BACKGROUND: 

Approximately half of the life-limiting events, such as cardiopulmonary arrests or cardiac arrhythmias occurring in hospitals, are considered preventable. These critical events are usually preceded by clinical deterioration. Rapid response teams (RRTs) were introduced to intervene early in the course of clinical deterioration and possibly prevent progression to an event. An RRT was introduced at the Cleveland Clinic in 2009 and transitioned to an anesthesiologist-led system in 2012. We evaluated the association between in-hospital mortality and: (1) the introduction of the RRT in 2009 (primary analysis), and (2) introduction of the anesthesiologist-led system in 2012 and other policy changes in 2014 (secondary analyses).

METHODS: 

We conducted a single-center, retrospective analysis using the medical records of overnight hospitalizations from March 1, 2005, to December 31, 2018, at the Cleveland Clinic. We assessed the association between the introduction of the RRT in 2009 and in-hospital mortality using segmented regression in a generalized estimating equation model to account for within-subject correlation across repeated visits. Baseline potential confounders (demographic factors and surgery type) were controlled for using inverse probability of treatment weighting on the propensity score. We assessed whether in-hospital mortality changed at the start of the intervention and whether the temporal trend (slope) differed from before to after initiation. Analogous models were used for the secondary outcomes.

RESULTS: 

Of 628,533 hospitalizations in our data set, 177,755 occurred before and 450,778 after introduction of our RRT program. Introduction of the RRT was associated with a slight initial increase in in-hospital mortality (odds ratio [95% confidence interval {CI}], 1.17 [1.09–1.25]; P < .001). However, while the pre-RRT slope in in-hospital mortality over time was flat (odds ratio [95% CI] per year, 1.01 [0.98–1.04]; P = .60), the post-RRT slope decreased over time, with an odds ratio per additional year of 0.961 (0.955–0.968). This represented a significant improvement (P < .001) from the pre-RRT slope.

CONCLUSIONS: 

We found a gradual decrease in mortality over a 9-year period after introduction of an RRT program. Although mechanisms underlying this decrease are unclear, possibilities include optimization of RRT implementation, anesthesiology department leadership of the RRT program, and overall improvements in health care delivery over the study period. Our findings suggest that improvements in outcome after RRT introduction may take years to manifest. Further work is needed to better understand the effects of RRT implementation on in-hospital mortality.

中文翻译：

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快速反应小组对住院死亡率的影响

背景： 

大约一半的生命限制事件，例如在医院发生的心肺骤停或心律失常，被认为是可以预防的。这些严重事件通常发生在临床恶化之前。引入快速反应小组 (RRT) 以在临床恶化过程中及早进行干预，并可能防止进展为事件。RRT 于 2009 年在克利夫兰诊所引入，并于 2012 年过渡到由麻醉师主导的系统。我们评估了住院死亡率与：（1）2009 年引入 RRT（初步分析）和（2 ) 2012 年引入麻醉师主导的系统以及 2014 年的其他政策变化（二次分析）。

方法： 

我们使用 2005 年 3 月 1 日至 2018 年 12 月 31 日在克利夫兰诊所的过夜住院病历进行了单中心回顾性分析。我们在广义估计方程模型中使用分段回归评估了 2009 年引入 RRT 与住院死亡率之间的关联，以解释重复访问的受试者内相关性。控制基线潜在混杂因素（人口统计学因素和手术类型），以使用倾向得分上的治疗逆概率加权。我们评估了在干预开始时住院死亡率是否发生变化，以及时间趋势（斜率）是否在干预开始之前和之后有所不同。类似模型用于次要结果。

结果： 

在我们数据集中的 628,533 例住院治疗中，177,755 例发生在我们的 RRT 计划引入之前和 450,778 例之后。RRT 的引入与住院死亡率的最初轻微增加相关（优势比 [95% 置信区间 {CI}]，1.17 [1.09–1.25]；P < .001）。然而，虽然 RRT 前住院死亡率的斜率随时间推移是平缓的（优势比 [95% CI] 每年，1.01 [0.98–1.04]；P = .60），但 RRT 后斜率随着时间的推移而下降，每增加一年的优势比为 0.961 (0.955–0.968)。这代表了与 RRT 前斜率相比的显着改善 ( P < .001)。

结论： 

我们发现在引入 RRT 计划后的 9 年内死亡率逐渐下降。虽然这种下降背后的机制尚不清楚，但可能性包括 RRT 实施的优化、RRT 计划的麻醉科领导，以及研究期间医疗保健服务的整体改进。我们的研究结果表明，引入 RRT 后结果的改善可能需要数年时间才能显现出来。需要进一步的工作来更好地了解 RRT 实施对住院死亡率的影响。