SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
January, 2017 - SUPPORT Summary of a systematic review | print this article | download PDF
Rapid-response systems were created to improve recognition of and response to deterioration of hospitalized patients, with the goal of reducing the incidence of cardiorespiratory arrest and hospital mortality. A rapid-response system consists of providers who immediately assess and treat unstable patients. Examples include medical emergency teams and rapid response teams. Preliminary evidence of improvements in patient outcomes led to widespread utilization of rapid response systems.
Key messages
People deciding whether to put rapid- response systems into practice
Maharaj R, Raffaele I, Wendon J. Rapid response systems: a systematic review and meta-analysis. Crit Care 2015; 19:254.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Hospitalized patients often experience unrecognized deterioration that may progress to cardiorespiratory arrest. Rapid-response systems, which were created to improve recognition of and response to deterioration of hospitalized patients, generally have three components:
1) Criteria and a system for notifying and activating the response team. These usually include vital signs (single-trigger criteria or aggregated and weighted early warning scoring) or general concern expressed by a clinician or family member.
2) A response team that generally uses a physician (trained in intensive care); rapid-response teams, which do not include a physician; or critical care outreach teams, which follow up on patients discharged from the intensive care unit but also respond to all ward patients.
3) An administrative and quality improvement component that collects and analyses event data, coordinates resources, and ensures improvement or maintenance over time.
| Review objectives: To assess the effect of the rapid response system on hospital mortality and cardiopulmonary arrest outside the intensive care unit. | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Comparisons between a control cohort and intervention (rapid response system) cohort that provided quantitative data about mortality rates or cardiopulmonary arrests. |
29 studies met the inclusion criteria: cluster-randomised trials (2), interrupted time series studies (2), controlled before-after study (1), and before-after studies with no contemporaneous control group (24) |
| Participants | Hospitalised patients |
Hospitalised adults (21 studies) and children (8) |
| Settings | Hospitals |
Academic teaching hospitals (22) and community hospitals (6) in the USA (11), Australia (7), Canada (3), the UK (2), Pakistan, Portugal, Saudi Arabia, South Korea, Sweden, the Netherlands (1 each) |
| Outcomes | Hospital mortality (primary outcome); non-intensive care unit cardiopulmonary arrest, and intensive care unit admissions (secondary outcomes) | Hospital mortality (27 studies), cardiopulmonary arrests (26), intensive care unit admissions (10) |
| Date of most recent search: December 2013 | ||
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Limitations: This is a well-conducted systematic review with only minor limitations. |
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Maharaj R, Raffaele I, Wendon J. Rapid response systems: a systematic review and meta-analysis. Crit Care 2015; 19:254.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
Twenty one studies were included in the systematic review that reported the effects of rapid-response systems for hospitalised adults. Twenty studies reported hospital mortality, 18 reported cardiopulmonary arrests, and 10 reported intensive care unit admissions for hospitalised adults. Most (16) of the studies were uncontrolled before-after studies with a high risk of bias. There was variation in the size of the effects observed in different studies. Neither the duration of the service or having a doctor present was associated with the size of the effect.
For hospitalised adults:
Rapid-response systems for hospitalised adults |
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| People: Hospitalised adults Settings: Hospitals Intervention: Rapid-response system (RSP) Comparison: No rapid response system |
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| Outcomes | Types of studies | Illustrative comparative risks | Relative effect (95% CI) |
Certainty of the evidence (GRADE) |
|||
| Without RSP | With RSP | ||||||
| Hospital Mortality | RCT, CBA, ITS
Before-after studies |
19 per 1000 admissions 19 per 1000 admissions |
18 per 1000 (16 to 19) 17 per 1000 (16 to 18) |
RR 0.91 (0.85 to 0.97) RR 0.88 (0.81 to 0.95)
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Low |
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| Cardiopulmonary arrest outside the ICU |
RCT, CBA, ITS Before-after studies |
4 per 1000 admissions 3 per 1000 admissions |
3 per 1000 (2 to 4) 2 per 1000 (2 to 2) |
RR 0.74 (0.56 to 0.98) RR 0.62 (0.54 to 0.98) |
Low |
||
| ICU admissions | All studies |
5 per 1000 admissions |
4 per 1000 (2 to 5) |
RR 0.90 (0.70 to 1.16) |
Low |
||
RCT: randomised trial CBA: controlled before-after study ITS: interrupted time series study ICU: intensive care unit
95% CI: 95% confidence interval RR: Risk ratio
GRADE: GRADE Working Group grades of evidence (see above and last page)
Eight studies were included in the systematic review that reported the effects of rapid-response systems for children. Seven studies reported hospital mortality, eight reported cardiopulmonary arrests, and none reported intensive care unit admissions for hospitalised children. Most (7) of the studies were uncontrolled before after studies with a high risk of bias.
Rapid-response systems for hospitalised children |
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| People: Hospitalised children Settings: Hospitals Intervention: Rapid-response system (RSP) Comparison: No rapid response system |
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| Outcomes | Types of studies | Illustrative comparative risks | Relative effect (95% CI) |
Certainty of the evidence (GRADE) |
|||
| Without RSP | With RSP | ||||||
| Hospital Mortality | RCT, CBA, ITS
Before-after studies |
96 per 10,000 admissions 75 per 1000 admissions |
73 per 10,000 (51 to 105) 60 per 10,000 (47 to 75) |
RR 0.76 (0.53 to 1.09)
RR 0.80 (0.63 to 1.00)
|
Very Low | ||
| Cardiopulmonary arrest outside the ICU |
RCT, CBA, ITS Before-after studies |
10 per 10,000 admissions 23 per 10,000 admissions |
4 per 10,000 (1 to 17) 15 per 10,000 (12 to 18) |
RR 0.35 (0.08 to 1.59) RR 0.64 (0.53 to 0.77) |
Low |
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| ICU admissions | No studies | - |
- |
- | |||
| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
| None of the included studies were conducted in a low-income country. |
When assessing the transferability of these findings to low-income countries the availability of resources and the capacity of hospital systems to implement rapid-response services needs to be considered. |
| EQUITY | |
| There was no information in the included studies regarding effects of the interventions on disadvantaged populations. |
Resources needed for rapid response systems may be less available in disadvantaged settings.
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| ECONOMIC CONSIDERATIONS | |
| None of the included studies assessed costs associated with rapid-response systems. |
Local costings should be undertaken, including the costs of training, support, personnel, equipment and supplies. |
| MONITORING & EVALUATION | |
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There is low certainty evidence about the effects of rapid response systems.
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More rigorous studies (randomised trials or interrupted time series studies) are needed to determine the effects and the cost-effectiveness of rapid-response systems prior to scaling up their use in low-income countries.
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*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm |
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Solomon RS, Corwin GS, Barclay DC, et al. Effectiveness of rapid response teams on rates of in-hospital cardiopulmonary arrest and mortality: a systematic review and meta-analysis. J Hosp Med 2016; 11:438-45.
Alam N, Hobbelink EL, van Tienhoven AJet al. The impact of the use of the Early Warning Score (EWS) on patient outcomes: a systematic review. Resuscitation 2014; 85:587-94.
Smith ME, Chiovaro JC, O'Neil M, et al. Early warning system scores for clinical deterioration in hospitalized patients: a systematic review. Ann Am Thor Soc 2014; 11:1454-65.
McNeill G, Bryden D. Do either early warning systems or emergency response teams improve hospital patient survival? A systematic review. Resuscitation 2013; 84:1652-67.
Winters BD, Weaver SJ, Pfoh ER, et al. Rapid-response systems as a patient safety strategy: a systematic review. Ann Intern Med 2013; 158:417-25.
Chan PS, Jain R, Nallmothu BK, et al. Rapid response teams: a systematic review and meta-analysis. Arch Intern Med 2010; 170:18-26.
Ranji SR, Auerbach AD, Hurd CJ, et al. Effects of rapid response systems on clini-cal outcomes: systematic review and meta-analysis. J Hosp Med 2007; 2:422-32.
McGaughey J, Alderdice F, Fowler R, et al. Outreach and early warning systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards. Cochrane Database Syst Rev 2007; 3:CD005529.
Agustín Ciapponi, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina
None declared. For details, see: www.supportsummaries.org/coi
An earlier version of this summary based on another review (Ranji 2007) was peer reviewed by Sumant
Ranji, Sameer Pathan, and Newton Opiyo.
Maharaj R, Raffaele I, Wendon J. Rapid response systems: a systematic review and meta-analysis. Crit Care 2015; 19:254.
Ciapponi A. Do rapid-response systems improve clinical outcomes? A SUPPORT Summary of a systematic review. January 2017. www.supportsummaries.org
evidence-informed health policy, evidence-based, systematic review, health sys-tems research, health care, low and middle-income countries, developing coun-tries, primary health care, rapid-response systems, medical emergency team, mortality, cardiac arrest and outcomes
