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Robotics and automated workstations for rapid response testing.

Rapid-response testing can help the critical care physician provide more medically relevant decisions when treating critically ill patients. Many technologies have appeared on the market to help deliver rapid analytical tests, including transportation systems, hand-held analyzers, or clinical instruments that have simple user interfaces. Each of these methods can be used to provide the necessary medical information but often at the expense of turnaround time, quality of service, or cost. A robotically automated laboratory system was created that provides rapid turnaround time and low cost, and each result is monitored and reviewed by a laboratory professional. To provide the best quality laboratory services at the lowest cost, we created a remotely controlled robotic clinical laboratory that provides whole-blood analysis of blood gases (pCO2,pO2), pH, electrolytes (sodium, potassium, and chloride), glucose, and hemoglobin near the patient beside yet maintains the distinct advantage of central laboratory control. The automated remote laboratory provides extremely rapid turnaround time, eliminates the costly steps involved with specimen processing, reduces the risk from contaminated specimens, reduces staff training, ensures that every result is reviewed by a professional, and improves patient care.

Automation↗

Rapid response to treatment for binge eating disorder.

The authors examined rapid response among 108 patients with binge eating disorder (BED) who were randomly assigned to 1 of 4 16-week treatments: fluoxetine, placebo, cognitive-behavioral therapy (CBT) plus fluoxetine, or CBT plus placebo. Rapid response, defined as 65% or greater reduction in binge eating by the 4th treatment week, was determined by receiver operating characteristic curves. Rapid response characterized 44% of participants and was unrelated to participants' demographic or baseline characteristics. Participants with rapid response were more likely to achieve binge-eating remission, had greater improvements in eating-disorder psychopathology, and had greater weight loss than participants without rapid response. Rapid response had different prognostic significance and distinct time courses for CBT versus pharmacotherapy-only treatments. Rapid response has utility for predicting outcomes and provides evidence for specificity of treatment effects with BED.

Adolescent↗

An innovative way of caring: palliative radiation therapy rapid response clinic.

The Palliative Radiation Therapy Rapid Response Clinic now receives referrals from community oncologists and family physicians who regularly send palliative patients to the clinic, as well as direct calls from patients and their families. Patients who responded well to radiotherapy treatment may seek further treatment if they develop other painful metastatic sites. The team receives positive feedback from patients, particularly those who responded to treatment in a very short period of time. The number of patients receiving palliative radiation is substantial and T-SRCC hopes to continue this service and possibly increase the number of patients seen in the clinic in the future. Due to the success of the T-SRCC's rapid response clinic, other centres are now planning to start similar services. The concept of the rapid response clinic was also introduced by Dr. David Hoegler to the cancer centre in Kelowna, British Columbia. Now located in Kelowna, Dr. Hoegler started treating patients palliatively in that location in April 1998. The gap in cancer care has been filled. Patients with advanced cancer, together with their families, are being served in a prompt and convenient manner. Pain relief is just a phone call away.

Empathy↗

Reducing mechanical restraints in acute psychiatric care settings using rapid response teams.

This article describes the use of rapid response teams to reduce the use of mechanical restraints (i.e., restricting a person's movement through the use of a mechanical device such as a backboard, net, or papoose) in an acute psychiatric care setting. Rapid response teams have proven highly effective for emergent medical patients, but have not typically been used in behavioral health care settings. Utilizing a rapid cycle process improvement approach, a response team was convened following each episode of mechanical restraint in an inpatient psychiatric treatment facility. Initial results, during a 6-week rapid cycle change process, showed that mechanical restraints were reduced by 36.4% when compared with a 6-week baseline and when compared with a 1-year baseline. Changes in hospital census during the implementation process did not appear to account for the reduction in restraints. Rapid response teams and rapid cycle process improvement are discussed as useful change vehicles for behavioral health care organizations.

Hospitals, Psychiatric↗

Rapid response to psychosocial treatment for adolescent depression: a two-year follow-up.

OBJECTIVE: To examine the differential course and treatment outcome of patients who participated in a randomized clinical trial, comparing cognitive, family, and supportive psychotherapies for adolescent major depressive disorder. METHOD: In a sample of 100 depressed adolescents, remission, clinical recovery, recurrence, and functional improvement were examined at the end of acute treatment and at 1- and 2-year follow-up, according to their type of response to treatment. Rapid response was defined as a decline of > or = 50% in the Beck Depression Inventory (BDI) score from pretreatment until the beginning of the second session of psychotherapy, intermediate as a decline of < 50% but > 0%, and initial nonresponse as a BDI score that stayed the same or increased. RESULTS: Rapid responders showed a better outcome at acute treatment, 1-year, and in some measures, 2-year follow-up. For those who had recurrences over time, rapid responders showed a longer period before recurrence. Subjects were most likely to respond rapidly, or not at all, in the supportive cell. CONCLUSIONS: These findings suggest that milder forms of depression may benefit from initial supportive therapy or short trials of more specialized types of psychotherapy. The use of a placebo run-in period might help to "wash out" nonspecific responders.

Adolescent↗

Implementing a rapid response team: factors influencing success.

Rapid response teams (RRTs), or medical emergency teams, focus on preventing a patient crisis by addressing changes in patient status before a cardiopulmonary arrest occurs. Responding to acute changes, RRTs and medical emergency teams are similar to "code" teams. The exception, however is that they step into action before a patient arrests. Although RRTs are acknowledge as an important initiative, implementation can present many challenges. This article reports on the implementation and ongoing use of a RRT at a community health care setting, highlighting important considerations and strategies for success.

Algorithms↗

A rapid-response outpatient model for reducing hospitalization rates among suicidal adolescents.

OBJECTIVE: The authors studied the clinical outcomes of suicidal adolescents who were treated within a rapid-response outpatient model in a setting in which a ten-day wait was usually required before outpatient treatment could be started, leaving hospitalization as the only immediately available alternative. METHODS: A total of 286 suicidal adolescents aged 12 to 17 years who came to the emergency department of a pediatric hospital were assigned to receive rapid-response outpatient follow-up (the experimental group) or to a control group. Demographic and clinical data were obtained at baseline, and outcomes data were obtained at two and six months. RESULTS: The demographic and clinical characteristics of the two groups were similar at baseline. Hospitalization rates in the experimental and control groups, respectively, were 10 percent and 40 percent at baseline, 17 percent and 41 percent at two-month follow-up, and 18 percent and 43 percent at six-month follow-up, corresponding to a relative risk of hospitalization of.41 in the experimental group at six months. No between-group differences were observed in changes in levels of suicidality or in overall functioning over the follow-up period, and none of the patients had died at six months. CONCLUSIONS: Suicidal adolescents who received rapid-response outpatient follow-up had a lower hospitalization rate than those who did not. The two groups achieved similar increases in levels of functioning and decrease in levels of suicidality, suggesting that suicidal adolescents can be treated within a rapid-response outpatient model and thus avoid hospitalization.

Adolescent↗

An apnea monitor using a rapid-response hygrometer.

OBJECTIVE: The aim of this study was to detect cyclic changes in the relative humidity (RH) occurring with spontaneous respiration using a rapid-response hygrometer, and to evaluate its potential applicability as an apnea monitor in nonintubated subjects. METHODS: Respiratory monitoring using a rapid-response hygrometer was performed in spontaneously breathing, nonintubated subjects. Changes in RH during spontaneous breathing were measured in adult volunteers, breathing room air and nonintubated infants who underwent cardiac catheterization under intravenous anesthesia. The detection of apnea by the hygrometer was assessed in the adult patients during the induction of anesthesia and those undergoing minor gynecologic surgery under epidural anesthesia. The hygrometric sensor was positioned in front of the nostril; a simultaneous recording of CO2 was obtained from nasal cannulas by a sidestream capnograph. Each waveform was collected and acquired by a PC-based computer, and data were analyzed off-line. RESULTS: The hygrometer showed a rapid response to the cyclic changes in RH during spontaneous respiration and could identify respiratory phases of tachypnea as high as 60 breaths per minute in infants. RH rapidly increased to 80% with a plateau on expiration and decreased to 40% on inspiration. These phasic changes, consisting of three distinct phases, expiratory upstroke, plateau and inspiratory downslope, preceded the corresponding capnographic changes by nearly two seconds. Expiratory increase in RH appeared to be influenced by the respiratory flow rate as well as the response time of the equipment. As respiration was depressed due to airway obstruction, the magnitude of RH gradually decreased and then disappeared at the time of apnea. CONCLUSIONS: The hygrometer could detect cyclic changes in RH during spontaneous respiration. Apnea was immediately detected by the decreases in the magnitude of RH. The results demonstrate the potential usefulness of a rapid-response hygrometer for monitoring respiratory rate and early detection of apnea.

Adult↗

Establishing a rapid response team (RRT) in an academic hospital: one year's experience.

BACKGROUND: Rapid response teams and medical emergency teams have been utilized to rapidly manage seriously ill patients at risk of cardiopulmonary arrest and other high-risk conditions but have not been extensively described in the American medical literature. OBJECTIVES: To describe a full year's experience of implementing a rapid response team (RRT) in an academic medical center. DESIGN: Retrospective analysis of our hospital's RRT database and description of the implementation process from July 2004 to July 2005. SETTING: Urban, academic medical center. RESULTS: The RRT system was activated for 307 potentially unstable patients. The most common reasons for an RRT activation were cardiac, respiratory, and neurological conditions. At least 37% of RRT calls were for off-unit inpatients and to outpatient/common areas frequented by outpatients and visitors, whereas at least 42% occurred in inpatient units. Most RRT calls, 82.9%, occurred during daytime hours. In the opinion of RRT leaders 98% of the evaluated calls were appropriate and 85% of the RRT responses resulted in the prevention of further clinical deterioration. CONCLUSIONS: An RRT was introduced into an academic medical center, and the results suggested it is capable of preventing clinical deterioration in unstable patients and may have the potential to decrease the frequency of cardiac arrests. The RRT also may fill a gap in patient safety by enabling rapid triage and expedited treatment of off-unit inpatients, outpatients, and visitors. The keys to the early success of our implementation of an RRT were multidisciplinary input and improvements made in real time.

Emergency Medical Services↗

Rapid response to inhaled frusemide in severe acute asthma with hypercapnia.

We report 7 patients with severe acute asthma unresponsive to standard medication, including sympathomimetic agents, aminophylline and corticosteroids, who responded to inhaled frusemide. All were hypercapneic with a mean PaCO2 of 7.7 kPa (57.7 mm Hg) [range 6.2-8.8 kPa (46.2-66.3 mm Hg)]. Following nebulization of 20 mg frusemide, clinical response was rapid, and the mean PaCO2 fell significantly to 5.4 kPa (40.6 mm Hg) [range 5.0-6.2 kPa (37.5-46.5 mm Hg)] within 20-60 min. No adverse effect was recognized. Inhaled frusemide should be considered for treatment of acute asthma refractory to conventional therapy.

Acute Disease↗

Rapid response teams in hospitals: improving quality of care for patients and quality of the work environment for nursing staff.

As the healthcare delivery system continues to evolve in the new millennium, initiatives such as the Institute for HealthCare Improvement's 100,000 Lives Campaign include the development of rapid response teams in hospitals. Introduction of rapid response teams provides nurses assistance in difficult clinical situations and provides early clinical intervention to mitigate negative patient outcomes and save lives. Development, implementation strategies, and benefits of rapid response teams are described.

Emergencies↗

Dying at home: evaluation of a hospice rapid-response service.

Various studies suggest that there is a preference among patients, professionals and the public for death to occur at home (Dunlop et al, 1989; Townsend et al, 1990; Hinton, 1994). Data indicates that some patients are denied the opportunity to exercise choice in the place of death. In areas where palliative rapid-response teams have been available more people have been able to die at home. This article presents the findings of an evaluation of a hospice rapid-response service in the Highlands of Scotland, which was designed to respond to the needs of people in crisis facing death. The study was designed to produce a rigorous and comprehensive description of a newly-operational service at the pilot stage. It reflects not only the views of the professionals involved but also focuses on the views of informal carers. Seventeen patients were referred to the rapid-response service in its first year of operation between April 1998 and March 1999. The service has shown some success in enabling patients to die at home and satisfaction with the service is high among professionals and lay carers.

Community Health Nursing↗

A new role for the ACNP: the rapid response team leader.

The implementation of a rapid response team or medical emergency team is 1 of the 6 initiatives of the Institute for Healthcare Improvement's 100,000 Lives Campaign with the goal to reduce the number of cardiopulmonary arrests outside the intensive care unit and inpatient mortality rates. The concept of RRT was pioneered in Australia and is now being implemented in many hospitals across the United States. This article reviews the current literature and describes the implementation of an RRT in a community hospital. The first-quarter data after implementation are described. The unique role of the acute care nurse practitioner in this hospital's model is described.

Acute Disease↗

Forty hours under pressure: a rapid-response improvement team achieves synergy.

A rapid-response team process was used to achieve unique team synergy and project success. The team's mission was to reduce the waiting time in the emergency care unit for inpatient telemetry beds. Data needed for root cause analysis were collected before the first team meeting, and "just-in-time" team training was provided at the team's first meeting. With leadership from the chief executive officer, a vice president, and a core group of physicians, the team was energized to complete the mission and present its plan to the entire executive team at the end of just 1 week.

Bed Occupancy↗

Panel 2.7: first 30 days: organizing rapid responses.

This is a summary of the presentations and discussion of Panel 2.7, First 30 Days: Organizing Rapid Response of the Conference, Health Aspects of the Tsunami Disaster in Asia, convened by the World Health Organization (WHO) in Phuket, Thailand, 04-06 May 2005. The topics discussed included issues related to organizing rapid responses as pertain to the responses to the damage created by the Tsunami. It is presented in the following major sections: (1) issues; (2) key questions; and (3) recommendations.

Disasters↗

Severe acquired vitamin K deficiency: a hypothesis for rapid response to therapy.

The potential mechanism underlying the rapid response to vitamin K replacement in acquired deficiency states is incompletely understood. To examine vitamin K metabolism, a 10-year-old boy with autoimmune enteropathy on oral vitamin K supplementation, who presented with profuse nosebleeds and calf tenderness, was evaluated. Laboratory analyses were consistent with severe vitamin K deficiency: vitamin K dependent protein (VKDP) levels < 5%, normal vitamin K epoxide level and depressed total prothrombin antigen (carboxylated and undercarboxyated forms). Intramuscular vitamin K (10 mg) was administered. Nine hours following therapy, VKDP levels corrected completely. Total prothrombin antigen increased indicating new prothrombin synthesis. However, the increase in the prothrombin-clotting assay far exceeded the increase in total prothrombin, supporting storage of undercarboxylated prothrombin in vitamin K deficiency states, with carboxylation and secretion after vitamin K replacement. Although this mechanism is known to occur in rodents, it has not been reported in humans. Our findings suggest a new potential mechanism of prothrombin metabolism in humans.

Blood Coagulation↗

Identification and characterization of 1,25D3-membrane-associated rapid response, steroid (1,25D3-MARRS)-binding protein in rat IEC-6 cells.

We report the presence of a mammalian equivalent of the avian Membrane-Associated Rapid Response, Steroid (1,25D3-MARRS)-binding protein specific for 1,25(OH)2D3 in a rat small intestinal cell line, IEC-6, that demonstrates rapid responses to the steroid hormone. Identification of transcript and protein was achieved using RT-PCR with several specific primer sets, Western blot analysis with two separate antibodies recognizing distinct regions of the protein, ribozyme knockdown and immunohistochemistry. Promoter analysis of the 1000-bp upstream region of the 1,25D3-MARRS gene in several species revealed the presence of a conserved smad-3 element in the 5' proximal promoter region, but no classical vitamin D response element (VDRE). Treatment of IEC-6 cells with transforming growth factor beta1 (TGFbeta1) increased steady-state levels of 1,25D3-MARRS (mRNA and protein) approximately two-fold over a 24-h period. In contrast, treatment with 1,25(OH)2D3 failed to significantly change 1,25D3-MARRS protein or mRNA levels. Localization studies showed rapid nuclear translocation of a pool of 1,25D3-MARRS protein after 1,25(OH)2D3 treatment, suggesting that the protein is subject to membrane-initiated signal pathway activation. Together these data point to complex interactions between the two important 1,25(OH)2D3 sensitive response systems in intestinal cells, 1,25D3-MARRS protein and the well-studied nVDR, that together work to fine tune intestinal Ca2+ absorption in a variety of avian and mammalian species.

Animals↗