1. Mortality Reduction in Medical/Surgical Care – Rapid Response Teams and SBAR Strategies
September 24, 2004

2. Presenter Bio
Robert Brush, MD, has practiced as a Pulmonary and Critical Care Specialist at Borgess Medical Center since 1977.
For the past two years, Dr. Brush has been the Chief Quality Officer at Borgess.

3. Rapid Response Teams
“A Rapid Response Team (RRT, MET) is a group of healthcare professionals who respond quickly to threatened clinical deterioration. They should be seen as a “pre-code” team that brings critical care skills to the patient’s bedside. The IHI considers the RRT as potentially the most important mortality reduction initiative.”

4. Attending asks medical resident to see patient.
How It Usually Goes:
A 65 y/o male with history of sleep apnea, post-op cholecystectomy complains of dyspnea. RR=30, SpO2 dropped to 87% on 4L O2/NC.
Nurse calls attending who gives additional morphine and increases O2 to 6L.
Patient “calms down” and RR=24, but SpO2 falls to 85% so nurse calls attending back.
Attending asks medical resident to see patient.

5. How It Usually Goes (continued):
Resident (HO-1) talks to the nurse on the phone and orders ABG, CXR, ECG, CBC and electrolytes. He says he’ll see the patient after he finishes with a new patient in ER.
Resident reviews the lab work 90 minutes later and asks the senior resident to see the patient with him.
As the residents enter the room, patient stops breathing. A “Code” is called. Patient survives but spends the next two weeks in ICU on a ventilator.

6. How It Should Go:
A 65 y/o male with history of sleep apnea, post-op cholecystectomy complains of dyspnea. RR=30, SpO2 dropped to 87% on 4L O2/NC.
Nurse feels the patient is “slipping” quickly and calls the Rapid Response Team.
Within five minutes, the patient is assessed, lab work and CXR is ordered and BiPAP is begun.
CXR and I&O review shows the patient is fluid overloaded.

7. How It Should Go (continued):
The patient is given IV Lasix.
The patient is transferred to a step down unit.
The diuretic is effective.
The patient returns to the Med/Surg Unit the following day and is discharged from the hospital two days later.

8. Rapid Response Team – What Is It?
Team with critical care skills that “brings critical care to the patient’s bedside”
Assist/augment floor nurse’s evaluation
Provides early intervention to slow or prevent clinical deterioration

9. RRT – Rationale (When Do You Open the Parachute?)
6 – 8 hour window pre-code when deterioration may be turned around
“Failure to Rescue” – failure to recognize (nurse or therapist) versus failure to respond (physician)

10. RRT – Structure Team composition may vary:
Physician – Intensivist versus Resident
Physician Assistant/Nurse Practitioner
Critical Care Trained Nurse
Respiratory Therapist

11. RRT – Functions Responds within minutes
Attending MD called after RRT is called
Assess patient with the floor nurse
Intervene with or without attending MD
Transport to higher level of care when needed
Summon Code Team if needed

12. RRT – When to Call Respiratory Rate > 24 or < 8 Falling SpO2
Δ level of consciousness
Δ BP and/or HR by 20% from baseline
Decreasing urine output
STAFF IS WORRIED ABOUT PATIENT!

13. RRT – Possible Interventions
Acute change in Respiratory Status:
Oximetry/ABG’s
Oxygen
CXR
Neb TX
BiPAP
Intubation

14. RRT – Possible Interventions (continued)
Acute change in HP/BP:
12 Lead ECG
ABG
Oxygen
Atropine
Amiodarone
External Pacemaker
Dopamine Infusion
Other

15. RRT – Possible Interventions (continued)
Acute Change in LOC:
ABG’s, Oxygen
Electrolytes, Glucose Level
Naloxone, Flumazenil
CT Brain, MRI

16. RRT – Outcomes ↓ Incidence of cardiac arrests
↓ Arrests on floor as ↑ # of RRT calls
↓ ICU transfers
↓ Overall mortality
Improve “critical thinking”

17. Before and After Trial of a Medical Emergency Team
Pre-MET
Post-MET
Cardiac Arrests 63 22
Deaths from Cardiac Arrest 37 16
ICU Bed Days
163 33
Hospital Bed Days
1353
159
Total Hospital Deaths
302
222
University of Melbourne (MJA 2003; 179(6): 283)

18. RRT – Metrics Number of RRT calls/number of discharges per month
Number of non-ICU codes/number of discharges per month
Number of deaths/number of discharges per month

19. Reduction in “Code Zeros”
RRT Trial Began
Borgess Medical Center

20. RRT – Building the Team Choosing and teaching the team
Communicating with the nurses
Communicating with the physicians
Encourage collegial relationships among nurses
Discourage intimidation
Teach “critical thinking” to all

21. RRT – Barriers PHYSICIANS – Threatened Autonomy
NURSES – Feel intimidated by critical care nurse/respiratory therapists

22. SBAR Defined
SBAR is a situational briefing tool that logically organizes information so that it can be transferred to others in an accurate and efficient manner.

23. SBAR
S – Situation
B – Background
A – Assessment
R - Response

24. SBAR - Rationale Fosters “critical thinking” skills
Nothing “lost in translation”
Saves time
Helps RNs/RTs be the patient advocate

25. Assertive Behavior
Individuals speaking up and stating their information with appropriate persistence until there is resolution, all done in the interest of better patient care.

26. Assertiveness - Obstacles
Hierarchy/Power distance
Lack of common mental model
“Don’t want to look stupid”
“Not sure I’m right”
“I’ve been burned before”

27. SBAR - Situation “I am (name and unit).”
“I am calling about (patient’s name and
room number).”
“The problem I am calling about is (state the problem).”

28. Situation - Example
“I am Mary, a nurse on 3 North, calling about your patient Mrs. Brown in room 345 bed 2. The problem I am calling about is her new complaint of dyspnea and her increasing respiratory rate.”

29. SBAR - Background State admission diagnosis and date of admission.
Give brief synopsis of hospital course and treatment to date.
Give vital signs including SpO2 and physical assessment pertinent to the problem.

30. Background - Example
“Mrs. Brown was admitted 3 days ago with pneumonia. She’s been on Levaquin and improving each day, no more fever and less cough and sputum.
Now her vital signs are RR=32 P=86, BP= 90/60, T=100.1 and SpO2= 88% on 2L.
Her breathing looks labored and she has new crackles in the right lower lobe.”

31. SBAR - Assessment
Give your impression of the present situation. A diagnosis is not necessary.
If the situation is unclear, at least try to indicate what body system is involved.
State how severe the problem seems to be.
If appropriate, state that the problem could be life threatening.

32. Assessment - Example
“I think Mrs. Brown could be developing worsening pneumonia in the right lower lobe.”

33. SBAR - Recommendation
Give the physician your recommendations for the thing(s) that you think should be done, based on your assessment.

34. Recommendation - Examples
“I have called the Rapid Response Team.”
“I think you should come to see the patient now.”
“I think you need to talk to the family about code status.”
“I think the patient needs a portable CXR and blood cultures.”

35. Before You Call Have patient’s chart and MAR Have today’s labs
Review most recent Progress Note
Review nursing notes for past shift
Know the “code status”

36. SBAR - Obstacles Nursing acceptance – “but this is what I
always do when I call the doctor.” Yes,
but is this the way you always document?
Physician acceptance – Doctors are not
accustomed to nurses or therapists giving
them unsolicited recommendations.

37. Before SBAR Nurse: “Dr. Green, room 345’s potassium was 3.1 today.”
Doctor: “Who’s potassium was 3.1?”
Nurse: “Mrs. Brown in 345 bed 1, your partner’s patient.”
Doctor: “What was her last potassium?”
Nurse: “I don’t know; let me go find the chart.”
3 min. later – “It was 3.5 two days ago.”
Doctor: “Is she on any diuretics?”
Nurse: “I don’t know. Let me go find the MAR.”
2 min. later: - “Yes, she’s on Lasix.”
Doctor: “Has she had any complaints tonight?”
Nurse: “I don’t know, her nurse is at lunch.”….etc.etc.

38. After SBAR
Nurse: “Hello, Dr. Green, this is Nancy the nurse taking care of your partner’s patient, Mr. Brown, in room 345, bed 1. I’m calling you because her potassium just returned and is 3.1.
He is a 46 y/o man admitted 2 days ago for CHF. He’s been on Lasix since admission but no potassium supplement. His V/S are P=80; BP 110/84; RR=14 and T= He is asymptomatic, no complaints of weakness and feels well.
I think he is hypokalemic from his Lasix and needs some potassium supplement.”

39. Rapid Response Teams and SBAR Contact Information
Borgess Medical Center Project Manager
Robert Brush, MD
Chief Quality Officer
Borgess Medical Center – Kalamazoo, MI
System Office Liaison
John Garbo
Director, Clinical Excellence