Since then, says Don Goldmann, MD, IHI senior vice president, rapid response teams have proliferated in hundreds to thousands of hospitals.
Goldmann says that while he agrees in principle with Pronovost's and Litvak's arguments, "Emergency department physicians and staff can't tell in every case which patients are going to experience some problems, even though when they are admitted they look like they'll be fine on a regular unit."
He also says that while he knows some question the validity of studies that says rapid response teams do save lives, it would hard to test the theory today with a trial. "Most institutional review boards would find it problematic to set up a control group," he says.
In an interview, Litvak expanded on ways to solve the problem. He said that much of the ICU demand may be alleviated by smoothing out elective surgical schedules. Hospitals can avoid having to move patients out of ICUs, or assigning them to non-monitored beds, by adjusting surgical schedules. That smoothes the flow of patients from the crowded emergency room as well, he said.
Goldmann says that the take-home message of the Pronovost and Litvak commentary should be that "as much as possible, patients' risks should be assessed. Their point is As much as possible, patients risks should be properly assessed, and if they need an intensive care or monitored bed, that's where they should go."
But Litvak says the problem goes much deeper: poor attention to patient flow management.
"If you ask me today, could you tell me which type of medical error is bigger: errors caused by clinical mistakes or errors from patient flow mismanagement I would have a real problem answering. And yet the whole country is concentrating on the first and the second is off the radar screen. It's at least equally significant and has been completely overlooked."