RESEARCH ARTICLES

(Kyle) Kurt Freund, RN, EMT-P

Monday, June 03, 2013
Nursing CCHS 315 Metro Summer 2013
Instructor: Kimberly S. Beistle, PhD, RHD, CDA
Epidemiology and Statistics
Evidence-Based Research Article Interpretation Assignment

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Abstract
This is a summary of two evidence based research articles. The first article reviewed shows
conclusive analysis of the benefit of using specialty trained Rapid Response Teams (RRTs) in
the management of critical crisis amongst decompensating hospitalized adults along with a
comparative study of these teams positive outcome in the pediatric critical population. The other
article compares prone positioning versus supine in patients suffering from Severe Acute
Respiratory Distress (ARDS).

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Evidence-Based Research Article Interpretation

American Journal of Critical Care
DOI: 10.4037/ajcc2013990
Am J Crit Care May 2013 vol.22 no. 3 198-210
Rapid Response Teams: Qualitative Analysis of Their Effectiveness
Linda Searle Leach, RN PhD, NEA-BC, CNL and Ann M. Mayo, RN, DNSc
Basic Identification and Summary of Statistical Information
My personal involvement as a critical care registered nurse (CCRN), working in a
downtown level one trauma center for eight years, created a driven interest in this particular
study. This is a qualitative analysis observational study of 30 cases regarding the use of
specialized teams involving multiple disciplines of specially trained health care professionals and
their role in improving critical crisis outcomes. These Rapid Response Teams (RRTs) are called
in to intervene with life threatening declines in patient presentation. Interdependent tasks are
delegated to members and implemented simultaneously. The grounded-theory method was
utilized in a combined observational and follow up interviewing process of key members of the
RRTs along with patient mortality outcome analysis, (Leach & Mayo, 2013).
The analysis reported mixed findings between adults and children. Rates of
cardiopulmonary arrest in adults were reduced by 33.8% (relative risk, 0.66; 95% CI, 0.54-0.80),
yet the rates were not associated with lower hospital mortality rates (RR, 0.96; 95% CI 0.841.09). The reduction in the rate of cardiopulmonary arrests for children was 37.7% (RR, 0.62;
95% CI, 0.46-0.84) and was associated with a 21.4% reduction in hospital mortality rates (RR,
0.79; 95% CI, 0.63-0.98), (Leach & Mayo, 2013).
The variation in patient conditions along with differing levels of experience and
collaboration of team members was considered. The study outlined the barriers, including
difficulties with team formation, variation in shared understanding of purpose and roles,
communication breakdowns, and power and hierarchy interference with collaboration, (Leach

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& Mayo, 2013). Most RRTs nurses shared a positive appreciation for the increased inclusion of
their input while the interns and residents described this as a potential barrier and disruption,
(Leach & Mayo, 2013). Regardless of the challenge to the traditional role expectations,
experienced RRTs implantation in critical crisis management showed definitive improvement
with both adult and children outcomes.

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Evidence-Based Research Article Interpretation

New England Journal of Medicine
DOI: 10.1056/NEJMoa1214103
This article was published on May 20th, 2013, at NEJM.org
Prone Positioning in Severe Acute Respiratory Distress Syndrome
Claude Guerin, M.D., PH.D., Jean Reignier, M.D., Ph.D., Jean-Christopher Richard, M.D.,
Ph.D., Pascal Beuret, M.D., Arnaud Gacouin, M.D. Alain Mercat, M.D., Ph.D., et al
My interest in this article stems from multiple interactions with Severe Acute Respiratory
Distress Syndrome (ARDS) patients in critical care. An extreme case that comes to mind is an
18 year old, otherwise healthy male athlete, who presented in full ARDS exacerbated by
necrotizing fasciitis and flash pulmonary edema. After multiple failed attempts to adequately
ventilate the respiratory decompensating patient; six of my colleagues, including myself, flipped
the patient into a prone (face down) position while suspending him over the bed with our
extended arms until an appropriate bed was obtained. In this position the uncompromised lung
tissue had more exposure to adequate air/gas exchange while allowing the massive fluid buildup
an escape from the thoracic cavity. 45 minutes later, with our arms heavy from holding up the
linebackers mass, the bed arrived and an appropriate prone position was available without the
previous exhausting efforts to perfuse the patients vital organs. The patient survived with no
cerebral injury; however, lifelong pulmonary compromise leading to limited physical capacity
was paramount.
Basic Identification and Summary of Statistical Information
This is a prospective, randomized, controlled trail (Guerin, et al., 2013), of patients
with severe ARDS and the difference in mortality of those placed in prone or supine positions
while on ventilator support. The patient base for this study was derived from 51,189 admissions
into 27 Intensive Care Units (ICU) from a study period of January 1st, 2008 through July 25th,
2011. 3449 had ARDS. 1434 were screened. 576 met eligibility requirements. 474 were
randomized which placed 234 into the supine position group and 240 into the prone positioned

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group, (Guerin, et al., 2013). It was estimated that the study would have 90% power to detect
an absolute reduction of 15 percentage points (to 45%) with prone positioning, at a one-sided
type I error rate of 5%, (Guerin, et al., 2013). The mean duration per prone position session was
17+/- 3 hours with an average of 4 sessions per patient. The main cause of ARDS was
pneumonia. Lung injury score in both groups was 3.3+/- 0.4.
This study has conflicting results with previous similar studies researching prone versus
supine positioning. One has to consider the funding of this study and a correlation with the
PROSEVA financial support from a manufacturer of the specialty beds that allow safe prone
positioning of ventilator dependent patients. The cost of these specialty beds is so exuberant
that most hospitals, including Spectrum Health Grand Rapids Michigan, rent them on a per
patient bases.
The conclusion of this analysis is that the mortality rate, after adjustments for use of
vasopressors (Levophed) and the SOFA score, was significantly lower in the prone group 16.0%
(38 of 237) in comparison to the supine groups mortality rate of 32.8% (75 of 229), (Guerin, et
al., 2013). The rate of cardiopulmonary arrests in the supine group that did not result in death
were also double that of the prone group (31 vs. 16). Stratified analysis considering PaO2
(partial pressure of arterial oxygen) and FiO2 (fraction of inspired oxygen) found no significant
variation in outcomes.
Prone positioning, as compared with supine positioning, markedly reduces the
overinflated lung areas while promoting alveolar recruitment. These affects (reduction in over
distention and recruitment enhancement) may help prevent ventilator-induced lung injury by
homogenizing the distribution of stress and strain within the lungs, (Guerin, et al., 2013). When
initiated within an hour of the onset of ARDS, according to this study, a higher survival rate and
less time of ventilator dependency is obtained when the patient is placed in a prone positioning
protocol.

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References
Guerin, C., Reignier, J., Jean-Christopher, R., Beuret, P., Gacouin, A., & al, e. (2013,
May 20). Prone Positioning in Severe Acute Respiratory Distress Syndrome.
New England Journal of Medicine. doi:10.1056/NEJMoa1214103
Leach, L. S., & Mayo, A. M. (2013, May). Rapid Response Teams: Qualitative Analysis
of Their Effectivness. American Journal of Critical Care, 22(3), 198-210.
doi:10.4037/ajcc2013990