The 100,000 Lives Campaign: Rapid Response Teams

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The 100,000 Lives Campaign Rapid Response Teams

• Institute for Healthcare Improvement

This document is in the public domain and may be
used and reprinted without permission provided
appropriate reference is made to the Institute
for Healthcare Improvement.
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What Is a Rapid Response Team?

• A Rapid Response Team known by some as a
  Medical Emergency Team is a team of clinicians
  who bring critical care expertise to the patient
  bedside (or wherever it is needed).
• The goal To prevent deaths in patients who are
  failing outside intensive care settings.

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Why Rapid Response Teams?

• People die unnecessarily every single day in our
  hospitals. The goal is to respond to a spark
  before it becomes a forest fire.

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Mortality Diagnostic 2 x 2 matrix
ICU Admission ?
Yes
No
Yes
Box 1
Box 2
Comfort Care Only?
No
Box 3
Box 4
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Mortality Diagnostic Aggregate Results for 64 US
Hospitals
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Three fundamental problems

• Failures in planning
• Includes assessments, treatments, goals
• Failure to communicate
• Patient-to-staff, staff-to-staff,
  staff-to-physician, etc.
• Failure to recognize a problem
• These three problems often lead to failure to
  rescue.

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Clinical Instability Prior to Arrest

• 70 (45/64) arrests with evidence of
  respiratory/neurologic deterioration with 8 hours
  (Schein, Chest 1990 98 1388-92)
• 66 (99/150) abnormal signs and symptoms within 6
  hours of arrest and MD notified 25 of cases
  (25/99) (Franklin, Crit Care Med199422
  224-247)

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Clinical Instability Prior to Arrest

• Warning signs within 6 hours of event
• MAP lt70 or gt130 mmHg
• Heart rate lt45 or gt125 per minute
• Respiratory rate lt10 or gt30 per min
• Chest pain
• Altered mental status

Franklin. Crit Care Med. 199422224-247.
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What difference can a Rapid Response Team make?
Bellomo. Med J Aust. 2003179(6)283-287.
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What difference can a Rapid Response Team make?

• 50 reduction in non-ICU arrests (Buist, BMJ 02)
• Reduced post-operative emergency ICU transfers
  (44) and deaths (37) (Bellomo, CCM 04)
  
• Reduction in arrest prior to ICU transfer (4
  v 30 ) (Goldhill, Anest 99)

Slide from Rothschild, 2004
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Codes per 1000 Discharges
Average
Codes per 1000 Discharges
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Hospital Codes Outside the ICU
44 decrease
44 decrease
Number of Codes
Medical Response Team (MRT) implemented August
2003
Medical Response Team (MRT) implemented August
2003
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Percent of Coded Patients Surviving at Discharge
(p-chart)
UCL
Medical Response Team (MRT) implemented August
2003
Average
Percent
48 increase
LCL
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Codes per 1000 Discharges
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What Is the Role of the Rapid Response Team?

• Assess
• Stabilize
• Assist with communication
• Educate and support
• Assist with transfer, if necessary

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Rapid Response Team Considerations

• Engage senior leadership support
• Determine the best structure for the team
• Provide education and training
• Establish criteria and mechanism for calling
• Establish structured documentation tool
• Establish feedback mechanisms
• Measure effectiveness

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Engage Leadership Support

• Executive and physician
• Clear and wide communication strategy

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Determine the Team Structure

• Considerations
• Available
• Accessible
• Able
• Multiple Models
• ICU RN and Respiratory Therapist (RT)
• ICU RN, RT, Intensivist, Resident
• ICU RN, RT, Intensivist or Hospitalist
• ICU RN, RT, Physician Assistant

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Provide Education and Training

• Medical Staff
• General information
• Benefits
• Myths

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Provide Education and Training

• Rapid Response Team Members
• ACLS or advanced critical care training
• SBAR
• Communication skills
• Appropriate expectations
• Importance of responding in a timely manner
• Importance of providing non-judgmental,
  non-punitive feedback to call initiator

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Provide Education and Training

• Nursing Staff
• 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

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Establish Criteria for Callingthe Rapid Response
Team

• Staff member is worried about the patient
• Acute change in heart rate lt40 or gt130 bpm
• Acute change in systolic BP lt90 mmHg
• Acute change in RR lt8 or gt28 per min
• Acute change in saturation lt90 despite O2
• Acute change in conscious state
• Acute change in UO to lt50 ml in 4 hours

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Mechanism for Calling the Rapid Response Team

• Beeper with or without overhead page
• Encourage staff to dial from the patients room
  number
• If not in a patient room, dial in the extension
  for the Rapid Response Team to call back for a
  location

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Communication and Documentation

• Embed SBAR
• Record the interventions and reasons for call
• Use data to drive educational programs

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Establish Feedback Mechanisms

• Feedback information on patient outcome.
• Look for lessons learned hospital-wide.
• Use data to drive educational programs.
• Share the success stories.

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Measure Effectiveness

• Key measures
• Codes per 1000 discharges
• Codes outside the ICU
• Number of rapid response team calls
• Other possible metrics
• Percent of coded patients surviving at discharge
• Transfers to higher level of care (ICU or other)
• Average ICU LOS for post Rapid Response Team ICU
  transfers vs med/surg ICU admissions
• Satisfaction with the Rapid Response Team process
• Post cardiac arrest ICU bed utilization
• Safety culture survey data

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Model for Improvement

• What are we trying to accomplish?
• How will we know that a change is an improvement?
• What changes can we make that will result in an
  improvement?

Act
Plan
Study
Do
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Other Possible Benefits of Rapid Response Teams

• Better outcomes
• Improved relationships
• Improved satisfaction
• Nursing
• Physician
• Patient
• Impact on nursing retention
• Financial benefits
• These require further study.

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Tips When 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 Rapid Response Team stories with
  medical and nursing staff.
• Maintain continuous awareness and reinforcement
  of Rapid Response Team through hospital
  publications, newsletters, etc. Keep it alive!

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Complete details about the 100,000 Lives Campaign
including materials, contact information for
experts, and web discussions available on the web
at www.ihi.org.