Giving hospital "rapid response" teams credit for saving lives of suddenly deteriorating inpatients is "like rewarding a pilot for ultimately landing safely after he or she had made a dangerous decision to take off during inclement weather," two prominent patient safety leaders claim.
Rather, hospitals and physicians should make sure the patients aren't assigned to units providing an inadequate level of care in the first place, wrote Peter Pronovost, MD, a Johns Hopkins University intensivist, and Eugene Litvak, president of the Institute for Healthcare Optimization in Newton, MA.
"It's a silly science when you take credit for your own bad decisions," Pronovost said in a statement.
In a somewhat harsh commentary in the Journal of the American Medical Association, Pronovost and Litvak spelled out the disastrous cascade that results when patients who are mistakenly assigned beds outside the intensive care unit suddenly get much worse and teeter toward death.
They acknowledged that some patients deteriorate despite being assigned to an adequate level of care, and may benefit from an organized system to identify and treat patients who get quickly worse.
But far too many other patients need rescue because they were simply assigned to the wrong level of care at the start, or reassigned, because beds providing the right level they need—an intensive care unit or monitored unit —were all filled up or there was an error in triage.
"Intensive care units and monitored beds are scare resources, demand for these resources periodically exceeds supply, and patients are often not admitted to these preferred units," they wrote.
The authors, in part, blame poor timing in the use of hospital services, such as elective surgical suites during prime emergency room days, Tuesday, Wednesday and Thursday. On those days, surges occur, although they are largely unpredictable.
"During these times, everything goes wrong, ambulances are diverted, patients are boarded in emergency departments, patients are often prematurely discharged from the ICU to make room for more ill patients or elective surgical cases, nurses are overloaded and stressed and patient discharges take place prematurely, resulting in patient readmissions.
"On days like these, hospital clinicians and managers face an unlikable dilemma, to admit a patient to a nonpreferred unit or to board the patient in the emergency department or the postanesthesia care unit until a bed in the preferred unit becomes available.
"During these times," they continued, "proper placement is an exercise in wishful thinking and the definition of a preferred bed becomes 'the one that is available.'"
In an interview, Litvak said, "We put patients wherever there is a hole. We're not in the position to put the right patient in the right bed."
They added that the benefits of such teams, also called "Code Blue" teams, have not been proven. "RRT studies were often of poor quality and clinicians often failed to call an RRT when they should have, leading to uncertainty in the estimates of benefit."
"It seems perverse to measure the success of RRTs by counting the number of saved lives that were put at risk by triage errors, driven by ineffective management of patient flow," they wrote.
The concept of rapid response teams was developed decades ago in Australia, but it was greatly advanced in the U.S. by new Centers for Medicare & Medicaid Services director Don Berwick, MD, then president and CEO of the Institute for Healthcare Improvement. IHI made rapid response teams one of the seven safety strategies in its "100,000 Lives Campaign" in 2005.
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."