RRT Data Aggregation and Performance Indicators Julia T. Lim, MD, MPH CPT(P), MC, USA Tripler Army Medical Center Honolulu, Hawaii

Overview Literature review General RRT measures Data collection process Tripler experiences

Brief Literature Review

Review of Literature Some studies demonstrate a positive impact of RRTs Significant reduction in incidence of and mortality from unexpected cardiac arrests in hospital1 Medical emergency team decreased incidence of postoperative adverse outcomes, postoperative mortality rate, and mean duration of hospital stay2 PA led RRT with specialized critical care skills – significant decrease in rates of in-hospital cardiac arrest and unplanned ICU admissions3 1. Buist et al, British Medical Journal, 2002:324387-390. 2. Bellomo et al, Crit Care Med, 2004;32(4):916-21. 3. Dacey et al, Crit Care Med, 2007; 35:2076–82. Some studies show a positive impact of the RRT in reducing cardiac arrests, unanticipated ICU admissions, and/or mortality Buist study - retrospective study in a 300 bed tertiary referral teaching hospital in Australia comparing data from 1996 and 1999, demonstrated a 50% reduction in cardiac arrest, reduction in mortality by 2 patients/1000 hospital admissions Bellomo et al – studied 4 month control phase and intervention phase in a university affiliated hospital among >2000 patients undergoing major surgeries (>1000 in each arm); significant decrease in the # of cases of respiratory failure, stroke, severe sepsis, ande acute renal failure, emergency ICU admissions Dacey et al – 350 bed community hospital in Rhode Island with RRT (critical care nurse with >= 5 yrs experience), respiratory therapist, PA as team leader (PA had undergone intensive airway management course, worked 1 month in the ICU with an intensivist); compared 5 months prior to Rapid response system and 13 months after; showed decrease in overall hospital mortality from 2.82% to 2.35%, and decrease in unplanned ICU admissions to 45% to 29% Over 20,000 combined medical and surgical admissions in Australia demonstrated a two-thirds reduction in cardiac arrest and mortality, and reduction in post-cardiac arrest bed occupancy Buist et al .: "Effects of a Medical Emergency Team on Reduction of Incidence of and Mortality From Unexpected Cardiac Arrests in the Hospital: Preliminary Study," British Medical Journal 324.7334 (2002): 387-390. Bellomo et al: "A Prospective Before-and-After Trial of a Medical Emergency Team," Medical Journal of Australia 179 (2003): 283-287. Devita et al.: "Use of Medical Emergency Team Responses to Reduce Hospital Cardiopulmonary Arrests” Quality and Safety in Healthcare 13 (2004): 251-254. MERITInvestigators, "Introduction of the Medical Emergency Team," Lancet, 2005, 365:2091-2096.

Review of Literature MERIT study Randomized study of 23 hospitals in Australia Hospitals with >20,000 admissions/year Increase in emergency team calling, but no substantial impact on cardiac arrest, unplanned ICU admissions, or unexpected death MERIT Investigators, Lancet, 2005, 365:2091-2096. Conflicting data in literature on whether RRTs reduce cardiac arrests, unanticipated ICU admissions, and/or mortality 23 hospitals randomized in Australia to their system w/o a MET and with a medical emergency team; primary outcome was cardiac arrest, unexpected death, or unplanned ICU admission for 6 month f/u period – no significant change/reduction Buist et al .: "Effects of a Medical Emergency Team on Reduction of Incidence of and Mortality From Unexpected Cardiac Arrests in the Hospital: Preliminary Study," British Medical Journal 324.7334 (2002): 387-390. Bellomo et al: "A Prospective Before-and-After Trial of a Medical Emergency Team," Medical Journal of Australia 179 (2003): 283-287. Devita et al.: "Use of Medical Emergency Team Responses to Reduce Hospital Cardiopulmonary Arrests” Quality and Safety in Healthcare 13 (2004): 251-254. MERITInvestigators, "Introduction of the Medical Emergency Team," Lancet, 2005, 365:2091-2096.

Winters BD et al. Critical Care Medicine, 2007, 35(5):1238-43. Recent Meta-Analysis Studies reviewed 1990-2005 8 studies, adult patients (5 historical controls, 1 concurrent control, 2 with cluster-randomized design) Weak evidence that RRTs are associated with a reduction in hospital mortality and cardiac arrest rates Limitations in the quality of the original studies and heterogenity of the studies Meta-analysis included the above mentioned studies (except the recent PA study) and others Winters BD et al. Critical Care Medicine, 2007, 35(5):1238-43.

Rationale for RRTs Early recognition of deteriorating patients can prompt intervention and prevent adverse outcomes May improve morbidity and mortality as well as staff and patient satisfaction The Institute for Health Care Improvement (IHI) identified RRTs as part of the 100,000 Lives Campaign Joint Commission 2008 National Patient Safety Goal - early recognition and response to a patient’s condition Rapid Response Team (RRT) - Team bringing critical care expertise to the patient at first evidence of distress BEFORE deterioration IHI – Institute for Health Care Improvement: National initiative designed to improve patient outcomes and prevent avoidable deaths JCAHO: one of the 2008 National Patient Safety Goals Recognition and Response to Changes in Patient’s Conditions Goal 16 Improve recognition and response to changes in a patient’s condition. Requirement 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. Rationale for Requirement 16A A significant number of critical inpatient events are preceded by warning signs for an average of 6 to 8 hours. Critical events such as cardiopulmonary and respiratory arrests or changes in patient’s vital signs are estimated to occur in 4% to 17% of inpatient admissions. Early response by a specially trained individual(s) to changes in a patient’s condition may reduce cardiopulmonary arrests and patient mortality. Note: This requirement has a one-year phase-in period that includes defined expectations for planning, development, and testing (“milestones”) at 3, 6, and 9 months in 2008, with the expectation of full implementation by January 1, 2009.

RRT Measures and Data Collection

Key Measures for RRT Effectiveness Overall unadjusted hospital mortality Codes per 1000 discharges Codes outside the ICU Utilization of RRT (number of RRT calls)

Other Outcomes Post-cardiac arrest ICU bed utilization and hospital days Staff satisfaction with the RRT Nursing turnover Average ICU patient length of stay following an RRT call vs. non-RRT Unplanned medical-surgical ICU admissions RRT calls transferred to higher levels of care Post-cardiac arrest survival rate to discharge

Calculating Codes per 1000 discharges Numerator: total inpatient codes Exclude those in the ED Denominator: total inpatient discharges Exclude stillbirths, deaths in ED patients Calculation: (numerator/denominator) x 1000 Collection: collect data on monthly basis Getting Started Kit: RRTs, How-to Guide, www.IHI.org

Sample Graph – Codes per 1000 discharges Getting Started Kit: RRTs, How-to Guide, www.IHI.org

Calculating Percent of Codes Outside ICU Numerator: in-hospital codes outside the ICU Exclude codes in ED Denominator: all in-hospital codes Calculate: numerator/denominator (%) Getting Started Kit: RRTs, How-to Guide, www.IHI.org

Sample Graph – Percent of Codes Outside ICU Getting Started Kit: RRTs, How-to Guide, www.IHI.org

Utilization of RRT – Sample Graph Getting Started Kit: RRTs, How-to Guide, www.IHI.org

Tripler Army Medical Center Rapid Response Team P OMOTE YOU PATIEN S SAFETY R R T Rapid Response Team

TAMC Rapid Response Team Implemented in November 2006 Coverage 24 hours a day, 7 days a week “Ramp Up” Model Comprised of an ICU registered nurse and a respiratory therapist ICU physician reviews each case and is available for immediate consultation Distinct from Code Blue Team

TAMC Activation Criteria Heart rate <40 or >130 Respiratory rate <8 or >24 Systolic blood pressure <90 O2 sat <90% on supplemental oxygen Acute mental status changes Physician, nurse, or family member concern

Responsibilities of the RRT Respond within 5 minutes of the page Assess the clinical problem Immediately determine if a Code Blue call is indicated Assist primary team physicians with bedside testing and therapies to stabilize patient Help assess need for transfer to higher level of care and assist with transfer Primary goal of the RRT is patient safety RRT serves as an advocate for the patient and bedside staff Also assist with communication and notify the attending physician team if not already done Provide education and support

Initial call record

Revised call record As of late Nov 2007

The Impact of the Rapid Response Team on Patient Care at Tripler Army Medical Center DCI approved research protocol - The Impact of the Rapid Response Team on Patient Care at Tripler Army Medical Center CPT Silvia Burgess, MC, USA CPT(P) Julia Lim, MC, USA Mrs. Christine Loyle, BA CPT Jason Burris, MC, USA COL Stephen Salerno, MC, USA

Research Protocol: Study Questions, Part 1 What are the baseline characteristics of patients associated with RRT activation? What are the most common circumstances for RRT activation? What are the major interventions performed by the RRT?

Research Protocol: Study Questions, Part 2 How do rates of unanticipated transfers to higher levels of care (progressive care and intensive care units) compare before and after RRT implementation? How do hospital mortality rates compare before and after RRT implementation?

Methods: Study Design Part 1 Total of 332 RRT call records reviewed (1 November 2006 – 31 October 2007) Data collection: Patient characteristics (age, gender) Reason(s) for RRT activation Time of call and location of patient Vitals when RRT arrived and post intervention Interventions performed Need for transfer to higher levels of care Final outcome of patient (discharge, death) 10 month period (1 Nov 2006 – 30 Aug 2007)

Methods: Study Design Part 2 Unanticipated transfers: Retrospective chart review 12 months pre RRT (1 November 2005 - 31 October 2006) 1354 records reviewed Retrospective chart review 12 months post RRT (1 November 2006 - 31 October 2007) 1331 records reviewed Death data: Retrospective chart review of patients who died during their hospitalization pre and post RRT 165 records reviewed - Patient names were obtained from the Patient Administrative Data Section and included a patient who was ever hospitalized in the PROGRESSIVE care unit or ICU – these charts were individually reviewed to determine if they were direct admissions to the ICU or PROG unit or were the result of an unanticipated transfer requiring higher level of care - Total number of adult admissions obtained from Patient Administrative Data

Methods: Death Data Electronic adult death records individually reviewed who died during admission Death categorized as expected: End of life care Hospice care Withdrawal of care Death categorized as unexpected: None of the above mentioned

Methods: Data Analysis Chi square test to compare vital signs pre and post RRT intervention Student’s t-test to compare age, gender, mortality rates, and unexpected transfer rates pre and post RRT

Results Total of 332 RRT calls over first 12 months Mean 27 calls per month Mean age 61.4 years 69% males Approx 60% of calls were from the Medicine wards and occurred between 0700 - 1700

TAMC Adult RRT Calls Nov ‘06 – Oct ’07 Total 332 Calls Average 27 calls per month

RRT Call Locations

Results – Reasons for Activation (total number)

Results – Interventions (total number) The majority of patients were provided supplemental oxygen and had an IV started. Over 50% of patients received oxygen and had an IV placed

Results – Call Dispositions Over half of patients stayed in the room (56%) <1/3 of patients were transferred to higher levels of care (31%)

TAMC Adult RRT Call Dispositions Remained in Room vs TAMC Adult RRT Call Dispositions Remained in Room vs. Higher Level of Care

RRT Calls – Outcomes of Patients Who Remained in Their Room Total 183 RRT calls 18 patients had repeat RRT calls, 21 had ≥ 2 unanticipated transfers 148 patients 2 remain hospitalized (1.4%) 130 discharged (88%) 14 died during hospitalization (9.5%) 2 incomplete records

RRT Calls – Outcomes of Patients Transferred to PROG / ICU Total 111 RRT calls 9 patients had repeat RRT calls, 25 had ≥ 2 unanticipated transfers 99 patients 5 remain hospitalized (5%) 69 discharged (70%) 25 died during hospitalization (25%)

Results - RRT Interventions RRT arrival Post intervention p-value Systolic BP (mm Hg) 123.80 123.71 0.33 Diastolic BP (mm Hg) 69.96 69.16 0.20 Heart rate 94.56 89.74 <0.01 Respiratory rate 22.06 21.25 0.02 Pulse oximetry 94.46 97.06 Chi-square testing

12 Months Pre RRT 2.3% of admissions were unexpected transfers 9491 adult admissions 2.3% of admissions were unexpected transfers 1354 patients were in the PROG / ICU environment during hospitalization 1136 patients were direct PROG / ICU admissions, or expected post-surgery or procedure 218 (16.1%) patients were unexpectedly transferred to PROG / ICU 35 (2.6%) patients who stayed in PROG/ ICU died during hospitalization

12 Months Post RRT 2.2% of admissions were unexpected transfers 9456 adult admissions 2.2% of admissions were unexpected transfers 1331 patients were in the PROG / ICU environment during hospitalization 1123 patients were direct PROG / ICU admissions, or expected post-surgery or procedure 208 (15.6%) patients were unexpectedly transferred to PROG / ICU 31 (2.3%) patients who stayed in PROG/ ICU died during hospitalization

Results – Death Data Total Deaths Total Deaths: Expected Deaths: Pre-RRT: 82 Post-RRT: 83 Expected Deaths: Pre-RRT: 33 (4 additional patients were dead on arrival) Post-RRT: 46 Unexpected Deaths: Pre-RRT: 45 Post-RRT: 37 Total Deaths

Results- Comparison Pre- and Post- RRT Pre-RRT Post-RRT p-value Total Adult Admissions 9491 9456 NA Unexpected Transfers 2.3% 2.2% 0.28 Unexpected Deaths 0.47% 0.39% 0.39 Deaths 0.86% 0.88% 0.72 No statistical difference between unexpected transfers and unexpected deaths pre and post RRT, but this is unadjusted by age or co-morbidities Unexpected transfers rate: numerator (those unexpectedly transferred)/total adult admissions x100 for a percentage Unexpected death rate: numerator (those who died “unexpectedly)/total adult admissions x 100 for a percentage Total death rate: numerator (total deaths)/total adult admissions x 100 for a percentage Death and transfer unadjusted by age or co-morbidities

Results Age (years) Gender (% Male) Unexpected Transfers Pre RRT Post RRT p value Unexpected Transfers 60.5 60.8 0.84 65% 68% 0.96 Unexpected Deaths 77.1 72.8 0.15 87% 73% 0.12 Total Deaths 71.8 72.2 0.74 76% 77% 0.42 Student’s t-test All others were pretty even Note that post-RRT, the mean age of males was decreased, and also the percentage of males was less compared to post RRT No significant difference pre and post RRT between age and gender

Discussion – Part 1 Most RRT calls occurred during the day and were from the inpatient Medicine wards The most common criteria that prompted RRT activation included staff concern and an abnormal vital sign Most common RRT interventions included IV access and providing supplemental oxygen

Discussion – Part 2 Patients had statistically significant decreased heart rates, respiratory rates, and higher pulse oximetry levels following RRT intervention No significant change in mortality or unexpected transfer rates of patients to higher levels of care

Limitations Retrospective chart review Length of study Examined crude mortality and transfer rates not adjusted for age or co-morbidities Limited data on cardiac arrests to compare rates pre & post RRT

Future Directions In-depth chart reviews with adjustment of mortality/unexpected transfer rates Effect of RRT on length of hospital stay Determination if standardized scoring systems of acuity in non-ICU settings can predict RRT activation Survey patients and staff for satisfaction In-depth chart review to examine: - associations for medical diagnoses - lab values - standardized scoring system (APACHE) - length of hospital stay

TAMC Adult RRT Staff Survey Results Nov ’06 – Oct ’07 Amounts to approx 140 surveys (mostly nurses). Each RRT call is supposed to be accompanied by a survey

Questions?