Rapid response team activations within 24 hours of admission from the emergency department: an innovative approach for performance improvement.

Objectives Performance improvement programs in emergency medicine (EM) have evolved beyond peer reviews of referred cases and now encompass a large set of quality metrics that are measured proactively. However, peer review of cases continues to be an important element of performance improvement, and selection of cases tends to be driven by an ad hoc referral process based on concerns about problems with care in the emergency department (ED). In the past decade, there has been widespread hospital adoption of rapid response teams (RRTs) that respond to patients who decline clinically to reduce adverse outcomes. In an effort to cast a wider net, to take a more systematic approach, and to avoid “blind spots” from individual variability in criteria for referring cases, the institution instituted a new process for selecting cases for ED peer review based on RRT activations within 24 hours of admission from the ED. The hypothesis was that a formal process for review of these activation cases would increase the number of cases for peer review. Methods This was a prospective, observational study conducted from July 1, 2012, to June 30, 2013, at an urban, academic medical center with an EM residency program. A new automated monthly report was created, capturing all RRT activations within 24 hours of admission from the ED. All events were reviewed by three physicians from the ED performance improvement committee to examine for systems issues, individual provider issues, or both, that might yield opportunities for improvement. Cases with potential opportunities were reviewed by the full ED performance improvement committee. Cases were classified according to the indication for response team activation using the system outlined by the U.S. Agency for Healthcare Research and Quality. Results During the study period 61,814 patients were treated in the ED, and 13,067 were admitted to inpatient status. Thirty-two RRT activations within 24 hours of admission from the ED occurred among these admitted patients, representing 0.24% of admissions (95% confidence interval [CI] = 0.16% to 0.33%). Of the 32 cases, only one was also referred independently for ED performance improvement review via the traditional ad hoc process. During the same period of time, 85 cases were referred to the ED performance improvement committee via the traditional ad hoc referral process. Thus, the RRT cases added an additional 31 cases, or 36.5%, to the 85 cases reviewed in ED performance improvement. Of the 32 cases, two were determined by the performance improvement committee to have individual provider factors in their ED care, which contributed to the clinical decline triggering the response teams; none had system factors. Most of the response team activations were for neurologic changes (n = 13) and respiratory status changes (n = 12). In two cases there was long-term morbidity or mortality related to the team activation event; in neither of these cases were ED system or individual provider factors judged to have contributed. Conclusions The review of RRT activations within 24 hours of admission from the ED significantly supplemented the typical ad hoc referral system for peer review of cases, highlighting cases that likely would not have received attention within the ED. This novel and unique case review process revealed opportunities for education and performance improvement. This and other systematic approaches to case detection may be useful adjuncts to traditional case referrals for review. Resumen Objetivos Los programas de mejora del rendimiento (MR) en Medicina de Urgencias y Emergencias (MUE) han evolucionado mas alla de las revisiones por pares de los casos referidos y actualmente abarcan un amplio conjunto de indicadores de calidad que son medidos de forma proactiva. Sin embargo, la revision por pares de los casos continua siendo un elemento importante de la MR, y la seleccion de los casos tiende a ser llevada a cabo por un proceso de referencia ad hoc basado en las preocupaciones acerca de los problemas de la atencion en el servicio de urgencias (SU). En la ultima decada, ha habido una adopcion generalizada en los hospitales de los equipos de respuesta rapida (ERR), que responden a los pacientes que empeoran clinicamente con el fin de reducir los resultados adversos. En un esfuerzo por lanzar una red mas amplia, para adoptar un enfoque mas sistematico y para evitar los “puntos ciegos” de la variabilidad individual en los criterios de los casos referidos, la institucion inicio un nuevo proceso para seleccionar los casos del SU basado en la revision por pares en las activaciones de los ERR en las primeras 24 horas del ingreso desde el SU (ERR24SU). La hipotesis fue que un proceso formal para la revision de casos de los ERR24SU aumentaria el numero de casos para la revision por pares. Metodos Estudio observacional prospectivo llevado a cabo en un centro medico universitario urbano con un programa de residencia en MUE desde el 1 de julio de 2012 hasta el 30 de junio 2013. Se creo un nuevo informe mensual automatizado, que capturo todos los eventos de los ERR24SU. Todos los eventos se revisaron ​​por tres medicos de la comision de MR del SU para examinar los sistemas y/o problemas del sanitario individual que podrian generar oportunidades para la mejora. Los casos con oportunidades potenciales se revisaron ​​por todo el comite de MR del SU. Los casos se clasificaron segun la indicacion para la activacion de los ERR usando el sistema descrito por la Agency for Healthcare Research and Quality. Resultados Durante el periodo de estudio 61.814 pacientes fueron atendidos en el SU y 13.067 fueron hospitalizados. Treinta y dos eventos de los ERR24SU ocurrieron en estos pacientes ingresados​​, lo que represento un 0,24% de los ingresos (IC 95% = 0,16% al 0,33%). De los 32 casos de los ERR24SU, solo uno se remitio tambien de forma independiente para su revision al comite de MR del SU a traves del proceso tradicional ad hoc. Durante el mismo periodo de tiempo, 85 casos se remitieron a la comision de MR SU a traves del proceso de remision tradicional ad hoc. Por lo tanto, los casos de los ERR24SU anaden 31 casos adicionales, o un 36,5%, a los 85 casos examinados en la MR SU. De los 32 de los casos ERR24SU, en dos el comite de MR determino que habia factores individuales del sanitario en la atencion en el SU que contribuyeron al deterioro clinico y desencadenaron el ERR; mientras que en ninguno hubo factores relacionados con el sistema. La mayoria de activaciones de los ERR fueron por alteraciones neurologicas (n = 13) y cambios del estado respiratorio (n = 12). En dos casos hubo morbilidad o mortalidad a largo plazo relacionada con el evento del ERR, y en ninguno de estos casos se juzgo que los factores del sanitario individual o del sistema hubieran contribuido. Conclusiones El proceso de los ERR24SU suplementa de forma significativa el sistema referido ad hoc tipico para la revision por pares de los casos, y detecta casos que probablemente no habrian sido considerados en el SU. Este proceso de revision de casos novedoso y unico revelo oportunidades para la formacion y la MR. Esta y otras aproximaciones sistematicas de deteccion del caso pueden ser complementos de utilidad a los casos tradicionales referidos para su revision.