Hospital "rapid response" as good when resident-led
NEW YORK (Reuters Health) - When hospital patients take a possibly dangerous turn for the worse, they are as likely to survive when a doctor-in-training leads the response as when a senior doctor is in charge, a new study suggests.
That at least seems to be the case at the University of Pennsylvania in Philadelphia, where the study was done. Researchers say it's not clear how broadly applicable their findings might be.
The study, published in the journal Resuscitation, looked at what hospitals call their "rapid response team." They swoop in when a patient develops certain symptoms - like unusual chest pain or concerning changes in heart rate or breathing - that sometimes foretell cardiac arrest.
Cardiac arrest, in which the heart stops, is fatal if not treated within minutes. Even when cardiac arrest happens in a hospital, the prognosis is grim.
"There's about a 15 percent in-hospital cardiac arrest survival," said Dr. Babak Sarani, an associate professor of surgery at George Washington University in Washington, D.C., who worked on the study.
So rapid response teams come in to try to prevent at-risk patients from progressing to cardiac arrest. In the U.S. and Canada, hospitals are required to have such teams. But there are no hard-and-fast rules on who should be on them.
"No one knows what the make-up should be," Sarani said.
RESIDENTS ORDER MORE TESTS
At the Hospital of the University of Pennsylvania, the rapid response team is led by an attending doctor from the intensive care unit (ICU) on weekdays. At night and on weekends, it's led by a senior resident - a doctor-in-training who has worked at the hospital for two or three years.
"We asked the question, what's better - attending-led or resident-led?" Sarani said.
It turned out that neither was better, when it came to patients' risks of cardiac arrest or death.
Over four years, the rapid response team was called for 1,400 patients, with a resident leading 62 percent of the time.
There was no real difference in patients' risk of progressing to cardiac arrest: just under 2 percent did when an attending doctor was at the helm, versus just over 2 percent with a resident in charge. Researchers thought even this small difference was likely due to chance.
Few patients died from the complications that triggered the team response: 0.2 percent died when an attending was in charge, and 0.8 percent died with a resident leading the team.
Overall in-hospital death rates, from any cause, were almost the same in both groups, at around 27 percent.
There were differences, however, in the specific ways the team responded, Sarani's team found.
When a resident was in charge, there were more tests and procedures - like chest x-rays, extra oxygen and treatment with diuretic drugs. And it did not seem to be explained by the patients' symptoms themselves.
That's where an attending's experience may come into play, according to Sarani.
"Residents may just not have the experience to rely on their clinical judgment," Sarani said.
So would that mean an attending-led team is better?
Not necessarily, according to Sarani. Residents may use more resources by ordering more x-rays or using oxygen more often. But having an attending in charge at all times is "very resource-intensive," Sarani said.
If an ICU attending is pulled away from that unit every time there is a rapid response call, that could push a hospital to have to hire more attendings. It also opens the possibility that an attending will be pulled away from a critical ICU patient to evaluate one who is not in real danger.
Sarani said the "ideal" makeup of the rapid response team is probably going to vary from center to center.
At some hospitals, a nurse leads the team and calls in more help if necessary. And that may work well for a smaller community hospital, Sarani noted.
"It may be that every hospital needs to take a look at their own situation," he said.
That, according to Sarani, would include reviewing the types of "triggers" that typically set off calls for the rapid response team. Knowing whether they are less serious ones, like a drop in a patient's blood sugar, or serious problems, like dangerous changes in heart activity, could tell a hospital a lot about who needs to lead the rapid response team.
SOURCE: bit.ly/NIgqbj Resuscitation, online July 26, 2012.
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