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
leAM
I Bun
dle
Cen
tral L
ine
Bund
leSIP
Budl
eM
ed R
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
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
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
Multiple RRT’sMultiple RRT’s
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)
Multiple RRT’sMultiple RRT’s
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 . .
Multiple RRT’sMultiple RRT’s
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.
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
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
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.
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”
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