Rapid Response Teams

1
Rapid Response Teams
What does the RRT Bring?

• Michael R. Jackson RRT-NPS CPFTRespiratory Care
  Clinical Educator Brigham Womens Hospital
  Boston, MA

2
Rapid Response Team

• Discuss the practicality of RRTeams
• Design rapid response teams
• Adult Care
• Newborn Care
• Anticipate the unique tools that RTs may bring
  to a rapid response call

3
RRT Outline

• What do you bring
• Discuss the practicality of Rapid Response Teams
• Are they necessary
• Are Respiratory Therapists needed?
• Size of institution
• Educational
• Self-limiting
• Design rapid response teams for
• Adult (including Obstetrical asthma)
• Newborn  services
• Anticipate unique tools RTs may bring to a rapid
  response call
• Monitoring
• Oximetery interpretation
• Capnography
• HFNC NPPV
• RT placed airways

4
Institute for Healthcare Improvement

• Rapid Response Teams
• Evidence-based care for MI
• Prevent adverse drug events
• Prevent central line infections
• Prevent ventilator-associated pneumonia

5
Rapid Response System

• Early recognition of the failing patient
• enhanced surveillance and documentation
• early warning criteria for MD notification
• Structured and concise communication between RT,
  RN MD
• Standardized urgent physician response
• response team (includes the patients
  intern/resident)
• care escalation algorithm

Slide courtesy of Jeffrey M. Rothschild, M.D.
6
Indicators for effective RRT applications?

• Adverse events cardiopulmonary arrests
• Hospital deaths
• ICU admissions
• Length of stay
• Cost
• Census
• Staff changes satisfaction
• Team survey

Slide courtesy of Jeffrey M. Rothschild, M.D.
7
Unnecessary deathsThree fundamental problems
(IHI)

• Failures in planning
• includes assessments, treatments, goals
• Failure to communicate
• patient-to-staff, staff-to-staff, staff-to-MD
• Failure to recognize a problems
• 48 of hospital deaths occur in patients
  admitted to a non-ICU setting and not expected to
  die (IHI, data from 64 hospitals)

Slide courtesy of Jeffrey M. Rothschild, M.D.
8
The Difference Between RRT Cardiac Arrest
Calls (Bellamo, 05)

• Cardiac arrest
• no time
• intervene first and ask questions later
• pandemonium
• RRT call
• there is time
• ask questions first
• thoughtful, planned approach

Slide courtesy of Jeffrey M. Rothschild, M.D.
9
Preventable cardiac arrests

• Many arrests are preventable
• Iatrogenesis or lost opportunity for early
  intervention Bedell, JAMA 91
• Clinical instability prior to arrest
• 70 (45/64) arrests with documented CNS or
  respiratory deterioration within 8 h of arrest
• Schein, Chest 90
• 66 (99/150) show abnormal signs/sx within 6 h of
  arrest and MD only notified in ¼ (25/99)
• Franklin, CCM 94

Slide courtesy of Jeffrey M. Rothschild, M.D.
10
Pre-ICU care / Late ICU transfers

• Care before ICU transfer (McQuillan, BMJ 98)
• 54 substandard care prior to transfer, including
  39 with delayed transfer
• mortality greater for substandard group (56 v
  35)
• Slow ICU transfers (Young, JGIM, 03)
• 1 of 11 criteria ? 4 hours prior to transfer
• slow transfer group were sicker by time reached
  ICU
• mortality 41 v 11 for rapid transfers

Slide courtesy of Jeffrey M. Rothschild, M.D.
11
RRT Evidence of benefits

• Reduction in arrest prior to ICU transfer (4
  v 30) Goldhill, Anest
  99
• 50 reduction in non-ICU arrests Buist,
  BMJ 02
• Reduced post-operative emergency ICU transfers
  (58) and deaths (37) Bellomo, CCM 04
• 17 reduction in cardiac arrests in an AMC (UPMC)
  DeVita, Quality and Safety in Healthcare 04
  

Slide courtesy of Jeffrey M. Rothschild, M.D.
12
RRT Evidence Recent MERIT Study (Lancet, 6/05)

• 23 Australian hospitals (17 teaching)
• Clustered RCT
• Control hospitals no MET (RRT)
• Intervention hospitals MET
• Outcomes of interest (events)
• Cardiac arrests, unplanned ICU transfers,
  unexpected deaths (not DNR)

Slide courtesy of Jeffrey M. Rothschild, M.D.
13
Hospital-wide Code Rates and MortalityBefore
After RRS Intervention

• Possible bias in some RRS studies
• reduction in non-ICU cardiac arrests may be at
  the expense of increased ICU arrests
• pre-post design not account for secular trends
  such as improved CAD and CHF care
• Nurse led RRT, teaching hospital
• no difference in outcomes pre ? post RRS
  intervention
• DNR deaths included in analysis
• during or soon after many RRS events patients
  became DNR
• RRS may improve end-of-life care among terminally
  ill patients

Chan, JAMA, Dec. 2008
Slide courtesy of Jeffrey M. Rothschild, M.D.
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RRS International Standards
Circulation, Feb. 2008
Slide courtesy of Jeffrey M. Rothschild, M.D.
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Standardized Response

• Rapid Response Team
• patients intern/resident are part of the team
• expected to return page immediately and evaluate
  the patient within XX minutes
• Care escalation algorithm
• call 1o attending if not improved in XX minutes
• call critical care attending if not stable in XX
  minutes

Slide courtesy of Jeffrey M. Rothschild, M.D.
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Inverse Dose-Response Relationship Between
Early Emergency Team Calls Serious Adverse
Events

• For every 10 increase in proportion of early
  emergency team calls, 2.0 fewer arrests per
  10,000 admissions and 0.94 fewer non-DNR deaths

Chen, Crit Care Med, Jan 2009
Slide courtesy of Jeffrey M. Rothschild, M.D.
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RRT Implementation Challenges

• Initially underutilized
• culture, awareness, fear of change
• Initially may be inappropriately used (false
  alarms)
• response should be non-judgmental and
  non-punitive
• Anybody can initiate a RRT request
• collegial interactions educate staff
• Auditing, monitoring and timely feedback

Slide courtesy of Jeffrey M. Rothschild, M.D.
18
Finding of the First Concensus Conference on
Medical Emergency TeamsCrit Care Med 2006 Vol.
34, No. 9

• Patients needing a RRS intervention are suddenly
  critically ill and have a mismatch of resources
  to needs.

• Crisis detection Response triggering
• Predetermined RR Team members
• Administrative level for resource allocation
• Evaluation system that leads to RRT QA

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Team

• Critical care nurse
• Respiratory Therapist
• Primary care team
• intern/resident
• Additional physician
• Critical care attending
• fellow
• Hospitalist
• Senior resident

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Systematic design, Implementation, development
upgrade of Rapid Response Team

• Rothschild JM, Woolf S, Finn KM, et al. A
  Controlled Trial of a Rapid Response System in an
  Academic Medical Center, Jt Comm J Qual Patient
  Saf. 200834417-425
•  

21
Situation Background Assessment Recommendations

• Rothschild JM, Woolf S, Finn KM, et al. A
  Controlled Trial of a Rapid Response System in an
  Academic Medical Center, Jt Comm J Qual Patient
  Saf. 200834417-425
•  

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Notable RRT (Respiratory Therapist)

• Michael J Hewitt, RRT-NPS, FAARC
• First Totally Respiratory Care Driven Rapid
  Response Team in The U.S. Very Effective High
  Risk Assessment Team _at_ Memorial Hermann Texas
  Medical Center in Houston

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Early Warning Criteria Adult

• Respiratory
• RR lt 8 or gt 30
• O2 sat lt 85 for gt 5 min
• Increase O2 supplement to 100 or non-rebreather
  mask
• threatened airway or new severe dyspnea
• Cardiovascular
• HR lt 40, gt140 with Sx or any rate gt160
• SBP lt 85, gt200 for more than 30 min
• DBP gt 110 with Sx

• Neurologic
• acute change LOC
• new focal weakness
• prolonged seizures
• Other
• acute change urine output to lt 50 over 4 hour
  period
• uncontrolled bleeding
• color change of patient or extremity
• temp gt 105
• staff member worried

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Newborn Criteria Developed by BWH
Activate the infant RRS if any of these Early
Warning Signs are present

• Other
• Uncontrolled bleeding
• Staff member worried about patient condition
• Rectal Temp greater than or equal to 100.4
  degrees F
• Persistent hypothermia (less than 97.7 deg. F)
  not responding to warming
• Glucose less than 20mg/dL
• Bilious emesis with distended abdomen
• Diffuse petechaie
• Vesicular eruptions
• Unexplained pain
• Unresolved parental concern for physiologic
  problem

• Respiratory
• RR rate lt 30 or gt 70
• 02 sat lt 95 for gt 2 minutes or need for O2
• Respiratory Distress
• Dusky spells
• Cardiovascular
• HR lt 75 or gt 210
• Neurological
• Acute change in LOC / Lethargy / Hypotonia
• New focal weakness
• Prolonged seizures

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A Survey of Rapid Response Team (RRT)
Participants Reports Success by all Team Members.
Sarah Mortell, RRT, Jeff Rothschild M.D., M.P.H.
PI, Seth Woolf, Michael R. Jackson, RRT-NPS,
CPFT, Paul F. Nuccio, RRT, FAARC. Department of
Respiratory Care, Brigham and Womens Hospital,
Boston, Massachusetts.
The introduction of Rapid Response Teams has
become popular nationwide over the past couple of
years. Hypothesis Participants will view the
function of a rapid response team as a valuable
asset in the care of patients who are at risk of
developing clinical complications to their
present illness.
Introduction The Rapid Response Team is a small
group of clinicians who bring critical care
expertise to the patients bedside (or wherever
it is needed). The RRT is one of the
interventions recommended by the Institute for
Healthcare Improvement (IHI) as part of their
100K Lives Campaign. Most rapid response teams
are comprised of a Registered Respiratory
Therapist, a Critical Care Nurse, and a
Physician.
Methods A survey was sent by email to all
respiratory therapists, nurses, and physicians
who participated in rapid response team calls
during a four-month pilot. The respondents
filled out the survey online, and the data was
entered into an excel file that kept track of
each respondent's answers.
Results Of 149 total surveys received, 105, or
70, were completed correctly and returned. 85
of nurses responded to the survey, as did 80 of
respiratory therapists and 53 of the physicians.
93 of all respondents rated the RRT call as
appropriate or very appropriate. 38 of
those that felt the RRT was not appropriate cited
the reason to be that either the patient did not
meet the criteria or the patient was already
receiving sufficient care. 80 of respondents
stated that they found the care provided by the
RRT to be beneficial or very beneficial. Of
those responding to the survey, 86 stated that
the RRT notification process operated
seamlessly.
Conclusion In the eyes of the clinician, the
Rapid Response Team is an effective method of
bringing expert clinicians to the bedside in a
rapid and effective manner. This early
identification and intervention program may help
to reduce complications resulting from
last-minute attempts at providing emergency care.
It may also result in a reduction in the number
of patients requiring transfer to an ICU.
27
A Survey of Rapid Response Team (RRT)
Participants Reports Success by all Team Members.
Sarah Mortell, RRT, Jeff Rothschild M.D., M.P.H.
PI, Seth Woolf, Michael R. Jackson, RRT-NPS,
CPFT, Paul F. Nuccio, RRT, FAARC. Department of
Respiratory Care, Brigham and Womens Hospital,
Boston, Massachusetts.
The introduction of Rapid Response Teams has
become popular nationwide over the past couple of
years. Hypothesis Participants will view the
function of a rapid response team as a valuable
asset in the care of patients who are at risk of
developing clinical complications to their
present illness.
Introduction The Rapid Response Team is a small
group of clinicians who bring critical care
expertise to the patients bedside (or wherever
it is needed). The RRT is one of the
interventions recommended by the Institute for
Healthcare Improvement (IHI) as part of their
100K Lives Campaign. Most rapid response teams
are comprised of a Registered Respiratory
Therapist, a Critical Care Nurse, and a
Physician.
Methods A survey was sent by email to all
respiratory therapists, nurses, and physicians
who participated in rapid response team calls
during a four-month pilot. The respondents
filled out the survey online, and the data was
entered into an excel file that kept track of
each respondent's answers.
Results Of 149 total surveys received, 105, or
70, were completed correctly and returned. 85
of nurses responded to the survey, as did 80 of
respiratory therapists and 53 of the physicians.
93 of all respondents rated the RRT call as
appropriate or very appropriate. 38 of
those that felt the RRT was not appropriate cited
the reason to be that either the patient did not
meet the criteria or the patient was already
receiving sufficient care. 80 of respondents
stated that they found the care provided by the
RRT to be beneficial or very beneficial. Of
those responding to the survey, 86 stated that
the RRT notification process operated
seamlessly.
Conclusion In the eyes of the clinician, the
Rapid Response Team is an effective method of
bringing expert clinicians to the bedside in a
rapid and effective manner. This early
identification and intervention program may help
to reduce complications resulting from
last-minute attempts at providing emergency care.
It may also result in a reduction in the number
of patients requiring transfer to an ICU.
28
Results of a Four-Month Rapid Response Team (RRT)
Pilot Study.
Michael R. Jackson, RRT-NPS, CPFT, Jeff
Rothschild M.D., M.P.H. PI, Seth Woolf, Paul F.
Nuccio, RRT, FAARC., Sarah Mortell, RRT, Marie
Duggan RRT, Department of Respiratory Care,
Brigham and Womens Hospital, Boston,
Massachusetts
Introduction The Rapid Response Team is a small
group of clinicians who bring critical care
expertise to the patients bedside (or wherever
it is needed). The RRT is one of the
interventions recommended by the Institute for
Healthcare Improvement (IHI) as part of their
100K Lives Campaign. Most rapid response teams
are comprised of a Registered Respiratory
Therapist, a Critical Care Nurse, and a
Physician.
Methods Specific criteria for initiating a
request for RRT activation were developed,
followed by extensive staff education in the
areas where the pilot would take place. Small,
laminated pocket cards were distributed to the
staff as reminders of the specific criteria.
Staff were also encouraged to activate the RRT if
they were just worried about the patient.  
The introduction of Rapid Response Teams has
become popular nationwide over the past couple of
years. Hypothesis The use of a Rapid
Response Team may result in a reduced need for
patient transfer to the Intensive Care Unit
(ICU), and a reduction in cardio-pulmonary arrest
requiring emergency resuscitation procedures.
Results During the four-month trial period, a
total of 104 calls were placed to the RRT.
Approximately half of the calls (48) were
registered during that day shift, with the other
half split between the evening (25) and night
(27) shifts. Approximately 46 of the calls
involved the presence of one or more criteria
that was directly respiratory-related. Team
interventions that took place as a direct result
of the
RRT activation included non-invasive positive
pressure ventilation (NPPV), increased
oxygenation, fluid resuscitation, and imaging
studies. ICU transfer was avoided in 66 of the
patients, while transfer of other patients to an
ICU was accomplished expediously. Conclusion
The Rapid Response Team concept provides expert
assessment and early intervention, allowing time
to
ask questions and formulate plans, unlike that
which occurs in a cardiac arrest scenario. The
role of the respiratory therapist is critical as
part of the RRT. Due to the potential benefit of
NPPV for many of these patients, a decision was
made to keep a non-invasive ventilator available
in all areas serviced by the RRT, allowing for
the immediate implementation by the respiratory
therapist.
29
Brigham Womens RRT Experience 2005
As part of University HeathSystem Consortiuum
30
Brigham Womens RRT Experience in 2005
258
Institute for Healthcare Improvement initiative
Medication
31
Recent MERIT Study (Lancet, 6/05)Study Results
Concerns

• Results
• both groups had a reduction in events from
  baseline, but not significantly better in
  intervention group
• overall, 30 reduction in unexpected deaths
• Methodology Concerns
• variability in RRT intervention
• VS not measured in 50 before serious events
• only 40 of patients meeting criteria had a RRT
  call under utilization
• underpowered

Slide courtesy of Jeffrey M. Rothschild, M.D.
32
Impact on Teaching Control (Lighthall,
Stanford Univ. 6/05)

• Sense of failure for primary team
• Still dedicated to the patient
• Still want to contribute to patient care
• Dont want to be an outsider
• Diminished educational opportunity
• Nurse empowerment

Slide courtesy of Jeffrey M. Rothschild, M.D.
33
Unique tools RTs bring

• Monitoring
• Oximetery interpretation
• Capnography
• NPPV HFNC
• RT airway
• Troubleshooting
• placement

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• Non-rebreather
• High Flow Cannula
• Salter
• FF (BWH)
• NPPV
• CPAP - oxygenation
• BiPAP - ventilation
• Ventilatory support
• Airway management

Apollo 13 Lithium Hydroxide mailbox. Failure
is not an option
Escalation
35
O2 oxygenationCO2ventilation
lung
36
surfneon.com
37
Higher Flow (15 50 LPM)Nasal Cannula
38
BWH Respiratory Care Nasal Cannula Devices
Humidity is relatively less as gas warms from
room temperature to body temperature.

• Waugh, JB, An Evaluation of 2 New Devices for
  Nasal High-Flow Gas Therapy, Respiratory Care,
  August 2004 V49 No 8
• Walsh, B, Comparison of Vapotherm 200i with a
  bubble humidier for High flow thaough an infant
  nasal cannula.

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Consistent Successful NPPV
40
Come to Brenda Grahams Trach Class 3 hour
presentation sign up through nursing education
41
Factors influencing acceptance of CO2 monitoring
in RRT

• Culture role norms
• Work in a silo
• knowledge base regarding application
• Device promotion
• Resource constraint
• Training / education
• Training of responders
• Documentation for responders

42
RRT Equipment

• Defibrillator
• Crash cart
• Airway intubation equipment
• Medications
• BiPAP device
• CO2 monitoring device
• Capnograph
• TCPCO2

43

• Device Options

• Portability ( potential for long term borrowing)
• Recording of trend data
• Clear clean waveform display
• Ability to perform during sepsis shock

Oridion Capnostream 20
Smiths Capnocheck
44

• Device Options

• High flow nasal cannula
• A way to achieve stable readings is needed
• Conventional cannula
• Swap for end tidal one
• May make assessment based upon waveform

45

• Device Options

• Capnograph
• Side sampling
• EtCO2, RR waveform
• Suitable for all patient groups
• Patient Sample Lines
• Nasal oral sampling
• Moisture handling
• Patient comfort

Microcap
Smart CapnoLine Plus
46
Lab StudySampled at 3 Sites

• Device Options

Smart CapnoLine Plus
Mask Port
Mask Connection
Megan Vaccaro
47

• Device Options

Lab StudySampled at 3 Sites
48
CPAP Summary

• Device Options

• All 3 sites were equivalent at
• Low pressure
• Low leak
• Smart CapnoLine Plus continued consistent
  readings
• No variance due to pressure changes
• No variance due to leak changes
• Tracked minute ventilation appropriately

Smart CapnoLine Plus
49
BiPAP Summary

• Device Options

• All 3 sites were equivalent at
• Low pressure
• Low leak
• Smart CapnoLine Plus tracked appropriately
• As pressures increased
• As leaks increased
• As minute ventilation changed
• Mask Port Mask Connection
• Did not trend appropriately to minute ventilation

50
Why Monitor CO2

• Application of Capnography

• Experience is limited but
• Could offer important clinical information in
• Ventilator management
• Optimizing CO2 elimination
• Decreasing work of breathing
• Can we improve our success
• Reduce ventilator time
• Improve patient outcomes

51
PaCO2 EtCO2

• Application of Capnography

• Arterial - End Tidal CO2 Gradient
• The normal PaCO2 to EtCO2 gradient is 2-5 mmHg
• In lung disease, the gradient will increase due
  to ventilation/perfusion mismatch

52
NIV Capnography

• Application of Capnography

CO2

• Capnography is an emerging application for
  monitoring NIV
• Monitoring the effectiveness of CO2 removal
• Hypoventilation and apnea assessment
• Breathing pattern assessment
• Shows rebreathing

53

• Application of Capnography

NIV Capnography

• Early intervention of NIV to increase chances for
  success
• Success correlates to an improvement in PaCO2 in
  the early stages
• In 2001, Dr. Hill stated that noninvasive CO2
  monitoring may be useful for trending purposes
  but cautions

recordings of end-tidal CO2 must be interpreted
with great caution if obtained from a mask during
NPPV, particularly if the patient has parenchymal
lung disease
Am J
Respir Crit Care Med Vol 163. pp 540577, 2001
.
54
Common ETCO2 applications

• Application of Capnography

• Estimation of PaCO2
• Adequacy of spontaneous respiration  
• Adequacy of NPPV function
• Airway placement
• Detection of air embolism
• Hypermetabolic states
• Monitoring of CPR

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Reasons for ETCO2 Monitoring

• Application of Capnography

• Fever
• Malignant hyperpyrexia
• Sodium bicarbonate
• Tourniquet releaseVenous CO2 embolism
• Increased cardiac output
• Increased blood pressure
• Hypoventilation
• Bronchial intubation
• Partial airway obstruction
• Rebreathing
• Inadequate fresh gas flows
• Leaks in breathing system
• Faulty ventilator

• Hypothermia
• Reduced cardiac output Hypotension
• Hypovolemia
• Pulmonary embolism
• Cardiac arrest
• Hyperventilation
• Apnea
• Total airway obstruction
• Partial airway obstruction
• Accidental tracheal extubation 
• Circuit disconnection
• Sampling tube leak

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Increasing ETCO2

• Application of Capnography

• Hypoventilation (decrease RR or TV)
• Increase in metabolic rate
• Increase in body temperature
• Malignant hyperthermia
• Release of tourniquet
• Absorption of CO2 from peritoneal insufflation
• Sudden increase in blood pressure

57
Decreasing ETCO2

• Application of Capnography

• Gradual
• Hyperventilation (increase RR or TV)
• Decrease in metabolic rate
• Decrease in body temperature
• Rapid
• Embolism (air or thrombus)
• Sudden hypotension
• Circulatory arrest

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• Device Options

Alternative Combined Transcutaneous CO2 SpO2
59
Summary of the Rapid Response System

• Early warning criteria
• Structured communication tool - SBAR
• Standardized urgent response
• rapid response team with RESPIRATORY THERAPIST
• care escalation algorithm

60
Future Steps

• Measure RRT utilization and effectiveness
• Refine early warning criteria
• Assess impact on resident experience and
  education
• Obtain consensus on physician team membership for
  a hospital wide team

Slide courtesy of Jeffrey M. Rothschild, M.D.
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