Hello, everybody. My name is Randy Wax. I'm an intensivist at Lake Ridge Health in Durham region just outside of Toronto, and I'm an associate professor in the Department of Critical Care Medicine at Queen's University. I'm going to be speaking about a few of the additional recommendations out of the guidelines, particularly focusing on the characteristics of rapid response systems. No disclosures as well. So one of the perpetual questions that comes up when you're designing rapid response systems is, who should actually be on that team that responds? And so we did ask a few questions about this. One of the questions we were asking, is there a difference between having a nurse respond versus what we call a prescribing clinician? And in the studies we saw, typically it was looking at a nurse practitioner. And we were able to make no recommendation despite looking at only two observational studies, and they looked at hospital mortality, hospital length of stay, unplanned transfer to a higher level of care, and there was really no difference, but again, limited data. Another question was, should a physician be attending versus not having a physician? There were only three observational studies, and these really looked at a physician defined as a resident or an attending physician, depending on the study. And in all three studies, the non-physician they described as an alternative was actually a nurse practitioner. And again, looking at outcomes of hospital mortality, cardiac arrest, and hospital length of stay, could not really detect any significant differences there, and were really unable to make any recommendations. So unfortunately, based on the current literature, we can't answer this question. And it may be because there's no difference between these different providers, or maybe we just haven't studied it properly. But at any rate, this is a question that may be an ongoing question in the future. We also looked at the role of palliative care and how that fits into rapid response systems. And so one of the questions we asked, if you have palliative care providers, trained providers as part of your rapid response team or medical emergency team, will that make a difference? Unfortunately, this is a great question, but no answers, because there's no literature to tell us anything about that one. So we were unable to give really any recommendation on that. However, there was a question, as part of your rapid response system, should you provide education or guidance for the clinicians outside of the ICU on the wards about how to elicit patients' goals of care, and making sure that they're able to establish treatment plans that will help guide their care if they're deteriorating, or hopefully in advance of deterioration, or even during that process while you're making the decision about a disposition for the patient. And there was one randomized controlled trial and two before-after studies. And we were able to make a suggestion that, in fact, a rapid response system should be including that as part of their system with conditional recommendation, with low certainty evidence. But overall, looking at these studies, it did favour that. And just to give you a bit of a flavour of what that meant, some of the outcomes we were looking for when this intervention was provided, it did look like there were potentially increased rates of re-evaluation of the documentation of goals of care, and increased rates of changing patient resuscitation status with this focused education for staff outside of the ICU. It did not increase the rate of involvement of a formal palliative care consultation or service, and unclear effects on ICU length of stay. But overall, it was felt, you know, with the conditional recommendation, this is something that many rapid response systems should be looking at if they're not doing already. And then there's a number of different interventions suggested as part of these studies, because they weren't just sort of a single intervention that was multifactorial, but things like trying to make sure you knew who the substitute decision maker was, discussing what the plan of escalation would be if the patient got sick, various kinds of education initiatives or standardized documentation. So there's lots of different initiatives, but in general, the recommendation is still people should think about it and see if they can potentially influence what's happening outside of the ICU before they have to come to the ICU. So we're bringing the right patients that should come and providing the appropriate care to patients who shouldn't come to the ICU. There was also a good practice statement that came out of the question, should quality improve or is there evidence to support quality improvement strategies or initiatives as part of rapid response systems? Lots of studies, 23 observational studies, but very heterogeneous, kind of three big buckets of some of these quality improvement strategies or interventions, looking at organized plans for education and structured implementation of rapid response systems, having some sort of audit or feedback mechanism and providing feedback to clinicians, and also enhancing teamwork and communication strategies. And again, it was a bit all over the map, but there's a number of different metrics that many rapid response systems use, could look at the number of activations of their patients, look at delays in activation, could look at cases of patients who end up in the ICU without prior activation that was probably warranted, and also looking for patients who had a non-ICU cardiac arrest that we know from the literature in many cases, those patients had something that would have helped predict that and maybe an earlier intervention would have helped. But we also recognize as a panel that the resources in different hospitals, depending on how big the hospital is, what kind of system it is, whether you're in a developing or country with more limited resources, it may differ in terms of what you can actually do as part of quality improvement interventions. So in places that don't have sort of sophisticated databases or systems, you can still look at cases and do individual case audits and still learn a lot from individual cases that will still help tweak your rapid response system. But if you have the opportunity to develop a database, you can identify trends and look at numeric trends over time, particularly things that whenever you're looking for mortality or ICU admission, you're adjusting for patient volume over time, and these opportunities are there. And finally, again, we got great feedback from our patient and family representation in the guideline group. When you're trying to think about quality improvement, what outcomes should you monitor? What's really important for patients and families? What interventions are important? And in particular, if you do have patient and family participation in the activation of the rapid response teams or MET teams, and it was mentioned in one of the other recommendations that we think incorporating them as part of the early warning system was a recommendation, we should be getting family and patient input on that. And just to wrap things up, so really our guideline looked at sort of what we call the forearms of the rapid response system. There was the afferent and efferent arms. So how do you detect? How do you respond? The quality improvement piece and overall structure of the rapid response system. Lots of questions still to be answered, and so we look forward to feedback from people after reviewing the guidelines. In particular, a lot of interest in the detection part and early warning systems and lots of new data that's come out since we developed the guidelines, and so I suspect there's going to be a lot of work looking at that in the near future. And thanks to our panelists on the guideline panel, and we'll turn it over to Dean. Thank you.

rapid response systems

team composition

critical care

quality improvement

patient and family input