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Understanding how medications contribute to clinical deterioration and are used in rapid response systems: A comprehensive scoping review

      Abstract

      Background

      In hospitals, rapid response systems (RRSs) identify patients who deteriorate and provide critical care at their bedsides to stabilise and escalate care. Medications, including oral and parenteral pharmaceutical preparations, are the most common intervention for hospitalised patients and the most common cause of harm. This connection between clinical deterioration and medication safety is poorly understood.

      Objectives

      To inform improvements in prevention and management of clinical deterioration, this review aimed to examine how medications contributed to clinical deterioration and how medications were used in RRSs.

      Review methods

      A scoping review was undertaken of medication data reported in studies of clinical deterioration or RRSs in diverse hospital settings between 2005 and 2017. Bibliographic database searches used permutations of “rapid response system,” “medical emergency team,” and keyword searching with medication-related terms. Independent selection, quality assessment, and data extraction informed mapping against four medication themes: causes of deterioration, predictors of deterioration, RRS use, and management.

      Results

      Thirty articles were reviewed. Quality was low: limited by small samples, observational, single-centre designs and few primary medication-related outcomes. Adverse drug reactions and potentially preventable medication errors, involving sedatives, analgesics, and cardiovascular agents, contributed to clinical deterioration. While sparsely reported, outcomes included death and escalation of care. In children, administration of antibiotics or nebulised medications appeared to predict subsequent deterioration. Cardiovascular medications, sedatives, and analgesics commonly were used to manage deterioration but further detail was lacking. Despite reported potential for patient harm, evaluation of medication management systems was limited.

      Conclusions

      Medications contributed to potentially preventable clinical deterioration, with considerable harm, and were common interventions for its management. When assessing deteriorating patients or caring for patients who require escalation to critical care, clinicians should consider medication errors and adverse reactions. Studies with more specific medication-related, patient-centred end points could reduce medication-related deterioration and refine RRS medication use and management.

      Keywords

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      References

        • Jones D.
        The epidemiology of adult Rapid Response Team patients in Australia.
        Anaesth Intensive Care. 2014; 42: 213-219
        • Devita M.A.
        • Bellomo R.
        • Hillman K.
        • Kellum J.
        • Rotondi A.
        • Teres D.
        • et al.
        Findings of the first consensus conference on medical emergency teams.
        Crit Care Med. 2006; 34: 2463-2478
        • Hillman K.
        Critical care without walls.
        Curr Opin Critical Care. 2002; 8: 594-599
        • Jones D.A.
        • DeVita M.A.
        • Bellomo R.
        Rapid-response teams.
        N Engl J Med. 2011; 365: 139-146
        • Hillman K.
        • Chen J.
        • Cretikos M.
        • Bellomo R.
        • Brown D.
        • Doig G.
        • et al.
        Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial.
        Lancet. 2005; 365: 2091-2097
        • Chan P.S.
        • Jain R.
        • Nallmothu B.K.
        • Berg R.A.
        • Sasson C.
        Rapid response teams: a systematic review and meta-analysis.
        Arch Intern Med. 2010; 170: 18-26
        • Winters B.D.
        • Weaver S.J.
        • Pfoh E.R.
        • Yang T.
        • Pham J.C.
        • Dy S.M.
        Rapid-response systems as a patient safety strategy: a systematic review.
        Ann Intern Med. 2013; 158: 417-425
        • Maharaj R.
        • Raffaele I.
        • Wendon J.
        Rapid response systems: a systematic review and meta-analysis.
        Crit Care. 2015; 19: 254
        • McCannon C.J.
        • Schall M.W.
        • Calkins D.R.
        • Nazem A.G.
        Saving 100,000 lives in US hospitals.
        BMJ. 2006; 332: 1328-1330
        • Australian Commission on Quality and Safety in Healthcare
        National safety and quality health service standards.
        2nd ed. ACSQHC, Sydney, Australia2017
        • Jones D.A.
        • Dunbar N.J.
        • Bellomo R.
        Clinical deterioration in hospital inpatients: the need for another paradigm shift.
        Med J Aust. 2012; 196: 97-100
        • Tan L.H.
        • Delaney A.
        Medical emergency teams and end-of-life care: a systematic review.
        Crit Care Resuscitation J Aust Acad Crit Care Med. 2014; 16 (Epub 03/05): 62-68
        • Australian Commission on Safety and Quality in Healthcare
        Literature review: medication safety in Australia.
        Australian Commission on Safety and Quality in Healthcare, Sydney, Australia2013
        • Edwards I.R.
        • Aronson J.K.
        Adverse drug reactions.
        Lancet. 2000; 356: 1255-1259
        • Roughead E.E.
        • Semple S.J.
        • Rosenfeld E.
        The extent of medication errors and adverse drug reactions throughout the patient journey in acute care in Australia.
        Int J Evid Based Healthc. 2016; 14: 113-122
        • Bates D.W.
        • Boyle D.L.
        • Vander Vliet M.B.
        • Schneider J.
        • Leape L.
        Relationship between medication errors and adverse drug events.
        J Gen Intern Med. 1995; 10: 199-205
        • Bates D.W.
        • Cullen D.J.
        • Laird N.M.
        • Peterson L.A.
        • Small S.D.
        • Servi D.
        • et al.
        Incidence of adverse drug events and potential adverse drug events.
        JAMA J Am Med Assoc. 1995; 274: 29-34
        • Cullen D.J.
        • Sweitzer B.J.
        • Bates D.W.
        • Burdick E.
        • Edmondson A.
        • Leape L.L.
        Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units.
        Crit Care Med. 1997; 25: 1289-1297
        • Institute for Safe Medication Practices
        2018-2019 Targeted medication safety best practices for hospitals.
        Institute for Safe Medication Practices, Horsham2018 (cited 2018 16 February)
        • Arksey H.
        • O'Malley L.
        Scoping studies: towards a methodological framework.
        Int J Soc Res Meth. 2005; 8: 19-32
        • Levac D.
        • Colquhoun H.
        • O'Brien K.K.
        Scoping studies: advancing the methodology.
        Implement Sci IS. 2010; 5: 69
        • Jones D.
        • George C.
        • Hart G.K.
        • Bellomo R.
        • Martin J.
        Introduction of medical emergency teams in Australia and New Zealand: a multi-centre study.
        Crit Care (London England). 2008; 12: R46
        • The Scottish Intercollegiate Guidelines Network
        Search filters Edinburgh: healthcare improvement scotland.
        2015 ([cited 2015 9 December]. Available from:)
        • OCEBM Levels of Evidence Working Group
        The Oxford 2011 levels of evidence Oxford: Oxford centre for evidence-based medicine.
        2011 ([cited 2016 26 April]. Available from:)
        • Howick J.
        • Chalmers I.
        • Glasziou P.
        • Greenhalgh T.
        • Heneghan C.
        • Liberati A.
        • et al.
        The 2011 Oxford CEBM evidence levels of evidence (introductory document): Oxford centre for evidence-based medicine.
        2011 ([cited 2016 April 26]. Available from:)
        • Howick J.
        • Chalmers I.
        • Glasziou P.
        • Greenhalgh T.
        • Heneghan C.
        • Liberati A.
        • et al.
        Explanation of the 2011 Oxford centre for evidence-based medicine (OCEBM) levels of evidence (background document): Oxford centre for evidence-based medicine.
        2011 ([cited 2016 April 26]. Available from:)
        • Lasak-Myall T.
        • Peters M.J.
        • Mlynarek M.
        Opportunity for pharmacy intervention on an urban teaching hospital rapid response team: a pilot study.
        J Pharm Technol. 2012; 28 (4p): 115-118
        • Gokhman R.
        • Seybert A.L.
        • Phrampus P.
        • Darby J.
        • Kane-Gill S.L.
        Medication errors during medical emergencies in a large, tertiary care, academic medical center.
        Resuscitation. 2012; 83: 482-487
        • Miano T.A.
        • Powell E.
        • Schweickert W.D.
        • Morgan S.
        • Binkley S.
        • Sarani B.
        Effect of an antibiotic algorithm on the adequacy of empiric antibiotic therapy given by a medical emergency team.
        J Crit Care. 2012; 27: 45-50
        • Huang E.J.
        • Bonafide C.P.
        • Keren R.
        • Nadkarni V.M.
        • Holmes J.H.
        Medications associated with clinical deterioration in hospitalized children.
        J Hosp Med Offic Publ Soc Hosp Med. 2013; 8: 254-260
        • Van De Vreede M.
        • Leong T.
        Using the medical emergency team to supplement an existing adverse drug event reporting framework.
        J Pharm Pract Res. 2007; 37: 197-199
        • Voepel-Lewis T.
        • Wagner D.
        • Burke C.
        • Tait A.R.
        • Hemberg J.
        • Pechlivanidis E.
        • et al.
        Early adjuvant use of nonopioids associated with reduced odds of serious postoperative opioid adverse events and need for rescue in children.
        Paediatr Anaesth. 2013; 23: 162-169
        • Marquet K.
        • Claes N.
        • De Troy E.
        • Kox G.
        • Droogmans M.
        • Vleugels A.
        A multicenter record review of in-hospital adverse drug events requiring a higher level of care.
        Acta Clin Belg Int J Clin Lab Med. 2017; 72: 156-162
        • Groth C.M.
        • Acquisto N.M.
        Pharmacists as members of the rapid response team.
        J Pharm Pract. 2016; 29: 116-120
        • Feih J.
        • Peppard W.J.
        • Katz M.
        Pharmacist involvement on a rapid response team.
        Am J Health Syst Pharm. 2017; 74: S10-S16
        • Benson L.
        • Hasenau S.
        • O'Connor N.
        • Burgermeister D.
        The impact of a nurse practitioner rapid response team on systemic inflammatory response syndrome outcomes.
        Dimens Crit Care Nurs. 2014; 33: 108-115
        • Rayan N.
        • Baird R.
        • Masica A.
        Rapid response team interventions for severe hyperkalemia: evaluation of a patient safety initiative.
        Hosp Pract (1995). 2011; 39: 161-169
        • Flabouris A.
        • Chen J.
        • Hillman K.
        • Bellomo R.
        • Finfer S.
        Merit Study Investigators from the Simpson Centre, et al. Timing and interventions of emergency teams during the MERIT study.
        Resuscitation. 2010; 81: 25-30
        • Wong K.
        • Levy R.D.
        Do surgeons need to look after unwell patients? The role of medical emergency teams.
        ANZ J Surg. 2005; 75: 848-851
        • Husband A.
        • Mercer I.
        • Detering K.M.
        • Eastwood G.M.
        • Jones D.A.
        The epidemiology of respiratory arrests in a teaching hospital.
        Resuscitation. 2014; 85: 364-368
        • Marquet K.
        • Claes N.
        • De Troy E.
        • Kox G.
        • Droogmans M.
        • Schrooten W.
        • et al.
        One fourth of unplanned transfers to a higher level of care are associated with a highly preventable adverse event: a patient record review in six Belgian hospitals.
        Crit Care Med. 2015; 43: 1053-1061
        • White K.
        • Scott I.A.
        • Bernard A.
        • McCulloch K.
        • Vaux A.
        • Joyce C.
        • et al.
        Patient characteristics, interventions and outcomes of 1151 rapid response team activations in a tertiary hospital: a prospective study.
        Intern Med J. 2016; 46: 1398-1406
        • Smith R.J.
        • Santamaria J.D.
        • Faraone E.E.
        • Holmes J.A.
        • Reid D.A.
        Rapid response team diagnoses: frequencies and related hospital mortality.
        Crit Care Resuscitation. 2017; 19: 71-80
        • Mullins C.F.
        • Psirides A.
        Activities of a Medical Emergency Team: a prospective observational study of 795 calls.
        Anaesth Intensive Care. 2016; 44: 34-43
        • Topple M.
        • Ryan B.
        • Baldwin I.
        • McKay R.
        • Blythe D.
        • Rogan J.
        • et al.
        Tasks completed by nursing members of a teaching hospital Medical Emergency Team.
        Intensive Crit Care Nurs. 2016; 32: 12-19
        • Krmpotic K.
        • Lobos A.T.
        Clinical profile of children requiring early unplanned admission to the PICU.
        Hosp Pediatr. 2013; 3: 212-218
        • Institute of Safe Medication Practices
        List of high-alert medications in acute care settings.
        ISMP, Pennsylvania, United States of America2014 ([cited 2017 1 November 2017]. Available from:)
        • Australian Commission on Quality and Safety in Healthcare
        APINCHS classification of high risk medicines Sydney, Australia.
        ACSQHC, 2017 ([cited 2017 1 November 2017]. Available from:)
        • Sarani B.
        • Palilonis E.
        • Sonnad S.
        • Bergey M.
        • Sims C.
        • Pascual J.L.
        • et al.
        Clinical emergencies and outcomes in patients admitted to a surgical versus medical service.
        Resuscitation. 2011; 82: 415-418
        • Oliver C.L.
        • Devita M.A.
        • Dunwoody C.J.
        • Johnson J.T.
        • Sok J.C.
        • Simmons R.L.
        Patient safety on the otolaryngology service: the role of an established rapid response system.
        Qual Saf Health Care. 2009; 18: 496-499
        • Weingarten T.N.
        • Venus S.J.
        • Whalen F.X.
        • Lyne B.J.
        • Tempel H.A.
        • Wilczewski S.A.
        • et al.
        Postoperative emergency response team activation at a large tertiary medical center.
        Mayo Clin Proc. 2012; 87: 41-49
        • Kaplan L.J.
        • Maerz L.L.
        • Schuster K.
        • Lui F.
        • Johnson D.
        • Roesler D.
        • et al.
        Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire.
        J Trauma. 2009; 67 (173-8; discussion 8–9)
        • Poole S.G.
        • Bell J.S.
        • Dooley M.J.
        • Kirkpatrick C.M.
        ROMEO consensus group. The reporting of MEdication use in observational studies (ROMEO) statement.
        Eur J Clin Pharmacol. 2015; 71: 897-899
        • Taguti PdS.
        • Dotti A.Z.
        • de Araujo K.P.
        • de Pariz P.S.
        • Dias G.F.
        • Kauss I.A.M.
        • et al.
        The performance of a rapid response team in the management of code yellow events at a university hospital.
        Revista Brasileira de terapia intensiva. 2013; 25: 99-105
        • Cooper B.E.
        Pharmacist involvement in a rapid-response team at a community hospital.
        Am J Health Syst Pharm. 2007; 64: 694-697
        • Sebat F.
        • Musthafa A.A.
        • Johnson D.
        • Kramer A.A.
        • Shoffner D.
        • Eliason M.
        • 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: 2568-2575
        • Umscheid C.A.
        • Betesh J.
        • VanZandbergen C.
        • Hanish A.
        • Tait G.
        • Mikkelsen M.E.
        • et al.
        Development, implementation, and impact of an automated early warning and response system for sepsis.
        J Hosp Med. 2015; 10: 26-31
        • Peebles E.
        • Subbe C.P.
        • Hughes P.
        • Gemmell L.
        Timing and teamwork-An observational pilot study of patients referred to a rapid response team with the aim of identifying factors amenable to re-design of a rapid response system.
        Resuscitation. 2012; 83 (6p): 782-787
        • de Vries E.N.
        • Ramrattan M.A.
        • Smorenburg S.M.
        • Gouma D.J.
        • Boermeester M.A.
        The incidence and nature of in-hospital adverse events: a systematic review.
        Qual Saf Health Care. 2008; 17: 216-223
        • Wilson R.M.
        • Runciman W.B.
        • Gibberd R.W.
        • Harrison B.T.
        • Newby L.
        • Hamilton J.D.
        The quality in Australian health care study.
        Med J Aust. 1995; 163: 458-471
        • Hillman K.
        • Lilford R.
        • Braithwaite J.
        Patient safety and rapid response systems.
        Med J Aust. 2014; 201: 654-656
        • Braithwaite R.S.
        • DeVita M.A.
        • Mahidhara R.
        • Simmons R.L.
        • Stuart S.
        • Foraida M.
        • et al.
        Use of medical emergency team (MET) responses to detect medical errors.
        Qual Saf Health Care. 2004; 13: 255-259
        • Jones D.
        • Duke G.
        • Green J.
        • Briedis J.
        • Bellomo R.
        • Casamento A.
        • et al.
        Medical emergency team syndromes and an approach to their management.
        Crit Care. 2006; 10: R30
        • Girotra S.
        • Nallamothu B.K.
        • Spertus J.A.
        • Li Y.
        • Krumholz H.M.
        • Chan P.S.
        • et al.
        Trends in survival after in-hospital cardiac arrest.
        N Engl J Med. 2012; 367: 1912-1920
        • Fitzgerald M.
        • Cameron P.
        • Mackenzie C.
        • Farrow N.
        • Scicluna P.
        • Gocentas R.
        • et al.
        Trauma resuscitation errors and computer-assisted decision support.
        Arch Surg. 2011; 146: 218-225
        • Merry A.F.
        • Webster C.S.
        • Hannam J.
        • Mitchell S.J.
        • Henderson R.
        • Reid P.
        • et al.
        Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation.
        BMJ. 2011; 343: d5543
        • Joynt K.E.
        • Bhatt D.L.
        • Schwamm L.H.
        • Xian Y.
        • Heidenreich P.A.
        • Fonarow G.C.
        • et al.
        Lack of impact of electronic health records on quality of care and outcomes for ischemic stroke.
        J Am Coll Cardiol. 2015; 65: 1964-1972
        • Rousek J.B.
        • Hallbeck M.S.
        Improving medication management through the redesign of the hopsital code cart medication drawer.
        Hum Factors. 2011; 53: 626-636
        • Fonarow G.C.
        • Zhao X.
        • Smith E.E.
        • Saver J.L.
        • Reeves M.J.
        • Bhatt D.L.
        • et al.
        Door-to-needle times for tissue plasminogen activator administration and clinical outcomes in acute ischemic stroke before and after a quality improvement initiative.
        JAMA. 2014; 311: 1632-1640
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • The PRISMA Group
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        PLoS Med. 2009; 6
        • Kim G.-W.
        • Koh Y.
        • Lim C.-M.
        • Han M.
        • An J.
        • Hong S.-B.
        Does medical emergency team intervention reduce the prevalence of emergency endotracheal intubation complications?.
        Yonsei Med J. 2014; 55: 92-98