Effect of a rapid response system for patients in shock on time to treatment and mortality during 5 years

Objective: Treatment of nontraumatic shock is often delayed or inadequate due to insufficient knowledge or skills of front-line healthcare providers, limited hospital resources, and lack of institution-wide systems to ensure application of best practice. As a result, mortality from shock remains high. We designed a study to determine whether outcomes will be improved by a hospitalwide system that educates and empowers clinicians to rapidly identify and treat patients in shock with a multidisciplinary team using evidenced-based protocols. Design: Single-center trial before and after implementation of a hospital-wide rapid response system for early identification and treatment of patients in shock. Setting. A 180-bed regional referral center in northern California. Patients: A total of 511 adult patients who met criteria for shock during a 7-yr period. Interventions. We designed a rapid response system that included a comprehensive educational program for clinicians on earlier recognition of shock, empowerment of front-line providers using specific criteria to initiate therapy, mobilization of the rapid response team, protocol goal-directed therapy, and early transfer to the intensive care unit. Outcome feedback was provided to foster adoption. Measurements and Main Results. We measured times to key interventions and hospital mortality 2.5 yrs before and until 5 yrs after system initiation. Times to interventions and mortality decreased significantly over time before and after adjusting for confounding factors. Interventions times, including shock alert activation, infusion of 2 L of fluid, central venous catheter placement, and antibiotic administration, were significant predictors of mortality (p <.05). Overall and septic subgroup mortality decreased from before system implementation through protocol year 5 from 40% to 11.8% and from 50% to 10%, respectively (P <.001). Conclusion: Over time, a rapid response system for patients in shock continued to reduce time to treatment, resulting in a continued decrease in mortality. By year 5, only three patients needed to be treated to save one additional life.