Panelists
The Rapid Response Team Jimmy Phillips: Catawba Valley Medical Center Jessie Miller: Martin General Hospital
Lawson Millner: Forsyth Medical Center A Panel Discussion Jhaymie Cappiello: Duke University Hospital
Reason for RRT initiation
Institute for Healthcare Improvement 2004 •66 % of patients showed abnormal signs & symptoms within 6 hours of arrest & the MD was notified in 25 % of those cases (Franklin & Mathew, 1994). 1. Delivery of Reliable, Evidence-Based Care for Acute Myocardial Infarction… • 2. Prevention of Adverse Drug Events (ADEs) 50% reduction in non-ICU arrests (Buist, BMJ 02) 3. Prevention of Central Line Infections •Reduction in arrest prior to ICU transfer (4 % v 30 %) (Goldhill, Anest 99) 4. Prevention of Surgical Site Infections •Reduced post-operative emergency ICU transfers (44%) and deaths (37%) 5. Prevention of Ventilator-Associated Pneumonia (Bellomo, CCM 04) 6. Deployment of a Rapid Response Team – early recognition and treatment of clinical deterioration can decrease the rate of cardioplulmonary arrests outside the critical care setting and unplanned intensive care admissions – The goal: To prevent deaths in patients who are failing outside intensive care settings.
IHI Recommendations for an RRT
1. What Is the Role of the Rapid Response Team
2. Determine the Team Structure 3. Provide Education and Training Where Are We Now? 4. Establish Criteria for Calling the RRT
5. Mechanism for Calling the RRT
6. Communication and Documentation
7. Establish Feedback mechanisms and Measure Effectiveness Catawba Valley Medical Center
32 nd Magnet Hospital in the Nation nd Rapid Response Team 2 hospital in North Carolina Re -designated 2010 which was our 3 rd re -designation Catawba Valley Medical Center Hickory, NC 258 bed acute care hospital
Jimmy Phillips RRT -NPS, RCP Director Cardio -Pulmonary and Critical Care Transport Svcs
Current Status Rapid Response Team
3,000+ hospitals nationwide enrolled Team of clinicians who bring in the IHI campaign critical care expertise to patient ’s 96 hospitals in North Carolina bedside or wherever it is needed – Critical Care Nurse – Critical Care Registered Respiratory Therapist Reference: Institute for Healthcare Improvement, (2005)
Fast Facts Goal of Rapid Response Team
Cardiac arrests can be prevented 70% of Prevent deaths from patients who the time ( Buist, 2002) show signs/symptoms of clinical 76% of patients show sign/symptoms of deterioration in areas outside of critical deterioration 6 -8 hours prior to the arrest. care (Buist, 2002) Role of RRT Benefits of RRT
Assess Brings clinical expertise to bedside Stabilize Provides staff with additional support Assist with communication Provides early intervention of clinical Educate and support patient and deterioration family Collaboration among members of Assist with transfer to ICU, if needed health care team
Reference: Institute for Healthcare Improvement, 2005
What ’s the Difference? Is it working?
Code Blue Team RRT 50% reduction in non -ICU arrest ( Bellamo, 2004) 44% reduction in post -operative emergency ICU transfers ( Bellamo, 2004) Initiated for any Responds before the patient experiencing or arrest 37% decrease in postoperative deaths ( Bellamo, 2004) in imminent danger of Provides early Baptist Memorial Hospital -29% reduction in cardiac experiencing cardiac or interventions to arrests ( Walker, 2005) respiratory arrest prevent the arrest from occurring Pittsburgh Medical Center - 17% reduction in cardiac arrests ( Buist, 2004)
Criteria for RRT 2010 CVMC RRT Data
Heart rate <40 or >140, with symptoms Average 18 RRT calls per month Systolic blood pressure less than 90 mm HG 24% medical unit Change in respiratory rate Pulse oximetry less than 85% 24% Ortho/Neuro/Inpatient Rehab Uncontrolled bleeding 19% Surgical unit Acute onset of anxiety 10% Maternal -Child Acute mental status change Failure to respond to treatment 10% other areas Seizures 5% Oncology, Psych, Secure Care Patient, Staff, or family worry or concern for any reason Most Common RRT Reasons for RRT calls Interventions
Most common reasons at CVMC O2 -Respiratory distress Breathing Treatment -hypotension ABG -Hypoxia Fluid Resuscitation -Cardiac Ekg Labs Portable Chest X -ray
2010 Code Blue CVMC Code Blue Data Outcomes
Average 24 Code blues per month Code Blue Survival Goal >25% -56% Inpatient -39% Critical Care 29% survived to discharge -17% other inpatient units 28% Survived code but died at a later -5.4 Codes per 1000 Discharges time 43% Expired at time of code blue -44% ED/Outpatient
CVMC ’s success References Code Blue versus RRT
Bellamo, R., Goldsmith, D., Uchino, S., Buckmaster, J., Hart, Goal > 50% will be code purple G., Opdam, H., Silvestre, W., Doolan, L & Gutteridge, G. outside of a critical care unit on a (2003). Prospective Before -and - After Trial of a Medical outside of a critical care unit on a Emergency Team. Medical Journal of Australia , 179(6), 283 -287. medical/surgical floor Buist, M., Moore, G., Bernard, S., Waxman, B., Anderson, J. & Nguyen, T. 2202). Effects of a Medical Emergency Team on Start RRT in late 2005 Reduction of Incidence and Mortality from Unexpected Cardiac Arrests in Hospital: Preliminary Study. British Medical 91 Code blue vs 22 RRT in 2006 Journal , 324, 1 -5. Institute for Healthcare Improvement. http://www.ihi.org 74 Code Blue vs 160 RRT in 2008 60 Code Blue vs 204 RRT in 2010 References
IHI Getting Started Kit: Improving Care for AMI. http://www.ihi.org/NR/rdonlyres/8D9C3B34 -A139 -4F30 -8DB5 - 942B3A8D7FD9/0/AMIHowToGuide5_25.pdf IHI Getting Started Kit: Preventing Adverse Drug Events. RAPID RESPONSE TEAM http://www.ihi.org/NR/rdonlyres/47D5AE1C-0B29-4A59-8D58- BABF8F4E829F/0/ADEHowtoGuideFINAL5_25.pdf IHI Getting Started Kit: Prevent Central Line Infections. http://www.ihi.org/NR/rdonlyres/BF4CC102 -C564 -4436 -AC3A - Martin General Hospital 0C57B1202872/0/CentralLinesHowtoGuideFINAL720.pdf IHI Getting Started Kit: Preventing Surgical Site Infections. Jesse Miller RCP, RRT http://www.ihi.org/NR/rdonlyres/00EBAF1F -A29F -4822 -ABCE - 829573255AB8/0/SSIHowtoGuideFINAL0803.pdf
Introduction An Overview
• Martin General Hospital is a 50 bed facility • Purpose: To provide a rapid multidisciplinary consisting of an ED, ICU, MSP, OR, Nursery, team approach to critically assess a patient and outpatient services. whose condition is deteriorating, in addition to • Owned by CHS/Community Health Systems, providing support and education to the staff. Inc., the company’s strategy is that financially • Definition: A multidisciplinary team that responds sound, hometown hospitals are vital to the to urgent patient situations throughout the health of community residents as well as the hospital. economic development of the areas they • Scope: The Rapid Response Team (RRT) will be serve. used in areas outside of the Emergency Dept., OR, and PACU.
Formation & Mission Statistics
• The Rapid Response Team (RRT) was • January 2011: Ten code blues occurred this approved by administration and made month. Seven occurred in the ED, 4 began outside the facility and three were initiated effective on July, 16 2008. within the facility. One of the seven codes was • The goal of the RRT is to provide early and successful. One in ICU and which was rapid intervention to promote improved unsuccessful. Two occurred on MSP both of outcomes such as: reduced cardiac and/or which were unsuccessful. There were no unusual occurrences during any of the codes. One RRT respiratory arrests in the hospital, higher level was initiated this month for a patient on MSP for of care, reduced intubations, and finally decreased mental status. The RRT was successful reduced hospital deaths. and the patient was transferred to ICU. • February 2011: Four code blues occurred this • March 2011: Five codes occurred this month. 3 month. All codes were deemed successful codes began outside the facility and continued in the ER, 2 of the patients were resuscitated and 1 with no adverse events. One originated expired. All three codes were successful and all outside the facility and continued in the ED. indicators were met. Two codes were initiated in The patient expired. Two originated inside the hospital and occurred on Med/Surg. Both the facility in ICU. One patient expired, one patients expired. Both codes were successful and patient was resuscitated and continued care all indicators were met. The Rapid Response Team was utilized once during March for a in ICU. One code originated with an ED patient with a decreased level of consciousness. patient, the patient was not resuscitated and Interventions were performed and the patient expired. There were no RRTs this month. recovered and remained on MSP.
• April 2011: Six codes occurred this month. 3 • May 2011: Six codes occurred this month. codes began outside the facility and continued in Four of those codes began outside the facility the ER. All codes were successful in that all staff and continued in the ER. All codes were were qualified and all equipment was present. successful in that all staff were qualified and On patient was resuscitated and admitted to the all equipment was present. The patients were ICU for further management. 3 codes were not resusitated. One code began in the initiated within the facility. Two began in the ED. facility in the ED. The code was successful Both were successful however both patients however the patient expired. One code expired. One code was initiated in the ICU, it was also successful however the patient expired. occurred in the ICU. The code was successful and the patient was resusitated and remained in ICU.
• June 2011: Four codes occurred this month. • July 2011: six codes occurred this month. None began outside the facility. All codes began Four began outside the facility. These patient in the facility. Two occured in the ED, both were successful in that all personnel were trained and were brought into the ED where the codes supplies and medications were correct. One continued. All codes were successful in that patient did expire. The other patient was all staff were properly trained and all admitted to ICU for management and then equipment was available and functioning, transferred out. One code occured on MSP, the however none of the patients were code was successful and the patient resuscitated and transferred to ICU for management. One resuscitated. Two codes occurred in ICU, both code occurred in ICU, it was successful however were successful regarding staff and the patient expired. equipment however the patients expired. Who is Involved? Role of the RT…..
• Respiratory Therapist (In House) • Keep everyone CALM!!!! (lol) • House Supervisor: Provides expertise and • Provide advanced respiratory assessment facilitates communication among team members. • Stabilize and/or maintain the airway • Staff Nurse: Provides background info. relating to • Provide immediate o2 therapy, tx’s or set-up of patient; stays with patient and provides any respiratory equipment (bi-cpap, vent., etc.) further assistance needed. • Review the situation with other team members • ED/ICU Nurse: Provides clinical expertise and and the staff nurse as a teacher and mentor. multidisciplinary approach and procedure with • ACLS/BLS certified drug administration as per protocol.
Criteria for Initiating a RRT Criteria cont…
• Response time must be within five (5) minutes of Change in o2 sat.( >90% despite o2 therapy) being called! Acute change in o2 needs requiring an Fio2 of • Call Code Blue if pt becomes apneic, pulseless. 50% or greater Or has an unstable cardiac rhythm!! Chest pain unrelieved by nitroglycerin SLx3 Acute change in HR from baseline (<40 or >130) Altered mental status or acute change in LOC Acute change in SBP from baseline (>200 & <90mmHG) Acute or significant bleeding Respirations <10 or >30, or New, repeated or prolonged seizures threatened/compromised airway Acute change in urine output (<50mls in 4 hrs)
Criteria cont… Interventions
Failure of patient to respond to treatment for • Maintain pt’s airway an acute problem/symptom • Increase Spo2 to keep >90% (o2 mask, BiCpap, Staff member concerned/worried about the NTS) patient! • Begin ACLS protocols if symptomatic dysrhythmia detected • EKG if HR abnormal or chest pain noted • Start IV access if not in place (consider 2 nd line and drawing blood for lab) Interventions cont… Monitoring and further data
• Administer NS 500ml bolus for hypotension (if • If patient has met any of the above criteria, then he/she should be transferred to our ICU so that further pt is not in CHF) critical care monitoring can take place, along with • Foley cath. if needed other diagnostic testing. • If a respiratory issue is suspected, then pt’s respiratory • Naloxone for opiate/narcotic overdose effort, rate and rhythm should be monitored, along with o2 sat. Abg should be drawn to assess • Finger stick to check blood sugar oxygenation/PO2, and acid/base balance. If positive pressure or mech. ventilation is needed, this is to the • D50 IV if blood sugar <50mg/dl and discretion of the Resp. Therapist and the MD. symptomatic • In general, pt’s Level of conciousness (LOC) should be assessed at least every Q1-Q2 hrs. • Albuterol unit dose for bronchospasm
Further diagnostic testing Lessons Learned
• If RRT is called in time, it improves the chance of patient • ABG survival, which is what healthcare is all about…..saving • Labs: CBC, BMP, PT, PTT, INR lives. • MD’s cannot do it all. Taking the initiative by calling a RRT • Labs: Troponin, CK, CKMB, if cardiac injury shows concern and integrity. suspected. (BNP) • If you follow the RRT criteria, and 1 or more apply to the patient, you cannot go wrong by initiating a RRT. As long as • Portable CXR (CT scan if indicated) you follow the criteria, do not be scared to activate the RRT!! • If temp. >101 and no work-up in 24 hrs., • Remember to use your good clinical judgement. Coupled with the RRT, your hospital should have a good clinical staff obtain blood cultures, UA w/C&S and sputum with improved response/reaction time for the patients. C&S
Conclusion
• In summation, utilizing your assessment skills, and this includes RN’s as well, the Rapid Response Team is a Forsyth Medical Center ’s highly effective skill to be used by the healthcare team Rapid Response Team to help prevent further deterioration in a patients status. • Most importantly, for the RRT to work it MUST BE UTILIZED! We are striving hard at Martin General to implement the RRT more often when appropriate. If Lawson Millner, RRT, RCP you feel the patient is in distress, DO NOT HESITATE to call an RRT! It’s the early intervention that makes all Winston Salem, NC the difference to your patients. Thank you very much. Forsyth Medical Center Our Mission … • Located in Winston Salem To reduce the number of unnecessary • 961 bed non-academic code blue events and deaths outside • 24/7 Hospitalist coverage our critical care units by empowering • Respiratory is a protocol nurses to initiate an immediate driven department response from qualified critical care – Protocols for everything from bronchodilator staff when a patient ’s condition therapy, A-Lines and appears to deteriorate. Intubations to Ventilator and HFOV management
In the Beginning Implementation
• Started as the “Rapid Assessment Team ” (RAT) • Project selected due to the number of events • We piloted on a general medicine floor. outside critical care • Started RRT program in 2007 • Bed shortages led to long holding times – Data Collection started in 2009 • Unable to adequately monitor deteriorating • Started letting the family members initiate patients the RRT call in January 2009 – calls are screened to ensure calls are If we couldn ’t get the patient to the unit, we appropriate before sending RRT team to room would bring the unit to the patient!
Team Composition Our “uniqueness ” • … no responding physician on the team • Critical care RN ’s from ICU, CICU and Critical Care Triage • RNs and therapists carry all the Critical care RCPs • Critical care RCPs responsibilities they have on their working • All are ACLS certified unit. • Patient ’s care nurse • Hospitalists are available for anything requiring additional physician orders RRT Criteria Stroke RRT
• Heart Rate < 40 or > 130 • Numbness or weakness of the face, arm, • Respiratory Rate < 8 or > 28 leg • Systolic BP < 90 mmHg • Trouble speaking or understanding • Drop in O2 Saturation below 90% • Trouble seeing • Unexpected change in LOC • Trouble walking • Change in urinary output < 50 ml in 4 • Severe headache hours • Concern for the patient – Probably the reason for the majority of our RRT calls
RRT Protocols/Standards Team Roles
• Expected response within 5 minutes • Team members have all the responsibilities they • The patient ’s primary caregiver or individual who would normally have in their working unit activated the team will provide a history of the • Ability to access and implement all emergency current changes to the team members orders • The assessment and response is a collaboration • RCPs are either trained in intubation or are in between the primary caregiver and the RRT training to develop the skill • The attending physician may be notified as • RCPs can implement any order covered under indicated following assessment by RRT the respiratory care protocol • The Rapid Response and Assessment Team will • If indicated, team members may participate in document their findings/assessments using the the transport of the patient to a higher level of RRT documentation form care
Total RRT Calls
100 Rapid Response Team Overview 90
80 Total RRT calls 70 2009: 544, (Mar -Dec) monthly average - 54 2010: 917, monthly average – 76 60 2011: 398, (Jan -Jun) monthly average - 66 50
40
Average Time per Activation 30
2009: 47 minutes 20 2010: 52 minutes 2010: 52 minutes 10 2011: 51 minutes 0 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
Total RRT Calls Stroke RRT Calls Non-Stroke RRT Calls RRT Calls Transferred to Critical Care RRT Bedside Time
70% 80
63% 70 60% 59%
55% 54% 60 are bed are 50% 46% 45% 46% 43% 50 44% 44% 39% 40% 41% 39% 38% 35% 40 32% 27% 30% 27% 26% 27% 30 27% 25% 26%
20% 20 percentage of RRT calls transferred to a critical c critical a to transferred calls RRT of percentage
10% 10
0 0% Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- 09 09 09 09 09 09 09 09 09 09 10 10 10 10 10 10 10 10 10 10 10 10 11 RRT Bedside Time (mins) Stroke RRT Bedside Time (mins) Non-Stroke RRT Bedside Time (mins)
Percentage of Codes in Non Critical Care RRT Calls Transferred to Critical Care Code Data 100% 20
90% 18
80% 16
14 70%
12 60%
10 50%
8 40%
6 30%
4 20%
2 10%
0 0% Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Qtr 1 2009 Qtr 2 2009 Qtr 3 2009 Qtr 4 2009 Qtr 1 2010 Qtr 2 2010 Qtr 3 2010 Qtr 4 2010 # Codes RRT calls developing into Codes # of Codes in Non-Critical Care
Lessons Learned Rapid Response Team
• Staffing Practice – Assigned to evaluators / RCP’s that are out on the floors. • Education/Orientation – New hires do an orientation rotation with the evaluators • Productivity – Possible increase • Codes – Use of RRT had decreased the number of codes outside of critical care Duke University Hospital • Family Initiated RRT – Better than we thought Jhaymie L Cappiello BS RRT • We hope we can get a designated RRT position in the future Implementation Team Composition
ICU Charge Nurse Respiratory Therapy Supervisor
ICU Fellow (as indicated)
Patient’s care nurse & House Staff
Unit charge nurse
Nursing Operations Administrator
The Education RRT Patient Criteria
Definition of a Rapid Response Team (RRT)
The role of the individual staff member When the patient experiences ACUTE changes in their condition -
Reason for creating a Rapid Response Team Heart rate <45 or >125 bpm
The DUH Rapid Response Team (RRT) call criteria Systolic BP <80 or >200 mmHg
Communicating the RRT Diastolic BP >110 mmHg Resp. rate <8 or >30 The role of the “Team” SpO 2 <90% Individual team member roles Seizures What Happens During a Call? Chest Pain When Does a RRT Call End? ACUTE change in mental status
Documentation Guidelines OR
Team Huddle/Debriefing If You are concerned or worried about your patient’s status
Equipment needed
RRT Protocols/Standards Respiratory Therapist
• Respond within less than 5 minutes Requirements Role • Will answer all RRT calls in person • Be non-judgmental to person initiating the call • ACLS, PALS, BLS within 5 minutes • The RRT will collaborate with primary care team to stabilize and guide stabilization • Registered Respiratory • Assess airway/oxygenation level of the patient . Therapist • Recommend respiratory therapy • Orders are obtained from the Primary Physician / House Officer or RRT MD • 2 years Crit Care Experience interventions • A Code Blue should be called if the patient becomes apneic, pulseless, or • Advanced Airway Certified • Provide respiratory therapy develops an unstable rhythm. (Unless the patient has a documented “Do Not • Advanced Care Practitioner interventions as ordered Resuscitate order”) • Communicate with team • Concluding the RRT call, the RRT nurse facilitates an assessment of the RRT with • Assist in transfer to higher level of the care nurse using the Situation, Background, Assessment, and Recommendation care, if necessary (SBAR) methodology Average Calls per Month Average Time per Activation
Rapid Response Team: Rapid Response Team: Most Frequent Interventions Top 5 Reasons for Activations
2006 2007 2008 2009 2010 2006 2007 2008 2009 2010 • Oxygen mask/nasal: 45% 48% 49% 56% 60% • Staff concerned/worried: 53% 64% 62% 65% 61% • ECG: 33% 34% 36% 34% 32% • Systolic BP less than 80: 23% 28% 27% 24% 23% • Arterial blood gas: 29% 35% 39% 39% 38% • Oxygen sat less than 90: 21% 21% 29% 31% 29%
• Heart rate > than 125: 20% 20% 25% 21% 22% • IV fluid bolus: 31% 32% 34% 30% 31%
• Acute Mental Status ∆: 20% 16% 20% 20% 23% • CXR: 14% 21% 24% 27% 23%
Rapid Response Team Outcomes Lessons Learned
• Work Volume – Unpredictable, potential for high impact on individual assignment • Staffing Model/Practice – Increased demand for qualified/available personnel • Education/Orientation – Added to orientation and yearly review • Productivity – No noticeable change • Training – Loss of staff exposure to acute events, led to acquiring “shadow pager” • RRT Progression – Condition “H”
Discussion