From Critical Care Response Team to Critical Care Response System

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The foundation of critical care service delivery across Ontario has evolved. This evolution was necessary due to many pressures on the health-care system. The unpredictable surge for hospital resources because of SARS exposed how stressed the system in Ontario had become. We are now faced with the unvarying pressure of a demographic surge. This demographic tsunami has the potential to fracture health-care systems worldwide.

The Ontario government has invested in a Critical Care Strategy that focuses on improving access, quality and system integration.One of the leading initiatives under the Critical Care Strategy is critical care response teams (CCRTs). A multidisciplinary group that believed the level of care received by patients should be dependent upon need rather than location within a hospital created the CCRT concept. CCRTs, composed of intensivists, registered nurses and respiratory therapists (RRTs) with specialized training in critical care, are designed to bring acute resuscitation knowledge, skills and resources to patients throughout the hospital. To date Ontario has 27 Adult and 4 Paediatric teams across the province. These innovative teams are providing safe, quality care when and where the patient needs it.

CCRTs model a system approach to health care. The teams are multidisciplinary, and move and respond across practice boundries. In order to be effective they rely on the dedicated nurses, RRTs and physicians throughout the hospital. These clinicians identify patients at risk of clinical deterioration and activate the CCRT members for assistance. As well, CCRT members ensure continuity of critical care by following patients discharged from the Intensive Care Unit.

To date there has been signficiant interest in the CCRT and Rapid Response Team phenomenon. The literature, not surprisingly, does suggest that a CCRT must be utilized in order to be effective. Therefore during the first years of CCRT implementation; the focus has been to ensure the CCRT’s are utilized.

Since implementation, it has been the privilege for CCRT members in Ontario to assist in the care of 152 267 patients. To reduce the number of ICU readmissions the vast majority of these are patients were identified prior to discharge from ICU’s and followed for a minimum of 48 hours. Clinician colleagues throughout the hospital utilizing specified calling criteria or their clinical judgement identified the remaining referrals. Over the last six months across the 27 Adult CCRT hospitals, there has been on average over 40 new consults/1000 hospital admissions. This referral rate, in this time period, is in excess of those established in similar centers around the world.

These activities have led to important improvements in patient safety and outcomes. For example, Toronto General Hospital, since the implementation of CCRT, has been able to identify and respond to patients earlier in the course of their acute illness. This has resulted in a near 40 per cent reduction in ICU mortality and a greater than 50 per cent reduction in the number of patients being admitted to the intensive care unit after cardiac arrest.

Benchmarking is an important concept in quality and performance improvement. Just as utilization was identified as the most important first step during the implemention of a Critical Care Response Team; data evaluation and feedback is vital to create a sustainable Critical Care Response System. Over the next year data will be analyzed, and the results provided to each CCRT. Each of these teams will utilize the data to determine areas for improvement; and, identify hospital wards and personnel in need of educational interventions. As well, each hospital will know how it compares to peers with respect to important outcome measurements. This process will guide continued performance improvement and promote a critical care response systems that is focused on patient safety and quality improvement.