Analysis and Optimization of Emergent & Urgent Response Nurses

Transcription

1 Analysis and Optimization of Emergent & Urgent Response Nurses Final Report The University of Michigan Health System The University Hospital, Nursing Department Submitted To: Kathleen Moore, Client Administrative Director, Nursing Administration University of Michigan Hospitals & Health Centers Richard J. Coffey, Ph.D., Project Coordinator Director, Program and Operations Analysis University of Michigan Health System Professor Mark Van Oyen Industrial & Operations Engineering Department University of Michigan Submitted By: Project Team 5 Industrial & Operations Engineering Student Team Andy Hung Kai-Ming Lau Marwan Malek Date Submitted: April 2, 29

2 Table of Contents Executive Summary... iii Background... iii Methodology... iii Findings... iv Conclusions... vi Recommendations... vi Introduction... Background... Key Issues... 3 Goals and Objectives... 3 Project Scope... 3 Existing Data... 4 Interviews with Nurse Managers... 4 Service Observations and Interviews... 5 Literature Search... 5 Findings... 7 Findings from Interviews with Nurse Managers... 8 Findings from Service Observations and Interviews... 9 Findings from Literature Search... 9 Findings from SWAT Data... 9 Findings from Adult RRT Data... 2 Findings from Adult Code Team Data... 5 Findings from Pediatric RRT Data... 6 Findings from Pediatric Code Team Data... 9 Findings from Analysis of Staffing Level, FTE, and Combination of Services... 2 Conclusions Recommendations... 3 Expected Impact... 3 Support Received from Operating Entities... 3 Appendix A: Job Requirements... A Appendix B: Comparison of Other Hospitals RRT... B Appendix C: Statistics of Backup RNs Needed... C Appendix D: Graphs of Data Analysis... D Appendix E: Flow Charts... G Appendix F: SWAT Arriving Demand by Any Hour for Day of the Week... L Appendix G: Adult RRT Arriving Demand by Any Hour for Day of the Week... N Appendix H: Adult Code Arriving Demand by Any Hour for Day of the Week... P Appendix I: Pediatric RRT Arriving Demand by Any Hour for Day of the Week... R Appendix J: Pediatric Code Arriving Demand by Any Hour for Day of the Week... T Appendix K: Fit-to-Distribution for Demand Data... V Appendix L: Calculated Number of RNs Needs to Staff Combined Services by Hour of Day and Day of Week... W i

3 Lists of Tables and Figures Table : Data Received... 4 Table 2: Observation Date, Hours, and Personnel... 5 Table 3: Descriptive Statistics of Demands and Durations of Emergent/Urgent Services. 7 Table 4: Calculated FTEs Needed At 85th Percentile of Current State Demand for Each Service Table 5: Total Value of Current Funded FTEs Table 6: Total Value of Calculated Needed FTEs with Services Separated Table 7: Total Value of Combination A Table 8: Total Value of Combination B Table 9: Total Value of Combination C Table : Total Value of Combination D (@ Adult RRT FTE Rate) Table : Total Value of Combination D (@ Pediatrics RRT FTE Rate) Table 2: Savings Comparison of Staffing Methods Figure : SWAT Demand Met Over hr Days in CY Figure 2: SWAT Demand Duration (Met Over) hr Days in CY Figure 3: SWAT Demand Duration (Met Over) hr Days in CY Figure 4: SWAT Demand Duration (Met Over) hr Days in CY Figure 5: Adult RRT Demand Met Over hr Days in CY Figure 6: Adult RRT Demand Duration (Met Over) hr Days in CY Figure 7: Adult RRT Demand Duration (Met Over) hr Days in CY Figure 8: Adult RRT Demand Duration (Met Over) hr Days in CY Figure 9: Adult Code Demand Met Over hr Days in CY Figure : Pediatrics RRT Demand Met Over hr Days in CY Figure : Pediatrics RRT Demand Duration (Met Over) hr Days in CY Figure 2: Pediatrics RRT Demand Duration (Met Over) hr Days in CY Figure 3: Pediatrics RRT Demand Duration (Met Over) hr Days in CY Figure 4: Pediatric Code Demand Met Over hr Days in CY Figure 5: Visualization of Combinations... 2 Figure 6: Sample Call Demand of Adult RRT... 2 Figure 7: Sample Call Demand of Adult RRT Partitioned into One Hour Periods... 2 Figure 8: Sample of Average Usage of Adult RRT by a Specific Day of the Week, by Hour and rounded up to the nearest integer, or calculated RN (staff)... 2 Figure 9: Sample conversion of 5th percentile (average usages) to 85th percentile usages Figure 2: Sample of entire Adult RRT 5th percentile (average) usages converted to 85th percentile usages Figure 2: Sample of entire Adult RRT Calculated Staff Needed using 85th percentile usages Figure 22: Sample calculation of Combination A s number of needed bodies (calculated staff) Figure 23: Sample of entire Combination A Calculated Staff Needed using 85th percentile usages ii

4 Executive Summary The Administrative Director of Nursing Administration at the University of Michigan Hospital System (UMHS) is concerned with the costs of staffing emergent/urgent response services. Currently, each emergent/urgent response services are staffed independently by its overseeing unit. The nature of such services creates large amounts of downtime during which service staff are being funded. The Administrative Director was interested in the feasibility of combining services as a solution to more efficiently allocate limited resources, but was unsure of the expected cost savings. The Administrative Director asked a team of Industrial and Operations Engineering (IOE) 48 students to conduct a feasibility study of reducing staffing costs of emergent/urgent care nursing services without losing the functional roles of these services. The emergent/urgent response service nurses that were included in the study are SWAT Nurses, Adult Rapid Response Team (RRT), Adult Code Team, Pediatric Rapid Response Team (RRT), and Pediatric Code Team. This report contains the methods for evaluating utilization, findings, conclusions, and recommendations regarding the feasibility of combining emergent/urgent response service nurses. Background The aforementioned emergent/urgent services play a critical role in UMHS, and as such, must be staffed optimally. In addition, they must meet a very high proportion of demand because these emergent/urgent response services are critically important. Their capacity to respond effectively must ensure that the maximum numbers of calls are handled promptly when they occur. These services are very costly, and staffing to a high probability of meeting demand leads to a substantial amount of non-value-added time, which is captured as high downtime and low utilization rates. Currently, managers of the five nurse emergent/urgent services staff each emergent/urgent response service independently. The UMHS is aiming to efficiently reallocate the number of FTE s and minimize their associated costs. The effects of combining two or more emergent/urgent services have not been investigated before. This strategy may minimize the full time equivalent (FTE) staff required and costs. The primary goal for this project was to conduct a feasibility study of reducing staffing costs of emergent/urgent care nursing services without losing the functional roles of these services. Methodology The IOE 48 team employed the techniques described below to collect and analyze data on the demands for these emergent/urgent response teams. iii

5 Collection of Existing Data The Administrative Director provided the student team with existing demand and duration data for calendar year 28 The team received salary and Full-Time Equivalent (FTE) staffing data The team analyzed the data on demands and durations for the emergent/urgent services using statistical and historical, numerical analysis Interviews with Nurse Managers The team interviewed nursing managers that oversee the emergent/urgent services studied with the goal to clarify the current state of nurse staffing The managers provided the team with an overview of operations in the services and detailed job requirements and job scopes of the services they oversee Service Observations and Interviews The team shadowed and observed the urgent/emergent services within the project scope. During the observations, short interviews were conducted with Registered Nurses from each service Further interviews were also arranged throughout the progress of the project with personnel from respective services Findings From the demand and duration date received, the team determined utilization for the current method of staffing each service independently. Table below lists the demand and durations for each service during calendar year 28. Table : Descriptive Statistics of Demands and Durations of Emergent/Urgent Services SWAT ARRT Adult Code Peds RRT Peds Code Sample Size Mean (Calls/hr) Stdev (Calls/hr) Mean Duration(mins) Stdev Duration (mins) Using received data on FTEs, and salaries, the team determined the value of funded FTEs for the current staffing method to be approximately $.5 million dollars per year. This amount was used as benchmark to compare various merging scenarios (Table 2). Table 2: Total Value of Current Funded FTEs FTE rate Service ($/hr) Available FTEs Value of Funded FTEs SWAT $ $,24,38.48 Adult RRT Adult Code $3. 5. $38,346.8 Pediatrics RRT $ $58,32. Pediatrics Code* $3.4. $. Total 2.2 $,5, *Covered by PICU Charge Nurse iv

6 To analyze and compare combinations of services to be staffed from a consolidated pool of nurse, in order to determine the most cost-effective staffing method for the emergent/urgent response service nurses, while maintaining quality of service. The combinations the team set out to compare are listed below. A visualization chart is also shown below in Figure. Combination A: o Combined Services: SWAT, Adult RRT, Adult Code Team, Pediatrics RRT, Pediatrics Code Team Combination B: o Combined Services: SWAT, Adult RRT, Adult Code Team o Separate Services: Pediatrics RRT, Pediatrics Code Team Combination C: o Combined Services: SWAT, Pediatrics RRT, Pediatrics Code Team o Combined Services: Adult RRT, Adult Code Team Combination D: o Combined Services: Adult RRT, Adult Code Team, Pediatrics RRT, Pediatrics Code Team o Separate Service: SWAT Figure : Visualization of Combinations For each of the combinations, the staff required to cover all demand was calculated and translated into required FTEs. Using required FTEs for each combination, the total value of funded FTEs was determined and compared to the current costs of operating these emergent/urgent services. Table 3 below lists the savings. Table 3: Savings Comparison of Staffing Methods Staffing Method Total of Value Funded FTEs Savings Compared to Current Funded FTEs Current $,5,787 $ Combination A $,287,24 $23,572 Combination B $,433,9 $66,876 Combination C $,493,73 $7,83 Combination Adult RRT RNs FTE Rate $,342,42 $58,384 Combination Peds RRT RNs FTE Rate $,346,642 $54,44 v

7 Conclusions From the findings, the team arrived at several conclusions. Most pertinent to the goals of this project, the team confirmed that the current state is inefficient. Given the analysis on the data collected of call demand, a significant amount of downtime is observed by Adult RRT/Code Team, as well as Pediatrics RRT and Pediatrics Code Team. Staffing any emergency response service includes substantial downtime, and high costs. This is true for ambulance services, emergency services, fire departments, etc. However, by combining emergent/urgent nurse response services differently, there is an opportunity of reducing costs without losing functional roles by merging. Also, the team s analysis showed that greatest savings can be realized by adopting Combination A, which calls for merging all the emergent/urgent services, even when calculated with the most costly FTE rate of a SWAT nurse. By merging services, downtimes are pooled and reduced. An estimated total 7. FTEs will need to be reallocated to staff for this combination. This is a reduction from the current allocation of 2.2 FTEs. An example of how this combination would be staffed is for SWAT RNs to respond to all calls. As a group, SWAT nurses are already adequately trained to take on the extra responsibilities. Recommendations After analyzing the collected data and discussions with the client, the team recommends Combination A as it would realize the greatest savings. This combination calls for merging SWAT, Adult RRT/Code, Pediatrics RRT, and Pediatrics Code Team into a single unit. Combination A has an estimated savings of $23,572.2 of staff time compared to the current situation. Further training, development of standard operating procedures and best practices should be established in responding to RRT and Code calls, and integrated with SWAT s current responsibilities. In particular, with greater responsibilities in terms of types of calls, and call demand, a detailed backup system of responding to multiple calls at a time needs to be developed, documented, and communicated during implementation. An implementation plan involving a gradual progression from the current state to Combination B, before reaching full scale combination of all services is recommended. The team also recommends further investigation of travel time for nurses staffed to this combination to respond to calls from different parts of the hospital. This is essential in maintaining the quality of health care service provided to patients. vi

8 Introduction The University of Michigan Health System (UMHS) has various emergent/urgent response services to respond to emergent and urgent calls. This report addresses the feasibility of consolidating two or more of the following emergent/urgent nurse services: These services are staffed with various combinations of physicians, registered nurse (RNs), respiratory therapists (RTs) and other professionals. These services play a critical role in the Health System, and as such, must be staffed optimally. In addition, because these emergent/urgent response services are critically important, they must meet a very high proportion of demand. Their capacity to respond effectively must ensure that the maximum numbers of calls are handled promptly when they occur. These services are very costly, and staffing to a high probability of meeting demand leads to a substantial amount of non-value-added time, which is captured as high downtime and low utilization rates. Downtime is classified as anytime not responding to emergency calls. During downtime, staff of these services do work related to their respective services or unit (eg. Patient follow ups, rounding, nurse-to-nurse consult, etc). Currently, various managers staff each emergent/urgent response service independently. The University of Michigan Health System is aiming to reduce the number of FTE s and their associated costs. The effects of combining two or more emergent/urgent services have not been investigated before. This strategy may reduce the full time equivalent (FTE) staff required and reduce costs. However, the effect of this change on the quality of service (in terms of delayed response to calls) is not known and should be considered when recommending changes to organizational structure. The primary goal for this project was to conduct a feasibility study of reducing staffing costs of emergent/urgent care nursing services without losing the functional roles of these services. The IOE 48 team employed various techniques to collect and analyze data on the demands for these emergent/urgent response teams, and worked towards optimizing the method for staffing nurses based on the analysis. Specifically, the team investigated methods used to staff registered nurses to the emergent/urgent response services. This final report describes the project s goals, methods, findings, and conclusion. The project spanned from January 2, 29 to April 5, 29. Background The emergent/urgent response services initially included in this analysis were: Survival Flight (later excluded from scope of analysis) SWAT Nurses Adult Rapid Response Team (RRT) Adult Code Team Pediatric Rapid Response Team (RRT) Pediatric Code Team

9 The RRTs and Code Teams have separate teams for Adult and Pediatric patients, which are staffed and operated as separate entities. Essentially, six teams of differing functions and job scopes are staffed from separate pools of nurses. The UMHS Survival Flight service is comprised of highly trained experts available 24 hours a day who respond to emergency calls. The Survival Flight service provides fixedwing, rotor-wing, and ground transportation services and emergency medical care. The service provides hospital-to-hospital transfer, as well as accident scene to hospital and organ transplant transportation, where time is of essence. This operation is highly critical, but also very expensive to operate. Staffing Survival Flight nurses is the responsibility of the Manager of Critical Care Transport. However, the client excluded Survival Flight from the project scope, and the team s recommendations do not include or affect Survival Flight. While Survival Flight provides critical care assistance to patients outside UMHS, the SWAT teams consist of nurses and paramedics who provide care to patients transported within the UMHS. They provide medical care during transportation. They are also the only group of emergent/urgent care nurses in the hospital that performs conscious sedation. Their mission statement is to provide safe, excellent, respectful, holistic care, and sedation to critically ill patients during transport, diagnostic procedures, and sedation/analgesia. Staffing the SWAT Nurses is also the responsibility of the Manager of Critical Care Transport. Rapid Response Teams respond to a wide range of acute changes in patients clinical status that attending nursing staff, physicians, and other staff may recognize as worrisome, prior to the patient going into cardiac arrest. The RRT service was formed as a preventative strategy to reduce cardiac arrests. The RRT staff consists of a physician, an Intensive Care Unit (ICU) nurse, and a respiratory therapist. On the other hand, Code Teams respond to calls after patients have gone into cardiac arrest. As mentioned before, separate RRT and Code Teams care for Adult and Pediatric patients. Adult RRT and Code Team nurse staffing is the responsibility of the Nurse Manager of Surgical Intensive Care Unit (SICU). While nurse staffing for Pediatric RRT and Code Team is the responsibility of the Nurse Manager of Pediatric Intensive Care Unit (PICU). During interviews with the SICU and PICU Nurse Managers, the team clarified the organizational structure of the RRTs and Code Teams. For Adult RRT and Code Teams, the same nurse is staffs both teams, at the same time. Thus, the scheduled nurse will respond to calls for both demands. This staffing method is not necessarily true for other members (physicians and respiratory therapists) of the RRT and Code Teams. For Pediatric RRTs and Code Teams, a PICU nurse is assigned to RRT, while the Charge Nurse responds to Code Team calls. 2

10 Key Issues The following key issues have driven the need for this project: Emergent/urgent response services are critical services and require high probability of meeting demand. These response services are very costly. To have a high probability of meeting demand, substantial non-value-added work will exist, and this is work captured as high downtime and low utilization rates. The Administrative Director of Nursing Administration is interested in the possibility of merging services to reduce costs. Goals and Objectives The Nursing Administration's goals for the emergent/urgent services are to: Reallocate staffing efficiently, thus reducing costs of emergent/urgent care nursing services Sustain or increase probability that nurse staff are available to handle emergent/urgent calls Analyze and compare combinations of services to be staffed from a consolidated pool of nurses To achieve these goals, the student team has: Collected quantitative and qualitative data on demand for emergent/urgent response services and available nurse resources Analyzed statistical demand data and compare to current available nurse staffing resources Analyzed the utilization and downtime resulting from current staffing methods for nurses in emergent/urgent response services Determined the most cost-effective staffing method for the emergent/urgent response service nurses, while maintaining quality of service Project Scope This project scope included nurses only from the following emergent/urgent response services: SWAT Adult RRT Adult Code Team Pediatric RRT Pediatric Code Team This project excluded: Survival Flight Nurses 3

11 Emergency Department Nurses Medical Doctors (MDs) Respiratory Therapists (RTs) Paramedics Other non-nurse staff Data Collection This section details the data collection methods used during the project. Existing Data The team received from the client daily demand data for the calendar year 28 (CY28) for the SWAT, the Adult RRT and Code Team, and the Pediatric RRT and Code Team. RRT and Code Team demand data for both adults and pediatrics are recorded separately. The team also received salary and Full-Time Equivalent (FTE) staffing data for the Pediatric RRT and Code Team Registered Nurses (RN). In addition, the team received the average FTEs and salaries of the SWAT RNs and the Adult RRT/Code Team RNs. Table below lists the sample size for each of data sets received. Table : Data Received Demand Data Num. of Service Calls SWAT Nurses 5,72 Adult Rapid Response Team,328 Adult Code Team 3 Pediatrics Rapid Response Team 84 Pediatrics Code Team 2 Staffing Data Num. Nurses in Role SWAT Nurses 8 Adult Rapid Response Team / Code Team 42 Pediatrics Rapid Response Team 39 Pediatrics Code Team 38 Interviews with Nurse Managers With the goal to clarify the current state of nurse staffing, the team interviewed the following nurse managers. The findings from these interviews are presented later in this report. Patient Safety Officer Manager of Critical Care Transport Nurse Manager of SICU Nurse Manager of PICU The managers provided the team with an overview of operations in the services and detailed job requirements and job scopes of the services they oversee. 4

12 Service Observations and Interviews The team shadowed and observed the urgent/emergent services within the project scope. During the observations, short interviews were conducted with Registered Nurses from each service. Table 2 below shows the date of observation, number of observation hours, and the number of nurses the team interviewed. Table 2: Observation Date, Hours, and Personnel Urgent/Emergent Service Date of Observation # of Hours Observed # of Nurses Interviewed Survival Flight Mar 5 th, SWAT Mar 4 th, Adult RRT/Code Mar th, 29 4 Pediatric RRT Mar th, Pediatric Code Mar th, 29 4 During observation, the team asked the following questions: What is the value of your service? What are your responsibilities and activities as a SWAT/RRT/Code nurse? What do you do when not responding to a service call? What steps are taken when responding to a service call? How can your service be improved? What do you think of a dedicated RRT/Code team that services both Adults and Pediatrics? Further interviews were also arranged throughout the progress of the project with personnel from respective services. Literature Search The following articles were used as background references during the project: Institute for Healthcare Improvement on RRTs ( Rapid Response Teams Can Save Hospitalized Kids ( Rapid Response Teams Don't Cut Hospital Heart Attacks, Death Rates ( The Effect of a Rapid Response Team on Major Clinical Outcome Measures in a Community Hospital ( d37e8c4c6b d44f7c375634c4) Use Of Rapid Response Team In Hospital Not Linked With Reduction In Cardio Arrests Or Deaths ( 5

13 In addition, the student team obtained background information and data on other hospital s Rapid Response Teams. The hospitals are: University of Pittsburgh Medical Hospital (Condition H) ( ntandinnovation/pages/conditionh.aspx) St. Barnabas Hospital (Bronx, NY) ( Vanderbilt University Hospital ( Duke University Health System (Pediatric) ( h/pediatric_rapid_response_teams) Johns Hopkins Children s Center (Pediatric) ( 6

14 Findings The team analyzed the collected data. First, the demands and durations for the emergent/urgent services were determined using statistical analysis. Table 3 below shows the summary of data analysis. Table 3: Descriptive Statistics of Demands and Durations of Emergent/Urgent Services SWAT ARRT Adult Code Ped RRT Ped Code Mean (Calls/yr) Mean (Calls/month) Stdev (Calls/month) Mean (Calls/wk) Stdev (Calls/wk) Mean (Calls/day) Stdev (Calls/day) Mean (Calls/hr) Stdev (Calls/hr) Calls/hr (7a p).973 Stdev (Calls/hr) (7a p).496 Mean Duration(mins) Stdev Duration (mins) Num RNs Req.223 Stdev RN Req.46 Funded FTEs k with 3% benefits 22k with fringe benefits FTE rate ($/hr) $36.2 $3. $3.4 $3.4 Available RNs SUM of FTE AVERAGE of FTE/RN StDev of FTE Value of Funded FTEs $,24,38.48 $38,346.8 $58,32. $58,32. SUM Salary $2,26,58.8 $2,, AVERAGE Salary $75,37 $62,42.8 $63,253 $63,253 StDev Salary $,2.39 $3,536.6 AVG Salary / FTE $75, $78,86.77 Current benefit rate 34.6% Ave sal plus benefits $,376.4 $84,8.4 $85,38.27 $85,38.27 Total sal plus benefits $,378,79.2 $428, $22, $22, * Given 7

15 With this data, the team then performed staffing analysis to determine the effects of merging services in several possible combinations. This section details these findings. General findings are categorized under the data collection method the findings are from. Findings pertaining to specific emergent/urgent services are stated under individual service findings. Findings from Interviews with Nurse Managers The team interviewed the UMHS Patient Safety Officer. She explained the evolution of Adult and Pediatric RRT at UMHS. As the Patient Safety Officer explained, during the development of the RRT, the design team decided not to use Emergency Department (ED) nurses on the team because of the high workload of ED nurses. She also explained the differences in organization structure between Adult and Pediatric RRTs. The team also learned that a physician always responds to a Pediatric RRT call. For Adult RRT calls, a physician will be paged only when the RT and nurse at the scene requires the presence of the physician. Included in Appendix E are flow charts that chart out the process of responding to a call. The Patient Safety Officer stated that one metric used to measure the effectiveness of RRT is number of codes per patients discharged. Ideally, there should be fewer codes with the introduction of RRT, but that is not the case for UMHS. The definition of a code at UMHS is when the patient has no pulse. She also said that internal survey results indicate that hospital staff members have a great affinity to the RRT service and that everyone loves the [RRT] service because it provides a safety net. The Nurse Managers of SICU and PICU informed the team that the Charge Nurse of the SICU/PICU responds to a call when the RRT RN is unavailable. In the rare event where both the RRT RN and charge nurse is unavailable due to other calls, the next most qualified nurse on the SICU/PICU will response. (Appendix E: Flow Charts) The matrix in Appendix A shows job requirements and certification of the urgent/emergent services. This matrix is based on detailed job requirement descriptions from individual nurse managers. The team then identified and differentiated required and desired qualifications, before establishing this matrix. This matrix differentiates the services based on job requirements. It also identifies gaps in requirements if services were to be merged. Of the services within this project s scope, SWAT nurses have the most qualifications, with extensive experience and certification. When hired, SWAT nurses are also required to be certificated in at least one of the following programs, with certification of the remaining two within 6 months of hire. Advance Cardiac Life Support (ACLS) Pediatric Advance Life Support (PALS) Neonatal Resuscitation Program (NRP) 8

16 A major difference in the job requirements between the services is the certification of ACLS, PALS, and NRP. Due to specialization, the Adult and Pediatric teams require different certifications. Adult RRT/Code nurses and Pediatric Code nurses require ACLS, while Pediatric RRT nurses are required to be PALS certified but not ACLS certified. Similarly, Adult RRT/Code nurses do not require PALS certification. Some job requirements do not require certification, but are based on the leadership team s evaluation of the nurse, such as Good Communication Skills. (Appendix A) Findings from Service Observations and Interviews Through the team s observations and interviews with individual services, flow charts were established for the current state. The flow charts can be found in Appendix E. The flow charts provided the team with a good understanding of the sequence of events nurses take to answer calls for the respective emergent/urgent services. Findings from Literature Search From the literature search, the IOE 48 team determined that the University of Pittsburgh Medical Hospital created the Condition H model (July 25), which addresses the needs of patient when the patient is unable to get the attention of a healthcare provider in an emergency situation. When Condition H is called, an RRT team arrives within minutes. Johns Hopkins Children s Center also incorporated Condition H in their hospital. Referring to those articles, the team determined that Condition H has reduced mortality rates. For the remaining three other hospitals, based on their articles, the team found that most of the hospitals agree that the Rapid Response Teams reduced mortality rates in their hospitals. Verification of the studies was not initiated as actual data were not available. Most the hospitals have similar staffing requirements for RRT except Duke University Health System where a rover team along with the RRT responded to calls. A rover team expands the Pediatric Rapid Response Team to include a proactive routine assessment of children at risk for clinical deterioration. Patients newly admitted and diagnosed at high risk for adverse outcomes, as well as patients transferred from the intensive care unit to intermediate care are evaluated by a rover team. Findings from SWAT Data Based on data analysis of the SWAT demand met data, the median number of calls (demands) met occurs at 2:5pm (Figure, over CY28, hr days). Fifty percent of the calls occurred between 2:pm and 5:3pm. The mean number of calls per month was with a standard deviation of The mean number of calls per week was 7.9 with a standard deviation of 6.6. The mean number of calls per day was 5.6 with a standard deviation of 9.2. The mean number of calls per hour was.65 with a standard deviation of.64. This is recorded in Appendix C. The team noticed a large number of outlier calls that were received. The calls are identified by the box in Figure. The calls were all recorded as very specific times. With the high frequency of outlier calls recorded as called received between midnight and 9

17 3:am, a root cause may exist for such a situation. As such, the team recommends a root-cause analysis be performed of the calls identified regarding actual received time, nature of the calls, and recording techniques. : SWAT Demand Met Over hr Days in CY28 2: Time of Day 6: 2: 8: Q3 = 7:3 Median = 4:5 Q = 2: 4: : Sample Size: 572 Demand Met Over 366 Days; Data Source: UMHS Office of Clinical Affairs Figure : SWAT Demand Met Over hr Days in CY 28 The median duration of a SWAT call is 6 minutes with a 25 th percentile of 45 minutes (Q) and 75 th percentile of 2 minutes (Q3) (Figure 2 and Figure 3). A total of 48 outliers lie outside the 45 2 minutes mid-spread (inter-quartile range) as can been see in Figure 2 and Figure 3. The mean process/service time was 92.6 minutes with a standard deviation of 83.8 (Appendix C).

18 7 SWAT Demand Duration (Met Over) hr Days in CY28 6 Duration (in minutes) Q3 = 2 Median = 6 Q = 45 Sample Size: 572 Demand Met Over 366 Days; Data Source: UMHS Office of Clinical Affairs Figure 2: SWAT Demand Duration (Met Over) hr Days in CY 28 (Demands Met Over Yr) SWAT Demand Duration (Met Over) hr Days in CY Duration (in minutes) Sample Size: 572 Demand Met Over 366 Days; Data Source: UMHS Office of Clinical Affairs Figure 3: SWAT Demand Duration (Met Over) hr Days in CY 28 Figure 4 shows that 47 of the duration of demand (calls) that were 2 standard deviations above the upper control limit of 34.6 minutes. This analysis employs a lower control limit of and an upper control limit of 2σ above the mean.

19 Moving Range of Demand Durations (in Mins) Individual Value of Demand Durations (in Mins) SWAT Demand Duration (Met Over) hr Days in CY Demands Met Over Yr Demands Met Over Yr Sample Size: 572 Demand Met Over 366 Days; Data Source: UMHS Office of Clinical Affairs 572 UCL=34.6 _ X=92.6 LCL=-9.4 UCL=26.4 MR=79.7 Figure 4: SWAT Demand Duration (Met Over) hr Days in CY 28 Using Minitab s Individual Distribution Identification, the team attempted to determine if SWAT Demand and the duration of the calls followed a type statistical distribution. Unfortunately, the results from both studies were inconclusive. None of the distributions was found to fit with SWAT Demand or duration of the calls as they all had a p-value below alpha =.5. The results were the same after stratifying the data to exclude any outliers shown in Figures and 2. The Manager of Critical Care Transport provided the team with general information regarding the operations of SWAT. The team learned that SWAT Nurses operates from 7am-pm on Mondays through Fridays, and 7am-7am on Saturdays. The number of RNs that are staffed varies over the course of a day. Typically, a minimum of 3 RNs are present by 7am, 5 RNs by 8am, and 6 by 9am. Staff levels typically range between 7-9 RNs from 9am to 5pm. The number of staff decreases towards the end of the day, with 4-5 RNs by 6pm, and 2RNs by 9-pm. There are always 2 paramedics staffed during the hours of operations. One paramedic is staffed outside the hours of operation to respond to calls. A total of 8 RNs and 8 paramedics are rotated through the staffing schedule. In the data received, the team noticed that SWAT responded to calls outside of their normal hours of operation. These calls are handled by the paramedic. Findings from Adult RRT Data Based on data analysis of the Adult RRT demand met data, the median number of calls (demands) met occurs at :35 am (Figure 5, over CY28, hr days). Fifty percent of the calls occurred between 6:3 and 7:2. The mean number of calls per month was.667 with a standard deviation of The mean number of calls per week was with a standard deviation of The mean number of calls per day was with a standard deviation of 2.2. The mean number of calls per hour was.5 with a standard deviation of.389, which are recorded in Appendix C. There were 29 times LCL= 2

20 where backup RN was needed, 9 times where 2 backup RNs were needed, and 2 times where 3 backup RNs were needed. : Adult RRT Demand Met Over hr Days in CY28 2: Time of Day 6: 2: 8: 4: Q3 = 7:2 Median = :35 Q = 6:3 : Sample Size: 328 Demand Met Over 366 Days; Data Source: UMHS Office of Clinical Affairs Figure 5: Adult RRT Demand Met Over hr Days in CY 28 The median duration of an Adult RRT call is 52 minutes with a 25 th percentile of 26 minutes (Q) and 75 th percentile of 78 minutes (Q3) (Figure 6 and Figure 7). There are a total of 83 outliers that are well beyond the minutes mid-spread (inter-quartile range), particularly between 5 and 25 minutes (Figure 6, Figure 7). Some of the durations were not recorded; however, the Administrative Director of Nursing Administration reported that the average duration is 59 minutes for an Adult RRT. Therefore, the team used 59 minutes to fill blank durations. The team though determined the mean process/service time was actually 65.7 minutes with a standard deviation of 7.6 (Appendix C) Adult RRT Demand Duration (Met Over) hr Days in CY28 Duration (in minutes) Q3 = 78 Median = 52 Q = 26 Sample Size: 328 Demand Met Over 366 Days; Data Source: UMHS Office of Clinical Affairs Figure 6: Adult RRT Demand Duration (Met Over) hr Days in CY 28 3

21 (Demands Met Over Yr) Adult RRT Demand Duration (Met Over) hr Days in CY Duration (in minutes) Sample Size: 328 Demand Met Over 366 Days; Data Source: UMHS Office of Clinical Affairs Figure 7: Adult RRT Demand Duration (Met Over) hr Days in CY 28 Figure 8 shows that 35 of the calls had durations that were 2 standard deviations above the upper control limit of 26.7 minutes. This analysis employs a lower control limit of and an upper control limit of 2σ above the mean Adult RRT Demand Duration (Met Over) hr Days in CY28 Individual Value of Demand Durations (in Mins) Demands Met Over Yr UCL=26.7 _ X=65.6 LCL= Moving Range of Demand Durations (in Mins) Demands Met Over Yr UCL=85.6 MR=56.8 LCL= Sample Size: 328 Demand Met Over 366 Days; Data Source: UMHS Office of Clinical Affairs Figure 8: Adult RRT Demand Duration (Met Over) hr Days in CY 28 Using Minitab s Individual Distribution Identification, the team attempted to determine if Adult RRT Demand and the duration of the calls followed a type statistical distribution. Unfortunately, the results from both studies were inconclusive. None of the distributions was found to fit with Adult RRT Demand or duration of the calls as they all had a p-value 4

22 below alpha =.5. The results were the same after stratifying the data to exclude any outliers shown in Figures 6 and 7. Findings from Adult Code Team Data Based on data analysis of the Adult Code demand met data, the median number of calls (demands) met occurs at 2:55 pm (Figure 9, over CY28, hr days). Fifty percent of the calls occurred between 7:59am and 5:27pm. The mean number of calls per month was.5 with a standard deviation of 2.5. The mean number of calls per week was 2.6 with a standard deviation of.5. The mean number of calls per day was.377 with a standard deviation of.662. The mean number of calls per hour was.6 with a standard deviation of.27. This is recorded in Appendix C. The team found that there were 3 occasions where 2 RNs were needed. : Adult Code Demand Met Over hr Days in CY28 2: Time of Day 6: 2: 8: Q3 = 7:27 Median = 2:55 Q = 7:59 4: : Sample Size: 3 Demand Met Over 366 Days; Data Source: UMHS Office of Clinical Affairs Figure 9: Adult Code Demand Met Over hr Days in CY 28 The duration of the Adult Code could not be analyzed because there were no duration data on it in the provided data. Due to the rarity of adult code calls, we also could not do an observational study. However, the Administrative Director of Nursing Administration reported that the average duration is 56 minutes for an Adult Code. Using Minitab s Individual Distribution Identification, the team attempted to determine if Adult Code Demand followed a type statistical distribution. The team found that Adult Codes followed a normal distribution after applying a Johnson Transformation because the test returned a p-value of.734 which is greater than an alpha of.5 ( Appendix K) 5

23 Findings from Pediatric RRT Data Based on initial data analysis of the Pediatrics RRT demand data, the median number of calls (demands) met occurs at :3 am (Figure, over CY28, hr days). Fifty percent of the calls occurred between 6:24am and 7:7pm. The mean number of calls per month was 7. with a standard deviation of 4.3. The mean number of calls per week was.6 with a standard deviation of.4. The mean number of calls per day was.23 with a standard deviation of.55.the mean number of calls per hour was. with a standard deviation of.. This is recorded in Appendix C : Pediatrics RRT Demand Met Over hr Days in CY28 2: Q3 = 9:7 Time of Day 6: 2: 8: 4: Median = :3 Q = 6:24 : Sample Size: 84 Demand Met Over 366 Days; Data Source: UMHS Office of Clinical Affairs Figure : Pediatrics RRT Demand Met Over hr Days in CY 28 The median duration of an Pediatrics RRT call is 5 minutes with a 25 th percentile of 2.25 minutes (Q) and 75 th percentile of 58 minutes (Q3) (Figure and 2). Therefore, 5% of the calls fall between 2.25 and 58 minutes. Some of the durations were not recorded; however the Administrative Director of Nursing Administration reported that the average duration for a Pediatrics RRT call. Therefore, 58 minute to fill blank durations. The mean process/service time was actually 6.3 minutes with a standard deviation of 96.3 (Appendix C). 6

24 8 7 Pediatrics RRT Demand Duration (Met Over) hr Days in CY28 Duration (in minutes) Q3 = 58 Median = 5 Q = 2.25 Sample Size: 84 Demand Met Over 366 Days; Data Source: UMHS Office of Clinical Affairs Figure : Pediatrics RRT Demand Duration (Met Over) hr Days in CY 28 5 Pediatrics RRT Demand Duration (Met Over) hr Days in CY28 (Demands Met Over Yr) Duration (in minutes) Sample Size: 84 Demand Met Over 366 Days; Data Source: UMHS Office of Clinical Affairs Figure 2: Pediatrics RRT Demand Duration (Met Over) hr Days in CY 28 Figure 3 shows that the durations of most demand (calls) fall within the upper control limit (UCL) of 23.4 minutes and below the average duration. Only two calls had lasted longer than the UCL. This analysis employs a lower control limit of and an upper control limit of 2σ above the mean. (Figure 3)

25 Individual Value of Demand Durations (in Mins) I-MR Chart of Pediatrics RRT Demand Duration (Met Over) hr Days in CY UCL=23.4 _ X=6.3 LCL= Demands Met Over Yr Moving Range of Demand Durations (in Mins) Demands Met Over Yr UCL=88. MR=57.6 LCL= Sample Size: 84 Demand Met Over 366 Days; Data Source: UMHS Office of Clinical Affairs Figure 3: Pediatrics RRT Demand Duration (Met Over) hr Days in CY 28 Using Minitab s Individual Distribution Identification, the team attempted to determine if Pediatrics RRT Demand and the duration of the calls followed a type statistical distribution. The team found that Pediatrics RRT followed a normal distribution after apply a Johnson Transformation because the test returned a p-value of.53 which is greater than an alpha of.5 (Appendix K). There were only 84 samples of Pediatrics RRT calls so there are some reservations about the results of the test as any Goodness of Fit Tests should be done with at least a sample size of. The results from the test on the duration of the calls were inconclusive. None of the distributions was found to fit as they all had a p-value below alpha =.5. The results were the same after stratifying the data to exclude any outliers shown in Figures. A significant finding from the observation sessions is the activities nurses perform during downtime. When the team performed data analysis, it was noticed that a significant amount of downtime is experienced by emergent/urgent services. Upon further investigation the team realized that activities related to the services responsibilities were not included in the received data sets. These activities included nurse-to-nurse consultations, covering PICU patient care duties, and continuous dialysis set ups. Hence, the instinctive conclusion that downtime is equal to idle time is not necessarily true. However, upon further discussion with the client and coordinator, it was agreed that these activities are not strictly RRT calls and are not be considered in the project s data analysis. 8

26 Findings from Pediatric Code Team Data Based on data analysis of the Pediatric Code demand met data, the median number of calls (demands) met occurs at :3 am (Figure 4, over CY28, hr days). Fifty percent of the calls occurred between 5:2am and 7:4pm. The mean number of calls per month was.8 with a standard deviation of.8. The mean number of calls per week was.396 with a standard deviation of.66. The mean number of calls per day was.57 with a standard deviation of.244. The mean number of calls per hour was.2 with a standard deviation of.49. This is recorded in Appendix C. There were no occasions where more than RNs were needed. : Pediatrics Code Demand Met Over hr Days in CY28 2: Q3 = 9:4 Time of Day 6: 2: 8: 4: Median = :3 Q = 5:2 : Sample Size: 2 Demand Met Over 366 Days; Data Source: UMHS Office of Clinical Affairs Figure 4: Pediatric Code Demand Met Over hr Days in CY 28 The duration of the Pediatric Code could not be analyzed because there was no duration data were in the provided data. Due to the rarity of pediatric code calls, the team also could not do an observational study. However, the Administrative Director of Nursing Administration reported that the average duration is 64 minutes for a Pediatric Code. Using Minitab s Individual Distribution Identification, the team attempted to determine if Pediatrics Code Demand followed a type statistical distribution. The team found that Pediatrics Codes followed a normal distribution after apply a Box-Cox Transformation because the test returned a p-value of.365 which is greater than an alpha of.5 (Appendix K). There were only 2 samples of Pediatrics Code so there are some reservations about the results of the test as any Goodness of Fit Tests should be done with at least a sample size of. 9

27 Findings from Analysis of Staffing Level, FTE, and Combination of Services One of the goals set forth by the Nursing Administration is to analyze and compare combinations of services to be staffed from a consolidated pool of nurse, in order to determine the most cost-effective staffing method for the emergent/urgent response service nurses, while maintaining quality of service. The combinations the team set out to compare are listed below (Figure A): Combination A: o Combined Services: SWAT, Adult RRT, Adult Code Team, Pediatrics RRT, Pediatrics Code Team Combination B: o Combined Services: SWAT, Adult RRT, Adult Code Team o Separate Services: Pediatrics RRT, Pediatrics Code Team Combination C: o Combined Services: SWAT, Pediatrics RRT, Pediatrics Code Team o Combined Services: Adult RRT, Adult Code Team Combination D: o Combined Services: Adult RRT, Adult Code Team, Pediatrics RRT, Pediatrics Code Team o Separate Services: SWAT Figure 5: Visualization of Combinations The team initially attempted to build staffing models based on queueing theory for each of the services to be compared to the above combinations. In order to develop the staffing models using queueing theory, CY8 demand data for each of the emergent/urgent services were fitted to statistical distributions using Minitab. Unfortunately, all the CY8 demand data was either fitted to distributions that are not usable for modeling, such as Box-Cox or Johnson Transformation, or did not fit to any distributions (Appendix K). Instead, the team used a method of analyzing staffing employed by the Program and Operations Analysis (POA) in analyses of operating room data. The method utilizes historical and numerical analysis of the CY8 demand data for each of the services. The same technique was used to analyze the aforementioned combinations to be compared to the current state. 2

28 The method was first used to further analyze the current state. The method requires multiple steps to arrive at the actual number of FTEs required. First, each individual call (demand) for each of the services was assigned into proportions of one hour periods from : to 23:. The hourly utilization proportions are then summed together by day of the week by hour, and averaged over 52 weeks to obtain the average usage at any day, any hour (Figure 6, 7). The average usage is then rounded up to the nearest integer to obtain the needed number of bodies (staffs) to cover the average usage (Figure 8). Figure 6: Sample Call Demand of Adult RRT Figure 7: Sample Call Demand of Adult RRT Partitioned into One Hour Periods Figure 8: Sample of Average Usage of Adult RRT by a Specific Day of the Week, by Hour and rounded up to the nearest integer, or calculated RN (staff) The 85 th percentile of the demand was used in all described calculations. The mean value was not used because it is not a suitable value in predicting probabilities in systems where high variation exists. The team reasoned that following the Pareto principle (also known as the 8-2 rule ) is a better strategy. However, in light of the services investigated in this project are emergent/urgent healthcare services, the team chose to increase the estimated demand by choosing a higher percentile value of the 85 th 2

29 percentile. The 85th percentile assumes that services generally observe a demand.7 times higher than the mean. The 85th percentile demand rate is estimated by multiplying the mean rate by.7 since the calculated mean is set as 5th percentile value (Figure 9). Figure 9: Sample conversion of 5th percentile (average usages) to 85th percentile usages The 85th percentile usages were rounded up to the nearest integer (Figure 2) to determine the numbers of bodies needed (calculated staff) for each service. Then, the numbers of bodies needed were converted to the actual number of FTEs need for each of the separated services. The following steps were done to convert to FTEs: Sum calculated staff needed in week (Figure 2) Multiply the sum by 52 weeks Add the maximum number of calculated staff needed in a day to account for 365th day of a year (Figure 2) Convert to FTEs by dividing by 28 (52 weeks x 4 hour work weeks) Multiply FTEs by.2 to take into account vacation days. The sample of Adult RRT (Figure 2) needed 5. FTEs. The above was done for each of the five services. Figure 2: Sample of entire Adult RRT 5th percentile (average) usages converted to 85th percentile usages 22

30 Figure 2: Sample of entire Adult RRT Calculated Staff Needed using 85th percentile usages To analyze the different combinations of the services, the same methods listed above were used, but for the combined services, they have their 85 th percentile usages added together first and then rounded up to the nearest integer (Figure 22) to calculate the required RNs (number of bodies needed). The calculated required RNs to staff by hour of day and day of the week is shown in Appendix L for each of the combinations. 23

31 Figure 22: Sample calculation of Combination A s number of needed bodies (calculated staff) Using the method described above regarding calculations, the number of FTEs was calculated for each combination. Figure 23 below, shows the estimated staffing needs for Combination A. 24

32 Figure 23: Sample of entire Combination A Calculated Staff Needed using 85th percentile usages Finally, using the FTE rates and FTEs calculated for each of the above combinations, the salaries of the combinations and corresponding savings was calculated and compared against the current state of having the services separated (Table ). It should be noted that this analysis is based on CY8 data. Table 3 below lists the actual number of FTEs needed at 85 th percentile of demand for each of the separated services. The calculated FTEs below were used in this analysis to benchmark against calculated FTEs for combinations. Table 4: Calculated FTEs Needed At 85th Percentile of Current State Demand for Each Service Service Available Funded FTEs FTEs Needed SWAT Adult RRT Adult Code Team Pediatrics RRT Pediatrics Code Team.4 25

33 When comparing the current state of the services against the combinations of the services, both the funded FTEs and calculated needed FTEs for each of the services for the current state were used (there are no funded FTEs for the Adult Code Team and Pediatrics Code Team). Tables 4 to below show the value of funded FTEs calculated. Table 5: Total Value of Current Funded FTEs Table 6: Total Value of Calculated Needed FTEs with Services Separated Table 7: Total Value of Combination A 26

34 Table 8: Total Value of Combination B Table 9: Total Value of Combination C Table : Total Value of Combination D (@ Adult RRT FTE Rate) Table : Total Value of Combination D (@ Pediatrics RRT FTE Rate) 27

35 Table and Figure 5 below show the savings of each staffing method as compared to the current funded FTEs, as well as the calculated needed FTEs. Table 2: Savings Comparison of Staffing Methods 28

36 Conclusions This section details the conclusions arrived at based on the team s findings and analyses. The conclusions are drawn mostly from the calculated FTEs and RN staffing model (Appendix L). The team would like to stress that the derived RN staffing model is only an estimate, and in reality may require minor adjustments during implementation. Current state is inefficient Given the analysis on the data collected of call demand, a significant amount of downtime is observed by Adult RRT/Code Team, as well as Pediatrics RRT and Pediatrics Code Team. Staffing any emergency response service includes substantial downtime, and high costs. This is true for ambulance services, emergency services, fire departments, etc. However, by combining emergent/urgent nurse response services differently, there is an opportunity of reducing costs without losing functional roles by merging. Combination A would realize the most savings The team s analysis showed that greatest savings can be realized by merging all the emergent/urgent services, even when calculated with the most costly FTE rate of a SWAT nurse. By merging services, downtimes are pooled and reduced. An estimated total 7. FTEs will need to be reallocated to staff for this combination. Appendix L shows a table with how to staff the addition FTEs. An example of how this combination would be staffed is for SWAT RNs to respond to all calls. As a group, SWAT nurses are already adequately trained to take on the extra responsibilities. Combination B would realize the second least savings Combination B calls for the merging of SWAT and Adult RRT/Code Team. An estimated total 6.94 FTEs will need to be reallocated to staff this combination. The FTEs allocated to Pediatrics RRT will remain at 2.5 FTEs. Appendix L shows a table with how to staff the addition FTEs. Despite realizing the second least savings, this combination is a natural progress towards greater savings in the implementation of Combination A. Combination C would realize the least savings If Combination C were to be implemented, it would realize the least savings. Therefore, it should not be recommended. An estimated total 5.6 FTEs will need to be reallocated to the combined services for this combination. The FTEs allocated to Adult RRT/Code Team will remain at 5. FTEs. Appendix L shows a table with how to staff the addition FTEs. Like Combination B, this combination could be an intermediate step towards greater savings in the implementation of Combination A. Combination D would realize the second most savings Combination D requires either the SICU or PICU to take on the other units RRT and Code Team responsibilities, and would lead to lesser savings than Combination A. The staffing method of combining Adult RRT/Code team, with Pediatrics RRT and Pediatrics Code team responsibilities would require several steps. First, it must be identified which ICU or group of ICUs to take on this responsibility. Next, the cross training of nurses would be necessary to cover 29

37 the other service s responsibilities. The additional cost and time of cross training was not factored into the team s calculations, but should be taken note of. Furthermore, this combination calls for nurses to cover patients and areas in the hospital that are not usually in their daily job scope. An estimated total 5. FTEs will need to be allocated towards the unit covering the combined responsibilities. Since there is no change to SWAT s responsibilities, the current 3.6 FTEs allocated to SWAT will remain unchanged Recommendations After analyzing the collected data and discussions with the client, the team recommends Combination A as it would realize the greatest savings. This combination calls for merging SWAT, Adult RRT/Code, Pediatrics RRT, and Pediatrics Code Team into a single unit. An estimated savings of $23,572.2 will be realized. Further training, development of standard operating procedures and best practices should be established in responding to RRT and Code calls, and integrated with SWAT s current responsibilities. In particular, with greater responsibilities in terms of types of calls, and call demand, a detailed backup system of responding to multiple calls at a time needs to be developed, documented, and communicated during implementation. An implementation plan involving a gradual progression from the current state to Combination B, before reaching full scale combination of all services is recommended. The team also recommends further investigation of travel time for nurses staffed to this combination to respond to calls from different parts of the hospital. This is essential in maintaining the quality of health care service provided to patients. Expected Impact The team has recommended an organization and staffing approach that minimizes Full Time Equivalent (FTE) and reduces costs while ensuring high probability of meeting the demand of calls. The recommendations should have the following impact on emergent/urgent response service nurses: Developed and analyzed optional staffing models to meet demand. Maintain or improve the quality of service. Reduce the cost and FTE. 3

38 Support Received from Operating Entities The team met weekly with the client and the project coordinator separately. During these weekly meetings, the current status and direction of the project was discussed. The client helped coordinate meetings with required staff and provided previously collected existing data. The following individuals participated actively in and contributed to the success of this project: Kathleen Moore, Administrative Director, Nursing Administration, Client Dr. Richard J. Coffey, Director of Program & Operations Analysis, Project Coordinator Maureen Thompson, Patient Safety Officer, Office of Chief of Clinical Affairs Denise Landis, Manager of Critical Care Transport Matt Green, SWAT Nurse, Critical Care Transport Lisa King, SWAT Nurse, Critical Care Transport MaryAnn Bettis, Nurse Manager, Surgical ICU and Adult RRT Sharon Dickinson, Clinical Nurse Specialist, Surgical ICU and Adult RRT Daniel Lagrou, SICU Clinical Nurse Supervisor Julie Juno, Nurse Manager, Pediatric ICU and Pediatric RRT Annette Scott, Clinical Nurse Specialist, Pediatric ICU and Pediatric RRT Alyssa Akers-Nowicki, Nursing Supervisor, Pediatric ICU and Pediatric RRT 3

39 Appendix A: Job Requirements Required Qualifications Desired Qualification Required Not Required SWAT Nurse Adult RRT/Code Nurse Ped RRT Nurse Ped Code Team Nurse (Charge Nurse) Current Michigan Licensure as RN Minimum 5 years nursing experience (including adult/pediatric critical care with Adult ICU, Ped ICU, Flight Nurse, CSR ICU Float, ED) Independent Decision Making Skill Outstanding Interpersonal Skills Minimum year nursing experience Excellent Clinical Judgement and Skills Good Communication Skills Nursing License Bachelor of Science Nursing (BSN) Basic Cardiac Life Support (BCLS) Advance Cardiac Life Support (ACLS) Pediatric Cardiac Life Support (PALS) Neonatal Resuscitation Program (NRP) Demonstrated effective problem solving skills (ie. Triage abilities, feedback/evaluations) Demonstrated leadership abilities, charge nurse role and/or preceptor experience Demonstrated professional responsibility and accountability Committee/unit involvement Specialty Certification (CEN, CCRN) Float Experience

40 Appendix B: Comparison of Other Hospitals RRT Hospitals University of Pittsburgh Medical Hospital St. Barnabas Hospital Vanderbilt University Hospital Duke University Health System Implemented Condition H? Does RRT s reduce mortality rate? No Data No Data No Data by 85 % Johns Hopkins Children s Center No Data Staff requirements for RRT s Internal medicine house physician Admin. nurse coordinator Patient relations coordinator Floor nursing staff member Nurse practitioner or critical care physician PICU charge nurse Respiratory therapist Rover Team Yes No B

41 Appendix C: Statistics of Backup RNs Needed C