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To purchase electronic or print 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.
Corresponding author: Kimberly Thomas, Team Leader, 2 West, Critical Care, Delnor-Community Hospital, 300 Randall Rd, Geneva, IL 60134 (e-mail: kim.thomas{at}delnor.com).
In 2004, in its 100000 Lives Campaign, the Institute for Health-care Improvement (IHI) encouraged American hospitals to implement rapid response teams (RRTs). The use of RRTs was 1 of 6 lifesaving strategies recommended by the IHI to improve patients’ outcomes; all 6 strategies were backed up by solid evidence in the medical literature. The national media focused on 2300 healthcare organizations that joined together to implement the strategies; today these strategies have become an established standard of care.6 According to the IHI, as of June 2006, an impressive 122300 lives had been saved since the implementation of evidence-based interventions in 2004. Hospitals are currently implementing RRTs as a proven strategy for preventing avoidable deaths of patients.7
An RRT is intended to prevent deaths outside the intensive care unit (ICU) by providing a resource team that can be called to a patient’s bedside 24 hours a day, 7 days a week. The RRT is expected to foster collaboration between critical care nurses and medical-surgical nurses in the care of patients through assessment, communication, immediate interventions, support, and education.
A patient’s baseline condition begins to deteriorate a mean of 6.5 hours before an unexpected critical event or actual cardiac arrest.8 Seventy percent of such events are preventable.7 Early recognition of warning signs of clinical deterioration and interventions by an RRT may provide better outcomes for general medical-surgical patients. Buist et al8 reported that RRTs resulted in a 50% reduction in the occurrence of cardiac arrest outside the ICU. In another study of RRTs, Bellomo et al9 reported that postoperative complications requiring transfer to the ICU were reduced by 58%, and postoperative deaths were reduced by 37%. RRTs may also decrease the number of unnecessary transfers to a higher level of care by a mean of 30% and decrease overall hospital mortality by a mean of 26%.9
RRTs may consist of different structured groups: physician and nurse, intensivist and respiratory therapist, physician assistant alone, critical care nurse and respiratory therapist, or clinical specialist alone.7 The RRT may be called upon at any time that a staff member becomes concerned about a patient’s condition. Physiological changes such as changes in heart rate, systolic blood pressure, respiratory rate, pulse oximetry saturation, mental status, or urinary output can be gradual or sudden.9 Changes in significant laboratory values such as sodium, glucose, and potassium levels could also be early indicators of a patient’s deteriorating status.10 Hospitals have established evidence-based criteria to facilitate early identification of physiological deterioration in both adult and child patients. These guidelines help novice staff members determine if an RRT should be called for a bedside consultation.11
Nurses must be aware of signs and symptoms that could lead to cardiopulmonary arrest, or a "code blue." The condition of a patient before a cardiac arrest can be recognized by staff, and early interventions can be initiated to prevent a code blue. When nurses are provided with an RRT and are on the alert for potentially dangerous scenarios, patients’ deaths may be prevented. Preventing a code blue should be a top priority for nurses in medical-surgical units because the survival rate to discharge after a full cardiopulmonary arrest is only 15%.12,13 Anticipation of code blue situations involves early recognition of vital signs before cardiac arrest, awareness of trends in the patient’s status, activation of an RRT, and nurse-to-nurse collaboration before it is too late to prevent a death.14
Three fundamental problems lead to failure to rescue in hospitals: (1) breakdown of communication between patients and staff (any caregiver), between staff and other staff, between staff and physician, and/or between physician and physician; (2) failure to recognize early signs of deterioration in a patient’s hemodynamic condition; and (3) incomplete assessments or inadequate treatments.15
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Implementation of an RRT |
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The RRT consisted of 1 critical care nurse and 1 respiratory therapist who were assigned to in-house call 24 hours a day, 7 days a week. Pagers were programmed with an easy-to-remember number (7999) so that staff members could type in the patient’s room number directly. Criteria were developed to determine when the staff should page the RRT. The ICU nurse and respiratory therapist would be expected to arrive at the patient’s bedside for a consultation within 5 minutes of being paged. The nursing supervisor and nurse chairperson of the RRT steering team were also included in the page to promote communication among staff and to provide backup support. Hospital staff and physicians were taught an effective communication technique called SBAR (situation, background, assessment, recommendations) to promote efficient reporting skills. By using a uniform communication technique, staff members were able to report their findings directly and in a concise manner, providing the physician with clear information about the patient’s condition, history, assessment, and recommendations.
The project’s steering team developed a set of criteria for determining when an RRT should be called in to consult on a medical-surgical patient. These criteria, known as activation criteria, were simple and unrestricted; they included concern about the patient among staff members and/or changes in the patient’s heart rate, heart rhythm, blood pressure, respiratory status, or mental status. No call would be considered inappropriate. Intense education throughout the hospital provided reassurance to nurses that "being worried about a patient" or "having a gut feeling" were legitimate reasons to call the RRT. Education was ongoing and stressed the importance of mutual respect between the nurses in the medical-surgical units and ICUs, respiratory therapists, and physicians.
The project’s steering team collaborated with the physicians to develop a protocol that would be initiated once the RRT was activated. The primary role of the RRT was to collaborate with the staff nurse at the patient’s bedside to determine if further interventions were needed. Diagnostic tests were incorporated into a protocol so that the RRT could initiate 5 interventions on their own before speaking with the primary physician. Types of interventions included arterial blood gas analysis, chest radiography, electrocardiography, oxygen per protocol, and/or tests to check blood glucose levels. The results from these interventions were then communicated to the physician to provide a more detailed assessment of the patient’s current status.
Key indicators were tracked in a database to measure patients’ outcomes before and after implementation of the RRT. Information on every RRT call was collected on a standardized form through the computerized documentation system. This nursing documentation became a permanent part of the patient’s medical record. Information collected included patients’ demographics, location, reason(s) for the call, call start time, call end time, and narratives formatted as SBAR (situation, background, assessment, and recommendations) for the primary physician. Attending physicians were always notified by telephone of an RRT call involving their patients. Findings based on physical assessment were documented immediately after the RRT consultation, as was the transfer of the patient to a higher level of care if needed. The patient’s status was documented again during a follow-up visit 8 hours after the initial RRT consultation. The RRT chairperson was responsible for compiling the data for each patient and for tracking the patient’s status until hospital discharge.
An essential component of the success of an RRT was a comprehensive and detailed communication plan to convey the purpose and goals of the RRT to physicians, administrators, clinical staff, and nonclinical staff. Hospital newsletters, physician newsletters, medical staff meetings, board of directors meetings, and frequent leadership and staff communications provided ongoing education for 2 months before and after the RRT initiative was launched. On May 1, 2005, the RRT was ready to go live. Engagement of all staff and physicians was essential to the success of the program. Members of the RRT proudly wore personalized white jackets with the newly designed RRT logo (Figure 1
). The ICU nurse and respiratory therapist assigned to the RRT visited all units to inform staff members and physicians of the purpose and goals of the team. Brightly colored stickers were placed on all telephones and bulletin boards to remind staff members of the activation number.
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The project’s steering team promoted the professional benefits of becoming a member of the RRT:
Once the criteria and benefits had been developed, applications were sent to all members of the critical care and respiratory therapy departments. Applicants were interviewed and selected by coordinators. Case scenarios were used during the interview process to determine the assessment and communication skills of each applicant.
After selection, RRT responders participated in ongoing educational sessions to strengthen the team’s clinical competency. RRT charting screens were developed in the computerized documentation system to reflect the SBAR technique with feedback from the responders. Practice sessions were held to allow the responders to become familiar with accurate documentation and customer service skills. Training sessions focused on active listening skills, critical thinking, and problem solving. Ongoing monthly training and education sessions were planned as an important component of building a high-performing RRT.
The extra staffing hours required for the commitment to a new team were not planned in the ICU budgets. Leaders and staff debated the RRT nurse’s role, the assignment of patients, and budget constraints. RRT responders working the day shift were not assigned to patients. Responders working the evening and night shifts were given "light" patient assignments, defined as either 2 telemetry patients or 1 stable intensive care patient. Other duties for RRT members included the following:
At the start of the program, members of the project’s steering team were rotated so that someone would always be available to the RRT by phone or pager. If team members had any questions, they could contact the on-call member of the project’s steering team for clarification. This support process continued for 2 weeks and was reimplemented as needed when new members were brought onto the team.
A major benefit of the RRT program was the general improvement it brought about in the hospital’s culture as a result of the greater emphasis on collaboration between staff members and physicians. Professional respect increased between critical care nurses, respiratory therapists, and nurses from the medical-surgical units. Bedside collaboration allowed staff members to teach one another about patients’ diagnoses and treatments. Improved communication between physicians and nurses and respiratory therapists was another benefit. Effective communication was enhanced by the SBAR communication system. Education of nursing staff about the criteria for activating the RRT, use of SBAR communication to report, and assertiveness and teamwork promoted rapid yet nonthreatening assessment of patients whose condition was deteriorating.
Physicians were positive about the RRT program because they perceived improved competence at the bedside as well as stronger cohesiveness among staff members. Nurses, especially during their "off " shifts, were grateful for opportunities to brainstorm with other staff members about possible reasons why a patient might be "just not right." Inexperienced staff members and recent graduates found the RRT resource to be especially valuable. Bedside collaboration with experienced ICU nurses and respiratory therapists provided them with confidence and a feeling of security.
The attitude that a staff member’s concern about a patient was a genuine reason to activate the RRT was pervasive in the organization and encouraged timid nurses to seek out consultations. The RRT slogan "Call Early . . . Call Often" was frequently e-mailed to staff to encourage participation in this new initiative. The ICU staff and respiratory therapist gained a new respect for the acuity of patients and for the workload of nurses in the medical-surgical unit. The mutual respect among healthcare workers contributed to the success of the RRT program. After each RRT call, staff members were provided with an evaluation form to express their opinion about the experience. The evaluation forms were sent to the RRT steering committee to be included as feedback in the educational sessions for the RRT responders.
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Challenges |
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RRT staff members were assigned specific duties and were given fewer patients to care for. During the early implementation phase, the ICU staff perceived a discrepancy between different nurses’ interpretations of these roles. Interpersonal conflicts emerged between staff members about their roles and responsibilities in the unit and on the RRT. It became apparent that different levels of professional motivation affected how staff members used their time when they weren’t responding to an RRT call. This variation in the level of professional motivation caused discord among the nurses. The environment became tense and apprehensive during this initial phase of RRT implementation.
Effective communication and consistent strong leadership were essential during the initial implementation period. It was important to obtain acceptance from staff members and to clarify the roles and duties of the members of the RRT. Staff meetings were held each month to give the nurses a chance to discuss their conflicts and explore possible solutions. A culture change within the ICU was required in order for the ICU nurses to accept routine daily collaborations with medical-surgical nurses about patients in the medical-surgical units. Staff members were encouraged to give their feedback and suggest ways to improve the RRT. Group meetings were held to promote staff cohesion and to stress the importance of the RRT in increasing patients’ safety.
Scheduling of the RRT was very challenging. In the first 90 days, it was necessary to schedule overtime hours for nurse leaders and clinical staff because of the high number of inexperienced ICU nurses. It was essential to continually develop ICU staff to meet the qualifications to become an RRT responder. During the first 90 days of RRT implementation, an extra day-shift nurse with no assigned patients was assigned to the RRT. The cost of staffing evening-and night-shift workers increased only minimally because RRT workers were assigned fewer patients. Overtime staffing was necessary only occasionally during these shifts, when staffing or acuity patterns required changes to the RRT schedule.
The initial startup required mentoring and increased staffing levels to adjust for the learning curve. After this initial period, ICU staffing returned to normal levels, which are based on patients’ acuity. The RRT assignment was integrated into the ICU nurses’ regular responsibilities, much like a code blue assignment, and did not require further increases in staffing. After 90 days of initial startup, no additional costs accrued to the organization for the 24-hour-a-day, 7-day-a-week operations of an RRT.
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Costs and RRT Financial Benefit Model |
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TopImplementation of an RRTChallengesCosts and RRT Financial...Impressive Results After 16...SummaryReferences |
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This RRT financial benefit model quantifies costs savings with the general assumption that improving quality increases the number of patients who can receive care, reduces length of stay, and increases flow of patients through the patient care system with no change in total cost.16 The conservative estimate of the organization’s financial savings of $171480 per year was calculated by using labor and cost accounting methods (see Table).
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Impressive Results After 16 Months |
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TopImplementation of an RRTChallengesCosts and RRT Financial...Impressive Results After 16...SummaryReferences |
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), use of RRTs during a 16-month period resulted in a 56% reduction in the monthly rate of code blues in medical-surgical units (Figure 3). In 2006, the mean number of code blues outside the ICU, emergency department, and operating room per 1000 discharges each month was 0.63, a decrease from 1.22 in 2005. Unanticipated transfers from the medical-surgical units to the ICU were decreased by 10%. Because of early interventions, 63% of all RRT patients remained in the medical-surgical units and did not require a change in the level of care (Figure 4). Overall, only 2% of all RRT patients experienced a code blue event during their hospital stay. Although RRT patients had a mean stay of 10 days, which implies a high clinical acuity level, the total survival rate at discharge was 86%.
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). In the past year, the RRT had a total of 267 calls with a mean of 18 calls per month. The activation call times were distributed throughout the 3 shifts, with the greatest number occurring during the 3 PM to 11 PM shift (41%). Surprisingly, more RRT calls (18%) occur on Wednesdays than on other days, but the calls were fairly evenly distributed across the week. The mean duration of an RRT consultation at the bedside was 30 minutes; consultations lasted from a maximum of 1 hour 57 minutes to a minimum of 9 minutes.
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). RRT nurses’ interventions that were started at the bedside during the call included the following (Figure 6): implementation of an oxygen protocol (63%), electrocardiography (29%), arterial blood gas analysis (23%), checking of blood sugar level (16%), chest radiography (21%), administration of furosemide (8%), treatments with a respiratory nebulizer (7%), and implementation of a hypoglycemia or hyperglycemia protocol (3%).
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Summary |
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TopImplementation of an RRTChallengesCosts and RRT Financial...Impressive Results After 16...SummaryReferences |
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Acknowledgment |
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References |
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TopImplementation of an RRTChallengesCosts and RRT Financial...Impressive Results After 16...SummaryReferences |
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This article has been cited by other articles:
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  S. M. Bagshaw, E. E. Mondor, C. Scouten, C. Montgomery, L. Slater-MacLean, D. A. Jones, R. Bellomo, R. T. Noel Gibney, and for the Capital Health Medical Emergency Team Inve A Survey of Nurses' Beliefs About the Medical Emergency Team System in a Canadian Tertiary Hospital Am. J. Crit. Care., January 1, 2010; 19(1): 74 - 83. [Abstract] [Full Text] [PDF]
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