Good Samaritan Hospital

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Good Samaritan Hospital

• RAPID RESPONSE TEAM
• One year strong and counting ..

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Your Hosts

• Kathleen Lynam RN,MPA,CNAA
• Vice President of Patient Care, CNE
• Marie Garrido RN, MS,CCRN CNS
• Clinical Specialist in Critical Care, Acting
  Manager of CCU

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Good Samaritan HospitalSuffern, New York

• 370 bed Community based hospital
• Member of Bon Secours Health System
• Level 2 Trauma
• Stroke Center- JCAHO/State Designated
• JCAHO AMI Center of Excellence
• Open Heart to begin January 2007
• 1199 Collective Bargaining Unit

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Good Samaritan

• 500 Nurses
• Average Age of Nursing 47
• Nurses gt35 year tenure- 15
• Highly competitive market for nursing
• Surrounded by 3 Magnet Hospitals
• 2003 Nursing Vacancy rate overall 25
• 2006 Vacancy rate overall 11.5

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The Motivation

• We believe IHI groupies
• Past few year history of vacancies and
  aggressive recruitment of GNs
• Past history of use of Agency Nurses
• Need to support off shift nurses
• Need to raise the level of care
• History of work done on Code 99 practice over
  the past 3 years

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Rapid Response Team

• Purpose/ Role
• A team of expert clinicians who bring
  critical care expertise to the patient bedside
  (or wherever it is needed).
• The team responds emergently to potential patient
  deterioration or crisis throughout the hospital

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RRT Role

• The role of the RRT involves
• Assisting the staff member in assessing and
  stabilizing the patients condition and
  organizing information to be communicated to the
  patients physician
• Educating and supporting staff
• Consultant/collaborator for the experienced and
  skilled nurses
• Assisting with transfer, as circumstances
  warrant, to a higher level of care

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The Plan

• Hand Pick some Super Nurses and Respiratory
  Therapists
• Market the plan to Medical Surgical Nurses
• Pilot on Days using our CNS as role model
• Present to Medical Executive Staff for support
• Go Live- two weeks after IHI 12/04

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The Tool

• SBAR Format utilized
• Records level of intervention and team attendance
• Revised recently to incorporate sepsis bundle
  protocol, palliative care referral and additional
  demographics

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ADULT RRT RECORD
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GOOD SAMARITAN HOSPITAL Bon Secours Charity
Health System
RAPID RESPONSE TEAM CRITERIA FOR CALLING

• Call Us If
• Staff member is worried about patient
• Acute change in Heart Rate
• Acute change in Systolic BP
• Acute change in Respiratory Rate/Status
• Acute change in O2 Saturation
• Acute change in Level Of Consciousness

RRT

• If you are concernedSO ARE WE
• FOR ADULT RRT CALL OPERATOR AND ANNOUNCE RAPID
  
• RESPONSE LOCATION it will be paged
  overhead and on RRT pager
• FOR PEDIATRIC RRT CALL OPERATOR AND ANNOUNCE
  PEDIATRIC
• RAPID RESPONSE LOCATION it will be paged
  overhead and on
• Pediatric RRT pager

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January 2004 December 2005In-Patient
Codes/1000 Discharges RRTs
RRT
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Comparison of In-Patient Codes Jan-Dec.
2004 vs. Jan-Dec. 2005 Adjusted for Census
Jan-Dec 05 (9/1000 Discharges)
Jan-Dec 04 (11.5/1000 Discharges)
22 Decrease in In-Patient Codes/1000 Discharges
(Jan-Dec05)
Jan-Dec05
Jan-Dec 04
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Rapid Responses January 05 April 06

• Total 458 calls (plus 1 pediatric and 6
  neonatal)
• Reason for Call
• Respiratory/low sats/ rales /congestion
• Dysrhythmias
• B/P issues Mental status change
• Pt doesnt look well/ pt diaphoretic
• Chest pain
• Mental status change
• Fever/temp
• Abd pain/seizures/blood transfusion reaction
• Medication / drip review
• Electrolyte/hyperkalemia
• GI bleeding

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Rapid Responses Jan 05-April 2006 (cont)

• Severe headache/weakness/ lightheaded/near
  syncope
• GI bleeding / bleeding IV site/ trach/around
  foley/epistaxis
• Drug reaction
• Hypoglycemia
• To assess non-working telemetry/alarm reading
  asystole
• Unable to get IV access/ insert foley

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Findings in First 16 months

• Patient Status at end of call
• 193 (42) transferred to higher level of care

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Reason for Calls
33 of calls
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Location of RRT Calls January 13, 2005 April
2006
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Team Tools

• Protocols
• Non invasive BP
• Pulse Oximeter
• Beepers

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RRT Policy and Procedure RRT Protocols

• Patient Assessment
• As per Rapid Response Team Record (SBAR
  documentation tool)
• Situation
• Background
• Assessment
• Recommendations
• Notify /communicate with attending physician in
  timely manner

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RRT Policy and Procedure RRT Protocols

• Diagnosticsas patient condition warrants
• Oxygen saturation
• Arterial Blood Gases
• if respiratory distress, SpO2lt 90, change in
  level of consciousness
• 12 Lead EKG
• if chest pain, dysrhythmia, other cardiac
  signs/symtoms
• Chest x-ray (portable)
• if acute respiratory distress with diminished
  breathsounds, new onset of significant rales,
  rhonchi, wheezing, difficulty ventilating patient

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RRT Policy and Procedure RRT Protocols

• Laboratory Data for suspected abnormalities
  based on patients clinical manifestations and
  status
• Fingerstick glucose (i.e. change in LOC in
  diabetic patient, suspected hypoglycemia)
• Chem 7 (i.e. previous or suspected
  hypo/hyperkalemia or hypo/hypernatremia)
• CBC (i.e. observed or suspected
  bleeding/hemorrhage, suspected infection/sepsis )
• PTT, PT/ INR (i.e. observed or suspected
  coagulation abnormalities/ bleeding/hemorrhage)

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RRT Policy and Procedure RRT Protocols

• I.V. Access / Fluids If no IV access and
  patient condition warrants
• Normal Saline
• Saline Lock
• Oxygen Therapy
• Nasal Cannula at ________L/min.
• O2 Mask (FiO2 as patient condition warrants)
  ________

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RRT Policy and Procedure RRT Protocols

• ACLS Protocol
• Implement as necessary to stabilize clinically
  deteriorating patients
• Dextrose 50 IVP
• for blood glucose below 50.

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December 2004 May 2006In-Patient Codes / RRTs
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December 2004 May 2006In-Patient Codes / RRTs
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Rapid Responses January- March 2006

• Interesting Findings
• January 17 RRT calls were for patients
  admitted lt 24 h
• February - 31 RRT calls were for patients
  admitted lt 24 hours
• March 25 RRT calls were for patients admitted
  lt 24 hours

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NICU / Pediatrics RRT

• Assessment tool modified for NICU
• NICU nurses called to assess newborns in labor
  and delivery and regular nursery
• Assessment tool modified for Pediatrics
• ED nurses called to assess pediatric patients in
  T-4 or Ambulatory Surgery Unit
• Average 5 calls per month
• Majority are NICU calls to evaluate newborns in
  Regular Nursery during transition phase

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Knowledge Gained

• Great support for staffhas become part of the
  culture
• Transfers to higher level of care has increased
  this year 2006 to gt49
• Code 99s outside of Critical Care and overall
  have been reduced by 22
• Sepsis Mortality rate is dropping
• Even if staffing does not allow critical care
  nurses respond to calls
• Increase referrals for Palliative care

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What do Patients / Families Have to Say

• My Mom was having trouble breathingthe nurses
  called the team, they came within minutesthey
  helped get things under controlI was so
  relieved.

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Other Findings

• Status change to DNR 10 of patients possible
  Palliative care referrals
• Conducted staff survey with RRT team members and
  staff who called for RRT to see if there was a
  positive impact.

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Rapid Response Team Staff Survey Results
Figure 5 Preliminary survey results based on 37
respondents -July 2005
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Rapid Response Team Staff Survey Results
Figure 6. Sample Survey results based on 22
respondents December 05
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Rapid Response Team Team Member Survey Results
Figure 7. Sample Survey results based on 14
respondents December 05
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Next Steps

• Continue to monitor patients admitted lt 24 hours
  for trend
• Incorporate referrals for palliative care
  consults on RRT tool
• Continue work of IHI Flow community to improve
  patient placement
• Consider expansion to family or patient
  initiated calls

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The Team
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Questions?