Rapid Response Team

1
Rapid Response Team

• Patty Gessner, RN MSN
• Alexian Brothers Medical Center

2
Concept

• Respond rapidly and effectively
• Restructure 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

3
Background

• Originated in the early 90s
• First published study Australia in 2002
• 50 reduction in unexpected hospital deaths
• Supported by the Institute for Healthcare
  Improvement

4
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

5
Rationale

• Unexpected cardiac arrests are preceded by
  critical signs of instability (Kleinpell, 2002)
• Junior staff
• ICU admissions often suffer a delay in optimal
  care prior to their admission (Bristow, 2000)

6
Key Factors Contributing to Delay of Treatment

• Failure to rescue
• Failure to educate
• Limitation of Skill

7
Review of the Literature

• Reduction of the relative risk of mortality
• 79 for respiratory failure
• 78 for stroke
• 74 for severe sepsis
• 88 for acute renal failure

(Critical Care Medicine 32(4) 916-921)
8
Review 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 13251-254)
9
Review 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)
10
Review 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)
11
What Other Hospitals Have To Say

• 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

12
Getting Started

• Do not rely on administrators
• Driven by clinicians

13
About us

• Alexian Brothers Medical Center
• Located in Elk Grove Village Illinois
• Non-teaching community hospital
• 370 bed
• Level II Trauma
• 32 total ICU beds

14
Our 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

15
Protocol

• On the scene within 5 minutes
• 30 minutes per call

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Activation 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

17
Team Members

• Critical care APN or designee
• Critical care Respiratory Therapist
• Intensivist

18
Units Included

• All inpatients
• Patients in ED and day surgery
• Patients in interventional/diagnostic departments

19
Spectrum of Services

• Stroke team
• Sepsis team

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Team 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

21
Floor Staff Expectations

• Initiate call to attending physician and the RRT
  team
• Describe the patients history, current
  condition, and how the support team can help
• Participate in patient management

22
Building a Program

• If you build it
• they may come,
• but if you dont educate
• they wont call

23
Outcome Measures

• Calls resulting in transfer to the ICU
• Number of avoided codes
• Survival of codes
• Number of arrests outside critical care
• Staff, physician, and family satisfaction

24
Data

• The next slides represent data collected
• 99 calls logged between October 2004 through
  April 2005

25
RRT Reason for Call
26
Calls By Nursing Unit
27
RRT Time of Call
28
RRT Outcome





29
Code Blue By Location
Implement RRT
30
Survival of Code
31
Results

• 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

32
Close Calls
33
Mr. M

• Respiratory distress
• Staff waiting for assistance
• RR 40s, unequal breath sounds, acrocyanosis, 90
  on NRB

34
Mr. P

• 29 y/o s/p hip replacement
• History of failed kidney transplant
• On dilaudid PCA
• RR 8,
• 55 saturations

35
Mrs. P

• Staff called to ask for an ICU bed, reason given
  needs intubation
• Investigation revealed
• 84 y/o
• RR less than 8 bpm
• PH 7.18 PCO2 89

36
Mrs. D

• Called for tachycardia, hypotension
• Not assessed was the acute abdominal pain
• Treated with analgesia and a surgical consult

37
Mr. P

• Called to evaluate desaturations
• PaO2 39
• Immediate intubation

38
Key to Success

• Immediate availability
• No questions asked

39
Benefits

• Provide early interventions for patients
• Provide support for the bedside nurse
• Improve relations between nurses and physicians
• Increase staff satisfaction

40
Challenges and Lessons Learned

• 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

41
Next Steps

• Reduce codes that occur outside ICU
• Increase awareness on night shift
• Retrospective examination of cases during the
  peak times
• Provide feedback to staff that initiated call
• Consider switching to a paging system

42
Questions

• Contact
• gessnerp_at_alexian.net