rapid response team patty gessner, rn msn alexian brothers medical center
TRANSCRIPT
Rapid Response TeamRapid Response Team
Patty Gessner, RN MSNAlexian Brothers Medical Center
ConceptConceptRespond rapidly and effectivelyRestructure the way care is delivered
– Bring the ICU to the patient– Bring the RN and RT out of the ICU to ‘triage
in the field
BackgroundBackground
Originated in the early 90’sFirst published study Australia in 2002
– 50% reduction in unexpected hospital deaths
Supported by the Institute for Healthcare Improvement
Which Hospitals Need RRT?Which Hospitals Need RRT?
The hospital that has ever wondered if a code could have been avoided
The hospital that has ever investigated a code and found obvious signs of deterioration in the hours preceding the arrest
RationaleRationale
Unexpected cardiac arrests are preceded by critical signs of instability (Kleinpell, 2002)
Junior staffICU admissions often suffer a delay in
optimal care prior to their admission (Bristow, 2000)
Key Factors Contributing to Key Factors Contributing to Delay of TreatmentDelay of Treatment
Failure to rescue– Failure to educate– Limitation of Skill
Review of the LiteratureReview of the Literature
Reduction of the relative risk of mortality79% for respiratory failure78% for stroke74% for severe sepsis88% for acute renal failure
(Critical Care Medicine 32(4): 916-921)
Review of the LiteratureReview of the Literature
Retrospective analysis of 3269 RRT calls and 1220 cardiopulmonary arrests over 6.8 years
Reduction in the monthly incidence of cardiopulmonary arrests by 17%
(Quality Safety Healthcare 13:251-254)
Review of the LiteratureReview of the Literature
Reduction in the number of unnecessary ICU admissions by 30%
Number of cardiac or pulmonary arrests outside critical care reduced by 50%
Reduction in hospital mortality by 15%
(Quality Letter 16(12):2-9)
Review of the LiteratureReview of the Literature
Reduction in code blue by 28%Number of code blues outside of critical
care dropped from 65% to 35% in 6 months time
Survival to discharge has doubled
(Quality Letter 16(12):2-9)
What Other Hospitals Have To What Other Hospitals Have To SaySay
“Both RT and nursing highly benefit from this collaborative effort”
“One key way of assisting with ventilator LOS is to prevent the patient from going on the ventilator in the first place”
“It also allows physicians the capability to start drips on the floor…”
OHRU writes “We began with 4 test units, but within a week we had a visit requested by another unit so we quickly opened the service housewide”
Getting StartedGetting Started
Do not rely on administratorsDriven by clinicians
About usAbout us
Alexian Brothers Medical Center
Located in Elk Grove Village Illinois
Non-teaching community hospital
370 bed
Level II Trauma
32 total ICU beds
Our ProgramOur Program
Proposal developed in June 2004
Approval achieved through medical and nursing departmental meetings
Awareness through attendance at the town hall meetings, flyers, and through the efforts of key support personnel
Start date October 1st 2004
ProtocolProtocol
On the scene within 5 minutes30 minutes per call
Activation of the TeamActivation of the Team
Staff recognize crises and call RRT phone
Criteria to call– Respiratory distress– Acute changes in heart rate or blood pressure– Acute changes in mental status– Uneasy feeling
Team MembersTeam Members
Critical care APN or designeeCritical care Respiratory Therapist Intensivist
Units IncludedUnits Included
All inpatientsPatients in ED and day surgeryPatients in interventional/diagnostic
departments
Spectrum of ServicesSpectrum of Services
Stroke teamSepsis team
Team ExpectationsTeam Expectations
Work under the auspices of an ICU without borders Patient assessment and management Assist communication between nurse and physician Document in patient chart Facilitate transfer to higher level of care Staff education Thank staff for calling early Complete log
Floor Staff ExpectationsFloor Staff Expectations
Initiate call to attending physician and the RRT team
Describe the patient’s history, current condition, and how the support team can help
Participate in patient management
Building a ProgramBuilding a Program
If you build it
they may come,
but if you don’t educate
they won’t call
Outcome MeasuresOutcome Measures
Calls resulting in transfer to the ICUNumber of avoided codesSurvival of codesNumber of arrests outside critical careStaff, physician, and family satisfaction
DataData
The next slides represent data collected – 99 calls logged between October 2004 through
April 2005
RRT Reason for CallRRT Reason for Call
39
33
1215
0
5
10
15
20
25
30
35
40
RESP CARDIAC LOC OTHER
Calls By Nursing UnitCalls By Nursing Unit
32%
12%7%15%
7%
22%
5% Tele
Ortho
Neuro
Oncology
Med
Surgical
Other
RRT Time of CallRRT Time of Call
0
510
15
20
2530
35
07-09 10-12 13-15 16-18 19-21 22-00 01-03 04-06
RRT OutcomeRRT Outcome
66%
34%
transferred
stabilized
$
$ $
$$
Code Blue By LocationCode Blue By Location
0
2
4
6
8
10
12
14
16
18
3rd Qtr 4th Qtr 1st Q 2005
critical care
all others
Implement RRT
Survival of CodeSurvival of Code
0
5
10
15
20
25
30
35
3rd Qtr 4th Qtr 1st Q 2005
% survived
ResultsResults
9 codes were averted 7 patients were made DNR
Avoided transfer to ICU in 34% of cases
Average time spent on call was 39 minutes
Peak call times have lead us to further investigation
Positive feedback from staff, physicians, and families
Close CallsClose Calls
Mr. MMr. M
Respiratory distressStaff waiting for assistanceRR 40’s, unequal breath sounds,
acrocyanosis, 90% on NRB
Mr. PMr. P
29 y/o s/p hip replacementHistory of failed kidney transplantOn dilaudid PCARR 8, 55% saturations
Mrs. PMrs. P
Staff called to ask for an ICU bed, reason given – needs intubation
Investigation revealed84 y/oRR less than 8 bpmPH 7.18 PCO2 89
Mrs. DMrs. D
Called for tachycardia, hypotensionNot assessed was the acute abdominal painTreated with analgesia and a surgical
consult
Mr. PMr. P
Called to evaluate desaturationsPaO2 39Immediate intubation
Key to SuccessKey to Success
Immediate availabilityNo questions asked
BenefitsBenefits
Provide early interventions for patientsProvide support for the bedside nurseImprove relations between nurses and
physiciansIncrease staff satisfaction
Challenges and Lessons Challenges and Lessons LearnedLearned
Acceptance of Attending Physicians Use standing protocols Keep attending informed
Difficulties with the phone Education Back up pager
Ongoing staff awareness Signs Presentations at unit meetings Information both
Next StepsNext Steps
Reduce codes that occur outside ICUIncrease awareness on night shift Retrospective examination of cases during
the peak timesProvide feedback to staff that initiated callConsider switching to a paging system
