Implementation of a rapid response team in a large nonprofit Brazilian hospital: improving the quality of emergency care through Plan-Do-Study-Act

ABSTRACT Objective: To describe the implementation of a rapid response team in a large nonprofit hospital, indicating relevant issues for other initiatives in similar contexts, particularly in Latin America. Methods: In general terms, the intervention consisted of three major components: (1) a tool to detect aggravation of clinical conditions in general wards; (2) the structuring of a rapid response team to attend to all patients at risk; and (3) the monitoring of indicators regarding the intervention. This work employed four half-year Plan-Do-Study-Act cycles to test and adjust the intervention from January 2013 to December 2014. Results: Between 2013 and 2014, the rapid response team attended to 2,296 patients. This study showed a nonsignificant reduction in mortality from 8.3% in cycle 1 to 5.0% in cycle 4; however, death rates remained stable in cycles 3 and 4, with frequencies of 5.2% and 5.0%, respectively. Regarding patient flow and continuum of critical care, which is a premise of the rapid response system, there was a reduction in waiting time for intensive care unit beds with a decrease from 45.9% to 19.0% in the frequency of inpatients who could not be admitted immediately after indication (p < 0.001), representing improved patient flow in the hospital. In addition, an increase in the recognition of palliative care patients from 2.8% to 10.3% was noted (p = 0.005). Conclusion: Implementing a rapid response team in contexts where there are structural restrictions, such as lack of intensive care unit beds, may be very beneficial, but a strategy of adjustment is needed.

摘要 研究目的：描述某大型非营利医院快速反应团队（rapid response team）的实施实践，并为同类场景（尤其是拉丁美洲地区）的相关项目提供参考依据。研究方法：整体而言，本次干预包含三大核心组成部分：（1）用于识别普通病房患者临床病情恶化的工具；（2）组建快速反应团队以收治所有存在病情风险的患者；（3）针对干预措施开展指标监测。本研究于2013年1月至2014年12月期间，实施了四轮半年度的计划-执行-研究-处理（Plan-Do-Study-Act, PDSA）循环，用于测试并调整干预方案。研究结果：2013至2014年间，该快速反应团队共收治2296名患者。本研究显示，患者死亡率从第1周期的8.3%降至第4周期的5.0%，降幅未达统计学显著性；但第3、4周期的死亡率保持稳定，分别为5.2%与5.0%。针对快速反应系统的核心前提——患者流转与重症照护连续性，本次研究发现重症监护病房（intensive care unit, ICU）床位等待时间有所缩短：无法在诊疗指征明确后即刻收治的住院患者占比从45.9%降至19.0%（p < 0.001），表明医院患者流转效率得到改善。此外，姑息治疗患者的识别率从2.8%提升至10.3%（p = 0.005）。研究结论：在存在重症监护床位短缺等结构性限制的场景中实施快速反应团队模式，或可带来显著收益，但需配套制定调整优化策略。