PICO Question : For infants and children in the in-hospital Setting (P), do pediatric medical
emergency teams (MET) or rapid response teams (RRT) (I), when compared to standard care (C),
improve outcomes (O)
Introduction
We identified 10 relevant articles in the literature addressing the above issue. They were all
observational before-and-after studies, often with retrospective reviews prior to invention (ie
implementation of the MET/RRT system, and a prospective review following implementation. Nine
were from US centres – either single Children’s centres or multi-centre collaborations. One was from
Pakistan.
Outcomes were measured as cardiac arrest, respiratory/pulmonary arrest, both cardiac and
respiratory/pulmonary arrest (CPA), code blue activations and mortality. Some focused on
morbidity/mortality in the hospital while others only looked at ICU rates.
We were unable to group/combine any set of the above studies due to the diverse and disparate
nature of study designs as well as the outcomes they separately measured.
Quality of Evidence
We found no randomized studies evaluating the effectiveness of rapid response teams (RRT) or
medical emergency teams (MET) of decreasing cardiac arrest frequency cardiac arrest frequency
outside the ICU, hospital mortality, overall hospital mortality, all arrests ( cardiac and respiratory)
outside the ICU or respiratory arrest. We found 10 observational studies which used a before-after
method of analysis.
For the critical outcome of outcome of cardiac arrest outside the ICU, we found 7 observational
studies of very low quality. One study (Ul-Haque, 2010) demonstrated a decrease in cardiac arrest
frequency (OR 0.52, 95 CI 0.12-2.26) in a tertiary care hospital in Pakistan. The majority of the calls
were for respiratory complaints. Mortality of patients transferred from the wards to the PICU also
decreased by 50% (OR 0.18, 0.09-0.35) Of the remaining 5 studies (Hanson 2010, Brilli 2007, Hunt
2008, Tibballs 2009, Kotsakis 2011, Bonafide 2014) from academic children’s hospitals in the
developed world, the rate of cardiac arrest outside the ICU declined after institution of RRT-METs in
all (RR < 1) but none achieved statistical significance.
For the critical outcome of all codes (cardiac and respiratory) outside the ICU, we found 4
observational studies (Hunt 2008, Sharek 2007, Zenker 2007, Hayes 2012) of very low quality. The
studies were from North American academic hospitals. One study demonstrated a statistically
significant decline while the other 3 did not after institution of RRT-METs.
For the critical outcome of respiratory arrest, we found 1 observational study Hunt 2008 of very low
quality from an academic children’s hospital. This study did observe a decline in respiratory arrests
after institution of an RRT-MET. (RR=0.27, 0.05-1.01, p = 0.035)
For the important outcome of cardiac arrest frequency, we found 1 observational study (Brilli 2007)
of very low quality from a large academic children’s hospital. There was a trend towards decline in
cardiac arrest frequency that was not statistically significant (RR=0.3, 0-1.04, p = 0.07)
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For the important outcome of overall hospital mortality, we found 6 observational studies (Hanson
2010, Brilli 2007, Tibballs 2009,Kotsakis 2011, Sharek 2007, Zenker 2007) of very low quality from
academic children’s hospitals. Three studies (Brilli 2007, Tibballs 2009, Sharek 2007) observed a
decline in deaths and 3 did not.
Of note, we were unable to calculate an overall RR for the outcomes, as the data were reported
variously as events/1000patient-days, events/1000admissions, or events/1000discharges. Since the
last review in 2005, we found only 4 additional studies (Ul-Haque 2010, Kotsakis 2011, Hayes 2012,
Bonafide 2014) One reported a significant change in the outcomes they reported (Ul-Haque 2010);
the other 2 did not. Additionally many of the studies use differing outcomes (rate of clinical
deterioration, PICU mortality, urgent admission to PICU, staff satisfaction, patient safety scores or
decline in preventable deaths. Many of these outcomes showed positive improvement.
Gaps Analysis
The strength of evidence in children compared to adults for the role of MET/RRT systems is very
low/weak. A major limitation is the low rate of cardiac arrest and mortality in pediatrics, and in the
hospitals from which the data in this analysis originates. As such, even trying to show a statistically
significant effect after a new implementation would be difficult at best. This is apparent in that most
studies demonstrated trends of improving mortality, though not statistically significant.
Use of a more valid and proximate outcome metric like Bonfide and team’s critical decision event
(CDE) would strengthen the case for implementation of MET/RRT in the paediatric inpatient setting.
The critical deterioration (CD) metric is defined as transfer to the intensive care unit (ICU) followed
by noninvasive or invasive mechanical ventilation or vasopressor infusion within 12 hours. More
current studies will therefore need to be done.
The other major limitation in our analysis is the use of before-and-after studies, with the inherent
limitations of unaccounted or confounding variables and inability to develop a comparable control
group. Joffe et al demonstrated the risk in these studies by comparing the mortatily rateat their
isntitusion, which did not initiate or organize a RRT/MET team, with 5 published studies ( all
reviewed here). The reduction in mortality at their institution over the same time period was similar
to the published results, illustrating the problems of confounding variables. It is unlikely, however,
that a fully controlled or even randomized study can be performed.
Treatment Recommendations
There is “Weak recommendation for implementation of a Medical Emergency Team / Rapid
Response Team/System for infants and children in an in-patient setting compared to the standard
care to improve outcomes in mortality and cardiac and/or respiratory arrests. “
We suggest implementation of pediatric RRT-METs in comparison with no RRT in hospitals that
care for children.
While such an implementation may result in decrease in mortality as well as cardiac and/or
respiratory arrests, this is conditional on the available resources available in the respective
institutions and its implementation must be balanced and calibrated against the respective
institution’s other more urgent/pressing needs in the delivery of care to its infants and children.
2
References
1.
Tibballs J and Kinney S. Reduction of hospital mortality and of preventable cardiac arrest and
death on introduction of a pediatric medical emergency team. Pediatr Crit Care Med 2009; 10 (3):
306-12.
2.
Brilli RJ, Gibson R, Luria JW, Wheeler TA, Shaw J, Linam M, McBride M. Implementation of a
medical emergency team in a large pediatric teaching hospital prevents respiratory and
cardiopulmonary arrests outside the intensive care unit. Pediatr Crit Care Med 2007; 8 (3): 236-46
3.
Sharek P, Parast LM and Leong K. Effect of a rapid response team on hospital-wide mortality
and code rates outside the ICU in a children's hospital. JAMA 2007; 298 (19): 2267-74
4.
Hunt E, Zimmer KP and Rinke ML. Transition from a traditional code team to a medical
emergency team and categorization of cardiopulmonary arrests in a children's center. Arch Pediatr
Adolesc Med 2008; 162 (2): 117-22
5.
Anwar ul H, Saleem AF, Zaidi S and Haider SR. Experience of pediatric rapid response team in
a tertiary care hospital in Pakistan. Indian J Pediatr 2010; 77 (3): 273-6
6.
Zenker P, Schlesinger A, Hauck M, Spencer S, Hellmich T, Finkelstein M, Thygeson MV,
Billman G.Implementation and Impact of a Rapid Response Team in a Children’s Hospital. The Joint
Commission Journal on Quality and Patient Safety. July 2007;33(7):418-25
7.
Hanson CC, Randolph GD, Erickson JA, Mayer CM, Bruckel JT, Harris BD, et al. A reduction in
cardiac arrests and duration of clinical instability after implementation of a paediatric rapid response
system. Qual Saf Health Care. 2009;18:500-4.
8.
Kotsakis A, Lobos AT, Parshuram C, Gilleland J, Gaiteiro R, Mohseni-Bod H. Bohn D.
Implementation of a multicenter rapid response system in pediatric academic hospitals is effective.
Pediatrics 2011; 128 (1): 72-8
9.
Bonafide CP, Localio AR, Roberts KE, Nadkarni VM, Weirich CM, Keren R. Impact of Rapid
Response System Implementation on Critical Deterioration Events in Children. JAMA Pediatr.
2014;168(1):25-33. doi:10.1001/jamapediatrics.2013.3266.
10.
Hayes, LW, Dobyns, DoGionine B, Brown AM, Jacobson S, Randall KH< Wathen B, Richard H,
Schwab C, Duncan KD, Thrasher J, Logsdon TR, Hall M, Markovitz B. A multicenter collaborative
approach to reducing pediatric codes outside the ICU. Pediatrics 2012;129 e785-e791.
11.
Joffe AR, Anton NR and Burkholder SC. Reduction in hospital mortality over time in a hospital
without a pediatric medical emergency team: Limitations of before-and-after study designs. Arch
Pediatr Adolesc Med 2011; 165 (5): 419-23
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Appendix A : TABLE OF OUTCOMES
Author/Date
Location /Hospital
Cardiac
arrest
Frequency
CA Outside ICU
Events/
1000ptdays
Hanson 2010
Brilli 2007
Hunt 2008
Events/
1000 nonICU pt-days
Stanford/Child Hosp
JHU/Child Hosp
Events/
1000
Events/
1000
Deaths/
1000
Deaths/
1000
admissions
discharges
discharges
admissions
RR0.35
(1-1.24)
p=.126
0.43
(0-1.6)
p=0.14
UNC/Academic
Hospital
RR = 0.3
(0-1.04)
p=0.07
Hospital mortality
RR= 0.5
(0-1.9)
p=.19
RR = 1
p=.97
Codes/
1000 ptdays
All Codes outside ICU
Codes/
1000
Codes/
1000
admissions
discharges
Tibballs 2009
Melbourne/Child
Hosp
Ul-Haque
2010
Pakistan/Tertiay
Care
Kotsakis 2011
Canada/Multicenter
RR=0.96
(.76-1.96)
Sharek 2007
Cinn/Child Hosp
Hayes 2012
Bonafide 2014
US/Multicenter
CHOP/Children's
Hospital
Zenker 2007
Minn/Child Hosp
Comments
RR=.76
(1-1.03)
p=0.78
RR=.42
(0-.89)
p=0.29
RR = 1
p=.99
RR=.91
(.5-1.64)
p=.75
OR= 0.52
(0.122.26)
p=0.004
Respiratory
Arrests
p =.1
RR=.35
(.57-.75)
p=.0001
Preventable
Deaths
MultiCenter
study
No standard
definitions
of team or
codes
p > 0.05
p=0.007
0.27
(.05-1.01)
p = .035
p =0.0008
p=0.6
p = 0.21
p = 0.57
p = 0.19
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APPENDIX B : USING GRADE : EVIDENCE TO RECOMMENDATION FRAMEWORK
Question : For infants and children in the in-hospital Setting (P), do pediatric medical emergency teams (MET) or rapid response teams (RRT) (I), when
compared to standard care (C), improve outcomes (O)
Population : Infants & children
Intervention : MET/RRT systems vs no MET/RRT systems improving outcomes
Setting : Inpatients
Decision Domain
Judgement
Reason for Judgement
Subdomains influencing judgement
Y
N
Balance of desirable and
Implementing MET.RRT systems is desirable. Baseline risk for desirable and undesirable outcomes:
undesirable outcomes
X
Only undesirable sequelae is the constraint
•
Is the baseline risk similar across subgroups?
Given the best estimate of
on existing limited resources.
•
Should there be separate recommendations for
typical values and
subgroups?
preferences, are you
Relative risk for benefits and harms:
confident that the benefits
•
Are the relative benefits large?
outweigh the harms and
•
Are the relative harms large?
burden or vice versa?
Requirement for modeling:
•
Is there a lot of extrapolation and modeling
required for these outcomes?
Typical values:
•
What are the typical values?
•
Are there differences in the relative value of the
critical outcomes?
Confidence in estimates if
Observational before-and-after studies.
Confidence in estimates of benefits and downsides,
effect (quality of evidence)
X
Final evidence of confidence rating : Very
confidence in estimates of resource use. Consider all
Is there high or moderate
low
critical outcomes, including the possibility that some
quality evidence
may not be measured.
Key reasons for rating evidence down or rating up
5
Values and preferences
Are you confident about the
typical values and
preferences and are they
similar across the target
population?
Resource implications
Are the resources worth the
expected net benefit from
following the
recommendation?
Overall strength of
recommendation
Evidence to
recommendation synthesis
X
Individual papers were assessed. We did not
combine any papers.
We only selected papers that focused on our
population.
Outcomes measured included mortality;
cardiac arrest; respiratory arrest;
cardiac/respiratory arrest; critical decision
events (CDEs) – some looked at outcomes
hospital wide while others looked only at
outside ICU outcomes.
While such an implementation may result in
decrease in mortality as well as cardiac
and/or respiratory arrests, this is conditional
on the available resources available in the
respective institutions and its
implementation must be balanced and
calibrated against the respective institution’s
other more urgent/pressing needs in the
delivery of care to its infants and children.
Source of typical values (panel or study of general
population or patients)
Source of estimates of variability and extent of variability
Method for determining values satisfactory for this
recommendation
What are the costs per resource unit?
Feasibility:
Is this intervention generally available?
Opportunity cost:
Is this intervention and its effects worth
withdrawing or not allocating resources from
other interventions
Differences across settings:
Is there lots of variability in resource requirements
across settings?
Weak for
There is “Weak recommendation for implementation of a Medical Emergency Team / Rapid Response
Team/System for infants and children in an in-patient setting compared to the standard care to improve
outcomes in mortality and cardiac and/or respiratory arrests. “
The very low level of confidence rating arises from the observational study. There are no ill effects should MET/RRT
systems be implemented. However, there is a question of how what significant positive outcome can be translated on the
floor when weighed against the costs needed to implement and sustain such systems.
This will be an even more significant factor for consideration in resource-challenged countries.
X
Ref :
Andrews JC, Schuunemannb HJ, Oxmand AD, et al. GRADE guidelines: 15. Going from evidence to recommendation -determinants of a recommendation’s
direction and strength. Journal of Clinical Epidemiology 66 (2013) 726-735
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