Score to door time: a benchmarking tool for rapid response systems

Introduction

Delay in recognition and treatment of deteriorating patients is a significant contributor to mortality of emergency admissions to intensive care (ICU) [1]. Rapid response systems (RRS) seek to improve this process. Service evaluation of RRS might be hampered by the lack of comparative quality assurance tools. The aim of this international collaborative audit was to test a benchmarking tool for the process of emergency admissions to the ICU in analogy to the door-to-needle time in cardiology.

Methods

Data were collected in August and September 2009. Collaborators were asked to audit data from a minimum of five emergency admissions to the ICU (range 3 to 35 admissions). The Score 2 Door time was defined as the time between first trigger of the local track-and-trigger system and time of admission to intensive care. Collaborators were asked to give possible causes for delays in transfer to the ICU. Observations were risk-stratified with an age-adjusted Modified Early Warning Score (MEWS-A) [2]. Data were anonymised and hospitals were coded in a random fashion.

Results

Up to 22 September, data for 125 patients from 17 hospitals had been submitted. Of these, four were non-UK hospitals (US × 1, Denmark × 1, Australia × 2) using medical emergency team type of systems and UK hospitals used a summary score. Median age was 67 years. Mean APACHE II score on admission to the ICU was 18 (SD 8). The median Score 2 Door time was 3:15 (range 0:09 to 19:45). Median time was shorter in the four non-UK hospitals (1:29 vs 4:05). Sicker patients (as evidenced by a higher MEWS-A trigger) did not have shorter Score 2 Door times. The main quoted causes for delays in ICU admission were transient improvement of condition (n = 4), immediate treatment on the ward (n = 9), a procedure (n = 12; that is, surgery, computer tomography), a shortage of intensive care beds at the time of referral (n = 11) or waiting for a senior review (n = 14).

Conclusions

Organisational and other delays in ICU admission might reduce the impact of RRS on care of deteriorating patients on general wards. The Score 2 Door time is a pragmatic tool to quantify and benchmark these delays in order to identify obstacles to patient flow and improve care.