Applying quality improvement meth-ods used in business to health care isa slippery slope, as anyone workingwith patients can tell you. So when

the first National Demonstration Project onQuality Improvement in Health Care waslaunched back in 1986 to explore the applica-tion of modern quality improvement methodsto their industry, health care leaders were, nodoubt, skeptical.

As the concept has matured over the years,however, hospitals have learned that whatworks in the wider world can work for themtoo. Nowhere has that been more evident than

in the initiatives established in 2004 by theInstitute for Healthcare Improvement (IHI),the group that grew out of that initial demon-stration project and is now driving majorchanges in the nation’s hospitals.

Over the past two years, more than 3,000hospitals — representing an estimated 75 per-cent of all U.S. hospital beds — have signed onto the IHI’s 100,000 Lives Campaign, imple-menting six quality improvement changes intheir facilities aimed at saving lives. (See side-bar for the complete list of changes.)

The AARC signed on as a campaign partnershortly after the initiative began; and from the

R a p i d R e s p o n s e Te a m s

52 AARC Tımes December 2006

Every nurse has been in

this position: A patient’s

vital signs are failing and

he just doesn’t look good.

In the past that meant,

put a call into the

physician and wait.

Now it means summon

the rapid response

team and get the

kind of immediate

assistance necessary

to keep a bad situation

from getting worse.

by Debbie Bunch

R a p i d R e s p o n s e Te a m s

beginning, respiratory therapistshave played a key role in the mostprominent of the initiatives — thedevelopment of “rapid responseteams” to quickly address the needsof patients who are rapidly failingoutside of the ICU. Teaming upwith nurses and sometimes physi-cians and pharmacists, therapistsare rushing to the bedsides ofpatients in need, delivering thetimely care necessary to stop dete-riorating conditions in their tracks.

RTs answer the cal lRespiratory therapists owe their

key involvement on these teams tothe fact that most cases involving arapid decline outside of the ICUhave a respiratory component.“Most critical events in a hospitalrelate to or have a component of acompromised respiratory status, soit is a natural fit to have a therapistas part of the team,” says JoeRohling, BS, RRT, manager of res-piratory therapy and transport ser-vices at Saint Clare’s Hospital inWeston, WI. The facility has had ateam in place since it first openedits doors last year. “Many times atherapist is the first call for addi-tional assessment or assistancewith patients whose status is dete-riorating,” notes Rohling.

As a brand new facility, Rohlingsays implementation of the rapidresponse team concept at SaintClare’s was a given, and inclusion ofan RT on the team along with anICU registered nurse (RN) wasnever in question. Richard Bailey,MD, FACP, who played a key role inthe development of the team,agrees. “Being a new organization,we had an overall young staff andwanted to do everything possibleto have the people succeed in theirroles.” They examined the modelsthat worked, and all had a respira-

R a p i d R e s p o n s e Te a m s

54 AARC Tımes December 2006

Activate a Rapid Response Team at the first sign that apatient’s condition is worsening and may lead to a moreserious medical emergency.

Prevent patients from dying of heart attacks by deliveringevidence-based care, such as appropriate administrationof aspirin and beta-blockers to prevent further heartmuscle damage.

Prevent medication errors by ensuring that accurate andcontinually updated lists of patients’ medications arereviewed and reconciled during their hospital stay,particularly at transition points.

Prevent patients who are receiving medicines and fluidsthrough central lines from developing infections byfollowing five steps, including proper hand washing andcleaning the patient’s skin with chlorhexidine.

Prevent patients undergoing surgery from developinginfections by following a series of steps, including thetimely administration of antibiotics.

Prevent patients on ventilators from developingpneumonia by following four steps, including raising thehead of the patient’s bed between 30 and 45 degrees.

100k lives CampaignSOME IS NOT A NUMBER. SOON IS NOT A TIME.

Goals of the

12

3

4

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R a p i d R e s p o n s e Te a m s

tory therapist as part of the team.At Saint Clare’s, the RT and RNrespond to the initial call, then call in a hospitalist if the situationwarrants.

The decision was made in thebeginning to have a respiratorytherapist on the team because wewanted to have as many supportpeople as we could to stabilize andpossibly transfer the patients asappropriate, as well as to facilitateteaching and education of thosewho request the rapid responseteam, says Jennifer Stankowski,RN, who headed the team forma-tion.

The Saint Clare team includes allthe respiratory therapists on staff.Rohling says, “Besides BLS*, alltherapists maintain an ACLS* andNRP* certification.”

Team configuration variesSaint Clare’s is just one example

of how hospitals are using respira-tory therapists on these teams.“RTs perform highly skilled levelsof care here, such as protocols,intubation, and arterial and PICC*line insertion, and are alreadyrelied upon for critical thinkingskills, so it was a given for us,” saysChristine Lager, BA, RRT, supervi-sor of pulmonary services at WestAllis Memorial Hospital/AuroraHealth Care in West Allis, WI. Herhospital initiated its team — dub-bing it the “STATTeam” — in Sep-tember of 2005, staffing it with acritical care unit (CCU) RN and anRT.

At Bethesda Memorial Hospitalin Boynton Beach, FL, Sheryle Barrett, BA, RRT, educationalcoordinator for respiratory care,

co-chaired (along with the ICUmanager) the intra-hospital com-mittee charged with developingher hospital’s team. (They calltheir ’s the “BEE Team,” forBethesda Emergency Evaluation.)“Our first meeting was in March of2005, and we started the actual ser-vice in May 2005. The goal was tocreate a systematic approach topromote early and appropriateintervention in the care of criti-cally ill patients to decrease thenumber of codes, mortality, andultimately, costs.”

The team consists of the RTcharge therapist and unit chargenurse. “This was decided becauseof two issues,” explains Barrett.“These positions do not routinelyhave a patient assignment and theirgoing to the call would be least dis-ruptive to patient care, and indi-

AARC Tımes December 2006 55

Just a few of Blessing Hospital’s Rapid Response Teammembers were able to sit long enough for this photo. (Back row, from left): Dorothy Bybee, RN, director criticalcare; Rod Poling, CRT; Lisa Surratt, RN; Teresa Ashley, CRT;and Dwayne Goodwin, CRT. (Front row, from left): KellySmyser, RN; Jolene Beaber, RRT; Lynnette Baughman, CRT;and Cheryl Reardon, CRT.

Richard Bailey, MD, FACP (left), medical director,inpatient care and hospitalist services; Jennifer

Stankowski, RN; and Joe Rohling, BS, RRT; collaborated on the development of the Rapid

Response Team at Saint Clare’s Hospital.

* BLS = basic life support; ACLS =advanced cardiac life support; NRP =neonatal resuscitation program; PICC =peripherally inserted central catheter

viduals who are in these positionsare there because they have a highlevel of assessment skills.” How-ever, therapists who are working onthe floor where the call originatesare asked to respond as well toensure the most timely response;and generally speaking, any respira-tory therapist close to the callresponds to lend a hand.

The team at Blessing Hospitalin Quincy, IL, which averagesabout 20 calls per month, also usesthe charge respiratory therapist asthe key team member along with acritical care RN, says JoleneBeaber, RRT, respirator y caredepartment mana ger. “Wedecided to use the respiratorycharge person, and we also traineda few more people because we rec-ognized that there might be timeswhen there could be more thanone rapid response called at atime.” All the therapists who par-ticipate must have ICU experi-

ence and competencies and goodpatient assessment and communi-cation skills, notes Beaber.

Rebecca Young, RRT, managerof cardiopulmonary services at Cit-rus Memorial Health System inInverness, FL, says the team at herhospital currently consists of aCCU RN and an RT, with the res-piratory therapist called in when arespiratory condition is involved.“The nurse is called and goes to thepatient to make an assessment. Heor she then calls the RT if it isbelieved to be a respiratory prob-lem,” she says.

The hospital has been collectingoutcomes since implementation ofthe program and estimates thatmortalities have been reduced by 17percent per 1,000 discharges, codesoutside of the CCU have declinedby 44 percent, and successful codes— defined as returning the patientto spontaneous circulation — haveincreased by 95 percent.

Similar results have been seen atthe other facilities, which havenoted a significant decline in thenumber of codes since their teamsbegan, a reduction in the mortalityrate, and a greater percentage ofpatients being stabilized on thefloors. The number of calls hasincreased as well, as floor nurseshave become more comfortablewith the concept.

Respiratory therapistswelcome the role

All of these managers say imple-menting their teams was a fairlysmooth process, with therapistsgenerally excited to be playing a keyrole. Joe Rohling says therapists athis hospital were “happy and eagerto be a part of this team,” notingthat because the team was startedwhen the hospital opened, thereweren’t any issues to overcome con-cerning workload.

Dr. Bailey credits the hospital’s

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56 AARC Tımes December 2006

Sheryle Barrett and other BEE Team members at BethesdaMemorial Hospital are identified with a “bee” on their namebadge. Their outcomes data show an inverse proportion ofbees to codes — the more bees, the less codes.

Saint Clare’s Rapid Response Team includes Joe Rohling, BS, RRT (left), Kristin Henrickson,

RRT; Laurie Dunk, CRT; Sandy Elsen, RRT; Judy Liegl, CRT; Renee Babbitts, RRT; Richard

Bailey, MD, FACP; and Jennifer Stankowski, RN.

R a p i d R e s p o n s e Te a m s

therapists with playing a valuablerole on the team, noting, “Our hos-pital is very fortunate to have thehighly skilled therapists that we do.”

Sheryle Barrett and ChristineLager say therapists at their hospi-tals were already providing a “rapidresponse” in situations where it waswarranted, so making the conceptofficial through the team fit rightinto the work ethic and was neveran issue. “For years we have unoffi-cially responded to calls by nursingto take a look at their patients pre-coding,” says Barrett. “The teamgives official recognition of this;and as we have also developed anRTprotocol for us to use, we can doABGs, treatments, oxygen set-ups,and order x-rays immediately with-out having to wait for a call to thedoctor. This relieves worry aboutwhat you can and can’t do and justlets you take care of the patient.”

Lager says her therapists wel-comed the new system as a way to

put a name to what they werealready doing on an individual basisas well. “The transition to a processwas very natural for us, so it wasreadily accepted without questionand implementation was ver ysmooth.”

In the spotl ightWhat’s been good for patient

care in facilities that have adoptedthe rapid response team concepthas been equally good for RTmorale. Indeed, inside facilitiesand out, rapid response teams havegarnered much attention, withrecognition from administrationand news coverage in the localpress. “The spotlight that has beenput on this program has been verypositive,” says Jolene Beaber. “Any-time that you can be a part of some-thing positive that is being cele-brated, it elevates morale andrecognition from others.”

Lager says the respiratory thera-

pists’ involvement on the team inher hospital has helped educatenurses and physicians about theimportance of respiratory therapyprofessionals. “The nursing staffactually has an opportunity to seeus use our knowledge and criticalthinking skills, which can’t help butbuild some respect for the profes-sion,” she says. “We have gainedrespect for our skills and decision-making abilities with physiciansalso… Our RTs feel like they finallyare getting to do what they went toschool for.”

But the bottom line for everyoneinvolved in these teams and all theother IHI initiatives is probablysummed up best with a quote fromDonald Berwick, MD, MPP, presi-dent and CEO of the Institute forHealthcare Improvement. “Thenames of the patients whose liveswe save can never be known. Ourcontribution will be what did nothappen to them.” •