Running head: THE ROLE OF NURSES 1

The Role of Nurses in the Activation of Rapid Response Teams

Mackenzie Moffatt, Jazmine Randolph, Andrea Ritchie, Elizabeth Siegrist, &

Jelena Tomljenovic

Oakland University

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The Role of Nurses in the Activation of Rapid Response Teams

The emergence of rapid response teams (RRTs) is a concept that dates back to 2004,

when the Institute for Healthcare Improvement launched an initiative to reduce morbidity and

mortality in the United States healthcare system. In addition, the Joint Commission instituted the

National Patient Safety Goals 16 and 16A in 2008, requiring hospitals to establish processes to

recognize and respond to patients with deteriorating conditions (Parker, 2014). RRTs emerged in

acute care hospitals to address a concept called failure to rescue (FTR), i.e. a situation in which

the medical staff fails to identify and intervene in a timely manner when a patient’s condition is

deteriorating. Evidence shows the FTR is correlated with an increased risk of death (Parker,

2014). Studies also show that early detection of warning signs, together with a proactive method

to deal with such signs, reduced deaths by a staggering 37% (Kapu, Wheeler, & Lee, 2014). The

role of nurses is not only to monitor and survey the patient’s condition, but also to react in a

timely manner when deterioration of physiological condition is observed. FTR can have very

serious consequences. Indeed, evidence suggests that 70% of patients who suffered from cardio-

pulmonary arrest had signs of respiratory deterioration within eight hours prior to the arrest

(Kapu, Wheeler, & Lee, 2014). Therefore, training and education on the proper nursing decision-

making process is imperative to patient care. The purpose of this paper is to write an empirically

based literature review related to the decision-making process that nurses should adopt in order

to minimize FTR when taking care of patients in acute care units.

Description of Clinical Issue

A 62-year old male patient was transferred to the neurological medical-surgical unit

from the emergency department, where he was initially admitted after being found unconscious

after failing for acute alcohol (ETOH) intoxication. During morning report, the night shift nurse

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reported the following: the patient was on a CIWA-Ar protocol and the most recent dose of

Ativan (0.5mg) had been administered at 0400; the patient had a low grade fever during the night

and Tylenol (2 tablets) was administered; the patient’s vital signs were within normal limits. The

initial assessment revealed characteristic symptoms associated with alcohol withdrawal,

including sleepiness, lack of appetite, no interest in communication, and a mild tremor.

Lisinopril (40mg) was administered, but Dulcolax was held due to low serum potassium levels

(3.0 mEq/L). In addition, 0.5mg of Ativan was deemed necessary based on the patient’s CIWA

score, to be administered after the preceptor and student nurse attended to the needs of other

patients that were identified as higher priority. Approximately 45 minutes post-administration,

one of the nursing assistants notified the student nurse and the preceptor about the patient’s

deteriorating vital signs (systolic blood pressure greater than 200 mmHg, diastolic pressure

greater than 100 mmHg, heart rate 135 bpm, O2 saturation 78%, respiratory rate greater than 30

breaths per minute, and visibly gasping for air. Based on these findings, the RRT was notified

and arrived within minutes. A seemingly normal situation quickly escalated into chaos, but with

the leadership of a well-organized team, the respiratory therapist was able to recognize the

symptoms of stridor, and administered a bronchodilator through a facemask. One of the

physicians ordered a beta-blocker (Lopressor, 50mg) to lower the patient’s blood pressure and

heart rate, as well as 1mg of Ativan to relax the patient. The patient’s condition improved and

stabilized within 15 minutes.

Review of the Literature

In a study by Parker (2014), the purpose of the study was to pinpoint the relationship

between nurses’ decision-making model during activation of the RRT and the frequency in

which RRT is activated. The study sample was composed of 87 medical-surgical registered

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nurses (RNs) from three community hospitals with RRTs located in southeastern Florida that had

activated the RRT at least once in the preceding 12 months. These hospitals ranged in size from

283 to 400 beds. The study design was a descriptive, cross-sectional, correlational quantitative

design. The data collection consisted of a 24-item version of the Nurse Decision-Making

Instrument (NDMI) used to measure and describe the decision-making model used by nurses in

the clinical setting. Participants were asked to recall a time they had activated the RRT for a

patient with a deteriorating condition and then complete the NDMI. The NDMI results were then

utilized to classify participant’s decision-making process during the RRT activation into one of

three categories: analytic, analytic/intuitive (mixed model), or intuitive decision-making. Of the

87 nurses in the study, 70.1% (n=61) used a mixed model of decision-making, 21.8% (n=19)

used an analytical decision-making model, and the remaining 8% (n=7) of the sample used an

intuitive decision-making model during RRT activation. A mean score of 4.7 RRT calls was

found for analytical decision makers. Mixed model decision makers had a mean score of 2.56

RRT calls and intuitive decision makers had a mean of 2.3 RRT calls. A one-way ANOVA

indicated differences in the number of RRT calls amongst all three decision-making models were

significant (p=0.003). The study findings indicated that RNs who used analytical decision-

making activated the RRT with significantly higher frequency than did nurses that used either a

mixed model or intuitive model of decision-making. In the aforementioned case of the declining

patient, the student nurse and preceptor were able to utilize analytical decision-making, which

requires highly effective critical thinking skills necessary for quick activation of the RRT.

Increased frequency of RRT activation has been linked to decreased patient mortality rates and

positive impact on patient outcomes, which benefited the declining patient (Parker, 2014).

Nursing Implications

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As addressed in Parker (2014), “effective, analytical, clinical decision making” can be

fostered within the nursing profession through quantifiable measures and efficient training

seminars. When faced with a patient in the clinical setting who is experiencing a rapid decline in

homeostatic functioning, and an RRT must be initiated, nursing professionals personally

incorporate one of three decision making approaches: analytical, intuitive, or mixed. During

clinical evaluation throughout the study, it was determined that “a difference exists in frequency

of RRT activation based on the decision-making model used by the nurse to activate the RRT”

(Parker, 2014, p. 163). When nurses implemented an analytical approach during a rapid

response, this yielded the greatest decrease in mortality. Analytical decision-making incorporates

five main components: data collection, hypothesis formation, further data collection, data

analysis, and decision-making (Parker, 2014). When caring for patients, it is the responsibility of

the staffed nurse to continuously collect data and synthesize trends regarding the state of the

individual’s health status. Two imperative implications relating analytical decision-making and

successful RRT outcomes are: the proficiency of the nurse to distinguish a patient’s decline and

effectively respond (Parker, 2014), and ambitious and timely hourly rounding for critical patients

(Braaten, 2015). In the case of missed or untimely activation of the RRT, due to non-adherence

of hourly rounds or incompetence in recognizing acute decline, the most severe consequence is

failure to rescue (Braaten, 2015). Furthermore, in the case of the declining patient previously

referenced, the RRT protocol was properly executed through proactive rounding and awareness,

and therefore, his vital signs were stabilized and brought to homeostatic norms. Hence, analytical

decision-making and implementation yielded successful results.

Conclusion

In conclusion, nurses play a principal role in the activation of RRTs. However, without

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efficient implementation of decision-making methods to initiate the RRT, patient outcomes

suffer. The use of an analytical decision making approach for initiating rapid response teams

leads to faster interventions and better patient outcomes (Parker, 2014). Nursing implications

relating analytical decision-making and successful RRT outcomes include the ability to quickly

recognize a patient’s decline in health and having the knowledge and skills to respond effectively

(Parker, 2014). These implications present a new perspective for the underutilization of RRTs by

taking into consideration the need for increased nursing knowledge and skill. A retroactive chart

review revealed that nurses only activated the rapid response team for three of seven identified

patients who met the criteria for RRT activation (McColl & Pesata, 2016). Nurses do not

consistently recognize the clinical significance or the urgency of abnormal vital signs, thus

requiring further educational advancement (McColl & Pesata, 2016).

Thorough nursing surveillance is another nursing implication, which offers a new

perspective for the underutilization of RRTs (McColl & Pesata, 2016). When compared to other

healthcare team members, nurses spend the most time with patients, and are in the best position

to recognize and prevent patient deterioration. Increased nurse surveillance, quick responses, and

early interventions will help nurses improve their role in RRT activation. Research supports the

connection between the broader issue of informal hierarchy within the hospital and the

underutilization of RRT and/or failure to rescue (McColl & Pesata, 2016). Nurses reported

feeling the need to justify RRT activation to responders and physicians. Nurses can empower

themselves and avoid RRT activation barriers by using an analytic decision making approach,

advancing their education, completing thorough surveillance of patients, and incorporating

teamwork to take full advantage of the RRT and improve patient outcomes (McColl & Pesata,

2016).

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References

Braaten, J. S. (2015). Hospital System Barriers to Rapid Response Team Activation: A Cognitive

Work Analysis. American Journal Of Nursing, 115(2), 22-33.

doi:10.1097/01.NAJ.0000460673.82070.af

Kapu, A. N., Wheeler, A. P., & Lee, B. (2014). Addition of acute care nurse practitioners to

medical and surgical rapid response teams: A pilot project. Critical Care Nurse,

34(1), 51-59. doi:10.4037/ccn2014847

McColl, A., & Pesata, V. (2016). When seconds matter: Rapid response teams and nurse

decision making. Nursing Management, 34-38. doi:10.1097/01.NUMA.0000479446.2028

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Parker, C. G. (2014). Decision-making models used by medical-surgical nurses to activate rapid

response teams. Medsurg Nursing, 23(3), 159-164.