Rapid Response Systems: History and Terminology

  • Bradford D. WintersEmail author
  • Michael A. DeVita


The Rapid Response System (RRS) concept has matured substantially since its inception in the early 1990s when critical care physicians, primarily in Australia; Pittsburgh, PA; and the UK started asking some crucial questions regarding why and how patients on general hospital ward deteriorate and often arrest without effective intervention prior to a terminal or near-terminal event. Specifically, they asked exactly what is happening to general hospital ward patients in the minutes and hours prior to their cardiorespiratory arrests and whether we can do something to intervene and halt these deteriorations prior to arrest. This was a sea change in thought and perspective since, at that time, resources focused on resuscitation were primarily concerned with how to improve performance of CPR and ACLS rather than preventing the event to start with. Critical care physicians were well aware, in a general sense, that patients admitted or readmitted to the ICU from the general ward uncommonly went from “just fine” to critically ill. This sense was confirmed by early studies that clearly showed that arrests and deteriorations were not sudden but rather commonly heralded by long periods of obvious hemodynamic and respiratory instability that was often unappreciated by general ward providers. Deteriorating general ward patients were not “suddenly critically ill”; they were only “suddenly recognized” as critically ill, and there is clearly time to intervene.


Rapid Response Systems History Terminology 


  1. 1.
    Sax FL, Charlson ME. Medical patients at high risk for catastrophic deterioration. Crit Care Med. 1987;15(5):510–5.CrossRefPubMedGoogle Scholar
  2. 2.
    Schein RM, Hazday N, Pena M, Robin BH, Sprung CL. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest. 1990;98(6):1388–92.CrossRefPubMedGoogle Scholar
  3. 3.
    Bedell SE, Deitz DC, Leeman D, Delbanco TL. Incidence and characteristics of preventable iatrogenic cardiac arrests. J Am Med Assoc. 1991;265(21):2815–20.CrossRefGoogle Scholar
  4. 4.
    Daffurn K, Lee A, Hillman KM, Bishop GF, Bauman A. Do nurses know when to summon emergency assistance? Intensive Crit Care Nurs. 1994;10(2):115–20.CrossRefPubMedGoogle Scholar
  5. 5.
    Smith AF, Wood J. Can some in-hospital cardio-respiratory arrests be prevented? A prospective survey. Resuscitation. 1998;37(3):133–7.CrossRefPubMedGoogle Scholar
  6. 6.
    Buist MD, Jarmolowski E, Burton PR, Bernard SA, Waxman BP, Anderson J. 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(1):22–5.PubMedGoogle Scholar
  7. 7.
    Hillman KM, Bristow PJ, Chey T, Daffurn K, et al. Antecedents to hospital deaths. Intern Med J. 2001;31(6):343–8.CrossRefPubMedGoogle Scholar
  8. 8.
    Hodgetts TJ, Kenward G, Vlachonikolis IG, et al. Incidence, location and reasons for avoidable in-hospital cardiac arrest in a district general hospital. Resuscitation. 2002;54(2):115–23.CrossRefPubMedGoogle Scholar
  9. 9.
    Kause J, Smith G, Prytherch D, et al. A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia, New Zealand, and the United Kingdom—The ACADEMIA study. Resuscitation. 2004;62(3):275–82.CrossRefPubMedGoogle Scholar
  10. 10.
    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.CrossRefPubMedGoogle Scholar
  11. 11.
    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(2):244–7.CrossRefPubMedGoogle Scholar
  12. 12.
    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(37):255–9.PubMedGoogle Scholar
  13. 13.
    Goldhill DR, White SA, Sumner A. Physiological values and procedures in the 24 h before ICU admissions from the ward. Anaesthesia. 1999;54(6):529–34.Google Scholar
  14. 14.
    Morgan RJM, Williams F, Wright MM. An early warning scoring system for detecting developing critical illness. Clin Intensive Care. 1997;8:100.Google Scholar
  15. 15.
    Stenhouse C, Coates S, Tivey M, Allsop P, Parker T. Prospective evaluation of a modified early warning score to aid earlier detection of patients developing critical illness on a general surgical ward. Br J Anaesth. 2000;84:663P.CrossRefGoogle Scholar
  16. 16.
    Subbe CP, Kruger M, Rutherford P, Gemmel L. Validation of a modified early warning score in medical admissions. Q J Med. 2001;94(10):521–6.CrossRefGoogle Scholar
  17. 17.
    Hodgetts TJ, Kenward G, Vlachonikolis IG, Payne S, Castle N. The identification of risk factors for cardiac arrest and formulation of activation criteria to alert a medical emergency team. Resuscitation. 2002;54(2):125–31.CrossRefPubMedGoogle Scholar
  18. 18.
    Lee A, Bishop G, Hillman K, Daffurn K. The medical emergency team. Anaesth Intensive Care. 1995;23:183–6.PubMedGoogle Scholar
  19. 19.
    Goldhill DR, Worthington L, Mulcahy A, Tarling M, Sumner A. The patient-at-risk team: identifying and managing seriously ill ward patients. Anaesthesia. 1999;54(2):853–60.CrossRefPubMedGoogle Scholar
  20. 20.
    Bristow PJ, Hillman KM, 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(5):236–40.PubMedGoogle Scholar
  21. 21.
    Buist MD, Moore GE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study. Br Med J. 2002;324(7334):387–90.CrossRefGoogle Scholar
  22. 22.
    Ball C, Kirkby M, Williams S. Effect of the critical care outreach team on patient survival to discharge from hospital and readmission to critical care: non-randomised population based study. Br Med J. 2003;327(7422):1014–6.CrossRefGoogle Scholar
  23. 23.
    Leary T, Ridley S. Impact of an outreach team on re-admissions to a critical care unit. Anaesthesia. 2003;58(4):328–32.CrossRefPubMedGoogle Scholar
  24. 24.
    Bellomo R, Goldsmith D, Uchino S, et al. A prospective before-and-after trial of a medical emergency team. Med J Aust. 2003;179(6):283–7.PubMedGoogle Scholar
  25. 25.
    Kenwood G, Castle N, Hodgetts T, Shaikh L. Evaluation of a medical emergency team one year after implementation. Resuscitation. 2004;61(3):257–63.CrossRefGoogle Scholar
  26. 26.
    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(7):1398–404.CrossRefPubMedGoogle Scholar
  27. 27.
    Bellomo R, Goldsmith D, Uchino S, et al. Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med. 2004;32(4):916–21.CrossRefPubMedGoogle Scholar
  28. 28.
    DeVita MA, Braithwaite RS, Mahidhara R, Stuart S, Foraida M, Simmons RL. Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Qual Saf Health Care. 2004;13(4):251–4.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Garcea G, Thomasset S, McClelland L, Leslie A, Berry DP. Impact of a critical care outreach team on critical care readmissions and mortality. Acta Anaesthesiol Scand. 2004;48(9):1096–100.CrossRefPubMedGoogle Scholar
  30. 30.
    MERIT Study Investigators. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet. 2005;365(9477):2091–7.CrossRefGoogle Scholar
  31. 31.
    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. 2005;9(6):R808–15.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    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(2):235–41.CrossRefPubMedGoogle Scholar
  33. 33.
    Jolley J, Bendyk H, Holaday B, Lombardozzi KAK, Harmon C. Rapid response teams: do they make a difference? Dimens Crit Care Nurs. 2007;26(6):253–60.CrossRefPubMedGoogle Scholar
  34. 34.
    Dacey MJ, Mirza ER, Wilcox V, et al. The effect of a rapid response team on major clinical outcome measures in a community hospital. Crit Care Med. 2007;35(9):2076–82.CrossRefPubMedGoogle Scholar
  35. 35.
    Chan PS, Khalid A, Longmore LS, Berg RA, Kosiborod M, Spertus JA. Hospital-wide code rates and mortality before and after implementation of a rapid response team. J Am Med Assoc. 2008;300(21):2506–13.CrossRefGoogle Scholar
  36. 36.
    Tibballs J, Kinney S, Duke T, Oakely E, Hennessy M. Reduction of pediatric in-patient cardiac arrest and death with a medical emergency team: preliminary results. Arch Dis Child. 2005;90(11):1148–52.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Tibballs J, Kinney S. Reduction of hospital mortality and of preventable cardiac arrest and death on introduction of a pediatric medical emergency team. Pediatr Crit Care Med. 2009;10(3):306–12.CrossRefPubMedGoogle Scholar
  38. 38.
    Brilli RJ, Gibson R, Luria JW, et al. Implementation of a medical emergency team in a large pediatric teaching hospital prevents respiratory and cardiopulmonary arrests outside the intensive care unit. Pediatr Crit Care Med. 2007;8(3):236–46.CrossRefPubMedGoogle Scholar
  39. 39.
    Sharek PJ, Parast M, Leong K, et al. Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a children’s hospital. J Am Med Assoc. 2007;298(19):2267–74.CrossRefGoogle Scholar
  40. 40.
    Zenker P, Schlesinger A, Hauck M, et al. Implementation and impact of a rapid response team in a children’s hospital. Joint Comm J Qual Patient Saf. 2007;33(7):418–25.CrossRefGoogle Scholar
  41. 41.
    Buist M, Harrison J, Abaloz E, Van Dyke S. Six-year audit of cardiac arrests and medical emergency team calls in an Australian teaching hospital. Br Med J. 2007;335(7631):1210–2.CrossRefGoogle Scholar
  42. 42.
    Jones D, Egi M, Bellomo R, Goldsmith D. Effect of the medical emergency team on long-term mortality following major surgery. Crit Care. 2007;11(1):R12.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Mailey J, Digiovine B, Baillod D, Gnam G, Jordan J, Rubinfeld I. Reducing hospital standardized mortality rate with early interventions. J Trauma Nurs. 2006;13(4):178–82.CrossRefPubMedGoogle Scholar
  44. 44.
    Tolchin S, Brush R, Lange P, Bates P, Garbo JJ. Eliminating preventable death at Ascension Health. Joint Comm J Qual Patient Saf. 2007;33(3):145–54.CrossRefGoogle Scholar
  45. 45.
    Offner P, Heit J, Roberts R. Implementation of a rapid response team decreases cardiac arrest outside of the intensive care unit. J Trauma. 2007;62(5):1223–8.CrossRefPubMedGoogle Scholar
  46. 46.
    Story D, Shelton A, Poustie S, Colin-Thome N, McIntrye R, McNicol P. Effect of an anesthesia department-led critical care outreach and acute pain service on postoperative serious adverse events. Anesthesia. 2006;61:24–8.CrossRefGoogle Scholar
  47. 47.
    King E, Horvath R, Shulkin D. Establishing a Rapid Response Team (RRT) in an academic hospital: one year’s experience. J Hosp Med. 2006;1(5):296–305.CrossRefPubMedGoogle Scholar
  48. 48.
    Hunt EA, Zimmer KP, Rinke ML, et al. Transition from a traditional code team to a medical emergency team and categorization of cardiopulmonary arrests in a children’s center. Arch Pediatr Adolesc Med. 2008;162(2):117–22.CrossRefPubMedGoogle Scholar
  49. 49.
    100K Lives Campaign. Accessed 10 Jul 2009.
  50. 50.
    Joint Commission National Patient Safety Goals. Accessed 10 Jan 2010.
  51. 51.
    Devita M, Bellomo R, Hillmam K, et al. Findings of the first consensus conference on medical emergency teams. Crit Care Med. 2006;34(9):2463–78.CrossRefPubMedGoogle Scholar
  52. 52.
    Sebat F, Musthafa AA, Johnson D, et al. Effect of a rapid response system for patients in shock on time to treatment and mortality during 5 years. Crit Care Med. 2007;35(11):2568–75.Google Scholar
  53. 53.
    Jones DA, McIntyre T, Baldwin I, Mercer I, Kattula A, Bellomo R. The medical emergency team and end-of-life care: a pilot study. Crit Care Resusc. 2007;9(2):151–6.PubMedGoogle Scholar
  54. 54.
    Chen J, Flabouris A, Bellomo R, Hillman K, Finfer S. MERIT study investigators for the Simpson Center and the ANZICS Clinical Trials Group, the Medical Emergency Team System and not-for-resuscitation orders: results from the MERIT study. Resuscitation. 2008;79(3):391–7.CrossRefPubMedGoogle Scholar
  55. 55.
    Jones D, Baldwin I, McIntyre T, et al. Nurses’ attitudes to a medical emergency team service in a teaching hospital. Qual Saf Health Care. 2006;15(6):427–32.CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Galhotra S, Scholle CC, Dew MA, Mininni NC, Clermont G, DeVita MA. Medical emergency teams: a strategy for improving patient care and nursing work environments. J Adv Nurs. 2006;55(2):180–7.CrossRefPubMedGoogle Scholar
  57. 57.
    Salamonson Y, van Heere B, Everett B, Davison P. Voices from the floor: nurses’ perceptions of the medical emergency team. Intensive Crit Care Nurs. 2006;22(3):138–43.CrossRefPubMedGoogle Scholar
  58. 58.
    Buist M, Bellomo R. MET. The emergency medical team or the medical education team? Crit Care Resusc. 2004;6:88–91.Google Scholar
  59. 59.
    Jones D, Bates S, Warrillow S, Goldsmith D, et al. Effect of an education programme on the utilization of a medical emergency team in a teaching hospital. Intern Med J. 2006;36(4):231–6.CrossRefPubMedGoogle Scholar
  60. 60.
    Braithewaite RS, Devita MA, Mahidhara R, et al. Use of medical emergency teams (MET) responses to detect medical errors. Qual Saf Health Care. 2004;13:255–9.CrossRefGoogle Scholar
  61. 61.
    American Heart Association National Registry for CPR. Accessed 23 Jan 2010.
  62. 62.
    Cretikos M, Parr M, Hillman K, et al. Guidelines for the uniform reporting of data for medical emergency teams. Resuscitation. 2006;68:11–25.CrossRefPubMedGoogle Scholar
  63. 63.
    Subbe CP, Davies RG, Williams E, Rutherford P, Gemmell L. Effect of introducing the modified early warning score on clinical outcomes, cardiopulmonary arrests and intensive care utilisation in acute medical admissions. Anesthesia. 2003;58(8):797–802.CrossRefGoogle Scholar
  64. 64.
    Goldhill DR, McNarry AF. Physiological abnormalities in early warning scores are related to mortality in adult inpatients. Br J Anaesth. 2004;92(6):882–4.CrossRefPubMedGoogle Scholar
  65. 65.
    Goldhill DR, McNarry AF, Mandersloot G, McGinley A. A physiologically-based early warning score for ward patients: the association between score and outcome. Anaesthesia. 2005;60(6):547–53.CrossRefPubMedGoogle Scholar
  66. 66.
    Sharpley JT, Holden JC. Introducing an early warning scoring system in a district general hospital. Nurs Crit Care. 2004;9(3):98–103.CrossRefPubMedGoogle Scholar
  67. 67.
    Gardner-Thorpe J, Love N, Wrightson J, Walsh S, Keeling N. The value of Modified Early Warning Score (MEWS) in surgical in-patients: a prospective observational study. Ann R Coll Surg Engl. 2006;88(6):571–5.CrossRefPubMedPubMedCentralGoogle Scholar
  68. 68.
    Jacques T, Harrison G, McLaws M, Kilborn G. Signs of critical conditions and emergency response (SOCCER): a model for predicting adverse events in the inpatient setting. Resuscitation. 2006;69:175–83.CrossRefPubMedGoogle Scholar
  69. 69.
    Harrison GA, Jacques T, McLaws ML, Kilborn G. Combinations of early signs of critical illness predict in-hospital death—the SOCCER study (signs of critical conditions and emergency responses). Resuscitation. 2006;71(3):327–34.CrossRefPubMedGoogle Scholar
  70. 70.
    Subbe CP, Hibbs R, Williams E, Rutherford P, Gemmel L. ASSIST: a screening tool for critically ill patients on general medical wards. Intensive Care Med. 2002;28(suppl):S21.Google Scholar
  71. 71.
    Haines C, Perrott M, Weir P. Promoting care for acutely ill children. Development and evaluation of a paediatric early warning tool. Intensive Crit Care Nurs. 2006;22(2):73–81.CrossRefPubMedGoogle Scholar
  72. 72.
    Duncan H, Hutchison J, Parshuram CS. The pediatric early warning system score: a severity of illness score to predict urgent medical need in hospitalised children. J Crit Care. 2006;21(13):271–9.CrossRefPubMedGoogle Scholar
  73. 73.
    Subbe CP, Gao H, Harrison DA. Reproducibility of physiological track-and-trigger warning systems for identifying at-risk patients on the ward. Intensive Care Med. 2007;33(4):619–24.CrossRefPubMedGoogle Scholar
  74. 74.
    Bell MB, Konrad D, Granath F, Ekbom A, Martling CR. Prevalence and sensitivity of MET-criteria in a Scandinavian University Hospital. Resuscitation. 2006;70(1):66–73.CrossRefPubMedGoogle Scholar
  75. 75.
    Green A, Williams A. An evaluation of an early warning clinical marker referral tool. Intensive Crit Care Nurs. 2006;22:274–82.CrossRefPubMedGoogle Scholar
  76. 76.
    Cretikos M, Chen J, Hillman K, Bellomo R, Finfer S, Flabouris A. MERIT study investigators. The objective medical emergency team activation criteria: a case-control study. Resuscitation. 2007;73(1):62–72.CrossRefPubMedGoogle Scholar
  77. 77.
    Smith GB, Prytherch DR, Schmidt PE, Featherstone PI, Higgins B. A review, and performance evaluation, of single-parameter “track-and-trigger” systems. Resuscitation. 2008;79(1):11–21.CrossRefPubMedGoogle Scholar
  78. 78.
    Smith GB, Prytherch DR, Schmidt PE, Featherstone PI. Review and performance evaluation of aggregate weighted “track-and-trigger” systems. Resuscitation. 2008;77(2):170–9.CrossRefPubMedGoogle Scholar
  79. 79.
    Santiano N, Young L, Hillman K, et al. Analysis of medical emergency team calls comparing subjective to “objective” call criteria. Resuscitation. 2009;80(1):44–9.CrossRefPubMedGoogle Scholar
  80. 80.
    Smith GB, Prytherch DR, Schmidt P, Featherstone PI, et al. Hospital-wide physiological surveillance. A new approach to the early identification and management of the sick patient. Resuscitation. 2006;71(1):19–28.CrossRefPubMedGoogle Scholar
  81. 81.
    Watkinson PJ, Barber VS, Price JD, Hann A, et al. A randomised controlled trial of the effect of continuous electronic physiological monitoring on the adverse event rate in high risk medical and surgical patients. Anaesthesia. 2006;61(11):1031–9.CrossRefPubMedGoogle Scholar
  82. 82.
    Tarassenko L, Hann A, Young D. Integrated monitoring and analysis for early warning of patient deterioration. Br J Anaesth. 2006;97(1):64–8.CrossRefPubMedGoogle Scholar
  83. 83.
    Pyke J, Taenzer AH, Renaud CE, McGrath SP. Developing a continuous monitoring infrastructure for detection of inpatient deterioration. Joint Comm. J. Safety and Quality. 2012;38(9):328–31.Google Scholar
  84. 84.
    Tanzear AH, Pyke J, Herrick MD, Dodds TM, McGrath SP. A comparison of oxygen saturation data in inpatients with low oxygen saturation using automated continuous monitoring and intermittent manual data charting. Anesthesia and Analgesia. 2014;118(2):326–31.CrossRefGoogle Scholar
  85. 85.
    DeVita MA, Schaefer J, Lutz J, Wang H, Dongilli T. Improving medical emergency team (MET) performance using a novel curriculum and a computerized human patient simulator. Qual Saf Health Care. 2005;14(5):326–31.CrossRefPubMedPubMedCentralGoogle Scholar
  86. 86.
    Wallin CJ, Meurling L, Hedman L, Hedegård J, Felländer-Tsai L. Target-focused medical emergency team training using a human patient simulator: effects on behaviour and attitude. Med Educ. 2007;41(2):173–80.CrossRefPubMedGoogle Scholar
  87. 87.
    Jones D, Duke G, Green J, et al. Medical emergency team syndromes and an approach to their management. Crit Care. 2006;10(1):R30.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  1. 1.Department of Anesthesiology and Critical Care MedicineThe Johns Hopkins University School of MedicineBaltimoreUSA
  2. 2.Department of SurgeryThe Johns Hopkins University School of MedicineBaltimoreUSA
  3. 3.Department of SurgeryCritical Care, Harlem Hospital CenterNew YorkUSA
  4. 4.Department of Internal MedicineCritical Care, Harlem Hospital CenterNew YorkUSA

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