Mortality Reduction in Medical/Surgical Care – Rapid Response Teams and SBAR Strategies

1. Mortality Reduction in Medical/Surgical Care – Rapid Response Teams and SBAR Strategies September 24, 2004

2. Presenter Bio • Robert Brush, MD, has practiced as a Pulmonary and Critical Care Specialist at Borgess Medical Center since 1977. • For the past two years, Dr. Brush has been the Chief Quality Officer at Borgess.

3. Rapid Response Teams • “A Rapid Response Team (RRT, MET) is a group of healthcare professionals who respond quickly to threatened clinical deterioration. They should be seen as a “pre-code” team that brings critical care skills to the patient’s bedside. The IHI considers the RRT as potentially the most important mortality reduction initiative.”

4. How It Usually Goes: • A 65 y/o male with history of sleep apnea, post-op cholecystectomy complains of dyspnea. RR=30, SpO2 dropped to 87% on 4L O2/NC. • Nurse calls attending who gives additional morphine and increases O2 to 6L. • Patient “calms down” and RR=24, but SpO2 falls to 85% so nurse calls attending back. • Attending asks medical resident to see patient.

5. How It Usually Goes(continued): • Resident (HO-1) talks to the nurse on the phone and orders ABG, CXR, ECG, CBC and electrolytes. He says he’ll see the patient after he finishes with a new patient in ER. • Resident reviews the lab work 90 minutes later and asks the senior resident to see the patient with him. • As the residents enter the room, patient stops breathing. A “Code” is called. Patient survives but spends the next two weeks in ICU on a ventilator.

6. How It Should Go: • A 65 y/o male with history of sleep apnea, post-op cholecystectomy complains of dyspnea. RR=30, SpO2 dropped to 87% on 4L O2/NC. • Nurse feels the patient is “slipping” quickly and calls the Rapid Response Team. • Within five minutes, the patient is assessed, lab work and CXR is ordered and BiPAP is begun. • CXR and I&O review shows the patient is fluid overloaded.

7. How It Should Go (continued): • The patient is given IV Lasix. • The patient is transferred to a step down unit. • The diuretic is effective. • The patient returns to the Med/Surg Unit the following day and is discharged from the hospital two days later.

8. Rapid Response Team – What Is It? • Team with critical care skills that “brings critical care to the patient’s bedside” • Assist/augment floor nurse’s evaluation • Provides early intervention to slow or prevent clinical deterioration

9. (When Do You Open the Parachute?) RRT – Rationale • 6 – 8 hour window pre-code when deterioration may be turned around • “Failure to Rescue” – failure to recognize (nurse or therapist) versus failure to respond (physician)

10. RRT – Structure • Team composition may vary: • Physician – Intensivist versus Resident • Physician Assistant/Nurse Practitioner • Critical Care Trained Nurse • Respiratory Therapist

11. RRT – Functions • Responds within minutes • Attending MD called after RRT is called • Assess patient with the floor nurse • Intervene with or without attending MD • Transport to higher level of care when needed • Summon Code Team if needed

12. RRT – When to Call • Respiratory Rate > 24 or < 8 • Falling SpO2 • Δ level of consciousness • Δ BP and/or HR by 20% from baseline • Decreasing urine output • STAFF IS WORRIED ABOUT PATIENT!

13. RRT – Possible Interventions • Acute change in Respiratory Status: • Oximetry/ABG’s • Oxygen • CXR • Neb TX • BiPAP • Intubation

14. RRT – Possible Interventions(continued) • Acute change in HP/BP: • 12 Lead ECG • ABG • Oxygen • Atropine • Amiodarone • External Pacemaker • Dopamine Infusion • Other

15. RRT – Possible Interventions(continued) • Acute Change in LOC: • ABG’s, Oxygen • Electrolytes, Glucose Level • Naloxone, Flumazenil • CT Brain, MRI

16. RRT – Outcomes • ↓ Incidence of cardiac arrests • ↓ Arrests on floor as ↑ # of RRT calls • ↓ ICU transfers • ↓ Overall mortality • Improve “critical thinking”

17. Before and After Trial of a Medical Emergency Team University of Melbourne (MJA 2003; 179(6): 283)

18. RRT – Metrics • Number of RRT calls/number of discharges per month • Number of non-ICU codes/number of discharges per month • Number of deaths/number of discharges per month

19. Reduction in “Code Zeros” RRT Trial Began Borgess Medical Center

20. RRT – Building the Team • Choosing and teaching the team • Communicating with the nurses • Communicating with the physicians • Encourage collegial relationships among nurses • Discourage intimidation • Teach “critical thinking” to all

21. RRT – Barriers • PHYSICIANS – Threatened Autonomy • NURSES – Feel intimidated by critical care nurse/respiratory therapists

22. SBAR Defined • SBAR is a situational briefing tool that logically organizes information so that it can be transferred to others in an accurate and efficient manner.

23. SBAR • S – Situation • B – Background • A – Assessment • R - Response

24. SBAR - Rationale • Fosters “critical thinking” skills • Nothing “lost in translation” • Saves time • Helps RNs/RTs be the patient advocate

25. Assertive Behavior • Individuals speaking up and stating their information with appropriate persistence until there is resolution, all done in the interest of better patient care.

26. Assertiveness - Obstacles • Hierarchy/Power distance • Lack of common mental model • “Don’t want to look stupid” • “Not sure I’m right” • “I’ve been burned before”

27. SBAR - Situation • “I am (name and unit).” • “I am calling about (patient’s name and room number).” • “The problem I am calling about is (state the problem).”

28. Situation - Example • “I am Mary, a nurse on 3 North, calling about your patient Mrs. Brown in room 345 bed 2. The problem I am calling about is her new complaint of dyspnea and her increasing respiratory rate.”

29. SBAR - Background • State admission diagnosis and date of admission. • Give brief synopsis of hospital course and treatment to date. • Give vital signs including SpO2 and physical assessment pertinent to the problem.

30. Background - Example • “Mrs. Brown was admitted 3 days ago with pneumonia. She’s been on Levaquin and improving each day, no more fever and less cough and sputum. • Now her vital signs are RR=32 P=86, BP= 90/60, T=100.1 and SpO2= 88% on 2L. • Her breathing looks labored and she has new crackles in the right lower lobe.”

31. SBAR - Assessment • Give your impression of the present situation. A diagnosis is not necessary. • If the situation is unclear, at least try to indicate what body system is involved. • State how severe the problem seems to be. • If appropriate, state that the problem could be life threatening.

32. Assessment - Example • “I think Mrs. Brown could be developing worsening pneumonia in the right lower lobe.”

33. SBAR - Recommendation • Give the physician your recommendations for the thing(s) that you think should be done, based on your assessment.

34. Recommendation - Examples • “I have called the Rapid Response Team.” • “I think you should come to see the patient now.” • “I think you need to talk to the family about code status.” • “I think the patient needs a portable CXR and blood cultures.”

35. Before You Call • Have patient’s chart and MAR • Have today’s labs • Review most recent Progress Note • Review nursing notes for past shift • Know the “code status”

36. SBAR - Obstacles • Nursing acceptance – “but this is what I always do when I call the doctor.” Yes, but is this the way you always document? • Physician acceptance – Doctors are not accustomed to nurses or therapists giving them unsolicited recommendations.

37. Before SBAR Nurse: “Dr. Green, room 345’s potassium was 3.1 today.” Doctor: “Who’s potassium was 3.1?” Nurse: “Mrs. Brown in 345 bed 1, your partner’s patient.” Doctor: “What was her last potassium?” Nurse: “I don’t know; let me go find the chart.” 3 min. later – “It was 3.5 two days ago.” Doctor: “Is she on any diuretics?” Nurse: “I don’t know. Let me go find the MAR.” 2 min. later: - “Yes, she’s on Lasix.” Doctor: “Has she had any complaints tonight?” Nurse: “I don’t know, her nurse is at lunch.”….etc.etc.

38. After SBAR Nurse: “Hello, Dr. Green, this is Nancy the nurse taking care of your partner’s patient, Mr. Brown, in room 345, bed 1. I’m calling you because her potassium just returned and is 3.1. He is a 46 y/o man admitted 2 days ago for CHF. He’s been on Lasix since admission but no potassium supplement. His V/S are P=80; BP 110/84; RR=14 and T= 98.6. He is asymptomatic, no complaints of weakness and feels well. I think he is hypokalemic from his Lasix and needs some potassium supplement.”

39. Rapid Response Teams and SBAR Contact Information Borgess Medical Center Project Manager • Robert Brush, MD Chief Quality Officer Borgess Medical Center – Kalamazoo, MI rbrush@borgess.com System Office Liaison • John Garbo Director, Clinical Excellence jgarbo@ascensionhealth.org 314-733-8193