Would your hospital benefit from a dedicated rapid response doctor?

Rapid response teams (RRT) and critical care outreach teams have become an integral part of UK hospitals since the early 2000s. Meta-analyses have suggested different results in terms of cardiac arrest rates, intensive care unit (ICU) admissions and mortality.^1,2 The presence of a consultant has not yet been shown to be associated with improved outcomes when compared to other structures.^2–4

We reviewed the impact of the introduction of a dedicated middle grade doctor and a dedicated seven-day-a-week consultant to the RRT. We compared two 19-month time periods – one with the nurse-led team and one with the consultant-led team.

Following the introduction of a consultant-led service, there was a statistically significant reduction in ICU admissions (1416 vs. 1218, p = 0.008).

The introduction of the consultant-led service was associated with a reduction in advanced cardiac support on ICU (OR 0.6, CI 0.48–0.76, p < 0.001) and multiple organ support on ICU (OR 0.8, CI 0.67–0.95, p = 0.01). There was an increase in the odds of requiring respiratory support (OR 1.19, CI 1.01–1.4, p = 0.04). There was no change in the odds of requiring advanced renal support (OR 0.96, CI 0.81–1.13, p = 0.64).

We saw no statistically significant difference in ICU length of stay (2.75 days vs. 3.2 days, p = 0.75).

Although not statistically significant, the consultant-led group saw an increase in the APACHE II score (15.5 vs. 15.9, p = 0.14), 30 day (16.5 vs. 18.5, p = 0.06), 60-day (16.8 vs. 18.9, p = 0.08) and 90-day (16.9 vs. 19, p = 0.09) mortality in patients admitted to ICU. We would suggest that this is a consequence of early senior intervention, allowing patients who respond rapidly to remain on the ward with a resultant skew towards more unwell patients being admitted to ICU. In summary, our enhanced RRT saw a reduction in unplanned ICU admissions and a consequent alteration in the profile of patients admitted to the ICU. We propose that a dedicated doctor, free from ICU duties, contributed to better ward management of deteriorating patients, allowing more patients to remain on the ward – reflected in the reduced total number of unplanned ICU admissions. In addition, the dedicated clinician is able to re-review patients to assess response to treatment. The profile of patients admitted to ICU therefore changed to a cohort of patients with disease that could not be improved with ward-based therapies – demonstrated by the increased odds of requiring advanced respiratory support. The role of a senior clinical decision maker to our RRT may also have contributed to a reduction in unplanned ICU admissions by identifying those patients in whom intensive care would be futile and thus preventing admission and unnecessary invasive therapies. In order to make these decisions, the clinician must have time to discuss with patients, family members and parent teams – we feel that the most effective way of doing this is through being freed of ICU duties.