Rapid Response System in the Recognising of the Deteriorating Patients: Respiratory Complaints are the Origins

Rapid response team (RRT) system is a structure that contains a set of clinical criteria for certain conditions to detect and intervene on any abnormal signs and symptoms that do not meet these criteria by a qualified expert team [1]. To date, as a professional respiratory therapist in Saudi Arabia, one of the most significant challenges for the Ministry of Health is to provide high standards of professional quality without harm. Notable examples of such a challenge are increasing numbers of patients with special care needs and a lack of a comprehensive team able to detect and manage acute symptoms of deteriorating patients before an emergency arises, and that specifically in wards areas. This is exemplified in a Saudi Arabian study conducted by Rehmani et al.[2] showing around 82% of ward patients who had cardiac arrests had deterioration signs in the previous 24 hours. Recently, several papers have been published reporting positive effects after implementations of RRT. Therefore, this article will review the literature in light of recent evidence to determine the implementation effectiveness of RRT system and role of respiratory therapists in improving serious conditions at the appropriate time for patients in hospital wards and decrease number of deaths.

In the literature, it has been demonstrated that nearly 50% of respiratory and cardiac arrests cases are headed by signs and symptoms of deterioration 6 to 8 hours prior to arrest [12][13][14][15]. Usually, codes are used in hospitals for medical practitioners, for example the 'code blue team' indicates serious emergency cases [14]. Indeed, 'Code blue' is the most popular code used to indicate urgent resuscitation, mostly as an outcome of respiratory or cardiac arrest [15].
However, a clear benefit of code blue in the prevention of respiratory and cardiac arrest could not be identified because the team effectively arrives too late at the point of, or after, the arrest. The most surprising aspect of the code blue team is that despite being in hospitals for years, there remains no significant rise in the success rate, as its rate is below 15 % [16]. In fact, the death rate is gradually increasing as a result of unexpected patient deterioration and cardiopulmonary arrests [17]. The development of awareness to unforeseen medical deterioration and the increase number of respiratory and cardiac arrests promote the necessity to implement RRT.
Such a system has several aspects that differ from the code blue team and these aspects will provide a great opportunity to avoid cardiopulmonary arrests (Table 1) [18].
The Role of RRT RRT has several titles in the literature that are used interchangeably, including medical emergency teams (METs), patient-at-risk teams (PARTs), medical emergency response teams (MERTs) and critical care outreach teams (CCOTs) [19]. This team has been recognised as a system that contains a set of clinical criteria for certain conditions to detect and intervene on any abnormal signs and symptoms that do not meet these criteria by a qualified expert team [1]. RRT is a multidisciplinary team that compromises various clinical staff, including a physician, a respiratory therapist and a nurse.
This team is principally responsible for the evaluation of patients who have signs and symptoms that indicate deterioration in hospital ward areas [5].
In fact, rapid response systems have various arrangements, as there is no ideal model and this could be related to the lack of comparative data among these models in the literature. According to Ranji et al. [7], there are two RRT models which are team is leading by doctors with nurses and team is leading by nurses or other critical care staff. This system has two major components, which are afferent and efferent limbs [1]. An afferent limb is responsible for identifying signs of deterioration in patients according to predefined criteria to activate an RRT response. Whereas an efferent team is to respond quickly by attending the intervention to assess patients. Despite these different types, the presence of a respiratory therapist is crucial, in my view. The importance of having a respiratory therapist in the RRT is because clinical conditions that progress to be more serious are often breathing problems. Moreover, in some cases, if the main problem is not respiratory, at least one part of the respiratory function will be affected and be a major part of the clinical issue [20]. Based on my experience, respiratory complications are a strong risk factor for the deterioration of patients that ultimately lead to cardiopulmonary arrest.

Respiratory Conditions are the Origins
Respiratory problems usually have a substantial role in developing cardiac arrhythmias such as pulse less electrical activity (PEA) and a systole. Respiratory therapist can play a major role in both the afferent and efferent limbs of rapid response systems (RRS). In the afferent team, the respiratory therapist can support the nurses to identify abnormal signs and symptoms early that relate to respiratory and take action. In  Also, they conclude that successful implementation of RRT has a significant impact on reducing morbidity and cost of ICUs [38]. By contrast, a number of studies have investigated the effects of RRT pre and post implementation and found no significant changes or considerable effects on clinical outcomes [39][40][41].
Additionally, the efficiency of RRT on certain kinds of patients was assessed by utilising prospective design research. Konrad  In terms of study designs, various systematic reviews have been developed and introduced to point out the weakness points of many trials that assess the effectiveness of RRT [5,7,8]. These reviews highlight some limitations for example, limited to one hospital, short periods of RRT observation, improve the care quality. In addition, the management of health care facilities, particularly the policies and protocols, can constrain RRT implementation, which ultimately alters the real outcomes [46]. Likewise, Ranji et al. [7] conducted a systematic review and meta-analysis that reported differences in RRT members in hospitals will affect the accuracy of results. For example, some RRTs are led by different hospital staff, for instance doctors or nurses or respiratory therapists, and this will lead to variations in outcomes.
In 2004, Priestley et al. [47] conducted the first RCT in the UK investigating the impact of implementing an RRT service on the hospital wards and length of stay in hospital. They found that RRT systems decrease the rate of mortality in hospital wards overall, compared to control wards. However, they documented that duration of stay could be increased with this system and it is still debatable as they were unable to confirm from their analysis.
A serious weakness with this RCT, however, is that the short period of observation was 60 days, and the randomisation caused concern because control and intervention groups were included [5,8].
Furthermore, another multicentre RCT was published in 2005 which found no significant effects and no relations among the incidence of cardiopulmonary arrests, sudden ICU admissions, unanticipated deaths and RRT implementation [40]. However, one criticism across much of the literature on this trial is that there was no standardisation during the RRT implementation in the sites that participated, inadequate education during this period and the time period for this investigation, which was only 6 months, where such a system needs at least two years to be evaluated [7,46].
Recently, one systematic review and meta-analysis was conducted in 2016 to evaluate the RRT effectiveness on hospital mortality and cardiopulmonary arrests [48]. They conclude that RRT implementation has reduced both hospital mortality and cardiopulmonary arrests. al. [49]. This tool can improve and enhance the confidence and performance for members of RRTs as are exposed to various conditions in practice to build and improve their clinical decisions. Finally, RRTs should improve the quality of care, as Hijasi et al. [37] found; around 30% of the responses of RRT are a result of medical human error, therefore reporting these errors to the management will help to raise awareness and decrease such margins.

Conclusion
To conclude, an RRT system has several important advantages resulting in a noteworthy decline in the frequency of cardiopulmonary arrests, and in most areas, the rate of mortality will be decreased following developments in the quality of care. RRT system can save patients from deterioration, as most signs and symptoms start a long enough time prior to severe deterioration onset when such events need immediate action. Furthermore, RRT system tends to change the health care culture and this change will lead to inform good by improving the critical thinking of staff and the decision making processes leading to better patient outcomes. As most of the cases that deteriorated are from respiratory compromise, respiratory qualitative study of RNs' perceived involvement in rapid response teams. Qual Saf Health Care 19: e13.
therapists have significant value in the management. Finally, implementation of RRT system in Saudi Arabia is highly recommended and the role of the respiratory therapist should be a central with other roles in the RRT system to upgrade clinical practice and meet the patient and institution expectations.

Formatting of Funding Sources
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.