Rapid Response Teams

Presenters Laurel Tyler, RN, MN Clinical Nurse Specialist CCU/IMC/Telemetry Virginia Mason Medical Center Diane Sanders, RNC, MN Director of Patient Care Services Kadlec Medical Center Nancy Dahlberg, RN, MSN, OCN Critical Care & Intermediate Care Unit Manager Kadlec Medical Center Carol Wagner, RN, MBA Director, Patient Safety WSHA

What is a Rapid Response Team? Rapid Response Teams (RRT) are summoned at any time by any staff in the hospital to assist in the care of a patient who appears acutely ill, before the patient has a cardiac arrest or other adverse event.

Rapid Response Team Presentation Overview This web conference will focus on:  Communication Strategies  Team Composition  Barriers  Measurement Strategies  Results

Virginia Mason Medical Center Medical Emergency Teams (MET)

Executive Sponsors: Guidance Team Medical Director Nurse Executive You need an administrative and physician champion!!

Work Group Participants Medical Director of Hospitalist Group Medical Director of Critical Care Unit Administrative Director of Specialty Units Critical Care Clinical Nurse Specialist Manager of Respiratory Therapy Clinical Practice Improvement Project Manager Clinical Decision Support

Members of RRT Comprised of a subset of our full Code Team −Hospitalist −Critical Care Charge Nurse −Respiratory Therapist Required no additional FTEs −Staff continue usual responsibilities in addition to RRT calls

Does not carry any emergency equipment −Respond from multiple locations −Use Code Cart on unit if needed Members of RRT

Activation of RRT Uses standard emergency number: 5555 Called by both overhead pages and individual pagers −Originally only activated via pager −Multiple pager failures – caused incomplete RRT response

Developing Physician Buy In Created physician champions Addressed physician concerns quickly −Timely notification of attending physician −Appropriate assessment and treatment of surgical patients

Developing Physician Buy In Solution Assign one of the RRT responders to: −Personally contact attending physician −Document assessment and interventions in patient record Don’t assume communication with the attending physician happened

Communication Key Focus of Communication −Medical Directors −Nurse Managers −Registered Nurses −Clinical Nurse Specialists Most Effective Through −Staff meetings −Flyers & phone / pocket cards

Recommendations Automatically activate with STAT Respiratory Therapy calls Set Time Goals −Respond within 5 minutes −Duration of calls < 30 minutes

Recommendations Emphasize notifying the attending simultaneously – not necessarily prior to RRT activation Add criteria: −High limit on O2 – 6L or use of non-rebreather mask −Progressive changes −Sepsis

MET 5555 (MEDICAL EMERGENCY TEAM & link to STROKE TEAM) *Inform/Page the Managing & Attending Physician/Provider prior to or concurrently with the MET call Note: MET or Provider will activate the Stroke Team Call MET: # 5555 MET 5555 (MEDICAL EMERGENCY TEAM & link to STROKE TEAM) *Inform/Page the Managing & Attending Physician/Provider prior to or concurrently with the MET call Note: MET or Provider will activate the Stroke Team Call MET: # 5555  Worried about your patient?  Acute change in Respiratory Rate? 30  Acute change in pulse oximetry saturation to < 90 despite O 2  Acute change in HR? 130  Acute change in BP? SBP < 90  Acute change in consciousness state?  Acute change in urine output? UO < 50ml in 4 hours Signs of Stroke?  Sudden numbness/weakness to face, arm or leg  Sudden difficulty speaking  Sudden confusion  Sudden loss of balance or trouble walking  Sudden difficulty seeing in one or both eyes  Sudden sever headache You must act fast……

Data Collection Forms Data points entered into excel spreadsh eet

Reason for MET Activation WorriedAcute Change in HR/BP Respiratory Distress/ Threatened Airway Acute Change in LOC Acute Change in Urine Output

Location of MET Calls

MET Interventions

MET Call Outcomes

Time of MET Calls

MET and Code 4 Events Jan 2004 – April 2005 Number of RRTs called increasing

Words of Advice Chart reviews indicate 20% of RRT calls could have been made sooner Some patients have progressive changes and multiple interventions −Need more education to recognize and treating early sepsis −More emphasis on “Are you worried?” −Encourage nurses to call even if physician is present

Words of Advice (cont.) No provider can “trump” a MET call Follow up by Medical Director or lead Hospitalist with physician problems

Words of Advice (cont.) RRT need to be ambassadors Work with RRT up front −Discuss expectations and responsibilities −Acknowledge some calls will seem inappropriate −Confirm message needs to be “Thank you for calling!” Make RRT calls overhead pages (free advertising)

Unexpected Positive Outcomes Opportunities identified from analyzing data from RRT of system problems – −Difficulty identifying which MD is on call −Educational opportunities for nurses in early identification −Sepsis −Vital signs

Positive Outcomes Patients lives have been saved through this process Our care to our patients has been improved

Kadlec Medical Center Rapid Assessment Team (RAT) Rapid Assessment Team (RAT)

Rapid Assessment Team (R.A.T.)

Committee Composition Director of Nursing Nurse Manager and Educator −Critical Care −Medical Unit −Surgical Unit Educator Respiratory Therapy Manager Respiratory Therapy Patient Safety Officer Lead Patient Care Coordinator

Physician Communications Intensivists (started here) Critical Care Committee Medical Executive Committee Full Medical Staff Committee Flyers to physicians CEO’s newsletter

Staff Roll Out Computer based education Staff meetings Scenario training Unit reminders

RAT Unit Reminders

Rapid Assessment Team Composition Critical Care Lead/Charge RN Respiratory Therapist Patient Care Coordinator/ Nursing Supervisor No physician is on the team Roles clearly defined

Critical Care Lead/ Charge RN Role Collaborate with patient’s nurse Assess patient with floor RN and RT Determine interventions Support patient’s RN as they call for orders Help Primary Care Coordinator with planning transfer if needed Assist with transport to CCU

Respiratory Therapist Role Assess patient for respiratory issues Evaluate clinical findings in relation to patient history and ongoing therapies Determine interventions in coordination with other team members

Patient Care Coordinator Role Coordinate bed needs and patient transfers Assist staff if chain of command issues arise Act as a facilitator to assure staff is communicating needs appropriately Support staff if physician issues arise

Patient’s RN Role Consult with lead/charge nurse Call Rapid Assessment Team Assess patient with R.A.T. Collaborate with team regarding treatment needs Call physician for needed orders Patient’s RN remains primary caregiver! This is an opportunity to learn.

Lead/Charge RN Role Consult with floor nurse regarding concerns Assure nurses other patients are cared for when CCU Lead and RT arrive

Criteria “Gut Feeling” −Follow your gut. If you don’t like the way the patient looks and feel that something may be wrong, call the R.A.T

Criteria (cont.) Respiratory −Respiratory rate 32 per minute −Difficulty in breathing −Sat 5 minutes (unless patient known to have chronic hypoxemia); or an increase in O2 needs

Criteria (cont.) Heart rate 140 Blood pressure −Unable or difficulty in obtaining a BP −Systolic BP 200 with symptoms Temperature −Temperature > 101.5ºF (38.5ºC) or < 96.8ºF (36ºC) plus any of | the above

Criteria (cont.) Acute neurological change −Deceased level of consciousness or acute loss of consciousness −Sudden loss of movement (or weakness) of face, arm or leg −Unexplained agitation for more than 10 minutes

Criteria (cont.) Other −Color change (of patient or extremity); pale, dusky, gray, blue, mottled, etc… −Anxiousness, restlessness −Uncontrolled bleeding −Diaphoresis with any of the above symptoms If in doubt, call the R.A.T.s!

R.A.T Documentation

Issues Physician’s concerns Keeping the team visible Tracking R.A.T. activations

Reasons for Calls Respiratory40% Neuro.19% Heart rate17% Blood pressure12% Gut feeling 7% Temperature 5%

Codes Outside of CCU This year is lower!!

Recommendations Go For It! Best change this year! Don’t focus on criteria. If in doubt, call the R.A.T.(s)!!

Rural Hospitals Focus on: Team comprised of who would come if there was a code −Getting a “second pair of eyes” Education of warning signs for deterioration for early intervention Calling early

Key Points Develop physician and administrative champions Compose the RRT with staff who can be a second pair of eyes Call early and if patient does not look right Take the opportunity to teach Catchy name is helpful for quick adoption

Measurement Number of RRT calls Number of codes called where patient met criteria for RRT but one was not called Satisfaction of patient’s RN Number of non-ICU, non- comfort measures deaths

Polling

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