Published in the March 2009 issue of Today’s Hospitalist
I HAVE ALWAYS TRIED to keep current with medical literature. I don’t want to be the doctor who stubbornly insists on using renal dose dopamine and consistently makes medical decisions based on an “N” of one. I bet that it is safe to say that most of us try to practice evidence-based medicine.
However “and with apologies to TV pundit Stephen Colbert “when it comes to the study in the Dec. 3, 2008, Journal of the American Medical Association (JAMA) that questions the efficacy of rapid response teams (RRTs), I have resigned myself to being “factose intolerant.”
Yes, I am aware that Peter Pronovost, MD “a MacArthur Genius, no less “warned us in the Oct. 2, 2006, JAMA, that we should “Walk, Don’t Run” in embracing RRTs. Yet, the “truthiness” (there’s Mr. Colbert again) of how effective RRTs are has been unmistakable in every community hospital at which I have worked. I have plenty of observational data, albeit far from publishable grade, that demonstrates decreased number of code blues and ICU transfers after a hospital’s RRT team has been put in place. But ultimately, common sense has been the biggest mandate for RRTs in my institutions.
The reality at community hospitals
Community hospitals, even tertiary ones, are different in many ways from an academic center where the recent evidence of RRTs’ ineffectiveness was generated. These differences were evident every time a patient went south prior to the advent of community-hospital RRTs.
In the community setting, a nurse would be forced to make judgments based on a phone conversation with an attending who was deep in REM sleep at home. That’s not the same situation as the nurse in an academic program who has the luxury of housestaff at the bedside.
Certainly, the creation of 24/7 hospitalist programs has significantly changed this paradigm. However, we need to remember that hospitalists serve as attendings for fewer than one-half of the hospitalized patients in most hospitals. Increasingly, when we do work the night shift, we cover 100 patients or more while doing a growing number of admissions. Such ratios demand that we have a good system of help in place, lest we end up practicing telephone medicine “even if we are more awake and only a few floors away.
I have been particularly impressed at hospitals that have further fortified the basic RRT concept, even though apparently there are no data to support such a beefed-up version. For example, at Virtua Memorial Hospital where I work, senior nursing leadership recognized that the night shifts were often filled by younger, less experienced nurses.
In what has been an extremely successful program, the advanced practice nurse who commands our nocturnal RRT program spends most of his or her time mentoring these newer nurses whenever they have questions regarding patient care. This “pre- RRT” program seems to have prevented many RRTs from being called in the first place.
And we have greatly liberalized the RRT trigger by encouraging nurses to activate RRTs if they have even the slightest concern that a patient’s condition may be worsening. Under this model, the hospitalist is notified only if the advanced practice nurse identifies the need for a physician at the bedside, after an RRT has been called. By reinforcing a culture that supports nurses, our “RRT-plus” program has been very beneficial for patients.
Waiting for more evidence?
The recent JAMA study calls for ” . . . well-designed multicenter adequately powered randomized controlled trials with sufficiently long follow-up . . . to rigorously evaluate the efficacy of rapid response teams prior to endorsing their widespread implementation.” That conclusion leads me borrow a quote from another pundit: Hall of Fame basketball player and sports commentator Charles Barkley.
I believe he and I have decidedly similar outlooks as far as my belief that RRTs are effective in community hospitals, regardless of the evidence to the contrary, and his reported penchant to over-imbibe, regardless of the evidence that inebriation is not good for his health (or his arrest record).
So said Mr. Barkley: “I read that heavy drinking is bad for your health. So I decided I better stop reading.”
Erik DeLue, MD, MBA, is medical director of the hospitalist program at Virtua Memorial Hospital in Mt. Holly, N.J.