Background
St. Barnabas Hospital took part in the IHI’s 100 K Lives Campaign challenge to make health care safer and more effective. In April 2006, Rapid Response Team was formed and implemented in St. Barnabas Hospital. A Rapid Response Team is a Team of clinicians who bring critical care expertise to the patient bedside.
Statement of the Issue
The need for Rapid Response Team was prompted by the information from studies that despite advances in treatment for cardiac arrest, only 17% of patients who experience a cardiac arrest survive to discharge. Survival rates are higher when arrests occur in monitored units than in non-monitored units. (Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adults in the hospital: a report of 14,270 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 2003;58:297-308. Sandroni C, Ferro G, Santangelo S, et al. In-hospital cardiac arrest: survival depends mainly on the emergency response. Resuscitation. 2004;62:291-297). Several studies indicate that patients often exhibit signs and symptoms of physiological instability for some period of time prior to a cardiac arrest. (Schein RM, Hazday N, Pena M, Ruben BH, Sprung CL. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest. 1990;98(6):1388-1392.) Patients developing arrest in the general hospital ward services have predominantly respiratory and metabolic derangements immediately preceding their arrests. Their underlying diseases are generally not rapidly fatal. Arrest is frequently preceded by a clinical deterioration involving either respiratory or mental function. (Franklin C, Mathew J. Developing strategies to prevent in hospital cardiac arrest: analyzing responses of physicians and nurses in the hours before the event. Crit Care Med. 1994;22(2):244-247). The fundamental failures in planning, communication and failure to recognize deteriorating patient condition, often lead to a failure to rescue. Rapid Response Team will serve as an important function in identifying patients who have acute symptoms prior to calling a “code”.
Project Goal
Prevent deaths in patients who are failing outside the critical care areas by implementing a Rapid Response Team. The ultimate goal is to save patient lives and eventually improve quality of hospital care and improve patient safety.
Methods
Recognize patients who are failing clinically which warrant a Rapid Response Team by using the criteria for calling RRT (see attached criteria card). Rescue patients who are clinically unstable by calling for Rapid Response Team. The mechanism for Rapid Response Team activation is thru an overhead page and designated RRT beepers. The Rapid Response Team members are composed of the medical chiefs, senior house, nurse manager/nurse supervisor. The respiratory therapist and the ICU attending are informal team members who may be called for rapid consultation. The role of the Rapid Response Team is to assess, stabilize, assist with communication, educate, support and assist with transfer of a patient to a higher level of care, if necessary. The Team members have the critical care skills necessary to assess and respond rapidly before the patient has a cardiac arrest or other adverse event. The Rapid Response Team Record form (see attachment) was utilized to serve as a documentation tool to measure effectiveness and to establish a feedback mechanism. The RRT was initially piloted for 2 weeks in only 1 unit (7 NO) however, all the other units of the hospital wanted to be involved and be a part of the campaign as soon as possible. This was apparent by the frequent activation calls of RRT outside the initial pilot unit. In addition, there were requests from other hospital personnel to have the RRT campaign instituted in their own units.
Results
Based on the 6 months of data (April 2006- September 2006), from the implementation, there were a total of 93 Rapid Response Team calls, averaging 15.5 activation calls per month.
The total Team 1 codes are reduced by 31 %(see attachment). Therefore early intervention of the Rapid Response Team has decreased the number of patients, which requires calling a code and thus preventing unnecessary deaths. 40.8 % of patients are transferred to ICU for closer monitoring after RRT. The primary reason for calling RRT is due to acute change in mental status of patients: 27%. Acute change in respiratory rate comes only second at 18% (see attachment).
Overall, floor nurses has positive reception towards the goal of the RRT campaign. The presence of nurse manager/supervisor on the floor serves as a motivator and an educational resource. There was also an overwhelming positive feedback from attending physicians, residents/interns, and even unit clerks who has initiated the RRT. The intervention also increased patient safety awareness and effective communication between the RRT responders and initiators. The focus of patient care has shifted from individual assessment and treatment to team forming for better patient outcome.
