Aaron Spaulding
Robert Ohsfeldt
Rapid Response Teams and Team
Composition: A CostrEffedaveness
Analysis
E xecutive S ummary
Cardiac arrest results in numer­
ous deaths and serious mor­
bidities in hospital settings
every year.
►
Rapid response teams (RRT),
consisting of interdisciplinary
team members, can be called
prior to a patient’s need for
resuscitation during cardiac
arrest.
Determining the effectiveness
of these teams has been a con­
cern to researchers as well as
to the hospitals implementing
these teams.
194
^
In this study, total personnel
costs associated with different
RRTs were analyzed, and RRT
effectiveness was compared to
existing code blue or cardiac
arrest teams.
^
RRTs that shared personnel
with the traditional cardiac
arrest team, yet also added
new personnel, provided better
care at a reduced cost when
looking at quality-adjusted life
years 6 months after cardiac
arrest.
arrests (Bedell, Deitz, Leeman, &
ardiac arrest results in
Delbanco, 1991; Kause et al.,
numerous deaths and seri­
2004) . Reports indicate the quality
ous morbidities in hospital
of cardiopulmonary resuscitation
settings every year. Within
is lacking, thus impairing patient
pediatric hospitals, children, who
safety outcomes (Abella et al.,
are not in the intensive care unit
2005) . In addition, costs per quali­
and experience heart failure, are
ty of life year gained are expen­
not able to be resuscitated 50% to
sive. A cost-effectiveness study
67% of the time (Nowak & Brilli,
conducted by Ebell and Kruse
2007). A study of cardiopulmon­
(1994) found that cost per qualityary arrest in a hospital in Australia
adjusted life year (QALY) for car­
revealed approximately 73% of
diopulmonary resuscitation was
children survived the initial car­
$61,000 in 1991 U.S. dollars, which
diac arrest resuscitation but only
equals almost $100,000 per QALY
34% survived for 1 year after the
in 2011 U.S. dollars (Bureau of
arrest (Tibballs & Kinney, 2006).
Labor Statistics, n.d.).
Genardi, Cronin, and Thomas
These studies produce sober­
(2008) indicate that less than 20%
ing evidence concerning the cur­
of adults experiencing cardiac
rent manner and cost for care
arrest while in the hospital sur­
delivered in our hospitals and
vive; and an overwhelming major­
demonstrate a need for interven­
ity of arrests occur after hours of
tions to occur before cardiac arrest
slow deterioration. Several other
and resuscitation events. To
researchers have pointed to vari­
reduce poor outcomes and pro­
ous antecedents to cardiac arrest,
vide better patient safety, hospi­
which if monitored, could allow
tals have attempted to implement
intervention to reduce or elimi­
a wide range of innovations designnate these “preventable” cardiac
C
AARON SPAULDING, PhD, MHA, is
ROBERT OHSFELDT, PhD, is Professor,
Assistant Professor, Department of Public
Health, Brooks College of Health, Univer­
sity of North Florida, Jacksonville, FL.
School of Rural Public Health, Depar­
tment of Health Policy and Management,
Texas A&M Health Science Center,
College Station, TX.
NURSING ECONOMIC$/July-August 2014/Vol. 32/No. 4
ed to improve performance. One
such innovation is the rapid res­
ponse team (RRT), also known as
emergency medical team (EMT),
w hich consists of interdiscipli­
nary team members who can be
called prior to a patient’s need for
resuscitation (Insitute for Health­
care Improvement, 2008).
Typically, nurses can call the
RRT w hen they feel a patient is
deteriorating, w hether or not there
is empirical evidence for the call.
These teams are designed to inter­
vene during the care process in
order to reduce or eliminate pre­
ventable cardiac arrests in hospi­
tal settings (Rothschild et al.,
2008; Sebat et al., 2007). They are
considered a preventative care
solution, w hich should reduce the
need for cardiac arrest or code
blue team activations. Code blues
are designed to bring physicians
and nurses to the patient to pro­
vide emergency care. For instance,
code blue teams are called during
cardiac arrest or w hen a patient
needs im m ediate resuscitation.
The following study sought to
determine costs and care effective­
ness associated w ith RRT to deter­
m ine if these teams provide addi­
tional benefit w hen compared to
cardiac or code blue teams.
Research Demonstrating Effect
Of RRTs/EMTs
Determining the effectiveness
of these teams has been a concern
to researchers as well as to the
hospitals im plem enting these
teams. A num ber of studies have
been conducted in a variety of set­
tings to better understand how
RRTs impact cardiac arrest and
mortality outcomes. By and large,
the studies indicate differing out­
comes; yet, most of the literature
indicates these teams are viewed
positively by those participating
w ith them, and some even report
they could impact the culture of
safety w ithin the hospital (Barbetti
& Lee, 2008; Iyengar, Baxter, &
Forster, 2009). There also tends to
be some disbelief concerning find­
ings indicating marginal impact
these teams have on patient safety
outcomes (Campello et al., 2009).
Recently, Chan, Jain, Nallmothu,
Berg, and Sasson (2010) conduct­
ed a meta-analysis of RRT/EMT
effectiveness. This meta-analysis
focused on random ized clinical
trials or prospective, active inter­
vention studies, and provides a
better estimation of RRT/EMT im ­
pact than previous analysis. Chan
and colleagues provide evidence
RRT/EMTs are correlated w ith
reductions in overall hospital car­
diac arrests, yet have little impact
on overall hospital mortality.
Barriers
There have been several ideas
posed as to why these teams are
not more effective. Some indicate
the traditional means of commu­
nication patterns betw een the
roles of patient, nurse, and physi­
cian could provide a large barrier
to successful implem entation and
use of RRT/EMTs (Daffurn, Lee,
Hillman, Bishop, & Bauman, 1994;
Thomas, VanOyen Force, Rasmussen,
Dodd, & W hildin, 2007). It may be
that nurses are uncom fortable
stepping outside the normal chain
of command and initiating a call
for RRT/EMTs, even when they
feel the need to do so (Azzopardi,
Kinney, Moulden, & Tibballs, 2011;
ECRI, 2006; Mahlmeister, 2006;
Tibballs & van der Jagt, 2008).
Physicians may feel nurses are
subverting physician authority
w hen a nurse disagrees w ith the
care plan and procedure, and, as a
result, calls a RRT/EMT (ECRI,
2006; Mahlmeister, 2006). General
confusion can occur w ith regard
to w hen to call the RRT/EMT or
what situations promote its use.
This indicates team composi­
tion may have some impact on the
effectiveness of the team, particu­
larly w ith regard to activation,
response, and diagnosis. It is rea­
sonable to assume fears concern­
ing the activation of these teams
may be correlated w ith who is on
the team, and how comfortable
individuals w ithin the organiza­
tion are w ith calling upon teams
NURSING ECONOMIC$/July-August 2014/Vol. 32/No. 4
of different structures.
Completely new teams may
provide a completely new set of
skills and abilities at the bedside
that are more capable of respond­
ing to deteriorating patients as
compared to emergency cardiac
arrest treatment. The hospital may
also be able to market the team in
a com pletely new m anner in
w hich patient care is provided.
However, RRTs/EMTs may receive
better acceptance if they are more
closely related to existing code
blue or cardiac arrest teams. This
may prim arily be due to the com­
fort level associated w ith calling
an existing team as compared to
calling a completely new team.
However, along this same line of
thinking, some propose improve­
ments seen after RRT/EMT im ple­
m entation could be based solely
on the training received by those
who have to activate the teams
(Campello et al., 2009; DeVita,
Schaefer, Lutz, Wang, & Dongilli,
2005). If this is indeed the case,
we w ould expect to see little dif­
ference in outcom es betw een
teams comprised of completely
new members and those com ­
prised of the same members who
make up the code blue or cardiac
arrest team. Differences in how
teams are structured, when com­
pared to existing code blue or car­
diac arrest response teams, may
help us to better understand dif­
ferences in the effectiveness out­
comes presented in the literature.
Methodology
This study provides analysis
for both total personnel costs asso­
ciated with different RRTs/EMTs,
and also RRT/EMT effectiveness
compared to existing code blue or
cardiac arrest teams. Composition
of RRT/EMT membership was ex­
tracted from studies found in the
most recent meta-analysis of RRT/
EMT effectiveness conducted by
Chan and colleagues (2010). Their
meta-analysis focused on random­
ized clinical trial or prospective
active interventions studies, thus
providing a better estimation of
195
RRT/EMT impact than previous
analysis. In all, 17 studies were
evaluated to assess the impact
RRTs/EMTs had on cardiac arrest
and mortality in hospitals in
Australia, England, Canada, and
the United States. However, this
study will only focus on adult
facilities that reported information
regarding the composition of their
RRT/EMT and impact on cardiac
arrests.
RRT/EMT membership and
wage costs. Each study included
in the 2010 meta-analysis was
revisited and the following items
were extracted: RRT/EMT compo­
sition, code blue/cardiac arrest
team composition, average care
time of RRT/EMT, number of
RRT/EMT calls, number of code
blue/cardiac arrest team calls,
number of cardiopulmonary arrests
before and after RRT/EMT imple­
mentation, study length, average
age of patients in the study, and
any estimates regarding costs asso­
ciated with RRT/EMT implemen­
tation.
Once data concerning RRT/
EMT composition was deter­
mined, all team members were
assessed and, in order to allow
comparisons between groups,
team members were matched to
U.S. personnel. This allows for
costs across the studies to be con­
sistent, since wage rates or salaries
were not reported in any of the
studies of interest. Cost data, and
average number of hours worked
per week for physicians, nurses,
and support staff, were obtained
through literature reviews (American
Medical Association [AMA], 2011;
Bureau of Labor Statistics, 201 Id;
Leigh, Tancredi, Jerant, & Kravitz,
2010; Ohio State Medical Center,
2011; 0*NET OnLine, 2010d).
Wage data for physicians in
training, including interns, resi­
dents, and fellows, were deter­
mined through the AMA and
Association of American Medical
Colleges FREIDA database which
contains survey data from medical
education programs (AMA, 2011).
These data are segmented by spe­
196
cialty and report first year post
graduation (PGl) average salary.
Since some of the RRT/EMT team
members include junior to senior
residents and fellows assumed to
be (PG62-PG9), data from The
Ohio State University Medical
Center, as well as graduate medical
education house staff stipends,
were used to make estimate (Ohio
State Medical Center, 2011). As
necessary, hourly wage data were
established by dividing salary into
reported average hours worked for
each job. When the number of
hours for the job was not reported,
an assumption of 40 hours of work
per week was used. All costs were
adjusted for inflation using the
Bureau of Labor Statistics infla­
tion calculator which uses the
average Consumer Price Index for
a given calendar year to standard­
ize costs to 2011 U.S. dollars
(Bureau of Labor Statistics, n.d.).
Resulting costs are reported in
Table 1.
Comparison of groups. This
analysis assumes there are certain
costs associated with each team
providing care, including training
and staffing. The study, from
which the cost data were extract­
ed, provided detail on the person­
nel membership of each team.
RRT/EMT composition and
cost are divided into three cate­
gories: (a) RRT and code blue team
using the same personnel but
requiring additional training (no
differences in personnel between
the two teams), (b) the RRT and
the code blue team sharing per­
sonnel but with additional mem­
bers added to the RRT, and (c) a
completely new RRT with distinct
personnel from the code blue
team. How these teams are
grouped, the ranges of costs relat­
ed to personnel wage, and result­
ing benefits, as reported through
cardiac arrest reductions for the
hospitals from which the teams
participated, are shown in Table 2.
Additionally, information regard­
ing reported control, RRT groups,
and cardiac arrests, including rel­
ative risks, are provided. Team
costs associated with each report
are estimated, and total costs of
each RRT/EMT call are estab­
lished by the following formula:
TC=2 (w/t)n
Where TC is total cost, w is
the hourly wage of each team
member, t is the average time
spent in care during the RRT/EMT
activation, and n is the total num­
ber of calls the team experienced.
The total number of calls respond­
ed to by the RRT/EMT were
reported in each study; however,
only a few studies reported aver­
age care time, ranging from
approximately 20 to 30 minutes
(Bellomo et al., 2003; DeVita et al.,
2004; Sharek et al., 2007). These
studies served as the baseline, and
30 minutes of care time was used
for all RRT/EMT activations
(DeVita et al., 2004), while 1 hour
was used for the time of care for
cardiac arrests (Vrtis, 1992a). The
base case analysis used the aver­
age of the total costs associated
with each team. Subsequent sensi­
tivity analysis used the maximum
and minimum calculated values.
Probabilities related to RRT/
EMT activation for each branch
were standardized to cardiac
arrest care only (standard care or
care in the absence of RRT/EMTs).
This was calculated through
dividing the total number of car­
diac arrests experienced by the
population of patients in all con­
trol groups within the study. This
standard care calculation allowed
for better comparison of the effec­
tiveness of each branch, as it elim­
inated the population risk of car­
diac arrest present within the dif­
ferent populations. The calcula­
tion of the probability of RRT/
EMT activation and the probabili­
ty of subsequent cardiac arrest for
each time is adjusted to standard
care.
Training costs associated with
code blues or RRT are not well
documented in the literature.
Most studies have indicated over­
all costs for training, yet, don’t
include enough specifics to pro­
vide adequate information from
NURSING ECONOMIC$/July-August 2014/Vol. 32/No. 4
Table 1.
Wage Costs
Jobs
Country
U.S. Equivalent
Annual
Pay ($)
Hourly
Pay ($)
Source
Anesthesiologists
United States
218,434.03
105.02
Cardiovascular ICU
nurse
United States
64,701.03
31.11
O'NET OnLine, 201 Oe
Critical Care Nurse
Bureau of Labor Statistics, 2011a
United States
64,701.03
31.11
O'NET OnLine, 201 Oe
Floor Nurse
United States
64,701.03
31.11
O'NET OnLine, 201 Od
Hospital Chaplain
United States
43,590.74
20.96
O'NET OnLine, 2010b
Hospitalist
United States
263,908.93
84.17
Leigh et al., 2010
Intensivist or Internal
Medicine
United States
173,278.97
58.46
Leigh et al., 2010
Intern
United States
48,224.66
14.36
American Medical Association, 2011
Junior Assistant
Resident
United States
49,637.11
14.78
Ohio State Medical Center, 2011
Nursing Supervisor
United States
69,199.50
33.27
PayScale, 2011
Pharmacists
United States
109,995.85
52.88
Bureau of Labor Statistics, 2011b
Physician
United States
167,588.30
67.42
Leigh et al., 2010
Physician Assistant
United States
87,507.71
42.07
Bureau of Labor Statistics, 2011c
Respiratory Therapist
United States
55,910.86
26.88
Bureau of Labor Statistics, 2011e
Security Officer
United States
87,146.67
41.9
Senior Assistant
Resident
United States
51,375.67
15.29
Ohio State Medical Center, 2011
Nurse Consultant
England
Clinical Nurse
Specialist
83,071.05
39.94
O'NET OnLine, 2010a
ICU Residents
Canada
ICU Residents
49,637.11
14.78
Ohio State Medical Center, 2011
Emergency Department
Doctor
Australia
Emergency
Department
Physician
252,585.22
102.48
Leigh et al., 2010
ICU Consultant
Australia
Attending Physician
167,588.30
67.42
Leigh et al., 2010
ICU Nurse
Australia
ICU Nurse
64,701.03
31.11
O'NET OnLine, 201 Oe
ICU Physician
Australia
Internal Medicine
173,278.97
58.46
Leigh et al., 2010
ICU Registrar
Australia
ICU Fellow
58,822.63
17.51
Ohio State Medical Center, 2011
Medical Registrar
Australia
Internal Medicine
Fellow or Chief
Resident
58,822.63
17.51
Ohio State Medical Center, 2011
Receiving Medical
Unit Fellow
Australia
Junior Attending
167,588.30
67.42
Leigh et al., 2010
Registered Nurse
Australia
Registered Nurse
57,996.68
27.88
Bureau of Labor Statistics, 2011d
Senior Intensive Care
Nurse
Australia
Senior ICU nurse
64,701.03
31.11
O'NET OnLine, 201 Oe
Senior Nurse
Australia
Senior Nurse
64,701.03
31.11
O'NET OnLine, 201 Od
NURSING ECONOMIC$/July-August 2014/Voi. 32/No. 4
O'NET OnLine, 2010c
197
Table 2.
RRT Characteristics
T o tal Cost
of R R T
P er Hour
C o n tro l
G roup
N u m b e r of
P a tie n ts
C o n tro l
G roup
C a rd ia c
A rre s ts
DeVita et a t, 2004
$344.62
143,776
Baxter, Cardinal, Hooper, & Patel, 2008
$131.23
C ita tio n
T o ta l C ost of
Code Team
Per Hour
E M T /R R T
A c tiv a tio n
RRT
G roup
P a tie n ts
RRT
G roup
C a rd ia c
A rre s ts
R e la tiv e
R is k
930
1,296
55,248
290
0.81
7,8 20
43
1,931
11,271
38
0.61
$133.55
21 ,09 0
63
99
20,921
22
0.35
$6 6 .1 3
19,317
73
152
22,847
47
0.50
7,503
8
0.49
D itte re n t R R T an d C o d e B lu e T e a m
B ellom o et a t, 2003
$81.42
B uist et a t, 2002
P a r tia lly D iffe re n t T e a m s
Jones et a t, 2005
$2 8 1.9 9
$1 1 6.0 4
7,504
16
Jones et a t, 2007
$28 1.9 9
$116.04
16,246
66
1,252
104,001
198
0.47
B ris to w et a t, 2000; h i vs. h2
$66.13
$66.13
13,059
66
150
18,338
69
0.88
B ris to w et a t, 2000; h i vs. h3
$66 .1 3
$66.13
19,545
99
150
18,338
69
1.00
$1 3 3.5 9
5,856
15
1,329
6,494
10
0.60
53,500
139
136
53,50 0
128
0.92
S am e Team s
H illm an et a t, 2005
Kenw ard, Castle, Hodgetts,
& Shaikh, 2004
which to base cost of training per
member in either team (Campello
et al., 2009; Dacey et al., 2007). In
one study, the combined training
cost for the RRT was $50,000
while airway and critical care
training was an additional
$60,000 in 2007 dollars (Dacey et
al., 2007). Cost of training a car­
diac arrest team was estimated to
be $175,425 in 1992 dollars (Vrtis,
1992b). Inflating training costs for
both teams to 2011 dollars results
in cardiac care team training costs
of $279,414 per team and RRT
training costs of $118,554 per
team. When individuals are mem­
bers of both the RRT and code
blue team, the overall costs for
training are calculated as the car­
diac arrest team cost plus the RRT
staff training cost which equals
$334,127 combined. Finally, the
number of individuals who are
present on each team is a result of
the average number of members
for each branch. The standard care
arm is the average number of
198
members for all code blue teams
reported in the study.
Effectiveness is reported as
cost per QALY 6 months after car­
diac arrest, and is based on the
average age of the individuals
within the hospital. QALYs for the
populations in the study are cal­
culated using data published in
the “US Norms for Six Generic
Health-Related Quality of Life
Indexes from the National Health
Measurement Study” (Fryback et
al., 2007). QALY measures associ­
ated with survivors of cardiac
arrest were obtained from Nichol
and colleagues’ (1999) study on
quality of life for survivors of car­
diac arrest. Both QALY measures
used in this study utilized the
Health Utilities Index Mark 3 sys­
tem (HUI3). The tree diagram used
to determine the cost effectiveness
of these teams is presented in Figure
1. This cost-effectiveness analysis
was conducted using TreeAge Pro
Software (Williamstown, MA).
Sensitivity analysis accounted
for time of treatment, variance in
team member costs, training, pop­
ulation risk, utility, and imple­
mentation costs. Particular em­
phasis was placed on sensitivity
analysis for training since these
values are not well reported in the
literature and the proposition that
variable costs are a driver of the
overall cost effectiveness of these
types of interventions.
Results
As expressed in Table 3, the
shared personnel and completely
new RRT models demonstrated
effectiveness in reducing the num­
ber of cardiac arrests as compared
to the standard care. To reiterate,
standard care involves the use of
only cardiac arrest or code blue
teams, and as such, is a single­
tiered system. The other strategies
provide an additional layer of sup­
port for those who might experi­
ence a cardiac arrest. The results
of the cost-effectiveness model
NURSING ECONOMIC$/July-August 2014/Vol. 32/No. 4
Figure 1.
Cost-Effectiveness Analysis of Rapid Response and Code Blue Teams
Cardiac Arrest
Table 3.
Cost-Effectiveness Rankings
S trategy
Effectiveness
In cre m en tal
Effectiveness
Cost
In cre m en tal
Cost
In cre m en tal Cost/
In crem en tal
Effectiveness
D om inance
A verage Cost
Effectiveness
Shared
Personnel
0.38499845
Completely
New RRT
0.384998194
($14,721,492,136.16)
$130,572.28
$3,766.90
($14,721,492,136.16)
Dominated
$339,150.38
Standard
Care
0.384926381
($2,117,554,026.98)
$279,414.99
$152,609.60
($2,117,554,026.98)
Dominated
$725,892.01
RRT Same as
Code Blue Team
0.384997116
($151,936,398,197.13)
$329,417.50
$202,612.11
($151,936,398,197.13)
Dominated
$855,636.27
$126,805.38
NURSING ECONOMIC$/July-August 2014/Vol. 32/No. 4
$329,365.96
199
Table 4.
Sensitivity Analysis for Code Blue Team Training Costs
C ode Blue Team
Training Cost
$150,000.00
$200,000.00
$250,000.00
$300,000.00
$350,000.00
S trategy
Incremental Cost-Effectiveness
Ratio
Dom inance
Shared Personnel
$319,441.83
Completely New RRT
$324,697.31
$(7,907,186,274.33)
Dominated
Standard Care
$389,686.61
$(374,864,623.67)
Dominated
RRT Same as Code Blue Team
$855,636.27
$(154,801,552,697.21)
Dominated
Shared Personnel
$323,276.07
Completely New RRT
$330,281.34
$(10,539,934,078.16)
Dominated
Standard Care
$519,581.58
$(1,048,163,091.97)
Dominated
RRT Same as Code Blue Team
$855,636.27
$(153,694,583,128.97)
Dominated
Shared Personnel
$327,110.32
Completely New RRT
$335,865.37
$(13,172,681,881.99)
Dominated
Standard Care
$649,476.54
$(1,721,461,560.27)
Dominated
RRT Same as Code Blue Team
$855,636.27
$(152,587,613,560.73)
Dominated
Shared Personnel
$330,944.57
Completely New RRT
$341,449.40
$(15,805,429,685.82)
Dominated
Standard Care
$779,371.51
$(2,394,760,028.57)
Dominated
RRT Same as Code Blue Team
$855,636.27
$(151,480,643,992.49)
Dominated
Shared Personnel
$334,778.82
Completely New RRT
$347,033.43
$(18,438,177,489.65)
Dominated
RRT Same as Code Blue Team
$855,636.27
$(150,373,674,424.25)
Dominated
Standard Care
$909,266.48
$(3,068,058,496.88)
Dominated
revealed teams who shared per­
sonnel between the RRT and the
code blue team were most cost
effective with an expected cost of
$329,365.96 for each QALY
gained. This team composition
dominated all other options in the
model (see Table 3).
RRTs/EMTs comprised of the
same members as the code blue or
cardiac arrest team were more
expensive than the standard care
using the base case estimates. A
sensitivity analysis concerning
total team training costs, time of
care, personnel costs, and differ­
ences in health state utility pro­
vides evidence these results are
somewhat dependent upon train­
ing costs, while the other variables
200
Increm ental C o st/
Increm ental
Effectiveness
have little to no impact (see Table
4). However, when training costs
for RRTs were adjusted, there were
slight changes in the incremental
cost effectiveness and all strate­
gies remained dominated by
teams who shared personnel bet­
ween the RRT and the code blue
team. When adjusting for training
costs for code blue/cardiac arrest
teams, changes only occurred
when code blue training costs
reached $350,000, at which point
standard care becomes the least
viable option.
Discussion
Previous arguments concern­
ing the effectiveness of RRTs have
focused around training costs, and
have proposed that training does
in fact provide the mechanism for
RRT success (Campello et al.,
2009). This study supports that
argument to some extent, but adds
a caveat which demonstrates team
composition plays a role in effec­
tiveness as well. The considera­
tion of team composition and the
impact different teams have on
patient safety and patient out­
comes seem to be an obvious over­
sight. This is particularly true in
light of the amount of team train­
ing, team satisfaction, team out­
come, and team culture studies
which exist in management and
health care. How can we decide to
implement teams of skilled per­
sonnel to achieve specific tasks
NURSING ECONOMIC$/July-August 2014/Vol. 32/No. 4
without first asking, “What is the
best combination of skills and
abilities within the team?” This
question is further highlighted
when considering the sensitivity
analysis results concerning the
impact of training.
Nursing leadership should
consider these issues as they im­
plement, staff, and monitor RRT
processes and procedures within
their organization. RRT activation
has been and continues to be an
issue that challenges traditional
roles within the hospital, and con­
tinued education and reassur­
ances related to the proper activa­
tion criteria are necessary for con­
tinued outcome enhancements
(Azzopardi et al., 2011). As nurs­
ing leaders consider how best to
staff these teams, they should also
consider the findings of this study
and promote a mixed team design
(some new members and some
from the existing cardiac arrest
team).
As such, the results indicating
sharing personnel between the
RRT and code blue team makes
intuitive sense when thinking
about continuum of care and the
ability for the team to respond to a
variety of issues. These results do
pose the question, “Why does the
strategy which uses the same team
for both not realize a greater
degree of effectiveness at reduced
costs?” The answer may lie in the
perspectives on which the original
ideas for RRTs are based. These
teams are designed to bring a new
set of eyes to a problem; thus,
helping to prevent problems
before they truly become complex
(Barbetti & Lee, 2008). When the
RRT and code blue team are the
same, there may be a tendency for
team members to attempt to “fix”
all patients using the same tools or
procedures. This also serves to
reduce the number of different
perspectives on which the under­
lying causes are evaluated. Bring­
ing a set of fresh or unbiased eyes
to a situation in order to deter­
mine future sequences of events
may allow for better diagnosis
and, consequently, better out­
comes.
Additionally, having mixed
membership may prevent some of
the barriers associated with nurses
activating the team (Azzopardi et
al., 2011). For instance, using the
same team for both pre-cardiac
and actual cardiac arrest events
may tempt nurses, or those acti­
vating the RRT, to view all events
as either one or the other, not as
independent events requiring dif­
ferent team activations. This
undermines the benefits associat­
ed with bringing a team in to help
evaluate the status of a declining
patient. Similarly, if the team is
comprised of all new members,
staff may be less likely to activate
the team due to its newness, and
therefore, may depend largely on
traditional means of care. When
mixing the composition of the
RRT with new members and exist­
ing code team members, activa­
tion may, in fact, be easier because
the team is able to provide both
evaluation and needed cardiac
arrest support. This is not to say
the other teams could not provide
the same services; however, it may
be the mixture of old and new
treatments of care creates an easier
transition into calling for help
then exists with other team
designs. Nevertheless, this argu­
ment rests on the assumption
those responsible for activating
the RRT understand the team’s
composition.
If team composition is not
known, the outcomes may be a
result of better evaluation and
continuum of care. That is, the
new perspective provided by the
new members of the RRT, and the
cardiac arrest experience residing
in the code blue members, may
provide better evaluation as to
causes of patient deterioration.
This evaluation may then allow
for more appropriate reactions to
those causes, thus providing for
better outcomes.
Regardless of whether im­
provements in care and costs
result from a better mix of per­
NURSING ECONOMIC$/July-August 2014/Vol. 32/No. 4
spectives or via continuity of care,
the relationship between patient
and hospital personnel is para­
mount. Nursing leadership has an
opportunity to continue to focus
and promote this viewpoint to all
involved with the RRT process.
Strong nursing leadership is re­
quired so that barriers created by
traditional health care roles can be
overcome and greater quality and
continuity of care through team
member communications and
actions are achieved.
Limitations
Literature concerning training
costs for either RRT or code blue
teams were universally lacking.
While hospitals .may have a
greater understanding of the costs
associated with training, those
proposing and evaluating the im­
pact of different treatment strate­
gies and particularly implementa­
tion of RRTs seem to have focused
on other aspect of RRTs; thus,
description and evaluation of the
impact of both initial and continu­
al training is lacking. However,
numerous studies report the need
to continue to train team members
and staff who activate RRTs
(Azzopardi et al., 2011; Kenward
et al, 2004).
Along with sparse data con­
cerning training, there are several
other limitations to this study.
This study utilized data from sev­
eral existing RRT or EMT team
studies from the United Kingdom,
Australia, and Canada. While
efforts were made to align caregiv­
er skills and responsibilities, there
is little doubt that clinicians
around the world are not the
same. In addition, since differ­
ences between RRT and code blue
teams were not always distinct,
some assumptions as to composi­
tion, particularly regarding the
code blue teams, were made.
While it is not believed these
assumptions greatly impacted the
findings, some change could be
present (based on sensitivity
analysis). Finally, as with any RRT
study, some difference between
201
his study continues and
ad van ces the d e b ate on
the im p a c t of RRTs on
c a rd ia c a rre s t and p a tie n t
s a fety w ith in the h o sp ita l.
the teams is related to activa­
tion criteria. This analysis
assumed those criteria to be
similar enough for compari­
son; yet, effectiveness meas­
ures do depend upon differ­
ences related to why some
teams are activated while others
are not.
Future studies resultant from
this cost benefit analysis of RRT
can take several different paths.
Studying team structure and cost
can benefit a number of different
areas within the hospital, includ­
ing surgical teams, emergency
department operations, and even
patient admittance procedures.
Teams are already a source of
interest for many researchers, and
many of these areas have received
a great deal of attention; however,
looking at the costs and associated
benefits relating to these teams
have not received research atten­
tion until now. Continued re­
search related to RRTs is needed,
and this study provides an initial
step at better understanding of dif­
ferences in outcomes associated
with these teams. Future studies
could focus on replication and
extension of this research, taking
training costs into a more central
view. Additionally, studies related
to RRT activation and nursing
staff perception relating to conse­
quences of activation based on
RRT composition can further in­
form our understanding of the
impact these teams have on the
patient safety culture existent in
the hospital.
Conclusions
This study continues and ad­
vances the debate on the impact of
RRTs on cardiac arrest and patient
safety within the hospital. RRTs
can be more cost effective than tra­
ditional cardiac arrest or code blue
teams, based upon case-control
studies evaluating cardiac arrests
within hospitals. While a number
of assumptions regarding training,
personnel, and activation criteria
are made, the results of this analy­
sis indicate that RRTs, when mixed
202
with existing code blue team mem­
bers, provide better care at reduced
costs. There are a variety of reasons
this may occur, many of them relat­
ing to the benefits of bringing mul­
tiple perspectives to the bedside.
Continued evaluation and further
consideration of these teams are
needed, especially in the areas of
training costs, amount of ongoing
training needed, activation criteria,
and perspectives of those activat­
ing RRTs. $
REFERENCES
Abella, B.S., Alvarado, J.P., Myklebust, H.,
Edelson, D.P., Barry, A., O’Hearn, N„
... Becker, L. B. (2005). Quality of car­
diopulmonary resuscitation during
in-hospital cardiac arrest. JAMA,
293(3), 305-310. doi:10.100l/jama.
293.3.305
American Medical Association (AMA).
(2011). FREIDA. Retrieved from
h ttp s://freid a .a m a-assn .o rg /am a/
pub/education-careers/graduate-medical-education/freida-online.page
Azzopardi, P., Kinney, S., Moulden, A., &
Tibballs, J. (2011). Attitudes and barri­
ers to a medical emergency team sys­
tem at a tertiary paediatric hospital.
Resuscitation, 82(2), 167-174. doi:
10.1016/j.resuscitation. 2010.10.013
Barbetti, J., & Lee, G. (2008). Medical emer­
gency team: A review of the literature.
Nursing in Critical Care, 13(2). 80-85.
d o i:1 0 .1 1 1 1 /j. 1 4 7 8 -5 1 5 3 .2 0 0 7 .
00258.x
Baxter, A.D., Cardinal, P., Hooper, J., &
Patel, R. (2008). Medical emergency
teams at The Ottawa Hospital: The
first two years. Canadian Journal of
Anesthesia/Joumal Canadien D’anesth
Esie, 55(4), 223-231.
Bedell, S.E., Deitz, D.C., Leeman, D., &
Delbanco, T.L. (1991). Incidence and
characteristics of preventable iatro­
genic cardiac arrests. JAMA: The
Journal o f the American Medical
Association, 265(21), 2815-2820.
Bellomo, R., Goldsmith, D., Uchino, S.,
Buckmaster, J., Hart, G. K., Opdam,
H........ Gutteridge, G. (2003). A
prospective before-and-after trial of a
medical emergency team. The
Medical Journal o f Australia, 179(6),
283-287.
Bristow, P.)., Hillman, K.M., Chey, T.,
Daffurn, K., Jacques, T.C., Norman,
S.L.....Simmons, E.G. (2000). Rates of
in-hospital arrests, deaths and inten­
sive care admissions: The effect of a
medical emergency team. The
Medical Journal o f Australia, 173(5),
236-240.
Buist, M.D., Moore, G.E., Bernard,
S.A., Waxman, B.P., Anderson, J.N., &
Nguyen, T.V. (2002). Effects of a med­
ical emergency team on reduction of
incidence of and mortality from unex­
pected cardiac arrests in hospital:
Preliminary study. BMJ, 324(7334),
387-390.
Bureau of Labor Statistics, (n.d.). Inflation
calculator: Bureau o f labor statistics.
Retrieved from http://www.bls.gov/
data/inflation_calculator.htm
Bureau of Labor Statistics. (2011a).
Anesthesiologists. Retrieved from
http://www.bls.gov/oes/current/oes2
91061.htm
Bureau of Labor Statistics. (2011b).
Pharmacists. Retrieved from http://
www.bls.gov/oes/current/oes291051.
htm
Bureau of Labor Statistics. (2011c). Physi­
cian assistants. Retrieved from http://
www.bls.gov/oes/current/oes291071.
htm
Bureau of Labor Statistics. (201 Id). Regis
tered nurses. Retrieved from http://
www.bls.gov/oes/201 l/may/oes2911
11.htm
Bureau of Labor Statistics. (2011e). Res­
piratory therapists. Retrieved from
http:/ / www.bls .gov/oes/current/oes 2
91126.htm
Campello, G., Granja, C., Carvalho, F., Dias,
C., Azevedo, L.F., & Costa-Pereira, A.
(2009). Immediate and long-term
impact of medical emergency teams
on cardiac arrest prevalence and mor­
tality: A plea for periodic basic lifesupport training programs. Critical
Care Medicine, 37(12), 3054-3061.
doi:10.1097/CCM.0b013e3181b02183
Chan, P.S., Jain, R., Nallmothu, B.K., Berg,
R.A., & Sasson, C. (2010). Rapid
response teams: A systematic review
and meta-analysis. Archives o f In­
ternal Medicine, 170(1), 18-26. doi:
10.1001/archinternmed.2009.424
Dacey, M.J., Mirza, E.R., Wilcox, V.,
Doherty, M., Mello, J., Boyer, A......
Baute, R. (2007). The effect of a rapid
response team on major clinical out­
come measures in a community hos­
pital. Critical Care Medicine, 35(9),
2076-2082.
Daffurn, K., Lee, A., Hillman, K.M.,
Bishop, G.F, & Bauman, A. (1994). Do
nurses know when to summon emer­
gency assistance? Intensive & Critical
Care Nursing, 10(2), 115-120.
DeVita, M.A., Braithwaite, R.S., Mahidhara,
R., Stuart, S., Foraida, M., & Simmons,
R.L. (2004). Use of medical emer­
gency team responses to reduce hos­
pital cardiopulmonary arrests. Qual­
ity & Safety in Health Care, 33(4), 251254. doi:10.1136/qhc.l3.4.251
NURSING ECONOMIC$/July-August 2014/Vol. 32/No. 4
DeVita, M.A., Schaefer, J., Lutz, J., Wang,
H., & Dongilli, T. (2005). Improving
medical emergency team (MET) per­
formance using a novel curriculum
and a computerized human patient
simulator. Quality & Safety in Health
Care, 14(5), 326-331. doi:10.1136/
qshc.2004.011148
Ebell, M.H., & Kruse, J.A. (1994). A pro­
posed model for the cost of cardiopul­
monary resuscitation. Medical Care,
32(e), 640-649.
ECRI. (2006). Rapid response teams
improve quality/safety. Risk Manage­
ment Reporter, 25(3), 1, 3-9.
Fryhack, D.G., Dunham, N.C., Palta, M.,
Hanmer, J., Buechner, J., Cherepanov,
D .,... Kind, R (2007). US norms for six
generic health-related quality-of-life
indexes from the National Health
Measurement study. Medical Care,
45(12), 1162-1170. doi:10.1097/MLR.
0b013e31814848fl
Genardi, M.E., Cronin, S.N., & Thomas, L.
(2008). Revitalizing an established
rapid response team. Dimensions of
Critical Care Nursing: DCCN, 27(3),
104-109. doi:10.1097/01.DCC.000028
6837.95720.8c
Hillman, K., Chen, J., Cretikos, M.,
Bellomo, R., Brown, D., Doig, G., ...
Flabouris, A. (2005). Introduction of
the medical emergency team (MET)
system: A cluster-randomised con­
trolled trial. Lancet, 365(9477), 2091.
Institute for Healthcare Improvement.
(2008) . Establish a rapid response
team. Retrieved from http://w w w .
ihi.org/resources/Pages/Changes/Esta
blishaRapidResponseTeam.aspx
Iyengar, A., Baxter, A., & Forster, A.J.
(2009) . Using medical emergency
teams to detect preventable adverse
events. Critical Care, 23(4), R126.
doi:10.1186/cc7983
Jones, D., Bellomo, R., Bates, S., Warrillow,
S., Goldsmith, D., Hart, G., ...
Gutteridge, G. (2005). Long term effect
of a medical emergency team on car­
diac arrests in a teaching hospital.
Critical Care, 9(6), R808-815.
doi:10.1186/cc3906
Jones, D., Opdam, H., Egi, M., Goldsmith,
D., Bates, S., Gutteridge, G........
Bellomo, R. (2007). Long-term effect
of a medical emergency team on mor­
tality in a teaching hospital.
Resuscitation, 74(2), 235-241. doi:10.
1016/j.resuscitation.2006.12.007
Kause, J., Smith, G., Prytherch, D., Parr, M.,
Flabouris, A., Hillman, K., ... New
Zealand Intensive Care Society
Clinical Trials. (2004). A comparison
of antecedents to cardiac arrests,
deaths and emergency intensive care
admissions in Australia and New
Zealand, and the United Kingdom the ACADEMIA study. Resuscitation,
62(3), 275-282.
Kenward, G., Castle, N., Hodgetts, T., &
Shaikh, L. (2004). Evaluation of a
medical emergency team one year
after implementation. Resuscitation,
61(3), 257-263. doi: 10.1016/j.resusci
tation.2004.01.021
Leigh, J. P., Tancredi, D., Jerant, A., &
Kravitz, R.L. (2010). Physician wages
across specialties: Informing the
physician reimbursement debate.
Archives of Internal Medicine, 170
(19), 1728-1734. doi:10.1001/archin
ternmed.2010.350
Mahlmeister, L.R. (2006). Best practices in
perinatal care: The role of rapid
response teams in perinatal units.
Journal o f Perinatal Sr Neonatal
Nursing, 20(4), 287-289.
Nichol, G., Shell, I.G., Hebert, P„ Wells,
G.A., Vandemheen, K., & Laupacis, A.
(1999). What is the quality of life for
survivors of cardiac arrest? A prospec­
tive study. Academic Emergency
Medicine, 6(2), 95-102. doi:10.1111/
j.1553-2712.1999.tb01044.x
Nowak, J.E., & Brilli, R.J. (2007). Pediatric
rapid response teams. JAMA: The
Journal o f the American Medical
Association, 298(19), 2311-2312.
Ohio State Medical Center. (2011). Benefits
for residents and fellows. Retrieved
from http://medicine.osu.edu/resi
dents/benefits/pages/index.aspx
0*NET OnLine. (2010a). Summary report
for: 11-9111.01 - Clinical nurse spe­
cialists. Retrieved from http://www.
o n e to n lin e .o rg /lin k /su m m a ry /ll9111.01
0*NET OnLine. (2010b). Summary report
for: 21-2011.00 - Clergy. Retrieved
from http://www.onetonline.org/link/
summary/21-2011.00
0*NET OnLine. (2010c). Summary report
for: 29-1071.00 - Physician assistants.
Retrieved from http://www.oneton
line.org/link/summary/29-1071.00
0*NET OnLine. (2010d). Summary report
for 29-1111.00 - Registered nurses.
Retrieved from http://www.oneton
line.org/link/summary/29-llll.00
0*NET OnLine. (2010e). Summary report
for 29-1141.03 - Critical care nurses.
Retrieved from http://www.oneton
line.org/link/summary/29-1141.03
PayScale. (2011). Nursing supervisor salary
(United States). Retrieved from
http://www.payscale.eom/research/U
S/Job=Nursing_Supervisor/Hourly_
Rate
Rothschild, J.M., Woolf, S., Finn, K.M.,
Friedberg, M.W., Lemay, C., Furbush,
K.A...... Bates, D.W. (2008). A con­
trolled trial of a rapid response system
in an academic medical center. Joint
Commission Journal on Quality and
Patient Safety, 34(7), 417-425, 365.
Sebat, F., Musthafa, A. A., Johnson, D.,
Kramer, A. A., Shoffner, D., Eliason,
M..... Spurlock, B. (2007). Effect of a
rapid response system for patients in
shock on time to treatment and mor­
tality during 5 years. Critical Care
Medicine, 35(11), 2568-2575. doi:
NURSING ECONOMIC$/July-August 2014/Vol. 32/No. 4
10.1097/01.CCM.0000287593.54658.
89
Sharek, P.J., Parast, L.M., Leong, K.,
Coombs, J., Earnest, K., Sullivan, J.....
Roth, S.J. (2007). Effect of a rapid
response team on hospital-wide mor­
tality and code rates outside the ICU
in a children’s hospital. JAMA: The
Journal o f the American Medical
Association, 298(19), 2267-2274.
doi:10.100l/jama.298.19.2267
Thomas, K., VanOyen Force, M.,
Rasmussen, D., Dodd, D., & Whildin,
S. (2007). Rapid response team:
Challenges,
solutions, benefits.
Critical Care Nurse, 27(1), 20-27; quiz
28.
Tibballs, J., & Kinney, S, (2006). A prospec­
tive study of outcome of in-patient
paediatric cardiopulmonary arrest.
Resuscitation, 71(3), 310-318.
Tibballs, J., & van der Jagt, E.W. (2008).
Medical emergency and rapid
response teams. Pediatric Clinics of
North America, 55(4), 989-1010.
doi:10.1016/j.pcl.2008.04.006
Vrtis, M.C. (1992a). Cost/benefit analysis of
cardiopulmonary resuscitation: A his­
tory of CPR - Part I. Nursing
Management, 23(4), 50-54.
Vrtis, M.C. (1992b). Cost/benefit analysis of
cardiopulmonary resuscitation: A
comprehensive study - Part II.
Nursing Management, 23(5), 44-46,
50-41.
ADDITIONAL READING
Hunt, E.A., Zimmer, K.P., Rinke, M.L.,
Shilkofski, N.A., Matlin, C., Garger,
C...... Miller, M.R. (2008). Transition
from a traditional code team to a med­
ical emergency team and categoriza­
tion of cardiopulmonary arrests in a
children’s center. Archives o f Pedia­
trics &■ Adolescent Medicine, 162(2),
117-122. doi:10.1001/archpediatrics.
2007.33
A Call to Action
co n tin u ed fro m page 193
Saver, C. (2012). Half of OR directors plan
to retire by the end of the decade. OR
Manager, 28(10), 1, 9-15.
Staiger, D.O., Auerbach, D.I., & Buerhaus,
P. (2012). Registered nurse labor sup­
ply and recession - Are we in a bub­
ble? New England Journal o f
Medicine, 366, 1463-1465.
Sverdlik, B.S. (2012). Who will be our
nurse leaders in the future? The role
of succession planning. Journal of
Nursing Administration, 42(7/8), 383385.
Thompson, P. (2008). Key challenges fac­
ing American nurse leaders. Journal
o f Nursing Management, 16, 912-914.
203
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