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Triggers Study Evaluates Regular Staff, ICU Specialists

Regular staff offers equal care in rapid response situations

BOSTON - A system of care focused on the detection and systematic assessment of patients with clinical instability can yield similar outcomes as rapid response teams staffed with trained intensive care specialists, a Beth Israel Deaconess Medical Center study has found.

The analysis of 177,347 patients over a 59-month period was published online in Critical Care Medicine, the journal of the Society of Critical Care Medicine. Rapid Response Teams have become an important part of hospital care in recent years, sending critical care-trained responders to the bedside of decompensating patients. Most rapid response teams in the United States send a special ICU-based team of additional providers to the bedside of these patients.

"We found that a rapid response team that relied on providers already assigned to a patient's care, rather than a separate ICU-based rapid response team was associated with a marked reduction in the rate of unexpected mortality," says Michael D. Howell, MD, MPH, a critical care specialist at BIDMC and Assistant Professor of Medicine at Harvard Medical School.

BIDMC launched a novel model of a rapid response team, called Triggers, in 2005. This program differs from the usual rapid response team approach because it does not add additional clinical staff to the patient's care. Instead, it organizes the response of providers who were already assigned to the patient's care.

The Trigger team includes the patient's nurse, intern, respiratory therapist, and the floor's senior nurse - all of whom respond to a patient's bedside when confronted with a number of diagnostic factors, such as heart rate, blood pressure, respiratory rater, oxygen saturation or urine output charge within set parameters. A "trigger" can also be called on the concern of the nurse caring for the patient or - in recent years - the team can be directly called by patients or family members who are worried.

If an initial evaluation warrants a follow-up, a resident and the senior attending physician must be notified.

In a study of cases from 2004 to 2008, researchers found that the Triggers program resulted in a 65 percent reduction in the odds of unexpected mortality among all patients admitted to the hospital. The risk of overall in-hospital mortality was 5 percent lower, but this was not a statistically significant difference.

Those findings are relevant to clinicians and policymakers for two reasons.

"Our lower-staffing intensity approach produces outcomes comparable with ICU-based approaches," Howell wrote. "This approach requires no additional clinical staffing, preserves provider continuity (which may limit adverse events and respects traditional tenets of medical education."

Given issues surrounding the shortage of intensivists, who are called upon to perform out-of-ICU duties, particularly in smaller hospitals "it may be that intensivists' time is better spent with the critically ill in the ICU rather than serving as part of a rapid response team."

In addition to Howell, co-authors include Long Ngo, PhD, Patricia Folcarelli, RN, PhD, Julius Yang, MD, PhD, Lawrence Mottley, MD, Edward R. Marcantonio, MD, SM; Kenneth E. Sands, MD, MPH and Mark Aronson, MD, all of BIDMC and Donald Moorman, MD.

The study was supported in part by the Physician Faculty Scholars Program of the Robert Wood Johnson Foundation; a Midcareer Investigator Award in Patient-Oriented Research from the National Institute of Aging and by the Silverman Institute for Health Care Quality and the Stoneman Center for Quality Improvement at BIDMC.

There are no reported potential conflicts of interest.

Beth Israel Deaconess Medical Center is a patient care, teaching and research affiliate of Harvard Medical School, and currently ranks third in National Institutes of Health funding among independent hospitals nationwide. BIDMC is clinically affiliated with the Joslin Diabetes Center and is a research partner of Dana-Farber/Harvard Cancer Center. BIDMC is the official hospital of the Boston Red Sox. For more information, visit www.bidmc.org.