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Rapid Response Systems: how to interpret levels of evidence

Marcello Difonzo

DOI: https://doi.org/10.7175/cmi.v11i2.1271

Abstract

BACKGROUND AND AIM: The Rapid Response System (RRS) has been introduced to prevent cardiac arrest, unplanned admissions to the intensive care unit, and death in hospitalized patients. Despite the constant and widespread presence of this system in worldwide hospitals, it remains debated whether its use improves patient outcomes. The aim of this narrative review is to describe the available evidence supporting the effectiveness of RRSs and to discuss the controversies on the lack of level 1 evidence studies.

METHODS: The literature search covers the period from 1 January 2000 to 31 March 2016.

RESULTS: Studies with different research designs, observational, quasi-experimental with non-randomized control group and experimental, and aggregate data of meta-analyses indicate a statistically significant reduction of in-hospital cardiac arrests and hospital mortality associated with the deployment of RRSs.

CONCLUSIONS: A RRS is a complex intervention in a complex system, such as a hospital. This complexity does not allow considering experimental trials only as the most appropriate methodology to answer at research objectives. Furthermore, the benefits of a RRS depend greatly on its proper use. Accumulating evidence suggests the importance to investigate barriers and facilitators that can affect the integration, within a hospital, of this complex intervention.

Keywords

Rapid Response Systems; In-hospital Cardiac Arrests; Hospital Mortality; Levels Of Evidence; Complex Interventions

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References

  • Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991; 324: 370-6; http://dx.doi.org/10.1056/NEJM199102073240604
  • Leape LL, Brennan TA, Laird NM, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991; 324: 377-84; http://dx.doi.org/10.1056/NEJM199102073240605
  • Schein RM, Hazday N, Pena M, et al. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest 1990; 98: 1388-92; http://dx.doi.org/10.1378/chest.98.6.1388
  • Fujiwara S, Koike T, Moriyasu T, et al; and IHCA study group. A retrospective study of in-hospital cardiac arrest. Acute Med Surg 2016; 3: 320-5; http://dx.doi.org/10.1002/ams2.193
  • Franklin C, Mathew J. Developing strategies to prevent in hospital cardiac arrest. Analyzing responses of physicians and nurses in the hours before the event. Crit Care Med 1994; 22: 244-7; http://dx.doi.org/10.1097/00003246-199402000-00014
  • Buist M, Jarmolowski E, Burton PR, et al. Recognising clinical instability in hospital patients before cardiac arrest or unplanned admission to intensive care. A pilot study in a tertiary-care hospital. Med J Aust 1999; 171: 22-5
  • Hillman K, Bristow PJ, Chey T, et al. Antecedents to hospital deaths. Intern Med J 2001; 31: 343-8
  • Kause J, Smith G, Prytherch D, et al. 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 2004; 62: 275-82; http://dx.doi.org/10.1016/j.resuscitation.2004.05.016
  • Hillman K, Bristow PJ, Chey T, et al. Duration of life-threatening antecedents prior to intensive care admission. Intensive Care Med 2002; 28: 1629-34; http://dx.doi.org/10.1007/s00134-002-1496-y
  • McGloin H, Adam SK, Singer M. Unexpected deaths and referrals to intensive care of patients on general wards. Are some cases potentially avoidable? J R Coll Physicians Lond 1999; 33: 255-9
  • McQuillan P, Pilkington S, Allan A, et al. Confidential inquiry into quality of care before admission to intensive care. BMJ 1998; 316: 1853-8; http://dx.doi.org/10.1136/bmj.316.7148.1853
  • Massey D, Aitken LM, Choaboyer W. What factors influence suboptimal ward care in the acutely ill ward patient? Intensive Crit Care Nurs 2009; 25: 169-80; http://dx.doi.org/10.1111/j.1365-2702.2010.03394.x
  • Hillman K. Critical care without walls. Curr Opin Crit Care 2002; 8: 594-9; http://dx.doi.org/10.1097/00075198-200212000-00019
  • Rosengart MR, Pinsky MR. Origins of the critically ill: the impetus for critical care medicine. In: Scales DC, Rubenfeld GD (eds.). The organization of critical care. An evidence-based approach to improving quality. Respiratory medicine 18. Springer Science Business Media New York, 2014, pp. 9-24. Available at http://link.springer.com/chapter/10.1007/978-1-4939-0811-0_2 (last accessed March 2017)
  • Tee A, Calzavacca P, Licari E, et al. Bench-to-bedside review: The MET syndrome-the challenges of researching and adopting medical emergency teams. Crit Care 2008; 12: 205; http://dx.doi.org/10.1186/cc6199
  • DeVita MA, Bellomo R, Hillman K, et al. Findings of the first consensus conference on medical emergency teams. Crit Care Med 2006; 34: 2463-78; http://dx.doi.org/10.1097/01.CCM.0000235743.38172.6E
  • Institute for Healthcare Improvement. 5 million lives campaign. Available at http://www.ihi.org/about/documents/5millionlivescampaigncasestatement.pdf (last accessed March 2017)
  • Berwick DM, Calkins DR, McCannon CJ, et al. The 100,000 lives campaign: setting a goal and a deadline for improving health care quality. JAMA 2006; 295: 324-7; http://dx.doi.org/10.1001/jama.295.3.324
  • Australian Government Department of Human Services. Safer systems–saving lives, implementing a Rapid Response System 2006. https://www.humanservices.gov.au/ (last accessed April 2017)
  • Implementation of Critical Care Response Teams (CCRTs) in Ontario hospitals-Year one. Prepared by the critical care secretariat, Ontario Ministry of Health and Long-Term Care. January 2007. Available at http://docplayer.net/26190034-Implementation-of-critical-care-response-teams-ccrts-in-ontario-hospitals-year-one.html (last accessed March 2017)
  • National Institute for Health and Clinical Excellence, NICE. Acutely ill patients in hospital: recognition of and response to acute illness in adults in hospital. July, 2007. Available at https://www.nice.org.uk/guidance/cg50 (last accessed March 2017)
  • Al-Qahtani S, Al-Dorzim HM. Rapid response systems in acute hospital care. Ann Thorac Med 2010; 5: 1-4; http://dx.doi.org/10.4103/1817-1737.58952
  • Lee A, Bishop G, Hillman KM, et al. The medical emergency team. Anaesth Intensive Care 1995; 23: 183-6
  • DeVita MA, Hillman K, Smith GB. Resuscitation and rapid response systems. Resuscitation 2014; 85: 1-2; http://dx.doi.org/10.1016/j.resuscitation.2013.11.005
  • England K, Bion JF. Introduction of medical emergency teams in Australia and New Zealand: a multicentre study. Crit Care 2008; 12: 151; http://dx.doi.org/10.1186/cc6902
  • Hillman K. Rapid response systems. Indian J Crit Care Med 2008; 12: 77-81; http://dx.doi.org/10.4103/0972-5229.42561
  • Hourihan F, Bishop G, Hillman KM. The medical emergency team: a new strategy to identify and intervene in high risk patients. Clin Intensive Care 1995; 6: 269-72; http://dx.doi.org/10.3109/tcic.6.6.269.272
  • Hillman K, Parr M, Flabouris A, et al. Redefining in-hospital resuscitation: the concept of the medical emergency team. Resuscitation 2001; 48: 105-10
  • Pringle R, Hanson C, Falk NL. Literature review on Rapid Response Systems (RRS). March 2011. Available from: http://docplayer.net/38769742-Literature-review-on-rapid-response-systems-rrs-march-2011.html (last accessed March 2017)
  • Jones DA, DeVita MA, Bellomo R. Rapid-Response Teams. N Engl J Med 2011; 365: 139-46; http://dx.doi.org/10.1056/NEJMra0910926
  • Goldhill DR, McNarry A. Intensive care outreach services. Curr Anaesth Crit Care 2002; 13: 356-61; http://dx.doi.org/10.1054/cacc.2003.0433
  • McDonnell A, Esmonde L, Morgan R, et al. The provision of critical care outreach services in England: findings from a national survey. J Crit Care 2007; 22: 212-8; http://dx.doi.org/10.1016/j.jcrc.2007.02.002
  • Critical Care Services Ontario. Critical care plan 2015-2018. June 2015. Available from: https://www.criticalcareontario.ca/EN/AboutUs/Documents/CCSO_OCCP_2015-2018_Web%20FINAL%20Sep_8_15.pdf (last accessed March 2017)
  • Bristow PJ, Hillman K.M, Chey T, et al. Rates of in-hospital arrests, deaths and intensive care admissions: the effect of a medical emergency team. Med J Aust 2000; 173: 236-40
  • Buist MD, Moore GE, Bernard SA, et al. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study. BMJ 2002; 324: 387-90
  • Jones D, Bellomo R, Bates S, et al. Long term effect of a medical emergency team on cardiac arrests in a teaching hospital. Crit Care Med 2005; 9: R808-R815; http://dx.doi.org/10.1186/cc3906
  • Jones D, Egi M, Bellomo R, et al. Effect of the medical emergency team on long-term mortality following major surgery. Crit Care 2007; 11: R12; http://dx.doi.org/10.1186/cc5673
  • Jones D, Opdam H, Egi M, et al. Long-term effect of a Medical Emergency Team on mortality in a teaching hospital. Resuscitation 2007; 74: 235-41; http://dx.doi.org/10.1016/j.resuscitation.2006.12.007
  • Winters BD, Pham JC. Rapid Response Systems: a review of the evidence. In: DeVita MA, Hillman K, Bellomo R (eds.). Textbook of Rapid Response Systems. Concept and implementation. Berlin: Springer Science+Business Media, LLC. 2011, pp. 65-78; http://dx.doi.org/10.1007/978-0-387-92853-1_7
  • Baxter AD, Cardinal P, Hooper J, et al. Medical emergency teams at The Ottawa Hospital: the first two years. Can J Anaesth 2008; 55: 223-31; http://dx.doi.org/10.1007/BF03021506
  • Ludikhuize J, Brunsveld-Reinders AH, Dijkgraaf MG, et al. Outcomes associated with the nationwide introduction of Rapid Response Systems in the Netherlands. Crit Care Med 2015; 43: 2544-51; http://dx.doi.org/10.1097/CCM.0000000000001272
  • Kotsakis A, Lobos AT, Parshuram C, et al. Implementation of a multicenter rapid response system in pediatric academic hospitals is effective. Pediatrics 2011; 128: 72-8; http://dx.doi.org/10.1542/peds.2010-0756
  • Salvatierra G, Bindler RC, Corbett C, et al. Rapid response team implementation and in-hospital mortality. Crit Care Med 2014; 42: 2001-6; http://dx.doi.org/10.1097/CCM.0000000000000347
  • Howell MD, Ngo L, Folcarelli P, et al. Sustained effectiveness of a primary-team-based rapid response system. Crit Care Med 2012; 40: 2562-8; http://dx.doi.org/10.1097/CCM.0b013e318259007b
  • Hanson CC, Randolph GD, Erickson JA, 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; http://dx.doi.org/10.1136/qshc.2007.026054
  • Maharaj R, Stelfox HT. Rapid response teams improve outcomes: no. Intensive Care Med 2016; 42: 596-8; http://dx.doi.org/10.1007/s00134-016-4246-2
  • Priestley G, Watson W, Rashidian A, et al. Introducing Critical Care Outreach: a ward randomised trial of phased introduction in a general hospital. Intensive Care Med 2004; 30: 1398-404; http://dx.doi.org/10.1007/s00134-004-2268-7
  • Hillman K, Chen J, Cretikos M, et al; MERIT study investigators. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet 2005; 365: 2091-7; http://dx.doi.org/10.1016/S0140-6736(05)66733-5
  • The “MERIT” trial of Medical Emergency Teams in Australia: an analysis of findings and implications for the 100,000 lives campaign. Available at https://tools.patientsafetyinstitute.ca/Communities/rrt/Shared%20Documents/General/merit[1].comments.pdf (last accessed March 2017)
  • Cooper DJ, Buist MD. Vitalness of vital signs, and medical emergency teams. Med J Aust 2008; 188: 630-1
  • Jones D, Bellomo R, DeVita MA. Effectiveness of the Medical Emergency Team: the importance of dose. Crit Care 2009; 13: 313; http://dx.doi.org/10.1186/cc7996
  • Cooper N, Forrest K, Cramp P. Essential guide to acute care. Oxford: Blackwell Publishing Ltd, BMJ Books, 2nd Edition, July 2006, pp. 1-13
  • Gale EAM. The Hawthorne studies-a fable for our times? QJM 2004; 97: 439-49;
  • Hillman K, Chen J, May E. Complex intensive care unit interventions. Crit Care Med 2009; 37 (1 Suppl): S102-S106; http://dx.doi.org/10.1097/CCM.0b013e3181920f18
  • Buist M, Harrison J, Abaloz E, et al. Six year audit of cardiac arrests and medical emergency team calls in an Australian outer metropolitan teaching hospital. BMJ 2007; 335: 1210-2; http://doi.org/10.1136/bmj.39385.534236.47
  • Cretikos M, Chen J, Hillman K, et al. The objective medical emergency team activation criteria: a case-control study. Resuscitation 2007; 73: 62-72; http://dx.doi.org/10.1016/j.resuscitation.2006.08.020
  • Cretikos MA, Chen J, Hillman KM, et al. The effectiveness of implementation of the medical emergency team (MET) system and factors associated with use during the MERIT study. Crit Care Resusc 2007; 9: 205-12
  • Chen J, Flabouris A, Bellomo R, et al.; MERIT Study Investigators for the Simpson Centre and the ANZICS Clinical Trials Group. The Medical Emergency Team System and not-for-resuscitation orders: results from the MERIT study. Resuscitation 2008; 79: 391-7; http://dx.doi.org/10.1016/j.resuscitation.2008.07.021
  • Chen J, Hillman K, Bellomo R, et al.; MERIT Study Investigators for the Simpson Centre and the ANZICS Clinical Trials Group. The impact of introducing medical emergency team system on the documentations of vital signs. Resuscitation 2009; 80: 35-43; http://dx.doi.org/10.1016/j.resuscitation.2008.10.009
  • Chen J, Bellomo R, Flabouris A, et al; MERIT Study Investigators for the Simpson Centre and the ANZICS Clinical Trials Group. The relationship between early emergency team calls and serious adverse events. Crit Care Med 2009; 37: 148-53; http://dx.doi.org/10.1097/CCM.0b013e3181928ce3
  • Chen J, Flabouris A, Bellomo R, et al.; MERIT Study Investigators for the Simpson Centre and the ANZICS Clinical Trials Group. Baseline hospital performance and the impact of medical emergency teams: modelling vs. conventional subgroup analysis. Trials 2009; 10: 117; http://dx.doi.org/10.1186/1745-6215-10-117
  • Flabouris A, Chen J, Hillman K, et al.; MERIT Study Investigators for the Simpson Centre and the ANZICs Clinical Trials Group. Timing and interventions of emergency teams during the MERIT study. Resuscitation 2010; 81: 25-30; http://dx.doi.org/10.1016/j.resuscitation.2009.09.025
  • Chen J, Bellomo R, Hillman K, et al; MERIT Study Investigators for the Simpson Centre and the ANZICS Clinical Trials Group. Triggers for emergency team activation: a multicenter assessment. J Crit Care 2010; 25: 359.e-7; http://dx.doi.org/10.1016/j.jcrc.2009.12.011
  • Chen J, Bellomo R, Flabouris A, et al. Delayed emergency team calls and associated hospital mortality: a multicenter study. Crit Care Med 2015; 43: 2059-65; http://dx.doi.org/10.1097/CCM.0000000000001192
  • Chen J, Ou L, Hillman KM, et al. Cardiopulmonary arrest and mortality trends, and their association with rapid response system expansion. Med J Aust 2014; 201: 167-70; https://doi.org/10.5694/mja14.00019
  • Chen J, Ou L, Hillman KM, et al. The impact of implementing a rapid response system: a comparison of cardiopulmonary arrests and mortality among four teaching hospitals in Australia. Resuscitation 2014; 85: 1275-81; http://dx.doi.org/10.1016/j.resuscitation.2014.06.003
  • Buist M, Mahoney A. In search of the “Holy Grail”: will we ever prove the efficacy of Rapid Response Systems (RRS)? Resuscitation 2014; 85: 1129-30; http://dx.doi.org/10.1016/j.resuscitation.2014.07.007
  • Maharaj R, Raffaele I, Wendon J. Rapid response systems: a systematic review and meta-analysis. Crit Care 2015; 19: 254; http://dx.doi.org/10.1186/s13054-015-0973-y
  • Solomon RS, Corwin GS, Barclay DC, et al. Effectiveness of rapid response teams on rates of in-hospital cardiopulmonary arrest and mortality: A systematic review and meta-analysis. J Hosp Med 2016; 11: 438-45; http://dx.doi.org/10.1002/jhm.2554
  • Kenward G, Castle N, Hodgetts T, et al. Evaluation of a medical emergency team one year after implementation. Resuscitation 2004; 61: 257-63; http://dx.doi.org/10.1016/j.resuscitation.2004.01.021
  • Jones DA, Bagshaw SM, Barrett J, et al. The role of the medical emergency team in end-of-life care: a multicenter, prospective, observational study. Crit Care Med 2012; 40: 98-103; http://dx.doi.org/10.1097/CCM.0b013e31822e9d50
  • Hillman K. Dying safely. Int J Qual Health Care 2010; 22: 339-40; http://dx.doi.org/10.1093/intqhc/mzq045
  • Rozen T, Butt W. Rapid response teams: how are they best used? Crit Care 2016; 20: 253; http://dx.doi.org/10.1186/s13054-016-1425-z
  • Chan PS, Jain R, Nallmothu BK, et al. Rapid Response Teams: a systematic review and meta-analysis. Arch Intern Med 2010; 170: 18-26; http://dx.doi.org/10.1001/archinternmed.2009.424
  • Sandroni C, D’Arrigo S, Antonelli M. Rapid response systems: are they really effective? Crit Care 2015; 19: 104; http://dx.doi.org/10.1186/s13054-015-0807-y
  • Brunsveld-Reinders AH, Ludikhuize J, Dijkgraaf MG, et al. Unexpected versus all-cause mortality as the endpoint for investigating the effects of a Rapid Response System in hospitalized patients. Crit Care 2016; 20: 168; http://dx.doi.org/10.1186/s13054-016-1339-9
  • Simmes FM, Schoonhoven L, Mintjes J, et al. Incidence of cardiac arrests and unexpected deaths in surgical patients before and after implementation of a rapid response system. Ann Intensive Care 2012; 2: 20; http://dx.doi.org/10.1186/2110-5820-2-20
  • DeVita MA, Winters B. It’s not “do” but “why do” rapid response systems work? Crit Care Med 2014; 42: 2133-4; http://dx.doi.org/10.1097/CCM.0000000000000421
  • Price RJ, Cuthbertson BH. Should hospital have a medical emergency team? In: Kuhlen R, Moreno R, Ranieri M, et al (Eds.). Controversies in Intensive Care Medicine. Berlin: MWV Medizinisch Wissenschaftliche Verlagsgesellschaft, 2008, pp. 363-71
  • Elamin MB, Montori VM. The hierarchy of evidence: from unsystematic clinical observations to systematic reviews. Chapter 2. In: Burneo JG, Demaerschalk BM, Jenkins ME (eds.). Neurology: An Evidence-Based Approach. Berlin: Springer Science+Business Media, LLC 2012, pp. 112-4; http://dx.doi.org/10.1007/978-0-387-88555-1_2
  • Burns PB, Rohrich RJ, Chung KC. The levels of evidence and their role in Evidence-Based Medicine. Plast Reconstr Surg 2011; 128: 305-10; http://dx.doi.org/10.1097/PRS.0b013e318219c171
  • Canadian Task Force on the Periodic Health Examination. The periodic health examination. Can Med Assoc J 1979; 121: 1193-254
  • Atkins D, Best D, Briss PA, et al. Grading quality of evidence and strength of recommendations. BMJ 2004; 328: 1490; http://dx.doi.org/.10.1136/bmj.328.7454.1490
  • Brozek JL, Akl EA, Alonso-Coello P, et al.; GRADE Working Group. Grading quality of evidence and strength of recommendations in clinical practice guidelines. Part 1 of 3. An overview of the GRADE approach and grading quality of evidence about interventions. Allergy 2009; 64: 669-77; http://dx.doi.org/10.1111/j.1398-9995.2009.01973.x
  • Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008; 336: 924-6; http://dx.doi.org/10.1136/bmj.39489.470347.AD
  • Pronovost P, Angus D. Evidence-Based Critical Care Medicine [monograph on the Internet]. Toronto: Centre for Evidence-Based Medicine. 2004. http://ktclearinghouse.ca/cebm/syllabi/crit/print/whole.htm (last accessed April 2017)
  • Eccles M, Grimshaw J, Campbell M, et al. Research designs for studies evaluating the effectiveness of change and improvement strategies. Qual Saf Health Care 2003; 12: 47-52; http://dx.doi.org/10.1136/qhc.12.1.47
  • Concato J, Shah N, Horwitz RI. Randomized, controlled trials, observational studies, and the hierarchy of research designs. N Engl J Med 2000; 342: 1887-92; http://dx.doi.org/10.1056/NEJM200006223422507
  • Booth CM, Tannock IF. Randomised controlled trials and population-based observational research: partners in the evolution of medical evidence. Br J Cancer 2014; 110: 551-5; http://dx.doi.org/10.1038/bjc.2013.725
  • Bruckel J. Evidence-based medicine and rapid response team implementation. Mcgill J Med 2006; 9: 5-7
  • Hawe P. Lessons from complex interventions to improve health. Annu Rev Public Health 2015; 36: 307-23; http://dx.doi.org/10.1146/annurev-publhealth-031912-114421
  • Shiell A, Hawe P, Gold L. Complex interventions or complex systems? Implications for health economic evaluation. BMJ 2008; 336: 1281-3; http://dx.doi.org/10.1136/bmj.39569.510521
  • Husereau D, Jacobs P, Manns B, et al; on behalf of the IHE-IHSPR Complex Interventions Working Group. Economic evaluation of complex health system interventions: a discussion paper. Edmonton AB: Institute of Health Economics; 2014 July. Available at http://www.ihe.ca/publications/economic-evaluation-of-complex-health-system-interventions-a-discussion-paper (last accessed March 2017)
  • Chen J. Evaluating effectiveness of complex system interventions. In: DeVita MA Hillman K, Bellomo R. Textbook of Rapid Response Systems. Concept and implementation. Berlin: Springer, 2011, pp. 371-80; http://dx.doi.org/10.1007/978-0-387-92853-1_33
  • Clay-Williams R, Nosrati H, Cunningham FC, et al. Do large-scale hospital- and system-wide interventions improve patient outcomes: a systematic review. BMC Health Serv Res 2014; 14: 369; http://dx.doi.org/10.1186/1472-6963-14-369
  • Chen Y-F, Hemming K, Stevens AJ, et al. Secular trends and evaluation of complex interventions: the rising tide phenomenon. BMJ Qual Saf 2016; 25: 303-10; http://dx.doi.org/10.1136/bmjqs-2015-004372
  • Winters BD, Weaver SJ, Pfoh ER, et al. Rapid-Response Systems as a patient safety strategy: a systematic review. Ann Intern Med 2013; 158 (5_Part_2): 417-25; http://dx.doi.org/10.7326/0003-4819-158-5-201303051-00009
  • Vatanpour H, Khorramnia A, Forutan N. Silo effect a prominence factor to decrease efficiency of pharmaceutical industry. Iran J Pharm Res 2013 Winter; 12 (Suppl): 207-16
  • Hillman K, Chen J, Aneman A. Continuum of hospital care: the role of intensive care. Curr Opin Crit Care 2010; 16: 505-9; http://dx.doi.org/10.1097/MCC.0b013e32833e11dc
  • Nosrati H, Clay-Williams R, Cunningham F, et al. The role of organisational and cultural factors in the implementation of system wide interventions in acute hospitals to improve patient outcomes: protocol for a systematic literature review. BMJ Open 2013; 3: e002268
  • Hillman K, Braithwaite J, Chen J. Healthcare systems and their (lack of) integration. In: DeVita MA Hillman K, Bellomo R. Textbook of Rapid Response Systems. Concept and implementation. Berlin: Springer Science+Business Media, LLC. 2011, pp. 79-86; http://dx.doi.org/10.1007/978-0-387-92853-1_8
  • Santiano N, Young L, Hillman K, et al. Analysis of medical emergency team calls comparing subjective to “objective” call criteria. Resuscitation 2009; 80: 44-9; http://dx.doi.org/10.1016/j.resuscitation.2008.08.010
  • Douw G, Schoonhoven L, Holwerda T, et al. Nurses’ worry or concern and early recognition of deteriorating patients on general wards in acute care hospitals: a systematic review. Crit Care 2015; 19: 230; http://dx.doi.org/10.1186/s13054-015-0950-5
  • Bagshaw SM, Mondor EE, Scouten C, et al. Survey of nurses’ beliefs about the medical emergency team system in a canadian tertiary hospital. Am J Crit Care 2010; 19: 74-83; http:// dx.doi.org/10.4037/ajcc2009532
  • Pusateri ME, Prior MM, Kiely SC. The role of the non-ICU staff nurse on a medical emergency team: perceptions and understanding. Am J Nurs 2011; 111: 22-9; http://dx.doi.org/10.1097/01. NAJ.0000398045.00299.64
  • Radeschi G, Urso F, Campagna S, et al. Factors affecting attitudes and barriers to a medical emergency team among nurses and medical doctors: a multicenter survey. Resuscitation 2015; 88: 92-8; http://dx.doi.org/10.1016/j.resuscitation.2014.12.027

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