Rapid Response Team and Patient Safety Terrence Shenfield BS, RRT-RPFT-NPS Education Coordinator A & T respiratory Lectures LLC
Objectives History of the RRT/ERT teams National Statistics Criteria of activating the RRT/ERT Outcomes of RRT/ERT Joint Commission and IHI Focus on Patient Safety Family involvement Effective communication
RRT/ERT Intro Video
History of the RRT/ERT The Institute of Medicine (IOM) published an alarming report called, To Err is Human: Building a Safer Health System ( 1999) 44,000-98,000, die in hospitals each year as a result of preventable medical errors Report suggested that these preventable medical errors cost between $17 billion and $29 billion per year nationwide
History of the RRT/ERT IHI (Institute for Healthcare Improvement ) 100,000 Lives Campaign in 2005 First coined the name Rapid Response Team The goal of the campaign was to significantly reduce morbidity and mortality in American health care On June 14, 2006, the IHI announced that in the 18-month time frame, more than 122,300 lives were saved with implementation of the RRT/ERT Joint Commission National Patient Safety Goals in 2008 reinforced the need for a team of specially trained responders Specifically, Goal 16 stated, Improve recognition and response to changes in a patient s condition.
National Statistics Reduced non-icu arrest by 50% Reduce deaths by 37% Initiated by patient families not just HCP Most hospitals have a system in place Survival rate was greater than 80% for RRT/ERT Versus 15 % cardiac arrest cases ( case-mix may vary results)
What is a Rapid Response Team? Rapid Response Teams (RRT) are summoned at any time by any staff in the hospital to assist in the care of a patient who appears acutely ill, before the patient has a cardiac arrest or other adverse event.
Choosing Members of Your Team Consider skill set ( what type of skills are being brought to the team) Communication skills Attitude and behavior Family members should be encouraged to activate the rapid response team without regard to distinguishing cardiopulmonary arrest Facility should have a process for educating patients and families on how to activate the rapid response team Situation, Background, Assessment, Recommendation (SBAR)- preferred method of communication
Preferred Outcomes of RRT/ERT Team Early intervention and stabilization to prevent clinical deterioration of any individual prior to cardiopulmonary arrest or other life-threatening event Decrease the number of cardiopulmonary arrests that occur outside of the intensive care unit and emergency department Increase patient, family and staff satisfaction Decrease hospital mortality
Members of RRT Team Members Critical Care Charge Nurse Respiratory Therapist PA or MD? Required no additional FTEs Staff continue usual responsibilities in addition to RRT calls
Interventions and Practices Considered Recognition of a worrisome or acute clinical change Quick assessment of respiratory status, heart rate, blood pressure, neurological changes, chest pain, uncontrolled bleeding Developing a behavioral emergency response team (BERT) to assist staff in proactively de-escalating patients who may be exhibiting potentially violent behaviors Implementation of an early warning score system Activation of the rapid response team Education of patients and families on how to activate rapid response teams
Interventions and Practices Considered Continued.. Initiation of appropriate interventions e.g., oxygen therapy, intravenous fluid administration, Narcan or D50, resuscitation if needed Consultation with the inpatient's appropriate provider and development of a continuing plan of care Situation, background, assessment, recommendation (SBAR) communication among team members Transferring the patient to a higher level of care (e.g., ICU ) when indicated Follow-up
Criteria for Rapid Response Team Activation Acute significant change in vital signs or status He/she does not "look right." The medical provider may have a "gut" feeling that something is not quite right with their patient Based upon previous experience with the same patient or a similar incident with another patient
Criteria for Rapid Response Team Activation Apnea Heart rate over 140/min or less than 40/min Respiratory rate over 28/min or less than 8/min Systolic blood pressure greater than 180 mmhg or less than 90 mmhg Oxygen saturation less than 90% despite supplementation Acute change in mental status
Additional criteria used at some institutions Chest pain unrelieved by nitroglycerin Dysrhythmia Threatened airway Seizure Uncontrolled pain Urine output less than 50 cc over 4 hours Staff member has significant concern about the patient's condition
What The JC and IHI Suggested Institute for Healthcare Improvement and Joint Commission National Patient Safety Goals have set recommendations to improve the safety of patients Does not mandate *Require hospitals to implement systems to enable "healthcare staff members to directly request additional assistance from a specially trained individual(s) when the patient's condition appears to be worsening"
Most common reason ERT are called The primary reason given for activating the RRT/ERT was acute respiratory insufficiency accounting for 40% of calls > 20% required some type of mechanical respiratory support of which 10% is NIV Advanced cardiac life support without cardiopulmonary resuscitation was used in > 17% of patients to treat heart rhythm disturbances Resuscitate shock with vasopressors if intravenous fluids alone did not prove adequate
Admittance to the ICU via the RRT/ERT for general floors Excluding normal ICU admittance practices over 50% of ICU admissions came from the RRT/ERT system Common characteristics of patients Older patients Severe comorbidities Higher severity score ( APACHE & SAPS 2) 3 times more often the diagnoses of sepsis upon admission
Admittance to the ICU via the RRT/ERT for general floors Around 20% of RRT/ERT admitted patients had severe sepsis as their admitting diagnosis RRT/ERT patients more often present in less obvious ways through deviations of pulse, blood pressure, or respiratory rate (subtle changes) Multiple RRT/ERT calls are made to this vulnerable group of patients RRT/ERT seem to play an important part in ethical and end-of-life care discussions
Outcomes that demonstrate patient safety Initiatives Cardiac arrest decreased from 7.6 to 3.0 cases per 1000 discharges per month ( roughly 60% decrease) Hospital mortality decreased from 2.82% to 2.35% Unplanned ICU admissions decreased from 45% to 29% Average LOS increased slightly ( as expected)
Family Members Calling of RRT/ERT Sorrel King ( hospital staff failed to recognize dehydration despite repeated concerns from mother) University of Pittsburgh Medical Center (UPMC) Shadyside and Children s Hospital ( 1 st in the nation to involve families in calling ERT s) Upon admission, patients and family members are invited to pick up any phone in the hospital to report a Condition H (for help ) fear something is seriously wrong and have expressed their concerns without validating or recognizing its potential importance experience a communication failure with the staff become confused about the patient s care need to know where to voice concerns feel something about the patient s condition is just not right Absolutely will improve Press Gainey scores
Effective Communication and Teamwork to Improve Safety of Patients Teamwork and communication have been important factors in improving safety in highrisk industries by overcoming hierarchical barriers, human limitations and system vulnerabilities Studies of flight crews indicate that focusing on individual human performance does not produce optimum safety in a team environment Surveys of surgical and intensive care teams find that nurses are less satisfied with the quality of teamwork, collaboration, and communication compared with physicians
Effective Communication and Teamwork to Improve Safety of Patients HCP frequently reported It is difficult to speak up Disagreements are not appropriately resolved More input into decision making is needed HCP input is not well received Recurring safety problems include delays in critical decision making poor communication between disciplines involved in care failure to escalate communication to obtain help inconsistent mobilization for emergency interventions
Structured communication Situation-Background-Assessment- Recommendation (SBAR) is an easyto-remember framework for communicating essential information in critical situations Situational awareness Performance is enhanced when individuals in a team maintain a shared understanding of the situation at hand, what is likely to happen next, and what to do if the expected does not happen
Structured communication Debriefing: After an event or activity, the team asks itself the following questions: What did we do well? What did we learn? What could we do better? What systems need correcting? Who is responsible for following-up? The quality of the debriefing is directly related to the quality of the briefing. Debriefing after an adverse event has occurred can be especially important to help team members cope and recover
Summary Select team members carefully Give adequate resources to team Promote family involvement Effective communication and follow up SBAR Measure outcomes
References ICU Admittance by a Rapid Response Team versus Conventional Admittance, Characteristics, and Outcome Gabriella Jäderling, MD, et al. Crit Care Med. 2013;41(3):725-731 The Effect of a Rapid Response Team on Major Clinical Outcome Measures in a Community Hospital. Michael J.Dacey, MD, FACP, et al. Crit Care Med. 2007;35(09):2076-2082. Institute for Healthcare Improvement. Rapid response teams: Heading off medical crises at Baptist Memorial Hospital-Memphis. Available at: www.ihi.org/