Development of a novel rapid response event review process for quality improvement.

INTRODUCTION: Rapid response team (RRT) and code activation events occur relatively commonly in inpatient settings. RRT systems have been the subject of a significant amount of analysis, although this has been largely focused on the impact of RRT system implementation and RRT events on patient outcomes. There is reason to believe that the structured assessment of RRT and code events may be an effective way to identify opportunities for system improvement, although no standardised approach to event analysis is widely accepted. We developed and refined a protocolised system of RRT and code event review, focused on sustainable, timely and high value event analysis meant to inform ongoing improvement activities. METHODS: A group of clinicians with expertise in process and quality improvement created a protocolised analytic plan for rapid response event review, piloted and then iteratively optimised a systematic process which was applied to all subsequent cases to be reviewed. RESULTS: Hospitalist reviewers were recruited and trained in a methodical approach. Each reviewer performed a chart review to summarise RRT events, and collect specific variables for each case (coding). Coding was then reviewed for concordance, at monthly interdisciplinary group meetings and 'Action Items' were identified and considered for implementation. In any 12-month period starting in 2021, approximately 12-15 distinct cases per month were reviewed and coded, offering ample opportunities to identify trends and patterns. CONCLUSION: We have developed an innovative process for ongoing review of RRT-Code events. The review process is easy to implement and has allowed for the timely identification of high value improvement opportunities.

Trends of in-hospital cardiac arrests in a single tertiary hospital with a mature rapid response system.

BACKGROUND: Most studies on rapid response system (RRS) have simply focused on its role and effectiveness in reducing in-hospital cardiac arrests (IHCAs) or hospital mortality, regardless of the predictability of IHCA. This study aimed to identify the characteristics of IHCAs including predictability of the IHCAs as our RRS matures for 10 years, to determine the best measure for RRS evaluation. METHODS: Data on all consecutive adult patients who experienced IHCA and received cardiopulmonary resuscitation in general wards between January 2010 and December 2019 were reviewed. IHCAs were classified into three groups: preventable IHCA (P-IHCA), non-preventable IHCA (NP-IHCA), and inevitable IHCA (I-IHCA). The annual changes of three groups of IHCAs were analyzed with Poisson regression models. RESULTS: Of a total of 800 IHCA patients, 149 (18.6%) had P-IHCA, 465 (58.1%) had NP-IHCA, and 186 (23.2%) had I-IHCA. The number of the RRS activations increased significantly from 1,164 in 2010 to 1,560 in 2019 (P = 0.009), and in-hospital mortality rate was significantly decreased from 9.20/1,000 patients in 2010 to 7.23/1000 patients in 2019 (P = 0.009). The trend for the overall IHCA rate was stable, from 0.77/1,000 patients in 2010 to 1.06/1,000 patients in 2019 (P = 0.929). However, while the incidence of NP-IHCA (P = 0.927) and I-IHCA (P = 0.421) was relatively unchanged over time, the incidence of P-IHCA decreased from 0.19/1,000 patients in 2010 to 0.12/1,000 patients in 2019 (P = 0.025). CONCLUSIONS: The incidence of P-IHCA could be a quality metric to measure the clinical outcomes of RRS implementation and maturation than overall IHCAs.

Relationship between the presence of dedicated doctors in rapid response systems and patient outcome: a multicenter retrospective cohort study.

BACKGROUND: Rapid response systems (RRSs) improve patients' safety, but the role of dedicated doctors within these systems remains controversial. We aimed to evaluate patient survival rates and differences in types of interventions performed depending on the presence of dedicated doctors in the RRS. METHODS: Patients managed by the RRSs of 9 centers in South Korea from January 1, 2016, through December 31, 2017, were included retrospectively. We used propensity score-matched analysis to balance patients according to the presence of dedicated doctors in the RRS. The primary outcome was in-hospital survival. The secondary outcomes were the incidence of interventions performed. A sensitivity analysis was performed with the subgroup of patients diagnosed with sepsis or septic shock. RESULTS: After propensity score matching, 2981 patients were included per group according to the presence of dedicated doctors in the RRS. The presence of the dedicated doctors was not associated with patients' overall likelihood of survival (hazard ratio for death 1.05, 95% confidence interval [CI] 0.93‒1.20). Interventions, such as arterial line insertion (odds ratio [OR] 25.33, 95% CI 15.12‒42.44) and kidney replacement therapy (OR 10.77, 95% CI 6.10‒19.01), were more commonly performed for patients detected using RRS with dedicated doctors. The presence of dedicated doctors in the RRS was associated with better survival of patients with sepsis or septic shock (hazard ratio for death 0.62, 95% CI 0.39‒0.98) and lower intensive care unit admission rates (OR 0.53, 95% CI 0.37‒0.75). CONCLUSIONS: The presence of dedicated doctors within the RRS was not associated with better survival in the overall population but with better survival and lower intensive care unit admission rates for patients with sepsis or septic shock.

Update on early warning scores.

Early warning scores (EWS) have the objective to provide a preventive approach for detecting those patients in general wards at risk of deterioration before it begins. Well implemented and combined with a tiered response, the EWS expect to be a relevant tool for patient safety. Most of the evidence for their use has been published for the general EWS. Their strengths, such as objectivity and systematic response, health provider training, universal applicability and automatization potential need to be highlighted to counterbalance the weakness and limitations that have also been described. The near future will probably increase availability of EWS, reliability and predictive value through the spread and acceptability of continuous monitoring in general ward, its integration in decision support algorithms with automatic alerts and the elaboration of temporal vital signs patterns that will finally allow to perform a personal modelling depending on individual patient characteristics.

Características epidemiológicas de los pacientes atendidos en el sector de reanimación de un servicio de emergencia en un hospital de tercer nivel de Argentina / Epidemiological features of patients admitted to the resuscitation unit at an emergency department of a third level hospital in Argentina

Introducción. Conocer las características epidemiológicas (CE) de una población resulta primordial para la definición de estrategias sanitarias. Nuestro objetivo es describir las características de pacientes críticos ingresados al sector reanimación (SR). Materiales y métodos. Estudio descriptivo y retrospectivo realizado en un servicio de urgencias de un hospital de tercer nivel entre 2/7/2018 y 1/7/2019. Se incluyeron todos los pacientes ingresados a SR. Se registró edad, sexo, motivo de ingreso, condición crónica, procedimientos diagnósticos y terapéuticos efectuados. Los datos fueron obtenidos del libro de registro y la historia clínica informatizada, y analizados con software Redcap Versión 8.9.2. Las variables categóricas se expresaron como frecuencias y porcentajes y las continuas con mediana y rango intercuartílico. Resultados. Ingresaron 2292 pacientes. El 94% fueron menores de 16 años. El 56,5% presentaba condiciones crónicas (CC), siendo más frecuentes las enfermedades neurológicas (29%), endocrino/metabólicas (15,5%) y cardiovasculares (11%). Los motivos de ingreso más habituales: enfermedad respiratoria aguda baja (31%), estado epiléptico (13%), sepsis (13%) y deshidratación grave (7%). Estudios complementarios más utilizados: laboratorio (54%), radiografía (28%), hemocultivos (23%). Los procedimientos realizados con más frecuencia fueron la colocación de acceso venoso periférico (67%), cánula nasal de alto flujo (6%) y ventilación mecánica (5%). Las drogas más indicadas: oxígeno (42%), fluidos (34%), antibióticos (22%). El 14% ingresó a cuidados intensivos. Hubo 11 paros cardiorrespiratorios y 6 óbitos. Conclusiones. En el SR se asisten pacientes críticos con patologías de alta prevalencia como también pacientes con enfermedades crónicas complejas. La evaluación periódica de CE resulta una herramienta fundamental para detectar dificultades y elaborar estrategias de mejora (AU)

Introduction. Knowledge on the epidemiological characteristics (EC) of a population is essential to define healthcare strategies. Our aim was to describe the characteristics of critical patients admitted to the resuscitation unit (RU). Materials and methods. A descriptive and retrospective study was conducted at an emergency department of a third-level hospital between 2/7/2018 and 1/7/2019. All patients admitted to the RU were included. Age, sex, reason for admission, underlying disease, and diagnostic and therapeutic procedures performed were recorded. The data were obtained from the logbook and electronic records, and analyzed using Redcap software Version 8.9.2. Categorical variables were expressed as frequencies and percentages and continuous variables as median and interquartile range. Results. 2292 patients were admitted; 94% were younger than 16 years of age. Overall, 56.5% had underlying diseases (UD), the most common of which were neurological (29%), endocrine/metabolic (15.5%), and cardiovascular (11%) disorders. The most common reasons for admission were acute lower respiratory tract disease (31%), status epilepticus (13%), sepsis (13%), and severe dehydration (7%). The most frequently used complementary studies were laboratory tests (54%), x-rays (28%), and hemocultures (23%). The most frequently performed procedures were peripheral venous line (67%), high-flow nasal cannula (6%), and mechanical ventilation (5%) placement. The most frequently indicated medications were oxygen (42%), fluids (34%), and antibiotics (22%). Overall, 14% required admission to the intensive care unit. There were 11 cardiorespiratory arrests and six deaths. Conclusions. Critical patients with highly prevalent diseases as well as patients with complex underlying diseases are seen at the RU. Periodic EC evaluation is a key tool for detecting difficulties and developing improvement strategies (AU)

An International Report on the Adaptations of Rapid Transient Ischaemic Attack Pathways During the COVID-19 Pandemic.

BACKGROUND: This report aims to describe changes that centres providing transient ischaemic attack (TIA) pathway services have made to stay operational in response to the SARS-CoV-2 pandemic. METHODS: An international cross-sectional description of the adaptions of TIA pathways between 30th March and 6th May 2020. Experience was reported from 18 centres with rapid TIA pathways in seven countries (Australia, France, UK, Canada, USA, New Zealand, Italy, Canada) from three continents. RESULTS: All pathways remained active (n = 18). Sixteen (89%) had TIA clinics. Six of these clinics (38%) continued to provide in-person assessment while the majority (63%) used telehealth exclusively. Of these, three reported PPE use and three did not. Five centres with clinics (31%) had adopted a different vascular imaging strategy. CONCLUSION: The COVID pandemic has led TIA clinics around the world to adapt and move to the use of telemedicine for outpatient clinic review and modified investigation pathways. Despite the pandemic, all have remained operational.

Nurses' ability to timely activate rapid response systems for deteriorating patients: A comparative case scenario study between Finnish and British nurses.

BACKGROUND: Failure or delay in using rapid response system is associated with adverse patient outcomes. OBJECTIVES: To assess nurses' ability to timely activate the rapid response system in case scenarios and to assess nurses' perceptions of the rapid response system. METHODOLOGY/DESIGN: A comparative cross-sectional study was conducted using a modified rapid response team survey. SETTINGS: A sample of medical/surgical registered nurses were recruited from one acute tertiary care hospital in Finland and one National Health Service acute care hospital in United Kingdom (N = 180; UK: n = 86; Finland: n = 94). RESULTS: The results demonstrated that in half of the case scenarios, nurses failed to activate the rapid response system on time, with no significant difference between countries. Nurses did not perceive doctor's disagreement with activation of the rapid response system to be a strong barrier for activating the rapid response system. Finnish nurses found doctor's disagreement in activating the rapid response system less important compared to British nurses. CONCLUSIONS: The study identified gaps in nurses' knowledge in management of deteriorating patients. Nurses' management of the case scenarios was suboptimal. The findings suggest that nurses need education for timely activation of the rapid response system. Case scenarios could be beneficial for nurses' training.

The impact of rapid response systems on mortality and cardiac arrests - A literature review.

BACKGROUND: Rapid response systems were created to improve recognition of and response to deterioration of general ward patients. AIM: This literature review aimed to evaluate the evidence on whether rapid response systems decrease in-hospital mortality and non-intensive care unit cardiac arrests. METHOD: Six databases (MEDLINE, Cochrane Central Register of Controlled Trials, Cumulative Index of Nursing and Allied Health Literature, SCOPUS, Web of Science and PubMed) were systematically searched for primary studies published between 1st January 2014 and 31st October 2017, recruiting general ward patients, where the intervention involved introducing/maintaining a rapid response system, the comparison referred to a hospital setting without a rapid response system and the outcomes included mortality and cardiac arrests. RESULTS: Fifteen studies met eligibility criteria: one stepped wedge cluster randomised controlled trial, one concurrent cohort controlled study and thirteen historically controlled studies. Thirteen studies investigated mortality of which seven reported statistically significant findings in favour of rapid response systems. Thirteen studies investigated cardiac arrests, of which eight reported statistically significant findings in favour of rapid response systems. CONCLUSION: Evidence suggests that when the process of introducing/maintaining a rapid response system is successful and under certain favourable conditions, rapid response systems significantly decrease mortality and cardiac arrests.

¿Puedes aportar valor más allá de la UCI? El reto de la enfermería en los Sistemas de Respuesta Rápida / Can you add value beyond the ICU? The nursing challenge in systems of Rapid Response

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The rapid response system: an integrative review.

Background: Clinical deterioration and adverse events in hospitals is an increasing cause for concern. Rapid response systems have been widely implemented to identify deteriorating patients. Aim: We aimed to examine the literature highlighting major historical trends leading to the widespread adoption of rapid response systems, focussing on Australian issues and identifying future focus areas. Method: Integrative literature review including published and grey literature. Results: Seventy-eight sources including journal articles and Australian government matierlas resulted. Pertinent themes were the increasing acuity and aging of the population, importance of hospital cultures, the emerging role of the consumer, and proliferation, evolution and standardisation of rapid response systems. Discussion: Translating evidence to usual care practice is challenging and strongly driven by local factors and political imperatives. Conclusion: Rapid response systems are complex interventions requiring consideration of contextual factors at all levels. Appropriate resources, a skilled workforce and positive workplace cultures are needed for these systems to reach their full potential.

Reasons for Repeat Rapid Response Team Calls, and Associations with In-Hospital Mortality.

BACKGROUND: Previous publications noted increased mortality risk in patients subject to repeat rapid response team (RRT) calls. These patients were examined as a homogenous group, but there may be many reasons for repeat calls. Those potentially preventable by the rapid response system have not been investigated. METHODS: In a retrospective cohort study, patients with potentially preventable repeat calls were classified into two categories: type 1 (patients who had a repeat call following an initial call that ended despite the patient still triggering RRT calling criteria [T1-PRC]) and type 2 (patients with a repeat call within 24 hours of an initial call and for the same reason [T2-PRC]). In-hospital mortality for these patients and for those with repeat calls for all other reasons (ORC) were compared to patients with only a single call during their admission (SC). RESULTS: Mortality occurred in 31 (43.7%) T1-PRC, 13 (15.1%) T2-PRC, 56 (28.9%) ORC, and 289 (13.9%) SC patients. Univariate odds ratios (ORs), in comparison to SC patients, were 4.81 (95% confidence interval [CI]: 2.96-7.81; p < 0.001), 1.10 (95% CI: 0.60-2.02; p = 0.75), and 2.52 (95% CI: 1.80-3.52; p < 0.001), respectively. Mortality effects persisted for the T1-PRC and ORC groups after adjustment for patient, admission, and initial call characteristics with ORs of 4.07 (95% CI: 2.36-7.01; p < 0.001) and 2.29 (95% CI: 1.57-3.34; p < 0.001), respectively. CONCLUSION: This study found that repeat calls following an initial call that ended with ongoing breach of predefined calling criteria were strongly associated with increased mortality. This highlights the risk to patients when the RRT leaves reversible clinical deterioration unresolved at the end of a call.

Role of the anesthesiologist-intensivist outside the ICU: opportunity to add value for the hospital or an unnecessary distraction?

PURPOSE OF REVIEW: Given the extremely expensive nature of critical care medicine, it seems logical that intensivists should play an active role in designing efficient systems of care. The true value of intensivists, however, is not well defined. RECENT FINDINGS: Anesthesiologists have taken key roles in improving patient safety in the operating room. Anesthesia-related mortality rates have decreased from 20 deaths per 100 000 anesthetics in the early 1980s to less than one death per 100 000 currently. Anesthesiologist-intensivists remain rare (less than 5% of certified anesthesiologists), but increasingly play multiple roles within multidisciplinary teams. This review outlines the roles of intensivists in performance improvement, perioperative assessment; sedation services, extracorporeal and mechanical support, and code/rapid response teams. Critical-care physicians, by definition, work in collaborative multispecialty and multidisciplinary teams that make it difficult to isolate each team member's precise contribution to healthcare value. SUMMARY: Anesthesiologist-intensivists working outside their usual environment provide leadership and clinical guidance towards improving patient outcomes.

Systems for recognition and response to clinical deterioration in Victorian emergency departments.

BACKGROUND: The study aim was to explore the systems for recognising and responding to clinical deterioration in adult and paediatric Victorian emergency department (ED) patients after their initial triage assessment. METHODS: A survey of Victorian EDs was conducted. Senior ED nursing staff was asked about ED characteristics, vital sign documentation, systems for recognising and responding to deteriorating ED patients, quality assurance and governance of ED rapid response systems (RRSs). RESULTS: Sixteen EDs participated (17 metropolitan and 13 regional or rural) giving a response rate of 53.3% (16/30). The organisational definition of a deteriorating patient applied to the ED at 50% of sites (n=8). Vital sign documentation was paper-based (43.6%), electronic (37.6%) or a combination (18.8%) of both. The majority of EDs (87.5%, n=14) had an ED RRS; 50% had one tier, single trigger RRS and 31.3% of EDs had a two tier, single trigger RRS. At 68.8% of sites the ED RRS activation criteria were the same as ward MET (medical emergency team) activation criteria. The most common method of escalation of care for deteriorating ED patients were face-to-face communication (87.5%) and overhead announcements within the ED (68.8%). The ED rapid response team (RRT) was composed of ED specific staff in 50.5% of sites, and staff external to the ED at 12.5% of sites. Two thirds of sites (68.7%) collected data about clinical deterioration in ED patients. CONCLUSIONS: Most EDs had an RRS but there was variability in activation criteria and members of the responding team both between EDs, and between ED and the ward RRSs.

Association of Pediatric Medical Emergency Teams With Hospital Mortality.

BACKGROUND: Implementation of medical emergency teams has been identified as a potential strategy to reduce hospital deaths, because these teams respond to patients with acute physiological decline in an effort to prevent in-hospital cardiac arrest. However, prior studies of the association between medical emergency teams and hospital mortality have been limited and typically have not accounted for preimplementation mortality trends. METHODS: Within the Pediatric Health Information System for freestanding pediatric hospitals, annual risk-adjusted mortality rates were calculated for sites between 2000 and 2015. A random slopes interrupted time series analysis then examined whether implementation of a medical emergency team was associated with lower-than-expected mortality rates based on preimplementation trends. RESULTS: Across 38 pediatric hospitals, mean annual hospital admission volume was 15 854 (range, 6684-33 024), and there were a total of 1 659 059 hospitalizations preimplementation and 4 392 392 hospitalizations postimplementation. Before medical emergency team implementation, hospital mortality decreased by 6.0% annually (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.92-0.96) across all hospitals. After medical emergency team implementation, hospital mortality continued to decrease by 6% annually (OR, 0.94; 95% CI, 0.93-0.95), with no deepening of the mortality slope (ie, not lower OR) in comparison with the preimplementation trend, for the overall cohort (P=0.98) or when analyzed separately within each of the 38 study hospitals. Five years after medical emergency team implementation across study sites, there was no difference between predicted (hospital mean of 6.18 deaths per 1000 admissions based on preimplementation trends) and actual mortality rates (hospital mean of 6.48 deaths per 1000 admissions; P=0.57). CONCLUSIONS: Implementation of medical emergency teams in a large sample of pediatric hospitals in the United States was not associated with a reduction in hospital mortality beyond existing preimplementation trends.

Effect of an automated notification system for deteriorating ward patients on clinical outcomes.

BACKGROUND: Delayed response to clinical deterioration of ward patients is common. METHODS: We performed a prospective before-and-after study in all patients admitted to two clinical ward areas in a district general hospital in the UK. We examined the effect on clinical outcomes of deploying an electronic automated advisory vital signs monitoring and notification system, which relayed abnormal vital signs to a rapid response team (RRT). RESULTS: We studied 2139 patients before (control) and 2263 after the intervention. During the intervention the number of RRT notifications increased from 405 to 524 (p = 0.001) with more notifications triggering fluid therapy, bronchodilators and antibiotics. Moreover, despite an increase in the number of patients with "do not attempt resuscitation" orders (from 99 to 135; p = 0.047), mortality decreased from 173 to 147 (p = 0.042) patients and cardiac arrests decreased from 14 to 2 events (p = 0.002). Finally, the severity of illness in patients admitted to the ICU was reduced (mean Acute Physiology and Chronic Health Evaluation II score: 26 (SD 9) vs. 18 (SD 8)), as was their mortality (from 45% to 24%; p = 0.04). CONCLUSIONS: Deployment of an electronic automated advisory vital signs monitoring and notification system to signal clinical deterioration in ward patients was associated with significant improvements in key patient-centered clinical outcomes. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01692847 . Registered on 21 September 2012.

Atendimentos realizados por times de respostas rápidas em hospitais / Care by rapid response teams in hospitals

A segurança do paciente tornou-se indispensável para o sistema de saúde, portanto iniciativas vêm sendo implantadas, no decorrer dos anos, com vistas a reduzir os eventos adversos. A atuação do time de resposta rápida (TRR) consolida-se como estratégia para prover atendimento ao paciente que apresente sinais de deterioração clínica no setor de internação geral em hospitais. O serviço é formado por equipe multiprofissional capacitada para prestar tratamento intensivo ao paciente com quadro de deterioração clínica aguda no setor de internação, por meio de códigos (amarelo e azul) instituídos para seu acionamento, com vistas a reduzir a probabilidade de agravamento do quadro clínico ou risco de óbito imediato do paciente, durante o seu período de hospitalização. O estudo objetiva caracterizar as exigências críticas nos atendimentos emergenciais realizados por TRR, em um hospital público no estado do Paraná e um filantrópico no estado de São Paulo. Pesquisa descritiva, exploratória, qualitativa, com utilização da Técnica do Incidente Crítico como guia do processo metodológico, realizada por meio de entrevistas com 19 médicos, 20 fisioterapeutas e 23 enfermeiros. Os resultados encontrados foram agrupados em 89 incidentes críticos extraídos das entrevistas. A análise dos dados constou da identificação e do agrupamento de 220 comportamentos e 130 consequências. A partir das situações, comportamentos e consequências identificadas, destacam-se a necessidade da melhoria na via aferente do TRR (reconhecimento da deterioração clínica e acionamento do TRR na unidade), a capacitação dos profissionais das unidades de internação para exercer as habilidades técnicas iniciais necessárias frente ao atendimento de emergência até a chegada do TRR, a falha na interação entre os diversos profissionais durante o atendimento do código azul com prejuízo na sistematização do atendimento de emergência para reverter o quadro de parada cardiorrespiratória dos pacientes e os sentimentos e emoções negativas geradas nos profissionais como dificultadores dos atendimentos emergenciais em código azul. Em relação aos destaques positivos a partir das situações, comportamentos e consequências identificados, ressaltam-se o tempo de chegada do TRR na unidade para realizar o atendimento de emergência, a sistematização do atendimento de reanimação cardiopulmonar realizada pela equipe multiprofissional, o restabelecimento das funções vitais do paciente após o atendimento e a sua transferência após a finalização do atendimento da unidade de internação para um ambiente de cuidados intensivos. Como principais sugestões ao TRR, os entrevistados pontuaram a importância da capacitação de atendimento de emergência aos profissionais das unidades de internação, a necessidade de mantê-los atuando exclusivamente no TRR, o número adequado de profissionais no quarto durante o atendimento de emergência e a importância do registro em prontuário do paciente sobre a decisão de não reanimação frente aos cuidados paliativos. Destaca-se a expressiva frequência dos resultados positivos comparados aos negativos que permearam as situações, comportamentos e consequências decorrentes das entrevistas. Infere-se que mesmo ocorrendo dificuldades, enfrentadas por esses profissionais durante os atendimentos realizados aos pacientes que se tornam críticos nas enfermarias, predominaram os relatos positivos nas diversas categorias que legitimaram a importância da implantação desse serviço, como contribuição à qualidade e segurança dos que estão hospitalizados

Patient safety has become indispensable for the health system. Therefore, initiatives have been implemented over the years to reduce adverse events. The performance of the Rapid Response Team (RRT) has been consolidated as a strategy to provide care to patients who get in critical conditions at the general hospital admission unit. The service is constituted by a multiprofessional team with an approach in the intensive treatment of patients with signs of acute clinical deterioration in the inpatient unit, through codes established for its activation, in order to reduce the probability of worsening of the clinical condition or imminent death risk of the patient during the hospitalization period. The study aims to characterize the critical requirements in emergency care provided by the RRT at a public hospital in the state of Paraná and a philanthropic hospital in the state of São Paulo, Brazil. This is a descriptive, exploratory study with a qualitative approach, adopting the Critical Incident Technique to guide the methodological procedures, performed with 62 health professionals, being 19 physicians, 20 physiotherapists and 23 nurses. The results were grouped into 89 critical incidents extracted from the interviews. Data analysis consisted of the identification and grouping of 220 behaviors and 130 consequences. Based on the situations, behaviors and consequences identified, there is a need to improve the afferent pathway of RRT (recognition of clinical deterioration and activation of the RRT in the unit), the qualification of the professionals of the inpatient units to perform the necessary initial technical skills in the emergency response until the arrival of the RRT, the failure in the interaction among the different professionals during blue-code care with negative effects for the systematization of emergency care to revert the patients' CPA and the negative feelings and emotions generated in the professionals as impediments to code-blue emergency care. Regarding the positive highlights from the situations, behaviors and consequences identified, the arrival time of the RRT in the unit to perform the emergency care, the systematization of the cardiopulmonary resuscitation service performed by the multiprofessional team, the restoration of the patient's vital functions after the care and transfer of the patient after the end of the care from the inpatient unit to an intensive care environment. As the main suggestions to the RRT, the interviewees pointed out the importance of emergency care training for the professionals of the inpatient units, the need to keep the professionals working exclusively in the RRT, the appropriate number of professionals in the room during emergency care and the importance of registering the patient's decision not to reanimate in the patient file in view of palliative care. The significant frequency of positive over negative results was highlighted, which permeated the situations, behaviors and consequences deriving from the interviews. It is inferred that, even though these professionals encountered difficulties during the visits to patients who became critical in the wards, the positive reports predominated in the various categories that legitimized the importance of implementing this service, as a contribution to the quality and safety of hospitalized patients