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Kathleen Johnson is a nurse manager in the medical intensive care unit at Christiana Care Health Service.
To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.
A Maureen A. Seckel, RN, MSN, APRN, BC, CCRN, and Kathleen Johnson, RN, MSN, CNA, BC, reply:
Critical care nurses have always been involved in the cutting edge of healthcare and patient safety. Many institutions have had programs that blur the borders of the intensive care unit (ICU) walls to bring critical care to the patient instead of waiting until the patient is admitted to the ICU.1 Our critical care colleagues in Australia and Europe have reported an important patient safety approach to prevent deaths in patients who are progressively failing outside the ICU, called the medical emergency team (MET).2,3 The MET is synonymous in the literature with the RRT. The RRT is designed to assist in the care of any patient who presents with a sudden assessment change or appears acutely ill, before the patient suffers a cardiac or respiratory arrest. Research has shown that patients often show signs or symptoms of instability for up to 6 to 8 hours before cardiac arrest.4 A call to the RRT can be initiated by any health-care provider for early signs or "sense" of physical deterioration.
RRTs were first pioneered in Australia where clinical trials demonstrated outcomes of a 50% decrease in adverse events and a 36.6% decrease in postoperative mortality.5,6 Also, since 2000, the United Kingdom has implemented a network of teams known as the critical care outreach and has demonstrated a reduction in the number of cardiac arrests.7
Composition of the Team
There have been multiple models of the team composition in the literature. These are often tailored to the institution and include:
The team members should be available to respond immediately via pagers or overhead calls, not unlike a "Code Blue" or cardiac arrest team. The major difference is that the RRT is intervening earlier; hopefully within the 6- to 8-hour window of warning before the patient suffers a cardiac or respiratory arrest. The members of the team should be onsite, able to free themselves from their assignments, and have the necessary critical care skills needed to assess and respond. Not unlike the cardiac arrest team, the RRT provides the immediate critical care intervention needed for the patient but also consults with the patient’s healthcare team to formulate the best plan of care for the patient. The RRT may stabilize the patient so that he or she is able to remain on the nursing unit, or assist with the transfer of the patient to a higher level of care, for example, to an intermediate care unit or an ICU. In addition, the new plan of care may also include implementing less aggressive measures including do-not-resuscitate orders and palliative care.
General Call Triggers
The triggers to initiate the RRT have similar characteristics in the research and in the institutions that have implemented teams.8,9 In general, the most important call criterion is that a staff member is "worried about the patient" and can initiate a call to the RRT.10 Other triggers may include:
Benefits of the RRT
Along with the known benefits of a reduction in non-ICU deaths with the implementation of an RRT, institutions have shown that the number of patients who survive to discharge after a code has been called is increasing.3,5,11 In addition, the patients who go on to suffer a cardiac arrest are more likely to be in an ICU environment with immediate critical skills and technology available directly at the bedside. Patients who are treated earlier in their crisis by RRT intervention may not need ICU admissions or their ICU stay may be shorter.2
Another important benefit is the mentoring and education role of the team. An important consideration for implementation and composition of the team is the communication skills of the members. It is a win-win situation for both the patient and the staff. The patient has the benefits of a rapid assessment and change to the plan of care if needed by critical care staff. In addition, the nursing staff on patient care units outside the critical care are has the advantage of reassurance and verification of their concerns, a plan for further care and assessment, and on-the-spot education.
Added Benefits
A goal for patient safety from the Institute for Healthcare Improvement is for hospitals to implement an RRT to prevent deaths and reduce complications in patients who are failing outside the ICU. Once implemented, the RRT is added value for the hospital system along with providing a safety net for the patient. The first international conference for METs took place in Pittsburgh, Pa, in June 2004, and the American Hospital Association, the Joint Commission on Accreditation of Healthcare Organizations, and the Society of Critical Care Medicine have all expressed interest in the concept. The future for patient safety at your hospital is enhanced by the addition of the new RRT.
References
The Society of Critical Care Medicine has a medical emergency and rapid response team forum that has an ongoing discussion at: forums.sccm.org.
The Institute for Healthcare Improvement has published a how-to guide at: www.ihi.org/IHI/Programs/Campaign.
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