Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
    • 10Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor
    • 11Division of Cardiovascular Diseases, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City
    JAMA Intern Med. 2019;179(10):1398-1405. doi:10.1001/jamainternmed.2019.2420
    Key Points

    Question  How do rapid response teams differ between top-performing and non–top-performing hospitals for resuscitation care?

    Findings  In this qualitative study of data collected from interviews with 158 key stakeholders at 9 Get With The Guidelines–Resuscitation hospitals, distinct differences were found in the organizational structure and function of rapid response teams. Top-performing hospitals feature rapid response teams with dedicated staff without competing responsibilities, serve as a resource for bedside nurses in surveillance of at-risk patients, collaborate with nurses during and after a rapid response, and can be activated by a member of the care team without fear of reprisal.

    Meaning  This study appears to provide important insights regarding strengthening rapid response teams across hospitals.


    Importance  Rapid response teams (RRTs) are foundational to hospital response to deteriorating conditions of patients. However, little is known about differences in RRT organization and function across top-performing and non–top-performing hospitals for in-hospital cardiac arrest (IHCA) care.

    Objective  To evaluate differences in design and implementation of RRTs at top-performing and non–top-performing sites for survival of IHCA, which is known to be associated with hospital performance on IHCA incidence.

    Design, Setting, and Participants  A qualitative analysis was performed of data from semistructured interviews of 158 hospital staff members (nurses, physicians, administrators, and staff) during site visits to 9 hospitals participating in the Get With The Guidelines–Resuscitation program and consistently ranked in the top, middle, and bottom quartiles for IHCA survival during 2012-2014. Site visits were conducted from April 19, 2016, to July 27, 2017. Data analysis was completed in January 2019.

    Main Outcomes and Measures  Semistructured in-depth interviews were performed and thematic analysis was conducted on strategies for IHCA prevention, including RRT roles and responsibilities.

    Results  Of the 158 participants, 72 were nurses (45.6%), 27 physicians (17.1%), 27 clinical staff (17.1%), and 32 administrators (20.3%). Between 12 and 30 people at each hospital participated in interviews. Differences in RRTs at top-performing and non–top-performing sites were found in the following 4 domains: team design and composition, RRT engagement in surveillance of at-risk patients, empowerment of bedside nurses to activate the RRT, and collaboration with bedside nurses during and after a rapid response. At top-performing hospitals, RRTs were typically staffed with dedicated team members without competing clinical responsibilities, who provided expertise to bedside nurses in managing patients who were at risk for deterioration, and collaborated with nurses during and after a rapid response. Bedside nurses were empowered to activate RRTs based on their judgment and experience without fear of reprisal from physicians or hospital staff. In contrast, RRT members at non–top-performing hospitals had competing clinical responsibilities and were generally less engaged with bedside nurses. Nurses at non–top-performing hospitals reported concerns about potential consequences from activating the RRT.

    Conclusions and Relevance  This qualitative study’s findings suggest that top-performing hospitals feature RRTs with dedicated staff without competing clinical responsibilities, that work collaboratively with bedside nurses, and that can be activated without fear of reprisal. These findings provide unique insights into RRTs at hospitals with better IHCA outcomes.