Diurnal variation in the performance of rapid response systems: the role of critical care services-a review article

Abstract

The type of medical review before an adverse event influences patient outcome. Delays in the up-transfer of patients requiring intensive care are associated with higher mortality rates. Timely detection and response to a deteriorating patient constitute an important function of the rapid response system (RRS). The activation of the RRS for at-risk patients constitutes the system's afferent limb. Afferent limb failure (ALF), an important performance measure of rapid response systems, constitutes a failure to activate a rapid response team (RRT) despite criteria for calling an RRT. There are diurnal variations in hospital staffing levels, the performance of rapid response systems and patient outcomes. Fewer ward-based nursing staff at night may contribute to ALF. The diurnal variability in RRS activity is greater in unmonitored units than it is in monitored units for events that should result in a call for an RRT. RRT events include a significant abnormality in either the pulse rate, blood pressure, conscious state or respiratory rate. There is also diurnal variation in RRT summoning rates, with most activations occurring during the day. The reasons for this variation are mostly speculative, but the failure of the afferent limb of RRT activation, particularly at night, may be a factor. The term "circadian variation/rhythm" applies to physiological variations over a 24-h cycle. In contrast, diurnal variation applies more accurately to extrinsic systems. Circadian rhythm has been demonstrated in a multitude of bodily functions and disease states. For example, there is an association between disrupted circadian rhythms and abnormal vital parameters such as anomalous blood pressure, irregular pulse rate, aberrant endothelial function, myocardial infarction, stroke, sleep-disordered breathing and its long-term consequences of hypertension, heart failure and cognitive impairment. Therefore, diurnal variation in patient outcomes may be extrinsic, and more easily modifiable, or related to the circadian variation inherent in human physiology. Importantly, diurnal variations in the implementation and performance of the RRS, as gauged by ALF, the RRT response to clinical deterioration and any variations in quality and quantity of patient monitoring have not been fully explored across a diverse group of hospitals.

Keywords: Afferent limb failure; Circadian variation; Diurnal variation; Intensive care unit; Rapid response teams.

Fig. 1

Diagram depicting the two limbs of the rapid response system

Fig. 2

Flow diagram representing detecting and responding to clinical deterioration and afferent limb failure. (# indicates an admission to ICU which was not planned or elective; usually follows a sudden, unexpected clinical deterioration)

Fig. 3

Contributors to afferent limb failure. * Davies et al. [76]. ø Tirkkonen et al. [77]. § Bragshaw et al. [78]. ϕ Galhotra et al. [79]. β Jacques et al. [80]. Ω Jones et al. [81]. α Azzopardi et al. [82]. ⁺ Radeschi et al. [83]

Fig. 4

Diurnal variation in MET and cardiac arrest occurrence

Fig. 5

Diurnal variation in MET outcomes (based upon patients who had a MET call during their hospital stay)