Steve Aguilar, MD

We appreciate the opportunity to continue dialogue regarding the optimal timing of defibrillation, standardized guidelines, and healthy skepticism as to whether they apply to all settings and patient populations. The transition to a single shock followed by resumption of chest compressions over 3 stacked shocks represents the integration of 2 concepts into a single algorithm.[1] The first reflects concern about delays in chest compressions related to rhythm analysis and charge of an automated external defibrillator. This justified a single shock followed by chest compressions to avoid unnecessary pauses. The same guidelines also recommended 2 minutes of cardiopulmonary resuscitation (CPR) prior to the initial and each subsequent defibrillation attempt, providing substrate to the myocardium and increasing the likelihood of shock success.[2, 3, 4] The underlying physiological concept is described by Weisfeldt and Becker as part of their 3‐phase model of ventricular fibrillation.[2, 5] Large randomized out‐of‐hospital studies have demonstrated that high‐quality CPR may prime the heart before defibrillation, as suggested by the 3‐phase model.[6, 7, 8]

Regardless of the theoretical construct(s) upon which the original recommendations were based, we agree with Mr. Stewart that these are misapplied to the inpatient setting that allow for expeditious attempts at defibrillation and stacking of subsequent attempts.

We appreciate the opportunity to continue dialogue regarding the optimal timing of defibrillation, standardized guidelines, and healthy skepticism as to whether they apply to all settings and patient populations. The transition to a single shock followed by resumption of chest compressions over 3 stacked shocks represents the integration of 2 concepts into a single algorithm.[1] The first reflects concern about delays in chest compressions related to rhythm analysis and charge of an automated external defibrillator. This justified a single shock followed by chest compressions to avoid unnecessary pauses. The same guidelines also recommended 2 minutes of cardiopulmonary resuscitation (CPR) prior to the initial and each subsequent defibrillation attempt, providing substrate to the myocardium and increasing the likelihood of shock success.[2, 3, 4] The underlying physiological concept is described by Weisfeldt and Becker as part of their 3‐phase model of ventricular fibrillation.[2, 5] Large randomized out‐of‐hospital studies have demonstrated that high‐quality CPR may prime the heart before defibrillation, as suggested by the 3‐phase model.[6, 7, 8]

Regardless of the theoretical construct(s) upon which the original recommendations were based, we agree with Mr. Stewart that these are misapplied to the inpatient setting that allow for expeditious attempts at defibrillation and stacking of subsequent attempts.

We appreciate the opportunity to continue dialogue regarding the optimal timing of defibrillation, standardized guidelines, and healthy skepticism as to whether they apply to all settings and patient populations. The transition to a single shock followed by resumption of chest compressions over 3 stacked shocks represents the integration of 2 concepts into a single algorithm.[1] The first reflects concern about delays in chest compressions related to rhythm analysis and charge of an automated external defibrillator. This justified a single shock followed by chest compressions to avoid unnecessary pauses. The same guidelines also recommended 2 minutes of cardiopulmonary resuscitation (CPR) prior to the initial and each subsequent defibrillation attempt, providing substrate to the myocardium and increasing the likelihood of shock success.[2, 3, 4] The underlying physiological concept is described by Weisfeldt and Becker as part of their 3‐phase model of ventricular fibrillation.[2, 5] Large randomized out‐of‐hospital studies have demonstrated that high‐quality CPR may prime the heart before defibrillation, as suggested by the 3‐phase model.[6, 7, 8]

Regardless of the theoretical construct(s) upon which the original recommendations were based, we agree with Mr. Stewart that these are misapplied to the inpatient setting that allow for expeditious attempts at defibrillation and stacking of subsequent attempts.

We appreciate very much Dr. Singh's interest and insight regarding our article, A Novel Configuration of a Traditional Rapid Response Team Decreases NonIntensive Care Unit Arrests and Overall Hospital Mortality.[1] Dr. Singh makes several critical points that are worth emphasis and additional commentary.

The importance of cultural change in the success of a rapid response team (RRT) program cannot be emphasized enough. The willingness of frontline staff to access an RRT is based on a belief in the potential benefit to the patient as well as a lack of concern about the repercussions of such an activation, whether these are from the primary physician team or the RRT members themselves. Both of these require institutional commitmentideally from administrative and clinical leadershipas well as routine, direct feedback to providers as to the effectiveness of the program. Both of these have been addressed in our advanced resuscitation training (ART) program, which has replaced traditional life‐support training and consolidates many efforts related to patient safety and preventable death.[2] The ART program represents adaptive training, in which arrest prevention is emphasized for nonintensive care unit staff and the importance of institutional processes such as RRT is emphasized.

Our approach to RRT configuration reflects the resource constraints referenced by Dr. Singh. Although the ideal RRT would include critical‐care nurses located physically outside the intensive care unit to allow regular assessment of at‐risk patients, this would have required expenditures that were not available for the program. In our opinion, a reasonable alternative was to train charge nurses from nonintensive care units as RRT members. The role expectation for these charge nurses included twice‐daily rounds, and their proximity to at‐risk patients facilitated regular reassessments throughout each shift. In addition, the ART program allowed routine training for bedside nurses to emphasize code/RRT issues on an annual basis and underscores the importance of early recognition of patient safety and preventable death. The ART program actually reduced life‐support expenditures and allowed implementation of both our RRT and institutional cardiac arrest resuscitation programs in a cost‐effective manner.

The last point made by Dr. Singh that we wish to address involves the balance between over‐ and under‐utilization of RRT resources. Our RRT‐to‐code ratios are relatively favorable, allowing the program to exist with efficient allocation of resources. This may be due, in part, to the approach to training with regard to recognition of deterioration. Most RRT programs appear to emphasize vital sign thresholds or use of scoring systems for activation, both of which rely upon single sets of vital signs. Instead, we focus on pattern recognition, emphasizing dynamic changes in vital signs and other clinical assessments and de‐emphasizing absolute values. We believe that this helps develop clinical decision‐making skills and improves both sensitivity and specificity with regard to RRT activation. Again, the adaptive nature of the ART program allows annual training to enhance these skills without additional expense to the institution.

We very much appreciate Dr. Singh's comments and urge other institutions to listen to his message carefully. There is no substitute for efforts spent in establishing just culture and creating an institution that supports its staff in addressing patient safety issues, ultimately reducing preventable deaths.

We appreciate very much Dr. Singh's interest and insight regarding our article, A Novel Configuration of a Traditional Rapid Response Team Decreases NonIntensive Care Unit Arrests and Overall Hospital Mortality.[1] Dr. Singh makes several critical points that are worth emphasis and additional commentary.

The importance of cultural change in the success of a rapid response team (RRT) program cannot be emphasized enough. The willingness of frontline staff to access an RRT is based on a belief in the potential benefit to the patient as well as a lack of concern about the repercussions of such an activation, whether these are from the primary physician team or the RRT members themselves. Both of these require institutional commitmentideally from administrative and clinical leadershipas well as routine, direct feedback to providers as to the effectiveness of the program. Both of these have been addressed in our advanced resuscitation training (ART) program, which has replaced traditional life‐support training and consolidates many efforts related to patient safety and preventable death.[2] The ART program represents adaptive training, in which arrest prevention is emphasized for nonintensive care unit staff and the importance of institutional processes such as RRT is emphasized.

Our approach to RRT configuration reflects the resource constraints referenced by Dr. Singh. Although the ideal RRT would include critical‐care nurses located physically outside the intensive care unit to allow regular assessment of at‐risk patients, this would have required expenditures that were not available for the program. In our opinion, a reasonable alternative was to train charge nurses from nonintensive care units as RRT members. The role expectation for these charge nurses included twice‐daily rounds, and their proximity to at‐risk patients facilitated regular reassessments throughout each shift. In addition, the ART program allowed routine training for bedside nurses to emphasize code/RRT issues on an annual basis and underscores the importance of early recognition of patient safety and preventable death. The ART program actually reduced life‐support expenditures and allowed implementation of both our RRT and institutional cardiac arrest resuscitation programs in a cost‐effective manner.

The last point made by Dr. Singh that we wish to address involves the balance between over‐ and under‐utilization of RRT resources. Our RRT‐to‐code ratios are relatively favorable, allowing the program to exist with efficient allocation of resources. This may be due, in part, to the approach to training with regard to recognition of deterioration. Most RRT programs appear to emphasize vital sign thresholds or use of scoring systems for activation, both of which rely upon single sets of vital signs. Instead, we focus on pattern recognition, emphasizing dynamic changes in vital signs and other clinical assessments and de‐emphasizing absolute values. We believe that this helps develop clinical decision‐making skills and improves both sensitivity and specificity with regard to RRT activation. Again, the adaptive nature of the ART program allows annual training to enhance these skills without additional expense to the institution.

We very much appreciate Dr. Singh's comments and urge other institutions to listen to his message carefully. There is no substitute for efforts spent in establishing just culture and creating an institution that supports its staff in addressing patient safety issues, ultimately reducing preventable deaths.

We appreciate very much Dr. Singh's interest and insight regarding our article, A Novel Configuration of a Traditional Rapid Response Team Decreases NonIntensive Care Unit Arrests and Overall Hospital Mortality.[1] Dr. Singh makes several critical points that are worth emphasis and additional commentary.

The importance of cultural change in the success of a rapid response team (RRT) program cannot be emphasized enough. The willingness of frontline staff to access an RRT is based on a belief in the potential benefit to the patient as well as a lack of concern about the repercussions of such an activation, whether these are from the primary physician team or the RRT members themselves. Both of these require institutional commitmentideally from administrative and clinical leadershipas well as routine, direct feedback to providers as to the effectiveness of the program. Both of these have been addressed in our advanced resuscitation training (ART) program, which has replaced traditional life‐support training and consolidates many efforts related to patient safety and preventable death.[2] The ART program represents adaptive training, in which arrest prevention is emphasized for nonintensive care unit staff and the importance of institutional processes such as RRT is emphasized.

Our approach to RRT configuration reflects the resource constraints referenced by Dr. Singh. Although the ideal RRT would include critical‐care nurses located physically outside the intensive care unit to allow regular assessment of at‐risk patients, this would have required expenditures that were not available for the program. In our opinion, a reasonable alternative was to train charge nurses from nonintensive care units as RRT members. The role expectation for these charge nurses included twice‐daily rounds, and their proximity to at‐risk patients facilitated regular reassessments throughout each shift. In addition, the ART program allowed routine training for bedside nurses to emphasize code/RRT issues on an annual basis and underscores the importance of early recognition of patient safety and preventable death. The ART program actually reduced life‐support expenditures and allowed implementation of both our RRT and institutional cardiac arrest resuscitation programs in a cost‐effective manner.

The last point made by Dr. Singh that we wish to address involves the balance between over‐ and under‐utilization of RRT resources. Our RRT‐to‐code ratios are relatively favorable, allowing the program to exist with efficient allocation of resources. This may be due, in part, to the approach to training with regard to recognition of deterioration. Most RRT programs appear to emphasize vital sign thresholds or use of scoring systems for activation, both of which rely upon single sets of vital signs. Instead, we focus on pattern recognition, emphasizing dynamic changes in vital signs and other clinical assessments and de‐emphasizing absolute values. We believe that this helps develop clinical decision‐making skills and improves both sensitivity and specificity with regard to RRT activation. Again, the adaptive nature of the ART program allows annual training to enhance these skills without additional expense to the institution.

We very much appreciate Dr. Singh's comments and urge other institutions to listen to his message carefully. There is no substitute for efforts spent in establishing just culture and creating an institution that supports its staff in addressing patient safety issues, ultimately reducing preventable deaths.