Have you implemented a rapid response team?
Lower mortality rates, fewer in-house codes
How do you think quick access to a team of clinicians with critical care expertise for patients in crisis would affect your hospital’s mortality rates? The Cambridge, MA-based Institute for Healthcare Improvement (IHI) recommends that organizations create rapid response teams (RRTs) to bring immediate help to the patient’s bedside or wherever it is needed.
More than 1,800 hospitals have signed up for the IHI’s 100,000 Lives campaign, with participating hospitals implementing specific care interventions to prevent avoidable deaths, including forming RRTs, with the goal of saving 100,000 lives between now and July 2006 and every year thereafter.
"According to the literature, benefits of RRTs may include a reduced incidence of in-hospital cardiac arrests, decreased bed utilization following cardiac arrest, and lower overall in-hospital mortality," says Terri Simmonds, RN, principal of Safe and Reliable Health Care and director of the IHI.
"We have found that when you provide nursing staff a reliable and efficient mechanism for bringing immediate resources to the bedside, the nurses are more likely to call for help in a crisis," says Michael DeVita, MD, associate professor of critical care medicine at University of Pittsburgh (PA) Medical Center. "Their sense of empowerment and safety increases."
Their ability to care for other patients in the unit also improves because resources are brought to the bedside to avoid "domino code" syndrome, with everyone caring for one patient and neglecting others, he adds.
"We have changed the culture at the bedside. People are trying to prevent crisis instead of preventing death," DeVita explains. "Most of our nurses now could not imagine working in a system that does not have this." By analyzing the event leading up to a crisis, you can generate extremely precise quality improvement data.
"When you look at a crisis, you are able to track the type of errors that are particularly dangerous, so you can target those," he says.
You also can target particularly dangerous combinations of events, such as use of patient-controlled analgesia (PCA) and sleep apnea. "We have found that patients who have a risk for sleep apnea have an extremely high risk for respiratory events," DeVita adds. "So we can target interventions for particular subpopulations of patients and treatments. You can’t do that with a normal error system. We have found a whole series of problems that are not errors in the normal sense of the word, but are things you want to avoid to prevent a crisis from occurring."
After a problem is identified, that problem then can be classified as an error, he explains. "It’s not an error today to have a patient with a history of sleep apnea on a PCA without monitoring, but in three years it will be," he says. "Four years ago, treating low glucose with a glass of orange juice was not considered an error, but today it is, because we’ve established a norm."
After the RRT had responded to several incidents of hypoglycemia, it was discovered that low blood sugar was being treated inconsistently. "We put together a task force to work on the problem and developed a hypoglycemia protocol so that every person gets treated the same way," DeVita notes. "Our rate of crises has gone way down."
One-third of events are not preventable, one-third have an error linked with them, and one-third have no errors linked to them but clearly are preventable, he says. "We don’t use the term error at all — instead we say process inefficiency’ or process issue,’ to capture both the mistakes and the preventable processes," he explains. "Our credo is to not only prevent this patient from dying but get clues to prevent the next 10 patients from dying."
The process doesn’t replace traditional quality improvement efforts, DeVita says. "But this is another way of finding areas of concern, and helps focus effort on high-risk areas," he says.
Quality professionals already have the skills to troubleshoot problems, such as doing a root-cause analysis and investigating and correcting errors, DeVita says. "But they will have to gain the ability to deal with a new data source," he says. "The RRT patient analysis is more fruitful data collection because it’s more focused. I don’t see it replacing current process improvement strategies — but it will become an important adjunct to them."
All five hospitals in the Mercy Health Partners network in southwest Ohio, are participating in the IHI’s campaign. "We have charged the associate medical directors at each hospital to be accountable for the implementation of these protocols and processes," says Robert Strub, MD, the organization’s interim chief medical officer. "We have given them the freedom to do this the best way for their facility, since you can’t make a cookie-cutter implementation — it varies according to the different cultures and service lines."
The goal is to decrease morbidity and mortality rates for each of the hospitals, improve overall quality of care, shorten length of stay by preventing complications and catastrophic events, and provide more cost-effective care, he says. "Sick people with complications consume a significant amount of health care resources and dollars," he adds.
When implementing an RRT at your organization, consider the following:
• Determine the best structure for the team.
One potential challenge is the allocation or reallocation of resources to staff the RRT, adds Simmonds. "Many organizations are using critical care and respiratory therapy charge persons, who are functioning in an administrative role during a given shift, to staff the RRT," she says. "These individuals may be free of direct patient care responsibilities and thus able to leave the unit to respond to a RRT call."
The University of Pittsburgh now has six different types of specialty RRTs, DeVita says: a medical emergency team that responds to any crisis, a stroke team, a chest pain team, a trauma team, and a blood administration team.
"If you’ve got a hospital that has open-heart surgery and a high-risk newborn nursery, you will need a different mix of professionals than a general med/surg hospital," Strub says. The basic RRT team consists of an intensive care unit (ICU) nurse, respiratory therapist, and an intensivist or hospitalist. "That is your basic team, although you can have an ICU nurse and respiratory therapist as the initial response for a smaller hospital, and then they would call the next level of specialized care as needed, such as an IV team or anesthesia," he says.
• Establish criteria for when the team is called.
"This is a challenge we have faced and will vary by the service line," Strub says. "Each facility needs to ensure that all employees know when it is appropriate to summon the team. Waiting too long to call is just as dangerous as calling too often when it is unnecessary."
IHI suggests using criteria such as a staff member being worried about a patient, or acute change in heart rate, systolic blood pressure, respiratory rate, oxygen saturation, conscious state, or urinary output.
• Provide education and training.
"The team needs to know what they are supposed to do, how they are supposed to do it, and what to do differently," Strub says. "This requires a whole re-education of staff to a degree, with a never-ending training and retraining process."
The goal is for the procedures to be hardwired in staff, he adds "This is what happens every time, and it is not something you have to think about. It’s just done. It should take only five minutes from the time somebody is notified to mobilize the team and hopefully less."
• Create a data collection tool.
The quality manager needs to be involved upfront in creating an appropriate data collection tool to document the time of the event, demographics, what happened that resulted in the call to the RRT, and what interventions were needed, Strub explains.
He recommends using the sample documentation forms posted on the IHI web site as templates and customizing these for your own organization. He suggests having the data recorded by a floor nurse, since the team caring for the patient also can’t be documenting.
"Examining the medical records of patients who’ve suffered cardiac arrests for evidence of clinical deterioration in the hours prior to the arrest may help organizations demonstrate the need for the RRT," says Simmonds. "Once the RRT has been implemented, data should be collected on the incidence and location of in-hospital codes, hospital mortality, and utilization of the rapid response team."
• Measure effectiveness.
To evaluate the impact of your RRT, the IHI recommends using these key measures: Codes per 1,000 discharges, codes outside the ICU, and utilization of the RRT. Other possible measures are post-cardiac arrests, ICU bed utilization, and percent of coded patients surviving at discharge.
"You need these data to evaluate how the patient came to need this care," Strub says. "The ultimate goal is to analyze it and come up with ideas as to how this could have been prevented in other patients. If postpartum patients are having problems with hemorrhaging, what are we doing to decrease risk for patients with a bleeding problem?" After the data are collected with an initial assessment, they should be presented to a quality and safety committee, with both good and bad outcomes discussed. "We will be looking to improve the measurable data that we’re getting now and moving that number in the right direction. This is a part of how we will improve our core measure data," he adds.
After policies are put into place, fewer patients should be transferred to the ICU from the floor, and the number of full-blown codes in the hospital should decrease, but this will vary according to your hospital’s volumes, Strub says. "If you have one less code, that may be a 10% drop for some hospitals, so you may have to look over a longer period of time. The stuff you see on ER should be the exception and not the rule. We will hopefully look at resuscitations on the floor as a thing of the past."
[For more information, contact:
- Michael DeVita, MD, Associate Medical Director, University of Pittsburgh Medical Center Presbyterian Hospital, C-111, 200 Lothrop St., Pittsburgh, PA 15213. Phone: (412) 647-1705. E-mail: [email protected].
- Terri C. Simmonds, RN, Safe and Reliable Health Care, Sudbury, MA 01776. Phone/Fax: (978) 443-6214. E-mail: [email protected].
- Robert Strub, MD, Interim Chief Medical Officer, Mercy Health Partners, 4600 McAuley Place, Cincinnati, OH 45242. Phone: (513) 551-1427. E-mail: [email protected].
- For more information on rapid response teams, go to the IHI’s web site at www.ihi.org. Click on "100,000 Lives Campaign," "Rapid Response Teams."]
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