Rapid Response Team

Chief Medical Resident St. Vincent Charity Hospital/Case Western Reserve University Sunday, February 10, 2008

M. Chadi Alraies

Acknowledgment
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Critical Care Committee Dr. J. Sopko Krystyna Strozewski Karen Komondor R.N. Dr. Abdul Alraiyes

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100,000 Lives Campaign Objectives (December 2004 – June 2006)
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Save 100,000 lives Enroll more than 2,000 hospitals in the initiative Build a reusable national infrastructure for change

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The 100,000 Lives Campaign Scorecard

An estimated 122,300 lives saved by participating hospitals Participation in Campaign interventions:  Rapid Response Teams: 60%  AMI Care Reliability: 77%  Medication Reconciliation: 73%  Surgical Site Infection Bundles: 72%  Ventilator Bundles: 67%  Central Venous Line Bundles: 65%  All six: 42%
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Campaign Objectives (Summer and Fall 2006)
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Save 100,000 lives. Enroll more than 2,000 hospitals in the initiative. Build a reusable national infrastructure for change. Raise the profile of the problem - and our proactive response. Complete implementation of all six Campaign interventions in participating hospitals by January 2007. M Chadi Alraies 7

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Prevent Pressure Ulcers Reduce Methicillin-Resistant Staphylococcus aureus (MRSA) Infection. Prevent Harm from High-Alert Medications... starting with a focus on anticoagulants, sedatives, narcotics, and insulin Reduce Surgical Complications... by reliably implementing all of the changes in care recommended by the Surgical Care Improvement Project (SCIP) Deliver Reliable, Evidence-Based Care for Congestive Heart Failure…to reduce readmissions Get Boards on Board….Defining and spreading the best-known leveraged processes for hospital 9 M Chadi Alraies Boards of Directors, so that they can become far

What is Rapid Response Team?

RRT is a team of clinicians who bring critical care expertise to the patient bedside (or wherever it is needed) Based on three problems which can lead to failure to rescue:

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Failures in planning (assessments, treatments, and goals) Failure to communicate (patient to staff, staff to staff and staff to physician, etc.) Failure to recognize deteriorating patient M Chadi Alraies 10 condition

What difference can the RRT make?
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50% reduction in non ICU arrests.

Buist MD et al. in BMJ. 2002; 324: 387-390.

Reduced post operative emergency ICU transfers (58%) and deaths (37%).

Bellomo R et al. in Crit Care Med. 2004; 32: 916-921

Reduction in arrest prior to ICU transfer (4% vs. 30%).

Goldhill DR et al. Anesthesia. 1999;54(9): 853-860.
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Why we are initiating RRT?

Why we are initiating RRT?
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Between 48,000 –96,000 lives are lost due to medical error each year. Fortunately, only a small fraction of errors and accidents actually result in harm. Patient Harm May Occur For A Variety Of Reasons.
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Medication Errors Procedure Errors Infection Harm Accidents Equipment Failures

Communication breakdowns are causally implicated in a majority of errors and M Chadi Alraies accidents.

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Why we are initiating RRT?

Often when you review the chart of several patients that suffered cardiac or respiratory arrest in our hospital you will find alterations in:
Subjective complaints,  Vital signs,  Telemetry changes,  Nursing documentation that precede the event from hours to days in advance. 

Right?
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In establishing a rapid response team, the goal is

To respond to a “spark” before it becomes a “forest fire”

background

Known by some as the Medical Emergency Team. The purpose of the RRT is to bring critical care expertise to the patient bedside (or wherever it’s needed). Team is not intended to take the place of immediate consultation with the physician if needed.
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background

After consultation with the Rapid Response Team, a call is placed to the appropriate physician. The intention is to help patients in the time window of clinical instability and not to replace physician involvement in that process.

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To Err Is Human: Building a Safer Health System

Report published in 1999 by the Institute of Medicine (IOM). 44,000 to 98,000 Americans die each year as the result of medical errors.

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Crossing the Quality Chasm: A New Health System for the 21st Century

Published in In 2001 by the Institute of Medicine (IOM). Fundamental changes that must be made to the American health care system in order to produce badly needed improvements in care.

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Six primary aims:
Safer,  More effective,  Efficient,  Patient-centered,  Timely, and  Equitable.

Crossing the Quality Chasm: A New Health System for the 21st Century

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failure to rescue

– –

Three main systemic issues contribute to the problem: 
Failures in planning (includes assessments, treatments, goals) Failure to communicate (patient to staff, staff to staff, staff to physician, and sign outs, etc.) Failure to recognize deteriorating patient condition

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Measure
No. cardiac arrests

Rapid Response Team Results
Before
63 37 163 1363 302

After
22 16 33 159 222

RRR

Deaths from cardiac arrest        No. days in ICU post arrest No. days in hospital post arrest  Inpatient Deaths

65% (p=.001) 56% (p=.005) 80% (p=.001) 88% (p=.001) 25% (p=.004)

Bellomo R, Goldsmith D, Uchino S, et al. A prospective before-and-after trial of a medical emergency team. Medical Journal of Australia. 2003;179(6):283-287. M Chadi Alraies 23

In our hospital

RRT Trigger Criteria

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Respiratory

New Respiratory rate less than 8 or greater than 28 New Acute change in oxygen saturation less than 90% New Threatened airway

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Cardiovascular

New Acute change in systolic BP to less than 90mmHg New Acute sustained increase in diastolic BP greater than 110mmHg New Acute change in HR less than 50 or greater than 120 New onset chest pain or chest pain different than admission assessment New Acutely cold, pulseless or cyanotic extremity
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Neurologic
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New Confusion, agitation, or delirium New Unexplained lethargy/difficult to arouse New Difficulty speaking or difficulty swallowing New Acute change in pupillary response New seizure
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Other

New Temperature greater than 39.0 Celsius New Uncontrolled pain (if different than admission pain assessment) New Acute change in urine output less than 50ml/4 hours New Acute bleeding (i.e., bleeding with a change in vital signs, urine output or mental status)
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When to activate the RRT call
1. 2.

When on of the above criteria deteriorate significantly (very fast). Two or more of the above criteria fulfilled.

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Three key features of the team members

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The team members must be available to respond immediately when called.  They must be onsite and accessible. They must have the critical care skills necessary to assess and respond.
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RRT team member

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ICU on-call resident/floor on-call resident Nurse supervisor ???Respiratory Therapist

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How to activate RRT

Overhead page

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Primary physician notification

After patient assessment by RRT

ICU oncall resident/nurse supervisor has to notify the PCP about the RRT plan

Taking actions before notifying the PCP is acceptable if the patient fulfilled the criteria. If PCP didn’t response…

Please notify Dr.

8195908

Sopko
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Teaching/non-teaching patients

ALL
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RRT work/audit sheet

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Utilization of the Rapid Response Team

Definition:

Track the number of calls to the Rapid Response Team each week to assess that the team is being utilized and to measure its effectiveness. Increase the use of the Rapid Response Team over time.  Determine the total number of calls to the Rapid Response Team each week.
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Goal:

Data Collection Plan:

Rapid Response Team Record

Rapid Response Team Record

SBAR
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Situation, Background, Assessment, Recommendation

Structure enhances communication among team members. Organizations are encouraged to customize this tool to meet their local requirements and standards.
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Rapid Response Team Record

This tool was developed to:
 Document,  Analyze,  Share
 Why

and

the Rapid Response Team was called?  What interventions took place?  What patient outcome was achieved?
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Directions

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Designate a team member to complete a RRT Record for each call.  Use the “work Sheet” to document. The Record should be filled out as soon after the call as possible.

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Rapid Response Team Education Checklist

Rapid Response Team Education Checklist

Medical Staff Education
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General information Benefits ACLS or advanced critical care training Communication skills Appropriate expectations
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RRT Education
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Importance of responding in a timely manner Importance of providing non-judgmental, nonpunitive feedback to call initiator.

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Rapid Response Team Education Checklist

Nursing Staff Education
Criteria for calling  Notification process  Communication and teamwork skills

SBAR, Assertiveness / Critical Language

Appropriate expectations
Importance of calling even when unsure  Non-judgmental, non-punitive nature of the Rapid Response Team  Have information available for Rapid Response Team (chart, medication administration record, etc.)  Role as a member of the team M Chadi Alraies 47

Questions?

References
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Bellomo R, Goldsmith D, Uchino S, et al. A prospective before-and-after trial of a medical emergency team. Medical Journal of Australia. 2003;179(6):283-287. Move Your Dot™: Measuring, Evaluating, and Reducing Hospital Mortality Rates (Part 1). IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324(6):370-376. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, Hebert L, Newhouse JP, Weiler PC, Hiatt H. The nature of adverse events in hospitalized patients: Results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324(6):377-384. Buist MD et al. in BMJ. 2002; 324: 387-390. M Chadi Alraies 49 Bellomo R et al. in Crit Care Med. 2004; 32: 916-921

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