A 65-year-old male, status postcholecystectomy with a history of sleep apnea, complains of difficulty breathing. His nurse notes that he's dyspneic with a respiratory rate of 30 breaths per minute and an Spo2that has dropped to 87% on 4-liter o2via nasal cannula. Worried, the nurse calls the attending surgeon, who orders additional morphine and increases the patient's o2to 6 liters. The patient "calms down," and his respiratory rate lowers to 24 breaths per minute, but his Sp o2falls to 85%. The nurse places another call to the attending surgeon. He asks the nurse to arrange for the medical resident to see the patient. The resident (House Officer Year 1) speaks to the nurse via phone and orders the following tests: arterial blood gases, chest x-ray, ECG, CBC, and electrolytes. The resident indicates that she'll see the patient after she finishes evaluating a new patient in the emergency department. Ninety minutes later, the resident reviews the labwork and asks the senior resident to see the patient with her. As the residents enter the patient's room, the patient stops breathing. A "code" is called. The patient survives, but spends the next 2 weeks in the ICU on a ventilator.
Does this scenario sound familiar? If so, in your opinion, was there anything wrong with the care of this patient? For many, the answer is no. This scenario is a normal, daily occurrence in countless inpatient settings. What if your facility had a system in place that allowed you to respond to the patient's deteriorating condition more rapidly and more efficiently? And what if this system prevented the patient from suffering a respiratory arrest? Many U.S. hospitals have recently embarked on a journey to create such a system by implementing rapid response teams (RRTs).
Three fundamental problems
People die unnecessarily every day in our hospitals. It's likely that most clinicians can provide an example of a patient who, in retrospect, shouldn't have died during his or her hospitalization. There's currently great variability in healthcare across both quality and safety. 1 In addition, recent research indicates that this variability exists specifically in hospital mortality rates. Even when multiple risk factors and community factors are considered, there's no clear explanation of differences from hospital to hospital. 2 And yet, we have an opportunity to reduce this variability by improving hospital care.
Numerous organizations are working with the Institute for Healthcare Improvement (IHI) to understand the causes of the problem, as well as potential improvement strategies, as part of the IHI's Innovation Community on Reducing Hospital Mortality Rates. The conclusions from this work and a review of the literature suggest that three main systemic issues contribute to the problem:
1. failures in planning (including assessments, treatments, and goals)
2. failure to communicate (patient to staff, staff to staff, staff to physician, etc.)
3. failure to recognize deteriorating patient condition.
These fundamental problems often lead to a failure to rescue. To address these issues, organizations across the country have begun implementing RRTs, also known as medical emergency teams. RRTs enable system redesign, bringing critical care expertise to the patient to augment the floor nurse's evaluation of the situation and provide early intervention to slow or prevent the patient's clinical deterioration. Studies indicate that patients exhibit signs and symptoms of physiological instability-frequently respiratory in nature-for some period of time, often as long as 6 to 8 hours prior to a cardiac arrest. 3-7
RRTs have been shown to reduce the incidence of cardiac arrests outside the ICU by 50% and prior to ICU transfer by 25% to 30%. RRT usage can decrease overall hospital mortality by as much as 26%. Using physiological criteria consistent with clinical deterioration, nurses can call RRTs to assist 24 hours a day. Because nurses rely heavily on experience when making complex decisions, it's important that the system of care supports their abilities to develop clinical skills while providing safe and timely care. 8
RRT rollout
To successfully implement an RRT, take the following actions:
[white diamond suit] Engage leadership support.
Pursuing system-level redesign or improvement activities without the support of your facility's leaders is often a recipe for failure. Administrative commitment to the strategic direction and overall goals-lower mortality and fewer cardiac arrests-is critical to the team's success. How these goals are adopted, articulated publicly, and communicated by leaders to various stakeholders is of importance. Identify nurse and physician leaders who'll champion the cause and educate colleagues on the benefits of RRTs.
[white diamond suit] Recognize RRTs play several key roles.
In addition to assisting the staff with assessing, stabilizing, and if necessary, transferring the patient to a higher level of care, RRTs can also help organize the information communicated to the patient's physician. Communication failures are a leading cause of unintentional patient harm. Organizing the information using a predictable, structured communication tool such as SBAR (situation, background, assessment, recommendation) can facilitate the transmittal of critical patient information in a clear, concise, and predictable manner. 9,10 The RRT can assist the patient's nurse in formulating the SBAR.
Initially, organizations may fear that RRTs will lessen the critical-thinking skills of non-ICU nurses. But, the opposite may be true. Ultimately, the goal is to build the critical-thinking capacity in non-ICU nurses. In their role as educators, RRT nurses have a unique opportunity for real-time education of non-ICU staff at the very time a clinical situation presents itself to non-ICU colleagues.
[white diamond suit] Determine the best structure for the team.
Data indicate that many different RRT models work well. Team members must be available to respond immediately each time they're called and can't be constrained by competing responsibilities that prevent them from responding to a call within minutes. They must have the skills necessary to assess and respond to critical situations. At a minimum, the team should include a nurse with critical care experience and a respiratory therapist. Other team members might include an intensivist, hospitalist, resident, or physician assistant.
It's helpful to examine current resources and major cultural influences when choosing RRT members in order to build on existing positive relationships and practice patterns. Select each member of the team carefully. Examine potential team members' skills as educators as well as clinical responders. Nurses must feel comfortable calling and interacting with the team. Nurses often feel unsure and anxious when calling the team, questioning if their decision was correct. This requires reassurance each and every time. Given the average length of a call (20 to 45 minutes) and the frequency with which calls occur (approximately 10 to 15 times per month, per 100 occupied beds), many organizations have been able to reallocate existing resources, particularly where ICU charge nurses don't carry patient assignments during the time they're participating as a member of the RRT. The power of the relationships that develop between staff nurses and team members can't be underestimated.
[white diamond suit] Provide education and training.
In addition to having advanced critical care or ACLS training, RRT members should receive education and training together that includes the following:
- SBAR: The team should use this as its established method of communicating and receiving communications.
- Communication: Members must respond in a timely, professional, and friendly manner. Members must also provide constructive, nonjudgmental, nonpunitive feedback to the person calling.
- Criteria: The team should learn the reasons for calls and notification procedures.
- Documentation requirements: Nursing staff should receive education and training regarding the criteria for calling and procedures for notifying the team, including basic communication and teamwork skills-SBAR, assertiveness, and the use of critical language-and documentation requirements. Medical staff should receive education regarding the potential benefits of having fast and accurate critical patient assessment available 24 hours a day, 7 days a week. It's also important to alleviate any fears about exclusion from the decision-making process, particularly at organizations in which the RRT includes a physician member.
[white diamond suit] Establish criteria and mechanisms for calling.
Each organization should determine the criteria and mechanism (for example, via beeper) used for calling the RRT. (See "Sample adult criteria.") At least two different approaches exist for calling the RRT. One approach is to educate staff members to the criteria and encourage them to call when any criteria are met or when they're worried about the patient, even though the patient may not meet any specific physiological criteria. Most organizations have chosen this approach. Another approach is to mandate staff to call when any criteria are met. After piloting, be sure to educate in the areas of interventional radiology, the GI suite, etc. Ultimately, all hospital employees should receive education regarding the team and the mechanism for calling.
[white diamond suit] Create a structured documentation tool.
The documentation form should capture information about the reasons for the call, as well as the type of interventions required and patient disposition. The team can use the form to capture and organize information about the patient condition prior to calling the physician. This information can then be analyzed for trends and used for educational purposes through existing quality improvement programs, such as, "with our push to improve our pain scores, we're unexpectedly seeing an increase in respiratory events related to narcotics." A sample documentation form and other resource materials are available at http://www.ihi.org. Constructing the documentation tool to include the SBAR communication technique can be quite effective at embedding the process into a clinician's usual practice.
[white diamond suit] Devise feedback mechanisms.
Providing feedback to involved staff regarding the patient's condition, sharing stories of positive patient outcomes throughout the organization, and letting staff know the call they placed to the RRT made a difference in patient outcome can be an effective means of driving cultural change and raising awareness about the potential benefits of activating the team.
[white diamond suit] Measure the team's effectiveness.
You can use four basic measures to evaluate RRT effectiveness. These include overall unadjusted hospital mortality, codes per 1,000 discharges, codes outside the ICU, and the number of RRT calls. For operational definitions of these measures, visit http://www.ihi.org.
Organizations may wish to collect data on other measures as well, such as postcardiac arrest ICU bed utilization, staff satisfaction with the RRT, nursing turnover, average ICU patient length of stay following an RRT call versus non-RRT, unplanned medical-surgical ICU admissions, RRT calls transferred to higher levels of care, postcardiac arrest ICU and hospital days, post-cardiac arrest survival rate to discharge, and safety culture data.
Revisiting the case scenario
A 65-year-old male, status postcholecystectomy with a history of sleep apnea, complains of difficulty breathing. His nurse notes that he's dyspneic with a respiratory rate of 30 breaths per minute and an Sp o2that has dropped to 87% on 4-liter o2via nasal cannula. Worried, the nurse calls the RRT. Within 5 minutes, the patient is assessed by the RRT nurse and respiratory therapist. Intake and output are reviewed, and the patient is noted to be in negative fluid balance. The nurse calls the attending physician and, using SBAR, informs him or her of the patient's potential fluid overload status. Orders for lab work and chest x-ray are obtained, and the patient is started on bilevel positive airway pressure. The portable chest x-ray findings confirm fluid overload. The patient is given furosemide (Lasix) intravenously, and after 30 minutes is transferred to a step-down unit. The surgical nurse caring for the patient receives an update on the patient's condition during her next shift on duty. The diuretic is effective, and the patient returns to the general surgical floor the following day. The patient is discharged from the hospital 2 days later.
The healthcare system in the post-RRT case scenario is one that's designed to prevent unnecessary clinical deterioration in this patient. Needless patient harm and suffering were avoided. The nurse and attending physician benefited by the team's fast, accurate assessment and treatment. The risk of this patient developing ventilator-acquired pneumonia was eliminated. Costly ICU resources were made available to another waiting patient. And, in a healthcare environment that struggles to retain valuable nursing resources, this surgical nurse was supported and empowered to provide the best care possible for her patient.
Sample adult criteria for calling an RRT
Contact the RRT anytime a staff member is worried about the patient, or the patient experiences an acute change in:
[white diamond suit] heart rate: 40< or >130 beats/min
[white diamond suit] systolic blood pressure: <90 mm Hg
[white diamond suit] respiratory rate: 8< or >28 per min
[white diamond suit] pulse oximetry reading: <90% despite oxygen administration
[white diamond suit] urine output: <50 ml over the last 4 hours
[white diamond suit] conscious state.
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