IJCS | Volume 32, Nº5, September/October 2019

538 Veiga & Rojas Performance of the rapid response systems Int J Cardiovasc Sci. 2019;32(5):536-539 Viewpoint However, when the impact of RRT on the reduction of mortality is assessed, the data are still conflicting. Ameta-analysis study and a systematic review, including 18 studies, showed a 33.8% reduction in the number of CA outside the ICU, without in-hospital mortality reduction. 22 A study involvingmore than 400,000 patients in 10 American hospitals, 23 compared mortality before and after the implementation of RRT, and showed that in-hospital mortality decreased in six hospitals. Nevertheless, it is not possible to attribute these results to the RRT. Jung et al. 24 in their turndemonstrated a reduction in mortality associated with the team performance (p = 0.002). A recent study shows a correlation between the hospital length of stay and worsened prognosis, in patients who presented with CA after admitting service within 48 hours of the RRT consultation. 25 However, new perspectives have been studied to better evaluate the effectiveness of RRT. 25,26 Brunsveld et al. 27 assessed unexpected deaths, that is, without a pre-existing limitation of treatment, rather than all-cause mortality, where the improvement in survival after introduction of a RRT was more pronounced compared to all deaths as the endpoint. Nonetheless, several aspects can also be associated with outcomes resulting from RRT, such as time of RRT activation. During daytime hours, latency time from changes in vital signs to RRT activation was shorter, compared to nighttime hours. Besides, activation during nighttime hours was associatedwith higher mortality. 28,29 Inclusion in the Guidelines of The American Heart Association - AdvancedCardiac Life Support (ACLS) In the updated version of the Guidelines of the American Heart Association, released in 2015, “Surveillance and Prevention” were included as the first link in the chain of survival. In this context, the presence of rapid response teams (RRT) in the institutions was encouraged, with the aim of providing initial intervention in patients with clinical deterioration and preventing in-hospital cardiac arrests. 21 Other organizations, such as the Joint Commission and the Institute for Healthcare Improvement also encourage the presence of RTT in hospitals. 3 A Brazilian study, which evaluated the presence of RRT in a large-sized hospital, showed statistically significant reduction in the number of cardiac arrests (CAs) after the implementation of RRT (p < 0.001). 3 The involvement and training of care staff are essential in the continuous and systematic search for clinical decompensation, at an early stage. Broadening the scope of performance Recently, several studies have been published, with assessments of the RRT performance in end-of-life patients’ care. Studies have shown that up to 25% of RRT activation involved patients with pre-existing limitation of treatments. 25 Smith et al. 26 showed that after implementation of rapid response teams, there was a significant increase in the do-not-resuscitate orders (p < 0.001), which may impact on reduction of resource utilization among this group of patients. Conclusions RRT implementation is related with in-patient safety, prevention of severe adverse events, such as cardiac events and impact on outcomes, resulting in reduced mortality. New scopes of performance have been established. However, the major challenge still lies in the early identification of clinical deterioration. Author contributions Conception and design of the research: Veiga VC and Rojas SSO. Acquisition of data: Veiga VC and Rojas SSO. Analysis and interpretation of the data: Veiga VC and Rojas SSO. Writing of themanuscript: Veiga VC and Rojas SSO. Critical revision of the manuscript for intellectual content: Veiga VC and Rojas SSO. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This study is not associated with any thesis or dissertation work. Ethics approval and consent to participate This article does not contain any studies with human participants or animals performed by any of the authors.