Swift Action Saves Lives
Monday May 5, 2008
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VHA Recommendations
- • Practice, practice, practice. The report found hospitals that had at least 10 RRT calls per 1,000 discharges achieved greater benefits than those with fewer than 10 RRT calls per 1,000 discharges. Hospitals with 15 calls or more per 1,000 discharges showed even greater gains.
• Hospitals should tightly link RRTs to other patient safety and clinical performance programs.
• RRTs should be integrated into hospital operations to ensure sustainability.
• RRTs should keep detailed records of activities and outcomes.
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“It’s a really good process,” says Nancy Curdy, RN, CNS, ANP-C, MSN, clinical nurse specialist for the Quality Institute at DeKalb Medical in Decatur, Ga., about the RRT. “It’s been a win-win for everybody — staff, the hospital, our patients, and families.”
DeKalb established the RRTs, called Partners Interacting Together (PIT) crews, in January 2006 while taking part in the Institute for Healthcare Improvement’s 100,000 Lives Campaign. A critical care nurse and respiratory therapist respond to more than 30 calls per month at the 250-bed facility. Since early 2006, the hospital’s mortality rate has decreased by 0.3% and the percentage of out-of-ICU codes has declined from 70% in early 2006 to less than 10% recently.
Saint Joseph’s Hospital, a 350-bed facility in Atlanta, piloted RRTs in fall 2005 and expanded them housewide in March 2006. The teams respond to between 80 and 90 calls each month.
Bethany Poole, RN, coordinator of rapid response teams at Saint Joseph’s, reports improved mortality rates for patients who coded as the teams have become more seasoned. In 2007, 76% of patients who coded with RRT involvement survived vs. 63% in 2006. The survival for patients who coded without RRT care was 46% in 2007 and 44% in 2006.
Piedmont Hospital in Atlanta had long provided critical care resource nurses, who were able to collaborate with colleagues on the floors, so when the idea for RRTs came along in June 2006, Kelly Hulsey, RN, BSN, CCRN, manager of patient flow at 481-bed Piedmont, wasn’t sure changing the name and embracing a more formal process would result in improved care. She was pleasantly surprised. In the first year, out-of-ICU codes decreased by 40% and risk-adjusted mortality declined. The hospital now has two STAT (stabilization, teaching, assessment, and transport) RRTs responding to at least 200 calls each month throughout the hospital’s campus, including ancillary areas.
“Nurses spread the rapid response team model,” says Lillee Gelinas, RN, BSN, MSN, FAAN, chief nursing officer at VHA and its RRT coordinator. Within eight months, 600 hospitals came on board. She found some physicians resisted, not wanting to cede authority to the teams.
“Rapid response teams operate on the premise of a nursing consultation model,” Gelinas says. “We ran into the issue that physicians didn’t want nurses to call each other.”
Gelinas estimates between 500 to 1,000 hospitals still lack RRTs, despite impressive results in those that do. And the teams cost little if anything to implement.
Activating the RRT
For successful implementation, nurses on the medical-surgical floors must understand what subtle changes occur before a person suffers a cardiac arrest, such as respiratory or mental function decline, so nurses know when to call the team. About six months before launching RRTs, Curdy presented educational sessions outlining when to call for objective measures, such as a change in blood pressure, heart rate, or urinary output, and for more difficult to quantify, subtle factors.
“If something doesn’t feel right and you feel you want someone else to put eyes on the patient, call a PIT,” Curdy advises. “Nine times out of 10, your gut is right. Something is wrong.”
Saint Joseph’s rewards nurses for calling the team, sending an “Angel Card” to the nurse who initiated the intervention, thanking him or her for recognizing early symptoms and taking action. The hospital also sponsors a monthly Good Save award for the nurse who makes a great call to the RRT. The unit has a party at which the senior vice president of medical affairs, Ralph Haynes, MD, presents the nurse with a certificate and the unit with a poster that explains what precipitated the call and the outcome.
Hospitals staff RRTs differently. DeKalb, Saint Joseph’s, and Piedmont have found it more effective not to give nurses on the team a patient-care assignment.
About 27 of Saint Joseph’s critical care nurses rotate to the RRT. When not responding to a call, the nurses round through the hospital and are sometimes able to intervene before a formal RRT call goes out. During the day, they focus on high-risk pulmonary patients and at night on all patients transferred out
of critical care beds that day to make sure they remain stable.
Nurses assigned to Piedmont’s STAT team monitor patients in the hospital’s electronic medical record, watching for laboratory changes indicating potential problems. If they see something unusual, they proactively visit that patient.
Christine Miles, RN, CCRN, BSN, a Piedmont STAT team nurse, enjoys the variety. “No day is the same, and no patient is the same. You don’t know what you will get called for,” she says.
“It has made the nurses taking care of the patients a little more aware of what is going on because they can intervene at the first sign something is happening with the patient, instead of waiting until a code needs to be called,” says Dawn Love, RN, a PIT crew nurse at DeKalb.
RRT members usually can start oxygen or perhaps an IV. At Piedmont, the RRT can order a chest X-ray, EKG, and some lab tests. In some facilities, the team can begin some treatments using standing orders approved by the medical staff, but that is not the case at DeKalb, Saint Joseph’s, and Piedmont. In each facility, the nurses must call the physician. Saint Joseph’s medical staff is now developing standing orders.
“When we started out, physicians were very against protocols,” Poole says. “I think they were afraid we would go to the floor and do something without calling them. Now, they see how well rapid response works, they want to give us protocols and give us autonomy to use our judgment.”
At the end of the RRT intervention, med-surg and critical care nurses complete an evaluation form about the call and note how it went and what could have been done differently or better.
“It’s an informal teaching mode,” Poole says. “The responders we have are laid back and not condescending. They won’t ask ‘Why didn’t you do this?’ or ‘Why didn’t you call me earlier?’ or ‘Why didn’t you look at the labs?’ They are easy to talk to and approachable.”
Having the RRT also has improved relationships between critical care and med-surg nurses. Poole finds the floor nurses no longer feel as intimidated by the critical care nurses’ assertive manners.
“It has opened the avenues of communication that we didn’t have before,” Hulsey adds.
ICU nurses also have a better appreciation for the challenges staff nurses face on the floors, leading to greater mutual respect and team building.
“It’s been a wonderful thing for the hospital,” Hulsey says. “Everybody is focused on the patient. The key has been the critical care nurses, the STAT team nurses. They have been awesome, willing to go into uncharted territory.”
Debra Anscombe Wood, RN, is a Nursing Spectrum contributing writer.
To comment, email editorFL@nursingspectrum.com.
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