'Clinical triggers' program cuts cardio arrest rate
QM finds alternative to rapid response team
Rapid response teams, in the classic sense, may not be the best option for all hospitals, as a recent article in The Joint Commission Journal on Quality and Patient Safety1 clearly shows. A "clinical triggers" program at the Denver Health Medical Center (DHMC), which did not involve the creation of a separate team to handle typical "RRT" situations, was able to reduce the cardiopulmonary arrest rate by 39% and significantly decreased the number of ICU "bouncebacks" within 48 hours or transfer from the ICU, from 4.62 to 3.27 per 100 ICU transfers.
"Before we started down the road of rapid response process, we were looking at some of our outcomes and in-depth case reviews, and four things jumped out at us: failure to recognize clinical deterioration; failure to communicate and escalate concerns; failure to physically assess the patient; and failure to diagnose and treat appropriately," recalls Kendra Moldenhauer, RN, BSN, director of patient safety, quality, and regulatory compliance, and lead author of the article. "As we looked at the situation and read more about rapid response teams, we thought that for us it might be more important to do some education with nurses and residents, and set up a process as opposed to a team, because we do have the necessary resources in our organization."
Departing from the model
In what ways, then, did the DHMC model differ from a more familiar RRT model? "The use of clinical triggers is similar, and having someone at the bed is the same, but not having a separate team — that's the core difference," says Moldenhauer. "The other thing we accomplished is not having to hand off to people who may not have any familiarity with the patient and their condition."
In addition, she says, "we felt we had a real opportunity to sharpen the nurses' clinical skills using this other process."
This was accomplished through two main initiatives, Moldenhauer continues."One was by developing the clinical triggers and getting them out there," she says. Dr. Phil Mehler, chief medical officer "and I spent a lot of time going to staff meetings, nurse educator meetings, and so forth, talking about the clinical triggers and how to make nurses aware of them, and we also made sure new nurses were educated."
The other initiative, she says, was a project using Lean methodology. "We did a rapid improvement event around nursing recognition of clinical deterioration," Moldenhauer explains. "We conducted education sessions with techs and CNAs [certified nursing assistants], and developed laminated prompts for those folks that were at the same location as the flow sheets, so they would have a list of the values that required notification."
In addition, she says, "we did lots of auditing." Not only did her team look at all the rapid response calls, but each nurse audited records on his or her floor to make sure that if there was a change in condition a physician was notified. "They were given immediate feedback," Moldenhauer adds.
One of the key messages of the entire program was "vitals are vital," and this was communicated on an ongoing basis through staff meetings, utilized by physicians in resident training and at different outcomes conferences and during "M&Ms," — "where the attendings were sure they made residents aware of that message," says Moldenhauer.
Promoting empowerment
In the article, the authors also emphasized the importance of empowering the nurses to communicate their concerns. "This was initially done by developing the [clinical triggers] form and the process for them to escalate, and telling nurses that they had to act on these clinical triggers," says Moldenhauer. "Then, you need to call someone to get help using SBAR [Situation-Background-Assessment-Recommendation] communications, and if you do not get help you are not only empowered, but required to escalate to the next level of care."
The physicians, she says, have responded very favorably, and now better relationships are developing, and feedback is positive.
As for the project's success, Moldenhauer also credits the involvement of leadership. "Having Dr. Mehler involved in the project and helping to drive this, as well as having support from directors of service from get-go was very important." she says.
Moldenhauer is not prepared to say her facility's approach is superior to an RRT approach. "I think that it's better for ourfacility," she explains. "Some people have been very successful using rapid response teams; what works for you and improves outcomes is the way to go."
She reiterates that teaching facilities have the resources necessary for her model. "Because we are a level I trauma center, we have a surgical attending in-house and anesthesia here all the time, as well as critical care attendings and hospitalists," she points out. "In a community hospital, you probably could not do this."
Moldenhauer says she remains open-minded, and is willing to change the process if need be. "But it does improve communications, it sharpens nursing skills, and has improved outcomes without adding one more handoff."
Reference
- Moldenhauer K, Sabel A, Chu ES, Mehler PS. Clinical triggers: an alternative to a rapid response team. Jt. Comm J Qual Patient Saf, 2009;35:164-174.
[For additional information, contact:
Kendra Moldenhauer, RN, BSN, Director of Patient Safety, Quality, and Regulatory Compliance, Denver Health Medical Center, Denver, CO. Phone: (303) 436-5698. E-mail: [email protected].]
Rapid response teams, in the classic sense, may not be the best option for all hospitals, as a recent article in The Joint Commission Journal on Quality and Patient Safety clearly shows.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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