Rapid Response Team

1. SAGH 11/2005; Updated 5/2006 Rapid Response Team

2. Rapid Response Team (RRT) • Institute for Health Care Improvement (IHI) 100,000 Lives Campaign • Research suggests that 3 main system issues contribute to hospital mortality • Failure to communicate • Patient-to-staff, staff-to-staff, staff-to-physician, etc. • Failure to recognize a problem or deteriorating patient condition • Failure in planning • Includes assessments, treatments, goals • These three problems often lead to failure to rescue!

3. RRT---What data shows • RRT’s have been shown to reduce the incidence in cardiac arrests outside the CCU by 50% and transfers to CCU’s by 25-30%. • Overall hospital mortality has been reduced by as much as 26%. • 70% (45/64) arrests had evidence of respiratory/neurologic deterioration within 8 hours prior. (Schein, Chest 1990; 98:1388-92) • 66% (99/150) had abnormal signs and symptoms within 6 hours of arrest and MD notified 25% of cases (25/99) (Franklin, Cit. Care Med; 1994; 22:224-247)

4. RRT---What is a Rapid Response Team? • A Rapid Response Team—some call it a Medical Emergency Team—is a team of clinicians who bring critical care expertise to the patient’s bedside • The goal: To prevent deaths in patients who are failing outside the critical care settings.

5. RRT---purpose • To assist staff to assess the patient/situation • To stabilize the patient • To assist with communications among interdisciplinary care providers • To educate and support the staff caring for the patient • To assist with transfer of the patient if necessary

6. RRT—team members • Team leader—Nursing Supervisor/ADM • Support the learning environment, ensure response obtained, ensure needed outcome is achieved, debrief staff, collect data for follow up • Team members • CCU RN with at least 3 years of CCU experience • Assessment, communications, documentation, interventions, outcomes • Respiratory Therapist • Assessment, communications, interventions • Availability • Response time—5 minutes • Length of response usually 15 minutes, supervisors to reallocate staff as needed if longer response required. • Contact made by beepers, activated through group page on speed dial, noting the patient room number and nurse responsible.

7. RRT----team member roles • Roles are similar in scope to those of the Code 99 team. Assignment to RRT will be done on the “elevator” sheet the same as Code 99. • Interventions can be initiated by RRT members based upon scope of practice and protocols • Intervention Ex.—pulse oximetry, O2, telemetry, VS monitoring, • Protocol Ex.—chest pain, PCA/Epidural, Hypoglycemia, blood transfusion reaction, CIWA/ETOH withdrawal, restraints

8. RRT—recognizing acute changes • HR < 40 or > 130 per minute • Resp. rate <8 or > 30 per minute • SBP < 90 or > 200 mmHg. • SpO2 <90% • FiO2 50% or > • Significant bleed • Mental status changes • Seizures, new onset or uncontrolled • Failure to respond to treatment • Urine output <50 ml. In 4 hours • Staff conern, worried about the patient

9. RRT—documenting response • The purpose is to collect data for quality improvement and education. • Rapid Response Team Transmittal Form is utilized to note activities that occur, interventions, contacts, outcomes, communications. • The tool functions as part of the debriefing process.

10. RRT—organizational data • Mortality review • Cardiac arrest reviews—baseline data • CCU admission reviews—future data collection on who get transferred to CCU, why, could we have made a difference • Patient populations—what are our top DRG’s that are likely to require rescuing?

11. RRT-SAGH top 10 medical diagnoses—non OB related • Simple pneumonia > 17 years of age • Joint replacement • Heart Failure and Shock • Uterine and adnexa (uterine appendages, such as ovaries, tubes) procedures • COPD—bronchitis and asthma included • Septicemia > 17 years of age • Intracranial bleed • Appendectomy • Chest pain • Kidney/UTI > 17 years of age

12. RRT—How have we put this plan together? • Medical Management Committee and the Hospitalists who participate have been interested in the process and integral in plan design. • RRT is part of the IHI’s 100,000 Lives Campaign, receiving much national attention. • System-wide there have been meetings on the topic and discussions on roll out in each facility. • Roll out/education will be done in nursing department staff meetings, nursing education meetings on Nov. 10th and upcoming Medical Department meetings. • Further specific training for responders is planned in the near future.

13. RRT--Education • CCU and respiratory staff who would be assigned to the RRT will need additional training on documentation, response, and SBARO communications. • Teach in Code 99 Class, which is required of all new nursing hires, RT and Pharmacy. • Prompts and reminders will be developed and posted in key areas of each department with telephone numbers, clinical guides and basic SBARO information.

14. How do we page it? • Use the Arch Wireless Paging system: Page 967-0796 for group response- Type in “RRT”, “Room Number” & the name of the person paging; press “send” (Preferred method) • Page by phone overhead via PA system-dial 8800. State “RRT”, “Room number” and your name.

15. RRT—communications—SBARO! • SBARO Report to a Physician • BEFORE CALLING THE PHYSICIAN: • Assess the patient • Review the chart for the appropriate physician to call • Know the admitting diagnosis • Have the chart in hand, be ready to report allergies, medications, IV fluids, lab and test results. • Every SBAR Report is different. Focus on the problem. Be concise. Not everything in the outline below needs to be reported – just what is needed for the situation. • SITUATION • State your name and unit. • I am calling about: Patient name and room number. • The problem I am calling about is _________________________________. • Say what the code status is. • BACKGROUND • Briefly state why the patient is in the hospital. • Give the vital signs, oximetry, and how much oxygen is being given. • Relate the complaint given by the patient and the pain level. • Relate the physical assessment pertinent to the problem. • ASSESSMENT • Give your conclusions about the present situation using words like “might be” or “could be”. • If the situation is unclear try to indicate what body system might be involved. • State how severe the problem seems to be. • If appropriate, state the problem could be life threatening. • RECOMMENDATION • Say what you think would be helpful or needs to be done, which might include: •  medicines  tests  x-rays  EKG  transfer to critical care •  physician evaluation  consultant evaluation • Make sure to clarify under what circumstances to call back. • Orders—what orders are received, repeated back to the phsycian

16. RRT RECORD

17. RRT---documentation • RRT response to a patient room will require an exception note to be written. We are recommending that the progress note follow the SBARO format • Situation • Background • Assessment • Recommendation/outcomes • Orders

18. RRT--debriefing • Debriefing and completion of the transmittal form is a key expectation. • The transmittal form will supply Quality Improvement with the needed tracking information on RRT response frequency and outcomes. • Feedback on patient outcomes • Education planning • Celebrate success • Reporting on outcomes will be shared through Clinical Practice and Medical Staff meetings. Key medical staff meetings will be Medical Management and Critical Services.

19. RRT---Getting Started • Be tolerant of “false alarms.” Praise and NEVER criticize for calling. • Communicate, communicate, communicate! Get the word out—initially and continuously. • Share the RRT stories with medical and nursing staff. • Maintain continuous awareness and reinforcement of RRT through hospital publications, newsletters, etc. Keep it alive!

20. How have we done so far? • First quarter of 2006 data shows RRT used 8 times. • All 8 episodes were managed without progression to Code 99; 3 required transfer to CCU. • Had only one actual Code 99 called in that time frame.