Patient Safety Grand Rounds

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Rapid
Response Teams
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Rapid Response Team Planning GroupServing
Vanderbilt Since February, 2005

• Anna Ambrose, Respiratory Therapy
• John Barwise, Critical Care
• John Bingham, CCI
• Devin Carr, Nursing
• Bobbie Dietz, CCI
• Julie Foss, Nursing
• Drew Gaffney, Chief Quality Officer
• Leah Golden, Resuscitation Program
• Eric Grogran

• Jeff Guy, Burn Unit
• Jeff Hill, CCI
• Brent Lemonds, Administrative Liaison
• Diane Moat, Risk Management
• Paul St. Jacques, Anesthesiology
• Susan Thurman, Nursing
• Les Wooldridge, Resuscitation Program
• Jeanne Yeatman, LifeFlight

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• The CampaignIHI will join hands with other
  leading American health care organizations in
  launching an unprecedented 100,000 Lives
  Campaign, which will disseminate powerful
  improvement tools, with supporting expertise,
  throughout the American health care system.
•  
• This campaign aims to enlist thousands of
  hospitals across the country in a commitment to
  implement changes in care that have been proven
  to prevent avoidable deaths. We are starting with
  these six changes
•  
• Deploy Rapid Response Teamsat the first sign of
  patient decline
• Deliver Reliable, Evidence-Based Care for Acute
  Myocardial Infarctionto prevent deaths from
  heart attack
• Prevent Adverse Drug Events (ADEs)by
  implementing medication reconciliation
• Prevent Central Line Infectionsby implementing a
  series of interdependent, scientifically grounded
  steps called the Central Line Bundle
• Prevent Surgical Site Infectionsby reliably
  delivering the correct perioperative antibiotics
  at the proper time
• Prevent Ventilator-Associated Pneumoniaby
  implementing a series of interdependent,
  scientifically grounded steps called the
  Ventilator Bundle

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Arrest Prevention Assessment Response Team
Rapid Response Team

• Team members
• Critical care nurses
• Respiratory Therapist
• Physician Intensivist
• When requested by team
• Professional consult service for nurses and
  physicians seeking evaluation of a deteriorating
  patient

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SBAR

• The SBAR (Situation-Background-Assessment-Recommen
  dation) technique provides a framework for
  communication between members of the health care
  team. SBAR is an easy-to-remember, concrete
  mechanism useful for framing any conversation,
  especially critical ones, requiring a clinicians
  immediate attention and action. It allows for an
  easy and focused way to set expectations for what
  will be communicated and how between members of
  the team, which is essential for developing
  teamwork and fostering a culture of patient
  safety.

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RRT Call 1

• S pt. desaturated when getting up to bedside
  commode took 20 minutes to resaturate from 60s
  to 95
• B pulmonary HTN, SOB, anemia
• A RR30, HR90s, SpO270
• R RRT called Pulmonary Fellow to bedside, who
  ordered EKG and 40 mg Lasix, transferred to MICU

• 10-7-05
• 1045
• 8 North
• 51 yo Female
• REASON FOR CALL
• Staff concerned
• Labored breathing
• SpO2 less than 90

Interpretation Appropriate Call, patient stayed
in MICU, made DNR by family and ultimately died.
Debriefing was held, thought to be useful. SBAR
tweaked.
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RRT Call 2

• S pt. desaturated to 94
• B none given
• A BP109/60, HR105, RR26, SpO294, crackles
  heard on left
• R suctioned large mucus plug and placed pt. on
  40 trach collar. Pt. remained on 8 North.

• 10-10-05
• 1805
• 8 North
• 60 yo Female
• REASON FOR CALL
• Staff concerned

Interpretation Appropriate call. New Nurses,
Good learning tool. Floor suctioned patient
while RRT enroute. RRT found problem resolved.
Patient Discharged on 10/18.
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RRT Call 3

• S 3 days post op Primary team aware and
  monitoring pt. symptoms progressing.
• B moved from 9 South at 1100 for respiratory
  distress and more intensive monitoring
• A BP104/57, HR142, RR38, SpO293
• R spoke w/ wife, who required approx. 20
  minutes of conference prior to allowing
  assessment to take place. Pt. continued w/
  increasing RR, HR and confusion-

• 10-15-05
• 1620
• 9 North
• 59 yo Male
• REASON FOR CALL
• Staff concerned
• RR greater than 30
• Labored breathing
• HR greater than 120
• Onset of agitation

Interpretation Appropriate call. Confusion
about consistency of team. Floor expecting MD as
first responder. Team needs to be identified to
staff and family upon arrival. Resident had
issues with team being called. Patient sent to
SICU and intubated.
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RRT Call 4

• 10-15-05
• 1815
• 9 North
• 78 yo Female
• REASON FOR CALL
• Staff concerned
• RR less than 8
• SpO2 less than 90
• Labored breathing
• Decreased LOC

• S RRT arrived to find pt. being ventilated w/
  bag-mask
• B ischemic bowel disease staff noted that LOC
  had been decreasing for 4 days.
• A none given
• R pt. intubated and transferred to SICU

Interpretation Appropriate call or would have
been appropriate for STAT team. Notable that LOC
had been decreasing for 4 days. Patient moved to
SICU. Discussing withdrawing care.
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RRT Call 5

• 10-29-05
• 0005
• 8 North
• 53 yo Male
• REASON FOR CALL
• Staff concerned
• RR less than 8
• Decreased LOC
• Onset of agitation
• SpO2 less than 90

• S admitted from ED approx. 15 mins prior to RRT
  call nurses noted increasing respiratory
  distress and eventual unresponsiveness and apnea
• B history of tongue CA s/p chemo and radiation.
  Of note, patient was confused upon admission to
  ED.
• A HR 126 SpO2 87 BP 160/98
• R several unsuccessful attempts made at
  establishing definitive airway, including LMA and
  fiberoptic bronchoscopy eventually transferred
  to OR for emergency tracheotomy and then on to
  MICU post-operatively

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RRT Call 6

• 10-29-05
• 355
• 9 North
• 65 yo F
• REASON FOR CALL
• Staff concerned
• SpO2 less than 90
• HR greater than 120

• S pt. became bradycardic (39) and then
  tachycardic (170s) and desaturated to 38.
  Bagged with 100 O2 in response to desaturation
• B history of esophageal CA tracheomalacia
  requiring tracheostomy of note, resident paged
  from 0400-0430 without response.
• A BP 153/68
• R scheduled metoprolol that was held at 2220
  given and patient stayed in room.

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RRT Call 7

• 10-30-05
• 535
• 8 South
• 55 yo F
• REASON FOR CALL
• Labored breathing

• S air hunger staff afraid her stoma will
  plug. Unable to pass 14 Fr. Suction catheter.
• B s/p laryngopharyn-gectomy undergoing
  radiation/chemo s/p trach 10-28
• A RR 30 SpO2 98 LOC intact HR 80
• R saline lavaged and suctioned w/ 10 Fr.
  Catheter by RT huge mucus plug obtained. Pt.
  reported immediate relief! Decision made to
  transfer pt. to 9 Northno beds transferred to 6
  South

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RRT Call 8

• S nurse holding pressure to incision small
  amt. blood bubbling around open incision
• B hx of end stage lung dz s/p bilat. Lung
  transplant 9-30-05
• A RR 20 SpO2 95 LOC intact HR 87
• R vaseline gauze to bedside CXR ordered Rt.
  Lower lung sounds diminished pt. stayed in room
  pending CXR result.

• 10-30-05
• 2045
• 9 North
• 54 yo M
• REASON FOR CALL
• Staff concerned pt coughed incision open

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Other Findings

• 9N code 9/30 PEA arrest unsuccessful after 20
  min
• 8S code 10/1 Resp arrest DNR family desired
  everything except CPR and defib extensive hx.
  Ovarian CA Pt moved to MICU and expired
• 8N 10/2 PEA arrest found on floor pulseless and
  apneic, possible PE, RUE DVT during admission
  despite anticoagulation, in and out of ICU
  several times including 2 intubations

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Pilot Unit Data
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Vanderbilt RRT Performance Measures
Vanderbilt RRT Performance Measures (n24)
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Vanderbilt Early Warning Signs
Vanderbilt Early Warning Signs(n24 for 9
patients)
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Highlighted Results of Collaborative20 Academic
Medical Centers

• 462 calls in collaborative
• 76 had early warning signs
• 71 discharged alive
• 8 went on to have cardiac arrest
• 41 transferred to ICU
• Concern about the patient was the most frequent
  early warning sign in 55 of the patients
• 99.7 of the staff using the teams said they
  would use the RRT in the future
• Resistance fades as RRT demonstrates value and
  benefit for patient care

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Housewide Rollout April 1, 2006
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Addition of Cardiology RRT

• Responding to Cardiology Floors
• November, 2008

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• Family Initiated RRT
• Initiated December, 2008 as a pilot