Continuing Education Rapid Response Teamccn.aacnjournals.org/content/27/1/20.full.pdf · The RRT is expected to foster collab-oration between critical care nurses and medical-surgical

20 CRITICALCARENURSE Vol 27, No. 1, FEBRUARY 2007 http://ccn.aacnjournals.org

All authors are employed by Delnor-Community Hospital in Geneva, Ill.

A current challenge facing

hospital administrators is how to

manage healthcare workers and

available resources so as to achieve

the best possible patient care and

outcomes. Increasing acuity levels

of patients, rapid admission and

discharge cycles, and the national

shortage of nurses make it difficult

to provide high-quality care at the

bedside.1 Failure to recognize changes

in a patient’s condition until major

complications, including death, have

occurred is referred to as failure to

rescue. That phrase is not intended

to imply negligence or wrongdoing.2-5

Failure to rescue is a measure of the

overall performance of a hospital

with respect to caregivers’ ability to

recognize and react autonomously

to postoperative complications such

as bleeding, pneumonia, or sepsis.

The early signs and symptoms of

deterioration in a patient’s condition

may not be recognized by staff or may

be acted upon too late to improve the

patient’s outcome.

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 pre-

venting 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 bed-

side 24 hours a day, 7 days a week.

CoverArticle

Authors

* This article has been designated for CE credit.A closed-book, multiple-choice examination fol-lows this article, which tests your knowledge ofthe following objectives:

1. Identify 3 fundamental problems leading to

failure to rescue

2. Describe the challenges in establishing a

rapid response team

3. Discuss benefits of a rapid response team in

terms of patient care

Kim Thomas, RN, BSNMary VanOyen Force, RN, BSN, CCRPDebbie Rasmussen, RN, CMSRNDee Dodd, RN, BSNSusan Whildin, RN, BSN, CNRN

Corresponding author: Kimberly Thomas, TeamLeader, 2 West, Critical Care, Delnor-CommunityHospital, 300 Randall Rd, Geneva, IL 60134 (e-mail: [email protected]).

To purchase electronic or print reprints, contact TheInnoVision Group, 101 Columbia, Aliso Viejo, CA92656. Phone, (800) 809-2273 or (949) 362-2050(ext 532); fax, (949) 362-2049; e-mail,[email protected].

CEContinuing Education

Rapid Response TeamChallenges, Solutions, Benefits

by AACN on May 21, 2018http://ccn.aacnjournals.org/Downloaded from

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The RRT is expected to foster collab-

oration between critical care nurses

and medical-surgical nurses in the

care of patients through assessment,

communication, immediate inter-

ventions, 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 preventa-

ble.7 Early recognition of warning

signs of clinical deterioration and

interventions by an RRT may pro-

vide 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 sat-

uration, 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 deteriorat-

Magnet hospital in the Chicago area,

began implementation of an RRT by

organizing an interdisciplinary rapid

response steering team. This project,

along with participation in the IHI’s

national Save 100000 Lives Campaign,

was approved by the hospital’s per-

formance improvement quality com-

mittee. A nurse and a physician

served as chairpersons for this proj-

ect. Steering team members included

6 nursing leaders, 4 ICU staff nurses,

3 respiratory therapists, and the chief

nursing officer. Weekly meetings

were planned with the goal of launch-

ing the new RRT within 5 months.

The project’s steering team formu-

lated action plans to accomplish the

following:

• Review current evidence-based

practice

• Establish an RRT structure

• Evaluate the skill level of the

responders

• Establish criteria for when to

call the RRT

• Create documentation and

data collection tools

• Measure results

• Provide education throughout

the institution

• Deploy program pagers

• Develop feedback mechanisms

• Provide ongoing education for

responders

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 ther-

apist would be expected to arrive at

ing 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 bed-

side 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 recog-

nized by staff, and early interven-

tions 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 cardiopul-

monary arrest is only 15%.12,13 Antici-

pation 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 collabo-

ration 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

Implementation of an RRTDelnor-Community Hospital, a

128-bed, nonteaching acute care

http://ccn.aacnjournals.org CRITICALCARENURSE Vol 27, No. 1, FEBRUARY 2007 21



the patient’s bedside for a consulta-

tion 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, recom-

mendations) 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, assess-

ment, and recommendations.

The project’s steering team

developed a set of criteria for deter-

mining 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 mem-

bers and/or changes in the patient’s

heart rate, heart rhythm, blood pres-

sure, 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 ongo-

ing 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 col-

laborated with the physicians to

develop a protocol that would be ini-

tiated 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, electrocardiogra-

phy, 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’ out-

comes before and after implementa-

tion of the RRT. Information on every

RRT call was collected on a standard-

ized 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 format-

ted as SBAR (situation, background,

assessment, and recommendations)

for the primary physician. Attend-

ing physicians were always notified

by telephone of an RRT call involv-

ing their patients. Findings based on

physical assessment were documented

immediately after the RRT consulta-

tion, 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 responsi-

ble 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 comprehen-

sive and detailed communication

plan to convey the purpose and goals

of the RRT to physicians, adminis-

trators, clinical staff, and nonclinical

staff. Hospital newsletters, physician

newsletters, medical staff meetings,

board of directors meetings, and fre-

quent leadership and staff commu-

nications 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 suc-

cess of the program. Members of the

RRT proudly wore personalized

white jackets with the newly designed

RRT logo (Figure 1). The ICU nurse


“being worried about a patient” or “having a gut feeling” were legitimatereasons to call the RRT

Figure 1 Logo for the rapid responseteam at Delnor-Community Hospital.



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 acti-

vation number.

The project’s steering team trained

staffing coordinators for the critical

care nursing and respiratory teams.

The role of the staffing coordinators

was to supervise and manage the

RRT staff and schedule. Their duties

included interviewing candidates,

scheduling staff, and assisting with

implementation of the program.

The coordinators developed a job

description for the RRT responders

and established qualifications for

the role. Qualifications included a

minimum of 2 years of critical care

experience. Communication skills

were essential to garnering support

for the project from nurses in the

medical-surgical units. Communi-

cating with bedside nurses in an

effective and nonthreatening manner

also was essential.

The project’s steering team pro-

moted the professional benefits of

becoming a member of the RRT:

• Professional growth and recog-

nition while promoting patients’ safety

• Designation as an RRT member

through newsletters and hospital

media

• Responsibility for an essential

role in the success of the IHI’s

100000 Lives Campaign

• Visibility as a member of the

RRT by wearing an attractive per-

sonalized jacket

• Collaboration with multidisci-

plinary teams within the hospital

• Recognition of members’ spe-

cialized knowledge

• Doing rounds of all medical-

surgical units every 2 hours to address

questions or concerns of staff

• Decreasing incidental overtime

• Performing other duties as

assigned

At the start of the program, mem-

bers 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 con-

tact the on-call member of the pro-

ject’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 pro-

gram 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. Pro-

fessional respect increased between

critical care nurses, respiratory ther-

apists, and nurses from the medical-

surgical units. Bedside collaboration

allowed staff members to teach one

another about patients’ diagnoses

and treatments. Improved commu-

nication between physicians and

nurses and respiratory therapists

was another benefit. Effective com-

munication was enhanced by the

SBAR communication system. Edu-

cation of nursing staff about the cri-

teria for activating the RRT, use of

SBAR communication to report,

and assertiveness and teamwork

promoted rapid yet nonthreatening

assessment of patients whose condi-

tion was deteriorating.

Physicians were positive about

the RRT program because they per-

ceived improved competence at the

bedside as well as stronger cohesive-

Once the criteria and benefits had

been developed, applications were

sent to all members of the critical

care and respiratory therapy depart-

ments. Applicants were interviewed

and selected by coordinators. Case

scenarios were used during the inter-

view process to determine the assess-

ment 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 com-

puterized documentation system to

reflect the SBAR technique with feed-

back from the responders. Practice

sessions were held to allow the

responders to become familiar with

accurate documentation and cus-

tomer service skills. Training ses-

sions 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 assign-

ments, defined as either 2 telemetry

patients or 1 stable intensive care

patient. Other duties for RRT mem-

bers included the following:

• Doing rounds with discharge

planner and primary nurse to assess

progress

• Facilitating RRT responders’

continuous education




ness 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.” Inexperi-

enced staff members and recent

graduates found the RRT resource to

be especially valuable. Bedside col-

laboration with experienced ICU

nurses and respiratory therapists

provided them with confidence and

a feeling of security.

The attitude that a staff mem-

ber’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 fre-

quently e-mailed to staff to encourage

participation in this new initiative.

The ICU staff and respiratory thera-

pist gained a new respect for the acu-

ity 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 opin-

ion about the experience. The evalua-

tion forms were sent to the RRT

steering committee to be included

as feedback in the educational ses-

sions for the RRT responders.

ChallengesAcceptance of their new RRT

roles was a challenge for ICU nurses,

who were concerned about “aban-

doning” their own patients to respond

to an RRT call from a nurse in the

medical-surgical unit. It was essen-

tial to reassure ICU nurses that

backup support would be available

to ensure the safe care of their pri-

mary patients. In a cooperative effort,

2 critical care units worked together

to decide who would serve as backup

for RRT calls when the other unit

was unavailable. Secondary support

was defined according to acuity lev-

els by using telemetry nurses, emer-

gency department nurses, or

nursing supervisors.

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 dif-

ferent 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 pro-

fessional 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 dis-

cord among the nurses. The environ-

ment became tense and apprehensive

during this initial phase of RRT

implementation.

Effective communication and

consistent strong leadership were

essential during the initial imple-

mentation 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 pro-

mote 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 implementa-

tion, 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. Over-

time staffing was necessary only

occasionally during these shifts, when

staffing or acuity patterns required

changes to the RRT schedule.

The initial startup required men-

toring 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.

Costs and RRT Financial Benefit Model

In addition to the operational

benefits of using an RRT, a financial

benefit also accrues. The hospital

experiences significant cost reductions

by avoiding unnecessary transfers to




the ICU, cardiopulmonary arrests,

and complications that cause longer

stays in the hospital. The process of

patient care involves multiple staffing

interactions and a complicated

application of caregivers’ knowledge,

skills, expertise, technology, supplies,

and medications. Patient care is not

one single intervention or a series of

isolated events. The RRT initiative

helps to keep patients on track to

ensure that they will have a timely

discharge. The financial impact of

RRT programs on healthcare organi-

zations will become apparent in

time, but this impact must be viewed

in light of RRTs’ immeasurable bene-

fits to patients and their contribution

to the overall decline in hospital

mortality and morbidity.

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

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%.

The RRT steering team collects

data on an ongoing basis and dis-

tributes monthly reports within the

organization. Data collected on loca-

tion, shift, day of the week, and

organization’s financial savings of

$171480 per year was calculated by

using labor and cost accounting

methods (see Table).

Impressive Results After 16 Months

According to data reported in

267 patients (Figure 2), 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


Calculating the annual cost savings of having a rapid response team (RRT) available 24 hours a day, 7 days a week

Using Managerial Labor and Cost Accounting SystemRapid Response Team Financial Benefit Calculator

FormulaInput dataInput dataInput dataInput data(B - C)x DInput dataInput dataInput data

G x HInput dataInput data

K - JInput dataInput dataInput data

I x KE + P

Amount122126

$1000$6000

3.83.524 84

$810$1970$1160

$0$200010.5

$165 480$171 480

IndicatorAnnual number of cases benefiting from RRTCodes before RRT implementation per yearCodes after RRT implementation per yearCosts per codePotential saving in cost of codes per yearMean length of stay in medical-surgical unit, daysMean length of stay in intensive care unit, days Decrease in number of transfers to intensive care unit per year since RRT was implementedFewer days in intensive care unit due to decrease in transfersCost of bed in medical-surgical unitCost of bed in intensive care unitCost of a transfer to higher level of careAnnual cost of RRTOne-time costs of implementing RRTMean length of stay of candidate for RRT call, daysCosts of patients who could have transferred to intensive care unit without RRTPotential annual savings due to RRT

KeyABCDEFGHIJKLMNOPQ

Figure 2 Total calls for rapid response team from May 2005 through August 2006.

403020

100

May 20

05

June

2005

July

2005

Augus

t 200

5

Septem

ber 2

005

Octobe

r 200

5

Novem

ber 2

005

Decem

ber 2

005

Janu

ary 20

06

Febru

ary 20

06

March 2

006

April 2

006

May 20

06

June

2006

July

2006

Augus

t 200

6

No. o

f cal

ls



triggers to activation assist in evalu-

ating staffing levels for the RRT and

the medical-surgical units (Figure 5).

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 min-

utes to a minimum of 9 minutes.

Many times, staff reported more

than 1 reason for activating an RRT:

a staff member was concerned about

the patient (50%) or the patient had

a change in respiratory status (45%),

mental status (24%), heart rate or

rhythm (14%), or blood pressure (12%;

Figure 5). RRT

nurses’ interven-

tions that were

started at the

bedside during

the call included

the following

(Figure 6):

implementation

of an oxygen

protocol (63%),

electrocardiog-

raphy (29%),

arterial blood

gas analysis

(23%), checking

of blood sugar

level (16%), chest

radiography

(21%), adminis-

tration of

furosemide

(8%), treatments

with a respira-

tory nebulizer

(7%), and implementation of a

hypoglycemia or hyperglycemia

protocol (3%).

These results show that reducing

the frequency of failure to rescue was

a benefit of an effective new RRT.

Data collection is ongoing for

monthly analysis to provide feed-

back for performance improvement

of the RRT team. Educational ses-

sions are organized for staff growth

and development.

SummaryIt is difficult to measure the num-

ber of lives that have been saved since

the implementation of RRTs. Dr Don

Berwick, president and chief execu-

tive officer of IHI, stated, “The names

of the patients whose lives we save

can never be known. Our contribu-


Figure 3 Total number of code blue calls outside of the intensive care units andemergency department from May 2005 through August 2006.

3

2

1

0

May 20

05

June

2005

July

2005

Augus

t 200

5

Septem

ber 2

005

Octobe

r 200

5

Novem

ber 2

005

Decem

ber 2

005

Janu

ary 20

06

Febru

ary 20

06

March 2

006

April 2

006

May 20

06

June

2006

July

2006

Augus

t 200

6

No. o

f cod

es

Figure 4 Patients seen by the rapid response team who remained in the medical-surgical unit: May 2005 through August 2006.

100%

50%

0%

May 20

05

June

2005

July

2005

Augus

t 200

5

Septem

ber 2

005

Octobe

r 200

5

Novem

ber 2

005

Decem

ber 2

005

Janu

ary 20

06

Febru

ary 20

06

March 2

006

April 2

006

May 20

06

June

2006

July

2006

Augus

t 200

6

% o

f pat

ient

s

Figure 5 Most common reasons that nurses in medical-surgicalunits called the rapid response team to a patient’s bedside.

60%50%40%30%20%10%0%

% o

f cal

ls

Nurse

conc

erned

Chang

e in h

eart

rate o

r rhy

thm

Chang

e in

blood

pres

sure

Chang

e in

mental

statu

s

Chang

e in

respir

atory

status

Figure 6 Interventions used by rapid response team duringbedside call (mean percentages): May 2005 through August2006.

NebulizerFurosemide

Electrocardiogram

Blood glucose check

Oxygen protocol

Arterial bloodgas analysis

Chest radiography



tion will be what did not happen to

them.”17 The hospitalwide operational

and financial benefits of implemen-

tation of an RRT greatly outweigh

the challenges of starting up an RRT.

Benefits include improved safety of

patients, shorter hospital stays, fewer

code blues, fewer transfers to the

ICU, increased awareness and identi-

fication by nurses of signs and symp-

toms leading to deterioration in a

patient’s condition, decreased mor-

tality and morbidity, increased satis-

faction of physicians with nurses,

increased satisfaction of patients

with their care, and increased job

satisfaction among nurses. Develop-

ing a structured RRT for patients’

safety empowers all staff to operate

at a higher competence level. Most

nurses have an intrinsic desire to

function at a higher level. RRTs are

nurse-driven, self-directed, and self-

managed working teams that pro-

mote patients’ safety and efficiency

within the hospital (see Case Study).

AcknowledgmentWe gratefully acknowledge Keith Gordey, MD, for his pas-sion for providing evidence-based patient care andRichard Roxworthy for his financial expertise.

References1. Rogers A, Wei-Ting Hwang S, Aiken L,

Dinges DF. The working hours of hospitalstaff nurses and patient safety. Health Aff(Millwood). 2004;23:202-212.

2. Clarke S, Aiken L. Failure to rescue. Am JNurs. 2003;103:42-47.

3. Aiken L, Clarke S, Sloane DM, Sochalski J,Silber JH. Hospital staffing and patient mor-tality, nurse burnout, and job dissatisfac-tion. JAMA. 2002;288:1987-1993.

4. Sochalski J, Aiken L. Accounting for variationin hospital outcomes: a cross-national study.Health Aff (Millwood). 1999;18:256-259.

5. Needleman J, Buerhaus P, Mattke S, StewartM, Zelevinsky K. Nurse staffing levels andthe quality of care in hospitals. N Engl JMed. 2002;346:1715-1722.

6. Gosfield A, Reinertsen J. The 100,000 livescampaign: crystallizing standards of carefor hospitals. Health Aff (Millwood).2005;24:1560-1570.

7. Institute for Healthcare Improvement.Available at: www.ihi.org/ihi/programs/campaign. Accessed November 1, 2006.

8. Buist MD, Moore GE, Bernard SA, WaxmanBP, Anderson JN, Nguyen TV. Effects of a

14. Ashcraft A, DiAgnostino A. Differentiatingbetween pre-arrest and failure-to-rescue.Medsurg Nurs. 2004;13:211-216.

15. Simmonds T. Best practice protocols:implementing a rapid response system ofcare. Nurs Manage. 2005;36:41-59.

16. Ward WJ. The Business Case for ImplementingRapid Response Teams [PowerPoint presen-tation]. Available at: www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Tools/BusinessCaseforImplementingRRTsPresentation.htm. Accessed November 2, 2006.

17. 100K lives campaign. Available at: www.ihi.org/IHI/Programs/Campaign/Campaign.htm?TabId=1. Accessed November 2, 2006.

medical emergency team on reduction ofincidence of and mortality from unexpectedcardiac arrests in hospital: preliminarystudy. Br Med J. 2002;324:387-390.

9. Bellomo R, Goldsmith D, Uchino S, et al.Prospective controlled trial of effect of med-ical emergency team on postoperative mor-bidity and mortality rates. Crit Care Med.2004;32:916-921.

10. Lee A, Bishop G, Hillman KM, Daffurn K.The medical emergency team. AnaesthIntensive Care. 1995;23:183-186.

11. Edson BS, Williams MC. 100,000 lives cam-paign and the application to children. J SpecPediatr Nurs. 2006;11:138-142.

12. Brindley PG, Markland DM, Mayers I, Kut-sogiannis DJ. Predictors of survival follow-ing in-hospital adult cardiopulmonaryresuscitation. Can Med Assoc J.2002;167:343-348.

13. Peberdy MA, Kaye W, Ornato J, et al. Car-diopulmonary resuscitation of adults in thehospital: a report of 14,720 cardiac arrestsfrom the National Registry of Cardiopul-monary Resuscitation. Resuscitation.2003;58:297-308.


Case StudyAn 87-year-old woman with a history of atrial fibrillation and congestive heart fail-

ure was admitted to the hospital with dyspnea. On assessment, her medical-surgical

bedside nurse found that the patient had a heart rate of 160/min, a respiratory rate of

30/min, and an oxygen saturation of 90% on room air. The patient had an initial chest

radiograph that showed ventricular enlargement and an echocardiogram that showed

enlarged ventricles, mitral valve prolapse, and an ejection fraction of 0.32. A myocar-

dial infarction was ruled out, and the patient was worked up for pneumonia and wors-

ening congestive heart failure.

The patient’s medications included 180 mg diltiazem hydrochloride daily, 10 mg

enalapril maleate twice daily, 40 mg furosemide twice daily, metoprolol succinate, and

warfarin sodium. Within 3 hours after assessment and initial workup, the medical-

surgical bedside nurse activated the RRT because she was concerned that her patient

was symptomatic with a heart rate of 160/min. Within 5 minutes, both a critical care

nurse and a respiratory therapist arrived to assess the situation. They found the

patient lying in bed; her skin was red, and she was awake and complaining of tightness

in her chest. The patient’s electrocardiographic rhythm via telemetry showed atrial fib-

rillation at a rate of 160/min. Her body temperature was 36.6ºC (97.8ºF), her pulse was

109/min, her respirations were 27/min, and her blood pressure was 136/69 mm Hg.

The RRT initiated the oxygen protocol and obtained an electrocardiogram. The

patient’s vital signs remained stable with a pulse of 130/min, respirations of 25/min,

and a blood pressure of 126/76 mm Hg.

The medical-surgical bedside nurse called the cardiologist and used the SBAR

technique to report her findings. The cardiologist ordered 40 mg furosemide, 0.25 mg

digoxin now and with the dose repeated in 6 hours, and 5 mg metoprolol tartrate. The

RRT used the opportunity to educate the nurse about atrial fibrillation, the signs and

symptoms associated with this condition, and the treatment needed to control the

rhythm.

The patient stayed in the telemetry unit and did not need to be transferred to the

next level of care. Eight hours after the initial RRT consultation, a follow-up visit was

made by the RRT. The patient was found sitting up in bed having breakfast without

complaints. The patient was treated for congestive heart failure and discharged back

to the nursing home 1 week later. This RRT call prevented an unnecessary critical care

admission and encouraged collaboration among nurses.



CE Test Test ID C071: Rapid Response Team: Challenges, Solutions, Benef itsLearning objectives: 1. Identify 3 fundamental problems leading to failure to rescue 2. Describe the challenges in establishing a rapid response team 3. Discuss benefits of a rapid response team in terms of patient care

Program evaluationYes No

Objective 1 was met � �Objective 2 was met � �Objective 3 was met � �Content was relevant to my

nursing practice � �My expectations were met � �This method of CE is effective

for this content � �The level of difficulty of this test was: � easy � medium � difficult

To complete this program, it took me hours/minutes.

Test answers: Mark only one box for your answer to each question. You may photocopy this form.

1. What group encouraged American hospitals to implementrapid response teams (RRTs)?a. The Institute for Healthcare Improvementb. American Heart Associationc. American Hospital Associationd. Institute for Continuing Care

2. Why was the use of RRTs recommended?a. To improve patient outcomeb. To reduce hospital costsc. To prolong hospitalizationd. To reduce the risk of malpractice

3. What is the goal of a RRT?a. To provide rapid response to emergency room patientsb. To provide rapid response to intensive care unit patientsc. To prevent deaths outside of the intensive care unitd. To prevent deaths in an emergency department

4. How does RRT foster collaboration?a. Through chart review and recommendationsb. Through assessment and immediate interventionc. Through medications and pharmacy consultd. Through dietary and physical therapy consult

5. How long before an unexpected critical event or actual cardiac arrest does a patient’s baseline begin to deteriorate?a. Mean of 30 minutesb. Mean of 2.5 hoursc. Mean of 4.5 hoursd. Mean of 6.5 hours

6. What percentage of postoperative complications requiring trans-fer to the intensive care unit can reportedly be reduced by RRTs?a. 30%b. 42%c. 58%d. 67%

7. Which communication technique was used at the Delnor Community Hospital in their implementation of RRTs?a. BCLSb. ACLSc. SBARd. SOAP

8. What was the criteria for determining when the RRT should becalled known as?a. Initiation criteriab. Activation criteriac. Problem criteriad. Situational criteria

9. What was the primary role of the RRT at Delnor CommunityHospital? a. Collaborate with the nurse at the patient’s bedside to determine if fur-ther interventions were neededb. Review the chart for the previous 24 hours to determine what wasoverlookedc. Call the primary physician to report symptomsd. Transfer the patient to the intensive care unit

10. In the f irst 16 months after implementation of Delnor Community Hospital’s RRT, the medical-surgical unit code blues were reduced by what percentage?a. 56%b. 68%c. 74%d. 86%

11. What was the challenge identif ied by intensive care unit nursesin acceptance of RRT roles?a. Communication with physiciansb. Staffing costc. Abandoning their own patientsd. Daily collaboration with medical surgical nurses

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Test ID: C071 Form expires: February 1, 2009 Contact hours: 1.5 Fee: $11 Passing score: 8 correct (73%) Category: A Test writer: Jane Baron, RN, CS, ACNP

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Kim Thomas, Mary VanOyen Force, Debbie Rasmussen, Dee Dodd and Susan WhildinRapid Response Team: Challenges, Solutions, Benefits

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Continuing Education Rapid Response Teamccn.aacnjournals.org/content/27/1/20.full.pdf · The RRT is expected to foster collab-oration between critical care nurses and medical-surgical