Fad or Function?, Rapid Response Teams (RRT). by Joel Ray RRT Harborview Medical Center Seattle, WA

Fad or Function?, Rapid Fad or Function?, Rapid Response Teams (RRT). Response Teams (RRT).

by Joel Ray RRT Harborview Medical Center

Seattle, WA

Topics of Discussion

Understanding the driving forces behind RRT and other patient safety initiatives

Getting RRT started at HMC

How many calls do we get, and what “triggered” them

Improvements for the future

From the “ “Land Down Under””

Many Australian hospitals instituted “Medical Emergency Teams” (MET) by the mid 1990’s.

Cardiopulmonary Arrest (CPA) (CPA)

Patients can exhibit clinical warning signs 8-12 hours before event.

Educating acute care staff on identifying clinical triggers and alerting “Code Team”.

Seen These Before?Seen These Before?

What is IHI?What is IHI?

The Institute for Healthcare Improvement (IHI) is a non-for-profit organization leading the improvement of health care throughout the world. IHI was founded in 1991 and is based in Cambridge, Massachusetts

To Error is HumanTo Error is Human

Despite the extraordinary hard work and best intentions of caregivers, thousands of patients are harmed in US hospitals every day. Hospital-acquired infections, adverse drug events, surgical errors, pressure sores, and other complications are commonplace.

We can do betterWe can do better

Based on data collected over several years from multiple partner institutions, IHI estimates 15 million incidents of medical harm occur in the US each year —a rate of over 40,000 per day.

400,000 deaths a year world wide.

The Campaign “Planks” --The Campaign “Planks” --Six Changes That Save LivesSix Changes That Save Lives

• Deployment of Rapid Response Teams

• Delivery of Reliable, Evidence-Based Care for Acute Myocardial Infarction • Medication Reconciliation • Prevention of Central Line Infections • Prevention of Surgical Site Infections • Prevention of Ventilator-Associated Pneumonias (VAP)

The 100,000 Lives Campaign ScorecardThe 100,000 Lives Campaign Scorecard

An estimated 122,300 lives saved by participating hospitals

Over 3,100 hospitals enrolled Over 78% of all discharges Over 78% of all acute-care beds Over 85% of participating hospitals sending IHI

mortality data

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%

Possible lives saved – IHI 100,000 Lives Campaign

010,00020,00030,00040,00050,00060,000

VAP

Bund

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dle

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tral L

ine

Bund

leSIP

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econ

RRTs

SOURCE: US New & World Report 2005

Washington Hospitals Getting Washington Hospitals Getting OnboardOnboard

Evergreen Harborview Overlake Sacred Heart Swedish Tacoma General-Allenmore Virginia Mason


Understanding the driving forces behind RRT and other patient safety initiatives.

Getting RRT started at HMC.How many calls do we get, and what “triggered” them.


What is UHC?What is UHC?

The University HealthSystem Consortium (UHC), formed in 1984, is an alliance of 97 academic medical centers and 149 of their affiliated hospitals representing nearly 90% of the nation’s non-profit academic medical centers.

Rapid Response Team Rapid Response Team WorkgroupWorkgroup

HMC’s Initial Process

Conference calls via UHC with other hospitals developing RRT programs. Helped our group anticipate possible stumbling blocks and where to focus energy.

HMC’s Rapid Response TeamHMC’s Rapid Response Team

Stat RN Charge Respiratory Therapist Pulmonary Fellow on MICU (called by

RRT with management concerns)

Clinical Triggers for Call: Intuitive sense that something is wrong with patient

Acute change in mental status New onset of agitation or

restlessness Acute change in respiratory

status: Stridor – noisy airway Respiratory rate < 12

> 32 Increased WOB SaO2 < 92% with increased

FiO2

ABG requested for respiratory concern

Acute change in CV status HR < 55 > 120 SBP <90 > 170 New onset of chest pain Acute change in temp. < 35

> 39.5

What can you call RRT for ?

HMC had a head startHMC had a head start

Stat RN program started in 1992 as one RN on nights. Currently staffs two RN’s 24/7. Duties include code response, helping ER, units transports.

Dedicated Charge Respiratory Therapist. No individual assignment. Been in place over 2 years.

Can take over 9 months to start RRT program from “scratch”. HMC took 2 months from start to inception.

Some decisions our group Some decisions our group mademade

Cell phones for RRT , help quicken call back time, enhance teams communication with each other.

No overhead pages, It’s not a code, extra sets of eyes not needed. All calls go over pager system.

Clinical Triggers must be resolved before RRT leaves (or ICU transfer)

No “Bogus Calls”, Our goal is to make this process worry free. We want calls to be made.

Advantages of RRTAdvantages of RRT

Much needed resource to acute care RN’s

Heavy assignments, new grad’s, are able to see other patients.

Help with triage, facilitate ICU transfer (Pulmonary Fellow )

Supports acute care RT

“ “ We are seeing sicker and sicker We are seeing sicker and sicker patients on the floor, they (the patients on the floor, they (the RRT) are a great resource.” RRT) are a great resource.”

“They are never threatening. “They are never threatening. They don’t make you feel stupid. They don’t make you feel stupid.

They are great!”They are great!”

Daniel M., RN

Burns/Pediatric Unit

“It is a great idea. When a patient doesn’t look right, they can see what is going on and put it into words that will get the doctors to pay attention.”

“This has saved lives..”

Maryse M., RNSurgery/Trauma Unit

“I just came from the night shift…It prevented a lot of things from going south. It made it a lot easier to call the doctor at 3AM.”

Joan M., RNOrthopedics

“ Rapid response has made a real difference. It is much better to get the rapid response page & get people there, rather than hearing about it as a STAT page overhead”.

“It frees me up to take care of my other patients”.

Lee , RRT

HMC

Criteria to remain on Acute floorCriteria to remain on Acute floor

Suctioning < q4 hr

FiO2< 50% (exception comfort care)

NPPV; Treatment of OSA (Type 2 intervention).

RRT AlgorithmRRT Algorithm Pt meeting “Clinical Trigger”

Primary nurse communicates with Charge nurse

Condition Improves

Code 199

Rapid Response called(Primary Team also paged)

10 Minute Window

RRT calls back in 5 minutes, responds to bedside in 10 minutes

Patient treated

Care coordinated with Primary

Team

Care coordinated

with RRT MDMandatory Elective

Able to receive appropiate level of

care?

Stay on Acute Care

floor

Transfer to ICU

Yes No

Multiple RRT’sMultiple RRT’s

Tiers of responseTiers of response

First callFirst call: : Stat RN 1 and Charge RTStat RN 1 and Charge RT


Tiers of responseTiers of response First call: Stat RN 1 and Charge RTFirst call: Stat RN 1 and Charge RT

Second callSecond call: : Stat RN 2 and Stat RN 2 and multitasking Charge RT (or next multitasking Charge RT (or next RT to answer my page)RT to answer my page)


Tiers of responseTiers of response First callFirst call: Stat RN 1 and Charge RT: Stat RN 1 and Charge RT

Second callSecond call: Stat RN 2 and multitasking Charge RT (or : Stat RN 2 and multitasking Charge RT (or next RT to answer my page)next RT to answer my page)

Third callThird call: : Nursing Supervisor calls a Nursing Supervisor calls a Charge RN from ICU Charge RN from ICU . .


Tiers of responseTiers of response First callFirst call: Stat RN 1 and Charge RT: Stat RN 1 and Charge RT Second callSecond call: Stat RN 2 and multitasking Charge RT : Stat RN 2 and multitasking Charge RT

(or next RT to answer my page)(or next RT to answer my page)

Third callThird call: : Nursing Supervisor calls a Nursing Supervisor calls a Charge RN from ICUCharge RN from ICU . .

Charge Therapist is reviewing Charge Therapist is reviewing retirement information.retirement information.




How many calls do we get, and what “triggered” them.


Number of Calls Since Number of Calls Since TransitionTransition

109

72 72

8893

98107100 97 94 94

1019099

0

20

40

60

80

100

120

Harborview has 369 beds

UCONNUCONN

UCONN has ~300 beds

HMC RRT SummaryHMC RRT Summary

Total calls per month - 93 (average) Average response time – 4 min

(range 1-25 min) Average call length is 76 minutes “Third Tier” (ICU RN from unit)

activations – 4 times per month RRT MD Consult – 3 times per month

10-05 to 11-06

0

10

20

30

40

Clinical Triggers Clinical Triggers Percentage of CallsPercentage of Calls

60%

35%

2%

0%10%20%30%40%50%60%70%80%90%

100%

Stayed ICU Tele

““Did they stay or did they Did they stay or did they go…”go…”

The Bottom LineThe Bottom Line

After the first 1.5 years of Rapid Response, outside the ICU CPA’s are down 7%. (No mortality or bounce back data)

Many other programs are experiencing up to 30% reduction in CPA’s




How many calls do we get, and what “triggered” them.

What are the future plans.

RRT Standing ordersRRT Standing orders Notify Primary Team of Rapid Response Team Activation Interventions: - Attach patient to monitor/defibrillator to treat dysrhythmias - Stat ECG for dysrhythmias / chest pain - O2 therapy – Titrate FiO2 to maintain SaO2 > 90% - IV therapy: Initiate IV therapy if not in place 1 liter NS bolus for acute blood loss or hypotension Labs / Tests: - Chem 7, CBC - ABG PRN respiratory distress, low SO2, or respiratory concern - CXR PRN respiratory distress, low SO2, or respiratory concern - Cardiac enzymes for PRN onset chest pain or dysrhythmias - Magnesium and ionized calcium PRN new onset dysrhythmias - Emergency hemorrhage panel PRN evidence of acute hemorrhage - Type and cross PRN evidence of acute hemorrhage - Blood culture x2 PRN temp > 39 if no blood cultures in prior 24 hours - Urine and sputum culture if warranted Medications: - Albuterol nebulizers PRN wheezing - Narcan 0.1 to 0.2 mg IV Q1minute to max of 2 mg PRN altered LOC

and documented narcotic administration (Dilute Narcan in 10 ml NS and administer 1-2 ml every minute until

LOC improved)

RRT Standing ordersRRT Standing orders

O2 therapy – Titrate FiO2 to maintain SaO2 > 90%

- ABG PRN respiratory distress, low SaO2, or respiratory concern

- CXR PRN respiratory distress, low SaO2, or respiratory concern

Albuterol nebulizers PRN wheezing

Improved Follow-upImproved Follow-up

Post Rapid Response Follow Up - If patient remains on acute care unit after rapid

response check vital signs including Temperature, Pulse, BP, RR, Pulse Oximetry and Neuro Check

Q 1h x 2 Q 2h x 3 Q 3h x 3

- Notify Rapid Response Team if the patient meets any of the Clinical Trigger Criteria

PROCESS: - This document will be given to primary team or

RRT MD in the event of an RRT call.

RRT RRT is here to stay

IHI data supports RRTActivated before emergency occurs.

Staff education of clinical triggers essential.

Team consist of ICU RN and RT (MD backup)Acute care support, “No Bogus Calls”

Documents

Fad or Function?, Rapid Response Teams (RRT). by Joel Ray RRT Harborview Medical Center Seattle, WA