Dr.Shailendra.V.L.Director of Patient Safety

Al Bukeriya general hospital

CODE PURPLE

Rapid Response team (RRT)Rapid Response team (RRT)

• Rapid Response Teams is a designated group of healthcare clinicians who can be assembled quickly to deliver critical care expertise in response to grave clinical deterioration of a patient located outside a critical care unit.

• RRTs provide early recognition & response to signs of patient's deterioration

Why the need for RRTWhy the need for RRT

– Floor nurses and other hospital staff are undertrained or are not trained to deal with patients in crisis

– Teaches staff how to manage patients in crisis prior to the actual code team’s arrival

– Part of a hospital quality Patient Safety program

– Meets regulatory requirements - MOH & CIBAHI

Scientific Evidence that RRTs helpScientific Evidence that RRTs help

• 50% reduction in the occurrence of cardiac arrest outside the ICU– (Buist, M.D. et al. Effects of a medical emergency team on reduction of incidence of and

mortality from unexpected cardiac arrests in hospital: preliminary study. BMJ 2002;324:1-6)

• 17% decrease in the incidence of cardiopulmonary arrests (6.5 vs 5.4 per 1000 admissions)

– (DeVita, M.A. et al. Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Quality and Safety in Health Care  2004;13(4):251-254)

• Severe postoperative adverse events (i.e., respiratory failure, stroke, severe sepsis, acute renal failure) were reduced by 58%, emergency ICU admissions were reduced by 44%, postoperative deaths were reduced by 37%, and mean duration of hospital stay decreased from 23.8 to 19.8 days in surgical patients

– (Bellomo, R. et al. Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Critical Care Medicine 2004;32:916-921)           

–  

Goals of RRTGoals of RRT

1. To save patient lives & eventually improve quality of hospital care & improve patient safety

2. Increase early intervention & stabilization to prevent clinical deterioration on any individual prior to the event of cardiopulmonary arrest or other life threatening health event

3. Decrease the number of cardiopulmonary arrests that occur outside the ICU & ER department

4. Increase patient, family & staff satisfaction5. Decrease hospital mortality rate6. Reduce severe postoperative adverse events

TO ERR IS HUMAN…………..TO ERR IS HUMAN…………..

• According to the 1999 Institute of Medicine Report ‘To Err Is Human’, approximately 100,000 Americans die each year from ‘preventable’ hospital errors.

• The annual toll exceeds the combined number of deaths and injuries from motor vehicle accidents, airline crashes, suicides, falls, poisonings and drowning

Plans employed for Save 100,000 lives Plans employed for Save 100,000 lives campaign in US started in 2004campaign in US started in 2004

• Deploy Rapid Response Teams…at the first sign of patient decline

• Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart attack

• Prevent Adverse Drug Events (ADEs)…by implementing medication reconciliation

• Prevent Central Line Infections…by implementing a series of interdependent, scientifically grounded steps called the “Central Line Bundle”

Plans employed for Save 100,000 lives Plans employed for Save 100,000 lives campaign in UScampaign in US

• Prevent Surgical Site Infections…by reliably delivering the correct peri-operative antibiotics at the proper time

• Prevent Ventilator-Associated Pneumonia…by implementing a series of interdependent, scientifically grounded steps called the “Ventilator Bundle”

Arrest PreventionArrest Prevention Assessment Response TeamAssessment Response Team

Team members:

1.Primary nurse (who activated RRT)2.Charge nurse of the unit 3.ICU airway nurse4.Nursing supervisor on duty5.Respiratory therapist6.Unit resident doctor on duty7.On call specialist8.ICU resident on duty9.ICU specialist on call

Key features of the RRT team Key features of the RRT team • There are three key features of the team members:

1.They must be available to respond immediately when called, and not be constrained by competing responsibilities

2.They must be onsite and accessible

3.They must have the critical care skills necessary to assess and respond

RRT team actionsRRT team actions

– Teams of clinicians rush to a patient’s location whenever a clinician feels the patient’s condition is deteriorating or has deteriorated

– Teams are designed to rescue patients early in their decline, before an adverse outcome occurs

• Hospitals using rapid response teams typically report reductions in the number of cardiac arrests, unplanned transfers to the ICU and overall mortality rates

The Joint Commission InternationalThe Joint Commission International2008 National Patient Safety Goals2008 National Patient Safety Goals

Goal 16: Improve recognition and response to changes in a patient’s condition.

Goal 16A: The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening

SBARSBAR• The SBAR (Situation-Background-Assessment-Recommendation)

technique provides a framework for communication between members of the health care team

• SBAR is an easy-to-remember, concrete mechanism useful for framing any conversation, especially critical ones, requiring a clinician’s immediate attention and action

• It allows for an easy and focused way to set expectations for what will be communicated and how between members of the team, which is essential for developing teamwork and fostering a culture of patient safety

SBARSBAR

100

Adult criteria for calling RRT Adult criteria for calling RRT 1. Temperature:

< 35 or > than 38.9 degree Celsius orally

2. Acute change in respiratory rate: 1. < 8 breaths per minute or > 28 breaths per minute

3. Acute change in heart rate:1. < 40 beats per minute or > 130 beats per minute

4. Acute changes in blood pressure:1. < 90 or > 40 change from baseline 2. Drop of blood pressure 20% from the baseline3. Systolic blood pressure > 190 4. Diastolic blood pressure > 110

5. Acute change in O2 saturation :1. < 90% on 60% FIO2

Adult criteria for calling RRT Adult criteria for calling RRT 6. Acute change in level of consciousness7. New onset of chest pain 8. New onset of seizures9. Significant bleeding or decrease in hematocrit10. Change in patient color (cyanosis) 11. Staff member worried or concerned

Pediatric criteria for calling RRTPediatric criteria for calling RRT1. Airway threat:

1. Breathing:1. Apnea2. Hypoxemia:

1. SpO2 < 90%2. SpO2 < 60% for children with cyanotic heart disease

3. Moderate to sever respiratory distress4. Tachypnoea

1. 0 -3 months > 60 2. 3 – 12 months > 503. 1 – 4 years > 404. Over 5 years > 30

2. Circulation:1. Heart rate:

1. < 1 year 100 – 1802. 1- 4 years 90 – 1603. 5 – 12 years 80 – 1404. 12 years 60 – 130

Pediatric criteria for calling RRTPediatric criteria for calling RRT

2. Hypotension: (systolic BP)< 3 months < 504 – 12 months < 601 – 4 years < 70 5 – 12 years < 80> 12 years < 90

4. Neurological :Acute change in mental statusSeizures

Calling RRT teamCalling RRT team

• The RRT may be called for physiologic changes in heart rate, systolic blood pressure, respiratory rate, pulse oximetry saturation, mental status or urinary output.

• Changes in laboratory values such as sodium, glucose and potassium could also indicate a patient’s condition is deteriorating.

• The nurse may also call the RRT because of a gut feeling that all is not right. 

How to call RRT ?????How to call RRT ?????1. Attending nurse / doctor dials hotline 100.2. Operator will announce CODE PURPLE followed by the ward

location three times3. Operator will page the RRT team as a group4. Five minutes is the response time for the group to arrive5. 15 minutes is the maximum time for the team arrival

Role of First nurse in RRTRole of First nurse in RRT1. Assesses patient, check vital signs2. Identifies crisis, refer patient’s condition following SBAR guidelines3. Call for help4. Stays with the patient5. Helps patient into comfortable position6. Shares pertinent information with RRT members upon their arrival

Role of Charge nurse in RRTRole of Charge nurse in RRT1. Bring crash cart to the site2. Help the first nurse

Role of Nursing Supervisor in RRT Role of Nursing Supervisor in RRT 1. Responds immediately to Code PURPLE announcement on public

address system 2. Assess situation especially with regards to activities of nursing staff

& provides additional assistance if needed3. Calls relevant consultants as requested by Code purple team leader4. Coordinated transfer of patient to ICU if the need arises5. Undertakes recording & documentation

Role of Intensive care unit nurse in RRT Role of Intensive care unit nurse in RRT 1. Responds to assist ICU resident on duty / ICU Specialist on duty to

access airway2. Prepares ionotropes as needed to transfuse with infusion pump

Role of Respiratory therapist in RRTRole of Respiratory therapist in RRT1. Assists the ICU resident / Specialist in managing airway2. Provides portable ventilator from ICU if the need arises3. Assists in transferring of the patient to ICU

Role of Unit resident on duty in RRTRole of Unit resident on duty in RRT1. Comprehensively assess the patient & initiates appropriate

interventions2. Controls drug therapy & overall procedure

Role of on call Physician in RRTRole of on call Physician in RRT1. Assess the clinical condition of the patient2. Stabilize the patient’s condition3. Assist with the mobilization of resources required to further support

the patient4. Decides about the transfer of patient to higher level of care5. Educates & support nursing & medical staff6. Conducts a debriefing session after the RRT for the team

Role of ICU resident on duty/ ICU Role of ICU resident on duty/ ICU specialist on callspecialist on call

1. Provides airway management, maintains oxygenation2. Provides ventilation manually or by the use of portable ventilator3. Assists in transfer to ICU if needed4. Assists in inter-hospital transfer if needed

What Is the Role of the RRT?What Is the Role of the RRT?

• Assists the staff member in assessing and stabilizing the patient condition.

• Assists the staff member in organizing information to be communicated to the patient’s physician.

• Educates and supports the staff as they care for the patient.

• If circumstances warrant, assists with patient transfer to a higher level of care.

What Is the Role of the RRT?What Is the Role of the RRT?

• RRT is not intended to replace care provided by the patient’s physician, since right after the consultation by the RRT the appropriate physician is called.

• The person who calls the RRT should become a key member of the team and assist the RRT.

• The team is usually trained to communicate and receive communication using SBAR – Situation / Background / Assessment / Recommendation).

• All team members should respond in a professional and friendly manner, providing non-judgmental, non-punitive feedback to the person that initiated the call. 

RRT DocumentationRRT Documentation

• A structured documentation form should be used by the RRT.

• The team can use a form to capture and organize information about the patient’s condition prior to calling them, as well as interventions that were required.

• This information can be used to analyze responses and plan quality-improvement activities where needed. Aggregate and quality data can also serve as a base for staff education.

• It is important that feedback be provided to staff about the successes of the RRT and lessons learned when responding to patients in crisis.

RRT response careRRT response care record record

RRT team order RRT team order sets- Adultsets- Adult

RRT team order sets- RRT team order sets- Pediatric Pediatric

Measurement of Effectiveness of the RRTMeasurement of Effectiveness of the RRT

• It has been suggested that several key measures be used to evaluate the effectiveness of the RRT:

• Codes per 1000 discharges• Codes outside the ICU• Number of unplanned ICU admissions• Utilization of the RRT• Mortality

RRT Call #1RRT Call #1

• 10-7-2015• 10:45 hours• FMW – Room 5• 51 years Female• REASON FOR CALL:

– Staff concerned– Labored breathing– SpO2 less than 90%

• S: pt. desaturated when getting up to bedside commode; took 20 minutes to re-saturate from 60 to 95%

• B: pulmonary HTN, SOB, anemia• A: RR=30, HR=90s, SpO2=70%• R: RRT called to bedside, Physician

ordered EKG and 40 mg Furosomide (Lasix), transferred to ICU

Interpretation: Appropriate Call, patient stayed in ICU,. Debriefing was held, thought to be useful.

RRT Call #2RRT Call #2

• 10-08-2015• 18:05• Male medical ward Room 9• 60 years Male• REASON FOR CALL:

– Staff concerned

• S: Patient desaturated to 85%• B: None given• A: BP=109/60, HR=105, RR=26,

SpO2=90%, crackles heard on left• R: Suctioned large mucus plug

and placed patient on 40% tracheal collar. Saturation improved to 95% with Oxygen. Patient remained in ward

Interpretation: Appropriate call. New Nurses, Good learning tool. Floor suctioned patient while RRT enroute. RRT found problem resolved. Patient Discharged on 15/08/2015.

RRT Call #3RRT Call #3• 10-01-2015• 18:15• Female medical ward room

7 - C• 78 year Female• REASON FOR CALL:

– Staff concerned– RR less than 8– SpO2 less than 90%– Labored breathing– Decreased LOC

• S: RRT arrived to find patient being ventilated with bag-mask

• B: Ischemic bowel disease; staff noted that LOC had been decreasing for 4 days.

• A: None given• R: Patient intubated &

transferred to ICU

Interpretation: Appropriate call for RRT. Notable that LOC had been decreasing for 4 days. Patient moved to ICU.

Family Initiated RRT

•Initiated December, 2008 as a pilot