Staff education, 'tough love' key to RRT success
Also, the ability to adapt program over time
The intensive care unit at University Hospitals Health System Richmond Heights (OH) Hospital, has achieved impressive results since its rapid response team went live in late April 2005.
"We have shown huge improvements; we are so, so thrilled," says Sharon Garretson, RN, BSc(Hons), the ICU's nurse manager. For example, the unit has decreased cardiac arrests per 1,000 discharges by 44%. "In year two, which started this May, we began seeing even more of a reduction," notes Garretson.
Mortality rates in the first year were reduced by 14%, and in year two the team again has seen even more of a decrease. "In the year before the rapid response team, our average mortality rate was 2.18%; in the year following, it was about 1.75%, and the early year-two data is around 1.45%," says Garretson.
In addition, she says, one of the biggest indicators used by the Boston-based Institute for Healthcare Improvement (which originated the rapid response team concept in the U.S.) is cardiac arrests that occur outside the ICU.
"You can't truly prevent 100% of cardiac arrests, but if you have one, it should be in the ICU," she notes. "We saw a reduction of 67% in year one."
The success story at Richmond Heights contains within it valuable lessons for facilities that are just beginning to implement rapid response teams. Among them, note Garretson and Mary Beth Rauzi, RN, MSN, manager of learning services, are intensive staff education and a "tough love" approach to staff who are reluctant to adopt the concept. Also critical, they say, are literature research and the ability to adapt along the way.
Set your criteria
It's important, says Rauzi, to establish your call criteria early on. "We did a real thorough search of the literature that was out there on rapid response teams and took what we thought was the best," she explains.
Their first criterion is whether a staff member is worried about the patient. "If they look at a patient and something is not right, even if the numbers may not give you cause for concern, you can call," she says. "You can also call if there is an acute change in heart rate, blood pressure, respiration rate, O2 saturation, level of consciousness, or mental status. You can also call if there has been a change in urine output in the last four hours or if the patient has chest pains."
The "formal" rapid response team includes an ICU nurse, a respiratory therapist, a hospitalist, and a senior medical resident that is in the hospitalist service. "We also stress, however, that the person who calls the team is the final member of the team, because without them the team would not know why they were called," notes Rauzi. "We also include the intern that's on call that day."
Shortly after the program began, the team changed the way calls were handled. "When we first started the program, we had regular pagers; we chose not to provide an overhead call as well, because we didn't want too many people showing up," recalls Garretson. "However, about two months into the program, I was in the ICU and noted that a patient had a change in heart rate; it had become very rapid. I placed a call for the team, went into the room for my assessment, and realized that it was a full four minutes later that my pager went off."
Since then, the team has combined the pager with an overhead call.
Provide 'real' education
Your staff education efforts must be concentrated and focused, Rauzi advises. "You can't just put up a poster and say the program is starting in a week," she observes. "We've talked to enough people across the country to know that that approach has not succeeded."
She conducted an education program that was mandatory for every nurse and the house physician staff — interns and residents. "For the staff nurses on the regular med/surg floor, we had a 30-minute session on what a rapid response team is, how you call, when to call, and what you can expect when you are called," she explains.
There was some opposition from nurses who said they did not need an ICU nurse to come down and tell them they "did not know how take care of patients." "We assured them that this would not happen," says Rauzi. "When we met with the ICU nurses, we stressed that this was a non-punitive process and that if there was a questionable call they should not, for example, roll their eyes. Each call is an opportunity for education and allows that nurse to help the staff nurse improve their assessment skills."
"At first, the ICU nurses were very put off; they wanted to know how many extra staff we were adding to provide this service, and they were very upset when I said 'none,'" says Garretson. "They felt it was too much to handle on top of the patients they already had."
How did she handle this opposition? "We took a two-pronged approach," she says. "The first was tough love. We told them we were doing this because it was the best patient care approach. I did actually say that if you did not want to be a part of this program that was OK, but that I knew of other hospitals that were hiring. But I also said that if we found out in three months that we were having 10 calls a day and they were never on their unit because of that, I promised we would look at staffing."
While some of the doctors were very much on board and served as champions, there was opposition from some of the others. "They were very upset that we would basically invite another physician to get involved with their patient," Garretson explains. "Some even went as far as to write formal orders that the rapid response team could not look at their patients — which we ignored."
She was able to do that because senior leadership on the board had empowered her to do so — another "must" for rapid response team success. "When we ignored those orders, the doctor went to the chief medical officer and was very upset to find that they backed us up," Garretson relates.
"The rapid response teams actually help the physicians," adds Rauzi. "It is the responsibility of the doctor who comes with us on the team to call the patient's physician and let them know the patient is stable. Communication is key."
So is flexibility. "A couple of months into the program, we found that the nursing assistants needed to be educated. They were asking, 'What is this all about?'" recalls Rauzi. "Then we brought in other departments, because the program is not just about nursing. We've empowered any staff at all in our hospital to file a rapid response."
For more information, contact:
Sharon Garretson, RN, BSc(Hons), ICU Nurse Manager, Mary Beth Rauzi, RN, MSN, Manager of Learning Services, Richmond Heights Hospital, Richmond Heights, OH. Phone: (440) 585-6156.
The intensive care unit at University Hospitals Health System Richmond Heights (OH) Hospital, has achieved impressive results since its rapid response team went live in late April 2005.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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