Rapid Response Teams

1. Rapid Response Teams New Jersey Council of Teaching Hospitals April 19, 2005 Terri Simmonds, RN Michael Leonard, MD

2. The Rapid Response Teama.k.a Medical Emergency Team • … is a team of clinicians who bring critical care expertise to the bedside (or wherever it’s needed). • Goal • Prevent deaths in patients who are failing outside intensive care settings by implementing rapid response teams (RRTs).

3. Why Rapid Response Teams? • People die unnecessarily every single day in our hospitals.

4. Mortality Diagnostic – 2 x 2 matrix ICU Admission ? Yes No Yes Box #1 Box #2 Comfort Care Only? No Box #3 Box #4

5. US 2X2 Table Aggregate64 Hospitals – updated October 2004

6. Three fundamental problems • Failures in planning • includes assessments, treatments, goals • Failure to communicate • patient to staff, staff to staff, staff to physician, etc. • Failure to recognize • These three problems often lead to failure to rescue

7. Clinical Instability Prior to Arrest • 70% (45/64) arrests with evidence of respiratory/neurologic deterioration with 8 hours (Schein, Chest 1990; 98: 1388-92) • 66% (99/150) abnormal signs and symptoms within 6 hours of arrest and MD notified 25% of cases (25/99)(Franklin, Crit Care Med;1994;22: 224-247)

8. Clinical Instability Prior to Arrest • Warning signs within 6 hours of event: • MAP < 70 or > 130 mmHg. • Heart rate < 45 or >125 per minute • Respiratory rate < 10 or >30 per min • Chest pain • Altered mental status • Franklin and Mathew; Crit Care Med;1994;22: 224-247.

9. What difference can an RRT make? MJA 2003; 179-7

10. What difference can an RRT make? • 50% reduction in non-ICU arrests (Buist, BMJ 02) • Reduced post-operative emergency ICU transfers (44%) and deaths (37%) (Bellomo, CCM 04) • Reduction in arrest prior to ICU transfer (4 % v 30 %) (Goldhill, Anest 99) Rothschild, 2004

11. Hospital Codes per 1000 Discharges (u-chart) UCL Average Codes per 1000 Discharges 23% decrease Medical Response Team (MRT) implemented August 2003 LCL (u-chart)

12. Hospital Codes Outside the ICU Number of Codes 44 % decrease Medical Response Team (MRT) implemented August 2003

13. Percent of Coded Patients Surviving at Discharge (p-chart) UCL Medical Response Team (MRT) implemented August 2003 Average Percent 48 % increase LCL

14. Codes per 1000 Discharges

15. What is the Role of the Team? • Assess • Stabilize • Assist with communication • Educate and support • Assist with transfer, if necessary

16. Rapid Response Team Considerations • Engage senior leadership support • Determine the best structure for the team • Provide education and training • Establish criteria and mechanism for calling • Establish structured documentation tool • Establish feedback mechanisms • Measure effectiveness

17. Engage Leadership Support • Executive and physician • Clear and wide communication strategy

18. Determine the Team Structure • Considerations • Available • Accessible • Able • Multiple Models • ICU RN and Respiratory Therapist • ICU RN, RT, Intensivist, Resident • ICU RN, RT, Intensivist or Hospitalist • ICU RN, RT, Physician Assistant

19. Provide Education and Training • Medical Staff • General information • Benefits • Myths

20. Provide Education and Training • RRT • ACLS or advanced critical care training • SBAR • Communication skills • Appropriate expectations • Importance of responding in a timely manner • Importance of providing non-judgmental, non-punitive feedback to call initiator

21. Provide Education and Training • Nursing Staff • Criteria for calling • Notification process • Communication and teamwork skills • SBAR, Assertiveness / Critical Language • Appropriate expectations • Importance of calling even when unsure • Non-judgmental, non-punitive nature of the RRT • Have information available for RRT (chart, medication administration record, etc.) • Role as a member of the team

22. Establish Criteria for CallingFor Example…. • Staff member is worried about the patient • Acute change in heart rate <40 or >130 bpm • Acute change in systolic BP <90 mmHg • Acute change in RR <8 or >28 per min or threatened airway • Acute change in saturation <90% despite O2 • Acute change in conscious state • Acute change in UO to <50 ml in 4 hours

23. Establish Mechanism for Calling • Beeper with or without overhead page • Encourage staff to dial from the patient’s room number, enter in the room # • If not in a patient room, dial in the extension for the RRT Team to call back for a location

24. Communication and Documentation • Embed SBAR • Record the interventions and reasons for call • Use data to drive educational programs

25. Feedback Mechanisms • Feedback information on patient outcome • Look for lessons learned hospital wide • Use data to drive educational programs • Share the success stories

26. Measure Effectiveness • Key measures • Mortality • Codes per 1000 discharges • Codes outside the ICU • Number of rapid response team calls • Other possible metrics • Transfers to higher level of care (ICU or other) • Average ICU LOS for post RRT ICU transfers vs med/surg ICU admissions • Satisfaction with the RRT process • Post cardiac arrest ICU bed utilization • Safety culture survey data

27. Possible Benefits of the Rapid Response Team • Better outcomes • Improved relationships • Improved satisfaction • Nursing • Physician • Patient • Impact on nursing retention • Financial benefits

28. Important things to keep in mind • Be tolerant of “false alarms”. Praise and NEVER criticize for calling • Communicate, communicate, communicate! Get the word out – initially and continuously • Share the RRT stories with medical and nursing staff • Maintain continuous awareness and reinforcement of RRT through hospital publications, newsletters, etc. Keep it alive!