Rapid Response Systems Teams Overview and Key Design Features Michael Leonard, MD Terri Simmonds, RN April 5, 2006

1. Rapid Response Systems (Teams)Overview and  Key Design FeaturesMichael Leonard, MDTerri Simmonds, RNApril 5, 2006 New Jersey Hospital Association

2. Two Components of Rapid Response System Ability to identify and respond to clinical deterioration 1. System to identify change in patient risk - patient at risk score, EWS, MEWS, etc. 2. System to respond - Rapid Response Team (RRT) or Medical Emergency Team (MET)

3. Rapid Response Team A Rapid Response Team (RRT, MET) is a group of healthcare professionals who respond quickly to threatened clinical deterioration bringing critical care skills to the patient�s bedside. Goal Prevent deaths in patients who are failing outside intensive care settings

4. ? Incidence of cardiac arrests ? Arrests on floor as ? # of RRT calls ? Overall mortality Improve �critical thinking�

5. Mortality Reduction Framework The purpose of the diagnostics is to get a clearer understanding of local conditions that contribute to mortality. These cases are often seen when retrospectively reviewing inpatient hospital deaths using a simple diagnostic tool called a �2 by 2 matrix, or �3 by 2 matrix� for our colleagues in the United Kingdom. This diagnostic consists of analyzing 50 consecutive deaths and placing them into one of the four boxes in the �2 by 2 matrix�. This is done by asking the following questions: Was the patient hospitalized for comfort care? Was the patient initially placed into an Intensive care unit? If the answer is yes to both questions, this is box1. If the answer is no to the ICU but yes for comfort care, this is box 2. If the answer is yes to ICU but no to comfort care, this is box 3. If the answer is no to both, then this is box 4. Box 4 should be further analyzed by asking if there was any evidence of communication failures, planning failures, or failure to recognize a deteriorating patient condition which often leads to situations of failure to rescue. Finally deaths in box 3 and 4 should be reviewed using the Global Trigger Tool looking for any evidence of adverse events. Ask these questions about the patient based on �initial presentation� to the hospital. We understand that patient condition may change during the hospitalization but for purposes of learning from the 2 xx 2The purpose of the diagnostics is to get a clearer understanding of local conditions that contribute to mortality. These cases are often seen when retrospectively reviewing inpatient hospital deaths using a simple diagnostic tool called a �2 by 2 matrix, or �3 by 2 matrix� for our colleagues in the United Kingdom. This diagnostic consists of analyzing 50 consecutive deaths and placing them into one of the four boxes in the �2 by 2 matrix�. This is done by asking the following questions: Was the patient hospitalized for comfort care? Was the patient initially placed into an Intensive care unit? If the answer is yes to both questions, this is box1. If the answer is no to the ICU but yes for comfort care, this is box 2. If the answer is yes to ICU but no to comfort care, this is box 3. If the answer is no to both, then this is box 4. Box 4 should be further analyzed by asking if there was any evidence of communication failures, planning failures, or failure to recognize a deteriorating patient condition which often leads to situations of failure to rescue. Finally deaths in box 3 and 4 should be reviewed using the Global Trigger Tool looking for any evidence of adverse events. Ask these questions about the patient based on �initial presentation� to the hospital. We understand that patient condition may change during the hospitalization but for purposes of learning from the 2 xx 2

6. US 2X2 Table Aggregate111 Hospitals � June 1, 2005

7. 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 There is a large amount of variability in healthcare today. Numerous articles have shown that this variability exists across both quality and safety. Fairly recent work by Dr Brian Jarman indicates that this variability exists in hospital mortality rates. Even when multiple risk factors and community factors are considered there is no clear explanation for differences from hospital to hospital. And yet, a An opportunity exists to close the gap on this variability by improving hospital care. During the past 18 months work has been carried out to understand the causes of the problem and work on potential improvement strategies. The conclusions from this work and a review of the literature are that there are 3 main systemic issues: failures in planning, failure to communicate, and failure to recognize deteriorating patient condition. These fundamental problems can often lead to a failure to rescue. There is a large amount of variability in healthcare today. Numerous articles have shown that this variability exists across both quality and safety. Fairly recent work by Dr Brian Jarman indicates that this variability exists in hospital mortality rates. Even when multiple risk factors and community factors are considered there is no clear explanation for differences from hospital to hospital. And yet, a An opportunity exists to close the gap on this variability by improving hospital care. During the past 18 months work has been carried out to understand the causes of the problem and work on potential improvement strategies. The conclusions from this work and a review of the literature are that there are 3 main systemic issues: failures in planning, failure to communicate, and failure to recognize deteriorating patient condition. These fundamental problems can often lead to a failure to rescue.

8. Literature: Clinical Instability Prior to Arrest 70% (45/64) arrests with evidence of respiratory/neurological 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) Several studies indicate that patients often exhibit signs and symptoms of physiological instability for some period of time prior to a cardiac arrest. (Insert annotations from bibliography here)Several studies indicate that patients often exhibit signs and symptoms of physiological instability for some period of time prior to a cardiac arrest. (Insert annotations from bibliography here)

9. Franklin�s article identified several warning signs present within 6 hours of arrest. These warning signs are shown here.Franklin�s article identified several warning signs present within 6 hours of arrest. These warning signs are shown here.

10. Before and After Trial of a Medical Emergency Team

11. Other Studies 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) Insert annotation from bibliography here.Insert annotation from bibliography here.

12. MET Retrospective analysis of 6 years of data with 1,220 cardiopulmonary arrests, 3,269 team calls Team used for 4 years for ICU transfers and serves as baseline before criteria for calls and expanded role initiated Cardiac arrest rate decreased by 17% from 6.5/1,000 admissions to 5.4/1,000 admissions Team usage 13.7/1,000 to 25.8/1,000

13. Single Australian Hospital: 5-Year Experience

14. MERIT Study Cluster-randomized controlled trial 23 hospitals 12 introduced MET � 11 did not 2-month baseline collection 4-month MET implementation 6-month follow up data collection

15. MERIT Study (continued)

16. Was this a negative study?

17. What have we learned? Successful implementation of RRT is a complex process and a cultural journey. (relationships) 1320 Campaign organizations committed to RRT Key intervention in IHI Mortality Community

18. Codes per 1000 Discharges426 bed Teaching Hospital (U.S.) 

19. Codes per 1000 Discharges489 bed Community Hospital (U.S.) Another organization, a smaller community non teaching hospital with an average daily census of approximately 225 patients have seen similar results in their overall reduction in codes per 1000 discharges.Another organization, a smaller community non teaching hospital with an average daily census of approximately 225 patients have seen similar results in their overall reduction in codes per 1000 discharges.

20. Key Design Features 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 Prior to testing and implementation of a rapid response team, organizations may wish to: Engage senior leadership (executive and physician) Determine team structure Provide education and training Establish criteria and procedures for calling Establish a structured documentation tool Feedback mechanisms Establish measures of effectivenessPrior to testing and implementation of a rapid response team, organizations may wish to: Engage senior leadership (executive and physician) Determine team structure Provide education and training Establish criteria and procedures for calling Establish a structured documentation tool Feedback mechanisms Establish measures of effectiveness

21. Engage Leadership Support Executive and physician Identify physician champion Establish ownership of the process Remove barriers Clear and wide communication strategy Engage senior leadership (Executive and physician) support and �buy in�, i.e. �we are going to do this; this is important and the right thing to do for our patients.� Organizations must make a commitment to establishing the RRT. Educate the medical staff about the benefits of RRT and dissuade the myths Benefits Fast and accurate critical patient assessment 24 x 7 Clear and concise communication using SBAR Link to lower mortality Myths RRT is not intended to take the place of immediate consultation with the physician if needed. After consultation with the RRT, a call is placed to the appropriate physician. The intention is to help patients in the time window of clinical instability and not to replace physician involvement in that process. Craft a very clear and widely disseminated communication message from senior leadershipEngage senior leadership (Executive and physician) support and �buy in�, i.e. �we are going to do this; this is important and the right thing to do for our patients.� Organizations must make a commitment to establishing the RRT. Educate the medical staff about the benefits of RRT and dissuade the myths Benefits Fast and accurate critical patient assessment 24 x 7 Clear and concise communication using SBAR Link to lower mortality Myths RRT is not intended to take the place of immediate consultation with the physician if needed. After consultation with the RRT, a call is placed to the appropriate physician. The intention is to help patients in the time window of clinical instability and not to replace physician involvement in that process. Craft a very clear and widely disseminated communication message from senior leadership

22. Determine Team Structure Multiple Models Most common: ICU RN and Respiratory Therapist Other models: ICU RN, RT, Intensivist, Resident ICU RN, RT, Intensivist or Hospitalist ICU RN, RT, Physician Assistant Nursing Supervisor with CC experience, RT Key Considerations Appropriate technical, �people� and educational skills Important to customize to fit local culture First, determine the best structure for the rapid response team. Our experience shows multiple models work well, including those listed here. In every model there are 3 key features of the team members: The team members must be available to respond immediately when called, and not be constrained by competing responsibilities. They must be onsite and accessible. They must have the critical care skills necessary to assess and respond . Organizations should examine their current resources and culture when choosing the rapid response team members and build on existing relationships and practice patterns, i.e. hospitalists program, less than 24 x 7 intensivist coverage, etc. Staff must feel comfortable calling the rapid response team. Care should be taken when choosing team members in order to maximize their capabilities as educators and responders. Select each member (physician, RN, RT) of the RRT team carefully. The physician team member should be one that is respected by both nurses and physicians and perceived as a good communicator and team player. Organizations are able to muster resources when patients progress to a cardiac arrest�. We must be able to find resources to prevent such cardiac arrests from occurring in the first place. First, determine the best structure for the rapid response team. Our experience shows multiple models work well, including those listed here. In every model there are 3 key features of the team members: The team members must be available to respond immediately when called, and not be constrained by competing responsibilities. They must be onsite and accessible. They must have the critical care skills necessary to assess and respond . Organizations should examine their current resources and culture when choosing the rapid response team members and build on existing relationships and practice patterns, i.e. hospitalists program, less than 24 x 7 intensivist coverage, etc. Staff must feel comfortable calling the rapid response team. Care should be taken when choosing team members in order to maximize their capabilities as educators and responders. Select each member (physician, RN, RT) of the RRT team carefully. The physician team member should be one that is respected by both nurses and physicians and perceived as a good communicator and team player. Organizations are able to muster resources when patients progress to a cardiac arrest�. We must be able to find resources to prevent such cardiac arrests from occurring in the first place.

23. Table Discussion Are your codes outside the ICU diminishing? Are you seeing results? If not, why not? What is the current monthly utilization of your RRT (10/100 ADC) ? How are you looking at the calls that are occurring? What do you know about the RRT/MET calls?� When were they deployed? What is your biggest barrier and major success?

24. Provide Education and Training Medical Staff RRT Members Nursing Staff Three major groups that will need education and training: Medical Staff Rapid Response Team Members General Nursing Staff Now you may want to educate patients and families of the RRT at some point but let�s just start with these 3. Provide the medical staff with general information about the RRT � structure, etc. � department meetings, grand rounds, etc. Educate the medical staff about the benefits of RRT and dispel the myths Benefits Fast and accurate critical patient assessment 24 x 7 Clear and concise communication using SBAR Link to lower mortality Myths RRT is not intended to take the place of immediate consultation with the physician if needed. After consultation with the RRT, a call is placed to the appropriate physician. The intention is to help patients in the time window of clinical instability and not to replace physician involvement in that process. Three major groups that will need education and training: Medical Staff Rapid Response Team Members General Nursing Staff Now you may want to educate patients and families of the RRT at some point but let�s just start with these 3. Provide the medical staff with general information about the RRT � structure, etc. � department meetings, grand rounds, etc. Educate the medical staff about the benefits of RRT and dispel the myths Benefits Fast and accurate critical patient assessment 24 x 7 Clear and concise communication using SBAR Link to lower mortality Myths RRT is not intended to take the place of immediate consultation with the physician if needed. After consultation with the RRT, a call is placed to the appropriate physician. The intention is to help patients in the time window of clinical instability and not to replace physician involvement in that process.

25. Provide Education and Training Medical Staff General information Benefits and myths Benefits Fast, accurate patient assessment and response 24 x 7 Myths Lack of involvement in their patients care

26. Provide Education and Training RRT Members ACLS or advanced critical care training SBAR and communication skills Appropriate expectations Their role as educators Importance of responding in a timely manner Importance of providing non-judgmental, non-punitive feedback Use of pre-approved protocols, if applicable The RRT should receive education and training together that includes If team members do not have ACLS or advanced critical care training already. Most ICU RNs and RT�s will likely have training already. SBAR � teams should use this as their established method of communicating and receiving communications Communication skills including responding in a professional and �friendly manner� Set Appropriate Expectations � responding in a timely manner every time they are called � within 5 minutes appears to be a goal set by several organizations. Set expectations that the team will provide non- judgmental, non-punitive feedback to the person that initiated the call to the RRT. The RRT may or may not have medical staff approved protocols under which they can function while on the call. The RRT should receive education and training together that includes If team members do not have ACLS or advanced critical care training already. Most ICU RNs and RT�s will likely have training already. SBAR � teams should use this as their established method of communicating and receiving communications Communication skills including responding in a professional and �friendly manner� Set Appropriate Expectations � responding in a timely manner every time they are called � within 5 minutes appears to be a goal set by several organizations. Set expectations that the team will provide non- judgmental, non-punitive feedback to the person that initiated the call to the RRT. The RRT may or may not have medical staff approved protocols under which they can function while on the call.

27. Provide Education and Training Nursing Staff Criteria for calling Notification process Communication and teamwork skills SBAR, assertiveness, use of critical language Appropriate expectations Importance of calling even when unsure Non-judgmental, non-punitive nature of the RRT Roles and responsibilities as a member of the team Have information available for RRT (chart, medication administration record, etc.) Nursing staff should receive education and training on Criteria and procedures for calling, how to notify the team. Communication and teamwork skills � use of SBAR, appropriate assertion and critical language skills Appropriate expectations � call even if you�re unsure. �It�s better to call than not�. Some organizations have set the expectation that nurses �will call when any criteria are met� � and not calling may have repercussions. The team that responds will do so in a non-judgmental, non-punitive way. Have information available for the team such as the chart, MAR, previous assessments, etc. The person who calls the RRT should become a key member of the team and assist the RRT. The RRT is not there to take over and assume care of the patient.Nursing staff should receive education and training on Criteria and procedures for calling, how to notify the team. Communication and teamwork skills � use of SBAR, appropriate assertion and critical language skills Appropriate expectations � call even if you�re unsure. �It�s better to call than not�. Some organizations have set the expectation that nurses �will call when any criteria are met� � and not calling may have repercussions. The team that responds will do so in a non-judgmental, non-punitive way. Have information available for the team such as the chart, MAR, previous assessments, etc. The person who calls the RRT should become a key member of the team and assist the RRT. The RRT is not there to take over and assume care of the patient.

28. Establish Criteria for Calling 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 (<50 ml in 4 hours) *Pediatric population requires different criteria Call every time criteria are met or at the discretion of the clinician? Each organization should determine which criteria will be used and educate the staff. Several organizations are using criteria similar to those listed here for use in their adult population. We�ve provided you with an example of adult criteria in the There are at least two different approaches to the use of criteria. The first is to educate staff to the criteria and to encourage them to call when any are met or when they are worried about the patient, even though the patient may not meet any criteria. Another approach is to mandate the staff to call when any criteria are met, thereby setting a different expectation. Tip: Ultimately, be sure to educate all hospital employees to the criteria. After piloting the rapid response team, be sure to educate areas such as radiology, endoscopy, etc. I find that nurses are almost always enthusiastic about the idea of RRT.It's not hard to sell them on it since they can always remember situations where they have been caring for a deteriorating patient and there was nohelp until the code was called. Same for respiratory therapists. The biggest barrier we face with nursing is them being uncomfortablecalling the RRT in certain situations. The worst scenario is when the nurse hasalready called the attending and gotten a less than helpfulresponse. ("I'll see him the morning, etc.") Patient continues to deteriorate and nurse knows full well from pastexperience that "going around the doc" will bring on an uncomfortable,even intimidating conversation with the attending doc at their nextencounter. What I tell the nursing staff is this: �When you know that, without this patient being seen by a physician and/or RapidResponse Team in the next 15 minutes or so, there will likely be continued deterioration that puts the patient at even higher risk for cardiac arrest than they already are, then you are obliged to call the team. Your responsibility as the patient's caregiveroverrides your collegial relationship with the physician. I realize that this is still often a hard thing for some nurses to do.This is precisely why a followup with those nurses letting them know whatthe outcome was and some words of encouragement about how they made adifference is so important.Each organization should determine which criteria will be used and educate the staff. Several organizations are using criteria similar to those listed here for use in their adult population. We�ve provided you with an example of adult criteria in the There are at least two different approaches to the use of criteria. The first is to educate staff to the criteria and to encourage them to call when any are met or when they are worried about the patient, even though the patient may not meet any criteria. Another approach is to mandate the staff to call when any criteria are met, thereby setting a different expectation. Tip: Ultimately, be sure to educate all hospital employees to the criteria. After piloting the rapid response team, be sure to educate areas such as radiology, endoscopy, etc. I find that nurses are almost always enthusiastic about the idea of RRT.It's not hard to sell them on it since they can always remember situations where they have been caring for a deteriorating patient and there was nohelp until the code was called. Same for respiratory therapists. The biggest barrier we face with nursing is them being uncomfortablecalling the RRT in certain situations. The worst scenario is when the nurse hasalready called the attending and gotten a less than helpfulresponse. ("I'll see him the morning, etc.") Patient continues to deteriorate and nurse knows full well from pastexperience that "going around the doc" will bring on an uncomfortable,even intimidating conversation with the attending doc at their nextencounter. What I tell the nursing staff is this: �When you know that, without this patient being seen by a physician and/or RapidResponse Team in the next 15 minutes or so, there will likely be continued deterioration that puts the patient at even higher risk for cardiac arrest than they already are, then you are obliged to call the team. Your responsibility as the patient's caregiveroverrides your collegial relationship with the physician. I realize that this is still often a hard thing for some nurses to do.This is precisely why a followup with those nurses letting them know whatthe outcome was and some words of encouragement about how they made adifference is so important.

29. Establish Mechanism for Calling Various options Beeper with or without overhead page Use of Vocera or Spectra link phone technology

30. Communication and Documentation Embed SBAR Record the interventions and reasons for call Examples of documentation forms are available. There is no need to reinvent the wheel. The SBAR communication technique can be embedded into the process by including it on the documentation form. The team can use the form to capture and organize information about the patient condition prior to calling the physician. The documentation form captures information on reasons for the RRT call as well as the types of interventions required. Together this information can be used for planning purposes and to inform nursing and medical staff educational programs.Examples of documentation forms are available. There is no need to reinvent the wheel. The SBAR communication technique can be embedded into the process by including it on the documentation form. The team can use the form to capture and organize information about the patient condition prior to calling the physician. The documentation form captures information on reasons for the RRT call as well as the types of interventions required. Together this information can be used for planning purposes and to inform nursing and medical staff educational programs.

31. Establish Feedback Mechanisms Feedback information on patient outcome to front line staff. Share success stories. Incorporate data into quality infrastructure Look for lessons learned hospital wide Use data to drive educational programs It is important to create feedback mechanisms to the staff. Particularly during the initial stages of establishing the team organizations find it useful to tell the stories of patients who were rescued by the team. These stories are useful in garnering support for the team. Organizations should look for lessons learned and patterns and trends, for example, respiratory events related to narcotic use. The information gained from the RRT calls can also be used to inform the overall educational plan for the organization. It is important to create feedback mechanisms to the staff. Particularly during the initial stages of establishing the team organizations find it useful to tell the stories of patients who were rescued by the team. These stories are useful in garnering support for the team. Organizations should look for lessons learned and patterns and trends, for example, respiratory events related to narcotic use. The information gained from the RRT calls can also be used to inform the overall educational plan for the organization.

32. Measure Effectiveness Key measures Mortality Codes per 1000 discharges Codes outside the ICU Number of rapid response team calls Four key measures are used to evaluate the effectiveness of the rapid response team. Insert operational definitions for these measures from the mortality IC measurement strategy. Organizations may wish to collect data on other measures such as post cardiac arrest ICU bed utilization, staff satisfaction with the rapid response team, safety culture survey data. why do we exclude ED codes altogether? We do not include ED codes because the rapid response team is generally used to support and help all areas of the hospital except for the ED and ICU. Since the rapid response team will not impact codes in the ED we exclude them. why it�s good to see codes outside the ICU decreasing? ��The purpose of the rapid response team is to support the hospital personnel outside of the ICU and the ED. Therefore we would expect the early intervention of the rapid response team to decrease patients who are coding within your facility who are outside of the ICU and EDFour key measures are used to evaluate the effectiveness of the rapid response team. Insert operational definitions for these measures from the mortality IC measurement strategy. Organizations may wish to collect data on other measures such as post cardiac arrest ICU bed utilization, staff satisfaction with the rapid response team, safety culture survey data. why do we exclude ED codes altogether? We do not include ED codes because the rapid response team is generally used to support and help all areas of the hospital except for the ED and ICU. Since the rapid response team will not impact codes in the ED we exclude them. why it�s good to see codes outside the ICU decreasing? ��The purpose of the rapid response team is to support the hospital personnel outside of the ICU and the ED. Therefore we would expect the early intervention of the rapid response team to decrease patients who are coding within your facility who are outside of the ICU and ED

33. Measure Effectiveness Other possible metrics Transfers to higher level of care 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 Four key measures are used to evaluate the effectiveness of the rapid response team. Insert operational definitions for these measures from the mortality IC measurement strategy. Organizations may wish to collect data on other measures such as post cardiac arrest ICU bed utilization, staff satisfaction with the rapid response team, safety culture survey data. why do we exclude ED codes altogether? We do not include ED codes because the rapid response team is generally used to support and help all areas of the hospital except for the ED and ICU. Since the rapid response team will not impact codes in the ED we exclude them. why it�s good to see codes outside the ICU decreasing? ��The purpose of the rapid response team is to support the hospital personnel outside of the ICU and the ED. Therefore we would expect the early intervention of the rapid response team to decrease patients who are coding within your facility who are outside of the ICU and EDFour key measures are used to evaluate the effectiveness of the rapid response team. Insert operational definitions for these measures from the mortality IC measurement strategy. Organizations may wish to collect data on other measures such as post cardiac arrest ICU bed utilization, staff satisfaction with the rapid response team, safety culture survey data. why do we exclude ED codes altogether? We do not include ED codes because the rapid response team is generally used to support and help all areas of the hospital except for the ED and ICU. Since the rapid response team will not impact codes in the ED we exclude them. why it�s good to see codes outside the ICU decreasing? ��The purpose of the rapid response team is to support the hospital personnel outside of the ICU and the ED. Therefore we would expect the early intervention of the rapid response team to decrease patients who are coding within your facility who are outside of the ICU and ED

34. A Business Case? Current State Codes: 20 X 10 X 1 = 200 Resource hrs / mo Future State Codes: 10 X 10 X 1 = 100 Resource hrs/ mo RRT: 30 X 2 X 0.5 = 30 Resource hrs/ mo This doesn�t take into account supplies, ICU bed utilization, LOS, nursing turnover

35. Tips for Getting Started Choose an �at risk� pilot area Create opportunities for the relationships to develop. RRT RN visits: floors asking for patients who meet criteria patients with RRT call in past 12 hours discharges from ICU in past 12-24 hours Develop contingency plan for simultaneous calls

36. Tips for Getting Started 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 Don�t forget your non-inpatient areas, cath lab, endoscopy suite, etc. Maintain continuous awareness and reinforcement of RRT through hospital publications, newsletters, etc. Keep it alive! Tips when getting started: 1. Be tolerant of �false alarms�. Staff should be praised for calling even if, after assessment, the patient condition did not appear to warrant calling. 2. Communicate, communicate, communicate! You cannot do enough of this. Particularly when trying to get the RRT off the ground, you need to get the word out, often and continuously. Be systematic and relentless with the communication. Make the process real by telling stories of patient rescues. Establish mechanisms to keep the RRT process alive in the organization. Tips when getting started: 1. Be tolerant of �false alarms�. Staff should be praised for calling even if, after assessment, the patient condition did not appear to warrant calling. 2. Communicate, communicate, communicate! You cannot do enough of this. Particularly when trying to get the RRT off the ground, you need to get the word out, often and continuously. Be systematic and relentless with the communication. Make the process real by telling stories of patient rescues. Establish mechanisms to keep the RRT process alive in the organization.

37. Our experience tells us� Team structure needs to be determined based on local culture. A significant reduction in codes IS possible IF properly implemented. Implementation of RRT is a complex process that requires attention to both the system and human components. Tips when getting started: 1. Be tolerant of �false alarms�. Staff should be praised for calling even if, after assessment, the patient condition did not appear to warrant calling. 2. Communicate, communicate, communicate! You cannot do enough of this. Particularly when trying to get the RRT off the ground, you need to get the word out, often and continuously. Be systematic and relentless with the communication. Make the process real by telling stories of patient rescues. Establish mechanisms to keep the RRT process alive in the organization. Tips when getting started: 1. Be tolerant of �false alarms�. Staff should be praised for calling even if, after assessment, the patient condition did not appear to warrant calling. 2. Communicate, communicate, communicate! You cannot do enough of this. Particularly when trying to get the RRT off the ground, you need to get the word out, often and continuously. Be systematic and relentless with the communication. Make the process real by telling stories of patient rescues. Establish mechanisms to keep the RRT process alive in the organization.