he minute-by-minute and hour-to-hour intense observation of patients for early signs of clinical deterioration and the rapid response to those signs and symptoms is the foundation of the medical practice of anesthesiology and critical care medicine. We spend our professional lives watching, under a clinical microscope, for potential adverse events in our patients. The intraoperative and perioperative realm (intensive care and postanesthesia care units) is inherently at high risk for clinical deteriorations.

Likewise adverse events also are common on general medical and surgical wards in acute care hospitals with perhaps hundreds or even thousands of patients experiencing serious harm, including death, cardiac arrest, respiratory arrest or unanticipated transfer to a critical care unit.¹ Published data imply that the prevalence of adverse events ranges from 4 percent to as high as 16 percent of all hospital admissions^{2, 3} with one study showing that more than 13 percent of adverse events ultimately led to the patient’s death. The true impact on patient morbidity and mortality is likely to be much higher, acknowledging that the ability to identify and capture such events and categorize them is often poor.

Many of these adverse incidents on general wards are preventable as they rarely happen suddenly or unexpectedly. A number of studies^4-9 have demonstrated that premonitory signs and symptoms clearly herald these adverse events. Many hours prior to the event, the signs of deterioration are identified; however, medical staff often underappreciate their significance. This concatenation to a critical or adverse event leaves time for successful intervention in many cases, if the significance of the signs are recognized in a contemporaneous fashion.^7,9,10

One strategy to help identify and treat patient problems prior to a patient suffering a critical or adverse event is the Rapid Response Team (RRT), also known as a Medical Emergency (Response) Team [ME(R)T], Patient At Risk Team (PART) or Critical Care Out-Reach Team (CCOT). For the purpose of this manuscript, we will use the more common term RRT. Using “alert criteria,” such as changes in vital signs, critical laboratory values or even general concern on the part of the floor staff, these teams are activated to come to a patient’s bedside to assess and intervene with the goal of stabilizing the patient and halting deterioration. This is conceptually and functionally different than a “code blue” team that responds once the patient has arrested, although both teams may use some or all of the same responders.

RRTs are being widely advocated and implemented in many hospitals around the United States, although the data on their effectiveness remain in evolution. The number of trials examining the effectiveness of RRTs is limited. There are only 10 studies^11-20 reported in the literature that examine outcomes in a controlled fashion, and only two of these use randomization in their methodology.^{11, 18} The outcomes of interest include hospital mortality, in-hospital cardiac arrest, unanticipated intensive care unit (ICU) admission, length of stay (both hospital and ICU) and ICU mortality. Unfortunately there is significant heterogeneity in definitions and denominators used in many studies, and since several of these outcomes involve subsets of patients exposed to the intervention, there is substantial risk for bias.

Several observational studies suggest improvement in hospital mortality and incidence of cardiac arrest (vide infra), but of the two cluster-randomized studies reported in the literature, the multicenter MERIT study demonstrated no benefit for these outcomes. This study, however, was relatively underpowered despite its excellent design, and the conclusions were questionable. The four observational trials, however, unanimously found statistically significant reductions in the incidence of in-hospital cardiac arrest with an RRT as compared to controls.^{13, 15-17} In light of these early findings, the likelihood remains that RRTs should be able to have significant impact on improving patient safety and quality of care.

Participation in RRT programs is a perfect opportunity for general (nonintensivist) anesthesiologists and subspecialist anesthesiologist/intensivists to bring their education and expertise to the greater hospital venue. The development and implementation of RRT programs is an endeavor that should be vigorously embraced by all departments of anesthesiology and critical care medicine based on the precedents in the literature, improvement of patient outcomes and for professional reasons. Of the studies that have reported outcome data over the last decade, 70 percent described their RRT as being staffed by a critical care physician (fellow and/or attending) either directly (60 percent) or as the medical consultant to a nurse-led team (10 percent). One used multiple teams in multiple hospitals. The remaining 20 percent were physician-led programs not specifying the educational background of the physician.

All studies^{11, 13-16} that demonstrated a reduction in mortality and cardiac arrest were led by physicians or had physician consultation available, and when identified, this physician was nearly always critical care-trained. Most studies used four physiological parameters (critical values or changes in blood pressure, heart rate, respiratory rate and mental status) to trigger the RRTs. Decrements in pulse oximetry values and concern or worry on the part of the ward staff also were commonly used. Specifically four studies^{13, 15-17} reporting benefit for in-hospital cardiac arrest were physician-led teams, with three of those specifically identifying the team leader as a critical care physician. Examining in-hospital mortality, three of four^13-15 studies demonstrating benefit were led by critical care physicians. The fourth study¹¹ had critical care physician consultation available for its senior nurse-led team.

Since so many of the programs are critical care physician-led or not specified, it is difficult to make a comparison to noncritical care physician-supervised programs. Thus there is no rigorous way of knowing whether there is an outcome benefit from having critical care physicians as members or leaders of the team as compared to another specialty. Historically, though, it is clear that most programs reported in the literature have chosen to use intensivists as the leaders of their teams. Where intensivists are not readily available, however, general anesthesiologists are extremely well-suited to lead RRTs.

Professionally, leadership of RRTs by intensivists makes intuitive sense. Intensivists are the best-educated and best-equipped physicians to take on leadership roles since the inherent purpose of RRT programs is to recognize and intervene in the development of critical illness. While the patient may not yet be an ICU patient or may not have deteriorated to the point of requiring transfer to an ICU, the care rendered is “intensive care,” creating an “ICU without walls” phenomenon.

Through this “out-reach,” one suggested additional benefit of RRTs is the potential reduction in unanticipated ICU admissions. While the data have yet to bear this out, patients who deteriorate to a critical event such as cardiorespiratory arrest or septic shock will inevitably be admitted to the critical care unit. Even when patients visited by an RRT still require admission to the ICU, early pre-ICU care may yield benefits in terms of mortality in the ICU and length of stay. Unfortunately there is insufficient data available to make those outcome determinations at the present time.

Through expansion of our practice to the general wards, we may be able to prevent adverse events, thereby improving patient safety and reducing poor outcomes. The potential reductions in in-hospital cardiac arrest and in-hospital mortality from having RRTs, when applied to all general wards admissions across the United States, should yield an improvement in lives saved on the same order of magnitude as staffing ICUs with intensivists. Through leadership of RRTs, intensivists may bring their expertise to the hospital-wide community, adding value to their care.

Anesthesiologist/intensivists are perhaps the best qualified of all critical care physicians for this role by virtue of their extensive education and experience in physiology and pharmacology, airway management and nonsurgical invasive procedures. Patients progressing to critical illness often require the benefits that all of these skills bring. Additionally, while there is no hard data to support availability of RRT services 24 hours a day, seven days a week, it seems incredulous not to do so. The RRT studies reported data on the timing of events; calls were either spread evenly throughout the day and night or tended to occur more at night. Since teams need physician coverage 24 hours a day, physician services already designed to provide this level of commitment are the best choice for leadership. Anesthesiologists and/or anesthesiologist/intensivists, in many instances, provide 24-hour-per-day hospital coverage. Few other physician specialties except trauma and emergency medicine provide such coverage.

Thus the nature of our practice — vigilance, rapid assessment and aggressive intervention, coupled with our broad expertise in medical and surgical issues and a nearly ubiquitous physical presence — puts anesthesiologists, particularly those with critical care education, in a position to be the natural and best-equipped leaders for RRTs.

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Gerald A. Maccioli, M.D., F.C.C.M., is ASA Director for North Carolina, and Director of Critical Care Medicine, Critical Health Systems of North Carolina, Raleigh Practice Center, Raleigh, North Carolina.

Bradford D. Winters, M.D., is Director, Adult Rapid Response Teams Project, and Assistant Professor of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.