1. Rapid Response Team Patty Gessner, RN MSN Alexian Brothers Medical Center

2. Concept Respond rapidly and effectively Restructure the way care is delivered – Bring the ICU to the patient – Bring the RN and RT out of the ICU to ‘triage in the field

3. Background Originated in the early 90’s First published study Australia in 2002 – 50% reduction in unexpected hospital deaths Supported by the Institute for Healthcare Improvement

4. Which Hospitals Need RRT? The hospital that has ever wondered if a code could have been avoided The hospital that has ever investigated a code and found obvious signs of deterioration in the hours preceding the arrest

5. Rationale Unexpected cardiac arrests are preceded by critical signs of instability (Kleinpell, 2002) Junior staff ICU admissions often suffer a delay in optimal care prior to their admission (Bristow, 2000)

6. Key Factors Contributing to Delay of Treatment Failure to rescue – Failure to educate – Limitation of Skill

7. Review of the Literature  Reduction of the relative risk of mortality  79% for respiratory failure  78% for stroke  74% for severe sepsis  88% for acute renal failure (Critical Care Medicine 32(4): 916-921)

8. Review of the Literature Retrospective analysis of 3269 RRT calls and 1220 cardiopulmonary arrests over 6.8 years Reduction in the monthly incidence of cardiopulmonary arrests by 17% (Quality Safety Healthcare 13:251-254)

9. Review of the Literature Reduction in the number of unnecessary ICU admissions by 30% Number of cardiac or pulmonary arrests outside critical care reduced by 50% Reduction in hospital mortality by 15% (Quality Letter 16(12):2-9)

10. Review of the Literature Reduction in code blue by 28% Number of code blues outside of critical care dropped from 65% to 35% in 6 months time Survival to discharge has doubled (Quality Letter 16(12):2-9)

11. What Other Hospitals Have To Say “Both RT and nursing highly benefit from this collaborative effort” “One key way of assisting with ventilator LOS is to prevent the patient from going on the ventilator in the first place” “It also allows physicians the capability to start drips on the floor…” OHRU writes “We began with 4 test units, but within a week we had a visit requested by another unit so we quickly opened the service housewide”

12. Getting Started Do not rely on administrators Driven by clinicians

13. About us Alexian Brothers Medical Center Located in Elk Grove Village Illinois Non-teaching community hospital 370 bed Level II Trauma 32 total ICU beds

14. Our Program Proposal developed in June 2004 Approval achieved through medical and nursing departmental meetings Awareness through attendance at the town hall meetings, flyers, and through the efforts of key support personnel Start date October 1 st 2004

15. Protocol On the scene within 5 minutes 30 minutes per call

16. Activation of the Team Staff recognize crises and call RRT phone Criteria to call – Respiratory distress – Acute changes in heart rate or blood pressure – Acute changes in mental status – Uneasy feeling

17. Team Members  Critical care APN or designee  Critical care Respiratory Therapist  Intensivist

18. Units Included All inpatients Patients in ED and day surgery Patients in interventional/diagnostic departments

19. Spectrum of Services Stroke team Sepsis team

20. Team Expectations Work under the auspices of an ICU without borders Patient assessment and management Assist communication between nurse and physician Document in patient chart Facilitate transfer to higher level of care Staff education Thank staff for calling early Complete log

21. Floor Staff Expectations Initiate call to attending physician and the RRT team Describe the patient’s history, current condition, and how the support team can help Participate in patient management

22. Building a Program If you build it they may come, but if you don’t educate they won’t call

23. Outcome Measures Calls resulting in transfer to the ICU Number of avoided codes Survival of codes Number of arrests outside critical care Staff, physician, and family satisfaction

24. Data The next slides represent data collected – 99 calls logged between October 2004 through April 2005

25. RRT Reason for Call

26. Calls By Nursing Unit

27. RRT Time of Call

28. RRT Outcome $ $ $ $ $

29. Code Blue By Location Implement RRT

30. Survival of Code

31. Results 9 codes were averted 7 patients were made DNR Avoided transfer to ICU in 34% of cases Average time spent on call was 39 minutes Peak call times have lead us to further investigation Positive feedback from staff, physicians, and families

32. Close Calls

33. Mr. M Respiratory distress Staff waiting for assistance RR 40’s, unequal breath sounds, acrocyanosis, 90% on NRB

34. Mr. P 29 y/o s/p hip replacement History of failed kidney transplant On dilaudid PCA RR 8, 55% saturations

35. Mrs. P Staff called to ask for an ICU bed, reason given – needs intubation Investigation revealed 84 y/o RR less than 8 bpm PH 7.18 PCO2 89

36. Mrs. D Called for tachycardia, hypotension Not assessed was the acute abdominal pain Treated with analgesia and a surgical consult

37. Mr. P Called to evaluate desaturations PaO2 39 Immediate intubation

38. Key to Success Immediate availability No questions asked

39. Benefits Provide early interventions for patients Provide support for the bedside nurse Improve relations between nurses and physicians Increase staff satisfaction

40. Challenges and Lessons Learned Acceptance of Attending Physicians Use standing protocols Keep attending informed Difficulties with the phone Education Back up pager Ongoing staff awareness Signs Presentations at unit meetings Information both

41. Next Steps Reduce codes that occur outside ICU Increase awareness on night shift Retrospective examination of cases during the peak times Provide feedback to staff that initiated call Consider switching to a paging system

42. Questions Contact gessnerp@alexian.net