Fad or Function?, Rapid Response Teams (RRT).

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Fad or Function?, Rapid Response Teams (RRT).

• by Joel Ray RRT
• Harborview Medical Center
• Seattle, WA

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• Topics of Discussion
• Understanding the driving forces behind RRT and
  other patient safety initiatives
• Getting RRT started at HMC
• How many calls do we get, and what triggered
  them
• Improvements for the future

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From the Land Down Under

• Many Australian hospitals instituted Medical
  Emergency Teams (MET) by the mid 1990s.

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Cardiopulmonary Arrest (CPA)

• Patients can exhibit clinical warning signs 8-12
  hours before event.
• Educating acute care staff on identifying
  clinical triggers and alerting Code Team.

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Seen These Before?
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What is IHI?

• The Institute for Healthcare Improvement (IHI) is
  a non-for-profit organization leading the
  improvement of health care throughout the world.
  IHI was founded in 1991 and is based in
  Cambridge, Massachusetts

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To Error is Human

• Despite the extraordinary hard work and best
  intentions of caregivers, thousands of patients
  are harmed in US hospitals every day.
  Hospital-acquired infections, adverse drug
  events, surgical errors, pressure sores, and
  other complications are commonplace.

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We can do better

• Based on data collected over several years from
  multiple partner institutions, IHI estimates 15
  million incidents of medical harm occur in the US
  each year a rate of over 40,000 per day.
• 400,000 deaths a year world wide.

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The Campaign Planks --Six Changes That Save
Lives

• Deployment of Rapid Response Teams
• Delivery of Reliable, Evidence-Based
• Care for Acute Myocardial Infarction
• Medication Reconciliation
• Prevention of Central Line Infections
• Prevention of Surgical Site Infections
• Prevention of Ventilator-Associated
• Pneumonias (VAP)

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The 100,000 Lives Campaign Scorecard

• An estimated 122,300 lives saved by participating
  hospitals
• Over 3,100 hospitals enrolled
• Over 78 of all discharges
• Over 78 of all acute-care beds
• Over 85 of participating hospitals sending IHI
  mortality data
• Participation in Campaign interventions
• Rapid Response Teams 60
• AMI Care Reliability 77
• Medication Reconciliation 73
• Surgical Site Infection Bundles 72
• Ventilator Bundles 67
• Central Venous Line Bundles 65
• All six 42

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Possible lives saved IHI 100,000 Lives Campaign
SOURCE US New World Report 2005
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Washington Hospitals Getting Onboard

• Evergreen
• Harborview
• Overlake
• Sacred Heart
• Swedish
• Tacoma General-Allenmore
• Virginia Mason

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• Topics of Discussion
• Understanding the driving forces behind RRT and
  other patient safety initiatives.
• Getting RRT started at HMC.
• How many calls do we get, and what triggered
  them.
• Improvements for the future

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What is UHC?

• The University HealthSystem Consortium (UHC),
  formed in 1984, is an alliance of 97 academic
  medical centers and 149 of their affiliated
  hospitals representing nearly 90 of the nations
  non-profit academic medical centers.

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Rapid Response Team Workgroup
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HMCs Initial Process

• Conference calls via UHC with other hospitals
  developing RRT programs. Helped our group
  anticipate possible stumbling blocks and where to
  focus energy.

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HMCs Rapid Response Team

• Stat RN
• Charge Respiratory Therapist
• Pulmonary Fellow on MICU (called by RRT with
  management concerns)

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What can you call RRT for ?
Clinical Triggers for Call ? Intuitive sense that something is wrong with patient Clinical Triggers for Call ? Intuitive sense that something is wrong with patient
? Acute change in mental status ? New onset of agitation or restlessness ? Acute change in respiratory status ? Stridor noisy airway ? Respiratory rate ? lt 12 ? gt 32 ? Increased WOB ? SaO2 lt 92 with increased FiO2 ? ABG requested for respiratory concern ? Acute change in CV status ? HR ? lt 55 ? gt 120 ? SBP ? lt90 ? gt 170 ? New onset of chest pain ? Acute change in temp. ? lt 35 ? gt 39.5
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HMC had a head start

• Stat RN program started in 1992 as one RN on
  nights. Currently staffs two RNs 24/7. Duties
  include code response, helping ER, units
  transports.
• Dedicated Charge Respiratory Therapist. No
  individual assignment. Been in place over 2
  years.
• Can take over 9 months to start RRT program from
  scratch. HMC took 2 months from start to
  inception.

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Some decisions our group made

• Cell phones for RRT , help quicken call back
  time, enhance teams communication with each
  other.
• No overhead pages, Its not a code, extra sets of
  eyes not needed. All calls go over pager system.
• Clinical Triggers must be resolved before RRT
  leaves (or ICU transfer)
• No Bogus Calls, Our goal is to make this
  process worry free. We want calls to be made.

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Advantages of RRT

• Much needed resource to acute care RNs
• Heavy assignments, new grads, are able to
  see other patients.
• Help with triage, facilitate ICU transfer
• (Pulmonary Fellow )
• Supports acute care RT

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We are seeing sicker and sicker patients on the
floor, they (the RRT) are a great resource.
They are never threatening. They dont make
you feel stupid. They are great!
Daniel M., RN Burns/Pediatric Unit
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• It is a great idea. When a patient doesnt
  look right, they can see what is going on and put
  it into words that will get the doctors to pay
  attention. This has saved lives..

Maryse M., RN Surgery/Trauma Unit
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• I just came from the night shiftIt prevented
  a lot of things from going south. It made it a
  lot easier to call the doctor at 3AM.

Joan M., RN Orthopedics
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• Rapid response has made a real difference. It
  is much better to get the rapid response page
  get people there, rather than hearing about it as
  a STAT page overhead.It frees me up to take
  care of my other patients.

Lee , RRT HMC
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Criteria to remain on Acute floor

• Suctioning lt q4 hr
• FiO2lt 50 (exception comfort care)
• NPPV Treatment of OSA (Type 2 intervention).

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RRT Algorithm
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Multiple RRTs

• Tiers of response
• First call Stat RN 1 and Charge RT

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Multiple RRTs

• Tiers of response
• First call Stat RN 1 and Charge RT
• Second call Stat RN 2 and
  multitasking Charge RT (or next RT to answer my
  page)

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Multiple RRTs

• Tiers of response
• First call Stat RN 1 and Charge RT
• Second call Stat RN 2 and multitasking
  Charge RT (or next RT to answer my page)
• Third call Nursing Supervisor calls a
  Charge RN from ICU .

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Multiple RRTs

• Tiers of response
• First call Stat RN 1 and Charge RT
• Second call Stat RN 2 and multitasking
  Charge RT (or next RT to answer my page)
• Third call Nursing Supervisor calls a
  Charge RN from ICU .
• Charge Therapist is reviewing retirement
  information.

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• Topics of Discussion
• Understanding the driving forces behind RRT and
  other patient safety initiatives.
• Getting RRT started at HMC
• How many calls do we get, and what triggered
  them.
• Improvements for the future

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Number of Calls Since Transition
Harborview has 369 beds
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UCONN
UCONN has 300 beds
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HMC RRT Summary

• Total calls per month - 93 (average)
• Average response time 4 min (range 1-25 min)
• Average call length is 76 minutes
• Third Tier (ICU RN from unit) activations 4
  times per month
• RRT MD Consult 3 times per month

10-05 to 11-06
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Clinical Triggers Percentage of Calls
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Did they stay or did they go
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The Bottom Line

• After the first 1.5 years of Rapid Response,
  outside the ICU CPAs are down 7. (No mortality
  or bounce back data)
• Many other programs are experiencing up to 30
  reduction in CPAs

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• Topics of Discussion
• Understanding the driving forces behind RRT and
  other patient safety initiatives.
• Getting RRT started at HMC
• How many calls do we get, and what triggered
  them.
• What are the future plans.

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RRT Standing orders

• Notify Primary Team of Rapid Response Team
  Activation
• Interventions
• - Attach patient to monitor/defibrillator to
  treat dysrhythmias
• - Stat ECG for dysrhythmias / chest pain
• - O2 therapy Titrate FiO2 to maintain SaO2 gt
  90
• - IV therapy
• Initiate IV therapy if not in place
• 1 liter NS bolus for acute blood loss or
  hypotension
• Labs / Tests
• - Chem 7, CBC
• - ABG PRN respiratory distress, low SO2, or
  respiratory concern
• - CXR PRN respiratory distress, low SO2, or
  respiratory concern
• - Cardiac enzymes for PRN onset chest pain or
  dysrhythmias
• - Magnesium and ionized calcium PRN new onset
  dysrhythmias
• - Emergency hemorrhage panel PRN evidence of
  acute hemorrhage
• - Type and cross PRN evidence of acute hemorrhage
• - Blood culture x2 PRN temp gt 39 if no blood
  cultures in prior 24 hours
• - Urine and sputum culture if warranted
• Medications

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RRT Standing orders

• O2 therapy Titrate FiO2 to maintain SaO2 gt 90
• - ABG PRN respiratory distress, low SaO2, or
  respiratory concern
• - CXR PRN respiratory distress, low SaO2, or
  respiratory concern
• Albuterol nebulizers PRN wheezing

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Improved Follow-up

• Post Rapid Response Follow Up
• - If patient remains on acute care unit after
  rapid response check vital signs including
  Temperature, Pulse, BP, RR, Pulse Oximetry and
  Neuro Check
• Q 1h x 2
• Q 2h x 3
• Q 3h x 3
• - Notify Rapid Response Team if the patient meets
  any of the Clinical Trigger Criteria
• PROCESS
• - This document will be given to primary team or
  RRT MD in the event of an RRT call.

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RRT is here to stay

• IHI data supports RRT
• Activated before emergency occurs. Staff
  education of clinical triggers essential.
• Team consist of ICU RN and RT
• (MD backup)
• Acute care support, No Bogus Calls

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