Rapid Response Team TAMC Pilot Program Eric A. Crawley M.D. LTC MC USA Medical Director, Critical Care Tripler Army Medical Center Honolulu, HI
Outline RRT definition and composition RRT literature review Impetus for RRT development at TAMC Planning and implementation Illustrative cases Lessons learned Preliminary data Conclusions
Rapid Response Teams A Rapid Response Team (RRT) Known by some as the Medical Emergency Team is a team of clinicians who bring critical care expertise to the patient bedside (or wherever it is needed).* Activated by staff or potentially family based on established call criteria Intent is to intervene early and thus prevent/reverse clinical deterioration * From IHI, RRT Getting Started Kit
The grim reality 66% of patients developing cardiopulmonary arrest demonstrated significant vital signs or clinical signs for 8 hours prior to the event Rarely were these recognized or documented Even when recognized, the physician response if notified was usually inadequate Schein RM, et all, Chest 1990:98:1388-1392 1392 68% of patients show abnormal signs and symptoms within 6 hours of arrest and MD is notified in 25% of cases Franklin C. Matthew J. Crit Care Med: 1994:22(2):244-247 247
Outcomes literature supporting the RRT concept Bellomo et. al. - Observational study - 4 month period prior to RRT implementation compared to 4 months with RRT in place Outcomes Respiratory failure 12 events vs. 74, p <.001 Acute Renal Failure - requiring hemofiltration 2 events vs 27, p <.001 Cardiac arrest 11 events vs 33, p <.003, (66.6% reduction) In-hospital surgical mortality, 37.5% relative risk reduction, p <.022 (roughly 22 fewer deaths over 4 month period) Post cardiac arrest bed days p <.0001 (2000 post-arrest bed days/yr saved) Critical Care Medicine. 32(4):916-921, April 2004
RRT Literature Cont. No RCT data exists to conclusively establish RRT efficacy* The ideal intervention for preventing, or identifying and responding to clinical deterioration is unknown Agreement among most that the historical standard is unacceptable There is a significant body of case series data supporting the RRT concept * Winters et al. JAMA.2006; 296: 1645-1647
TAMC and RRT development Institutional recognition that: Some suboptimal outcomes were in retrospect predictable and potential preventable Failures to intervene were often related to Knowledge or skill deficits: e.g. failure to recognize signs of clinical deterioration Communication breakdown among members of the healthcare team Cultural issues such as, rank structure, GME, physician/nurse hierarchy - may impede effective communication RRT might be a vehicle for improving patient outcomes
RRT Development Collaborative efforts of Tripler AMC: Critical Care Medicine Command Group Patient Safety Department MEDCOM Patient Safety RRT implemented on 1 November 2006
RRT Team Composition Current TAMC model ICU nurse - team leader and ICU bed manager Respiratory Therapist ICU attending - team consultant When fully staffed, a hospitalist will be added to the team as team leader.
Equipment RRT Nurse i-stat lab device i.v.. access supplies D50, naloxone,, iv fluids RRT record document RRT Respiratory Therapist Oxygen delivery supplies Suctioning supplies Nebulizer equipment Medication: albuterol and ipratropium Pulse oximeter
TAMC RRT Activation Criteria Respiratory rate <8 and > 24 Saturation < 90% despite oxygen Pulse < 40, > 140 SBP < 90 Acute change in mental status Staff or family worried about patient s s status Criteria differ slightly from those of the IHI as TAMC criteria establish a lower high respiratory rate threshold for activation
Implemenation Plan Establish implementation timeline allotting 4-6 months for: Education - responders Minimum standards - BLS, ACLS, TAMC RRT responder training program Education - hospital staff RRT concepts and call criteria SBAR communication tool Sustainment education via newcomer orientation and BMAR Policy development addressing: pagers and call activation supplies/equipment documentation requirements/forms RRT and primary team roles/responsibilities Data tracking/reporting Closely modeled on IHI RRT Getting Started Kit http://www.ihi.org
Education Program success or failure hinges on education: 4-66 month period of staff education and train up Training includes The activation criteria Mechanism for activating What the response delivers The fact that there are no bogus or inappropriate calls The fact that there are no repercussions or second guessing of the staff member activating Recognition that this is NOT the CODE BLUE Team
Physician Education Physicians: Physician buy-in is essential and is best accomplished via a departmental physician champions. Reassurance that: RRT will not assume control, or usurp primary team authority Primary team to be consulted at time of RRT call RRT acts to support the primary team RRT brings resources (I-stat), and nursing skills which may not be available on the ward. Recognition that staff should not be dissuaded from calling the RRT
Cases 60y.o. woman on psychiatry ward for anxiety and suspected functional dyspnea.. Patient complains of shortness of breath- Bedside nurse concerned enough to call the RRT Call parameter - staff concern Response - patient noted to be in myasthenic crisis transferred to step-down, eventually requiring mechanical ventilation/tracheostomy tracheostomy Recovering with treatment of MG RRT training empowered the psychiatry nurse to get help for her patient thus averting respiratory arrest and likely morbidity/mortality
Cases Young woman s/p vaginal delivery, becomes light headed mild hypotension on ward, staff activates RRT OB team at bedside RRT expedites evaluation and transfer (post-partum partum hemorrhage) Patient in OR 11 minutes after call initiated. Excellent outcome OB retained control and RRT facilitated stabilization and a rapid seamless transfer Ready availability of an ICU nurse brings advanced nursing expertise to patient, ability to perform bedside lab testing
Cases 30y.o. woman admitted with unexplained abdominal pain. She develops hypoxemia, respiratory distress and relative hypotension The surgical team was unavailable RRT activated Call criteria sat<90%, RR >24 and SBP <90 High flow oxygen administered Diagnosis felt to be massive Pulmonary Embolism Pulmonary Embolism confirmed Systemic thrombolysis administered. Resolution of clinic findings
Lessons Learned Education Once is not enough, staff quickly forget basic concepts unless there is follow on education Educational items especially magnets badge holders and pens with call criteria and pager numbers were extremely effective High staff turnover mandates RRT training for all new and redeploying staff
Lessons Learned RRT call barriers are often related to hospital culture Nursing fear of physician anger or of appearing to undermine the physician Resident physician concerns that RRT calls represent failure, or failure to recognize that help is needed These will be ongoing challenges
Lessons Learned Post response surveys confirm a very high level of satisfaction with the RRT response Coupling of RRT Nurse role with ICU bed manager shortened transfer time, and improved bed utilization
Lessons Learned Dedicated nursing staff for the RRT/Code team role are essential Optimal RRT implementation requires additional nursing assets Sustainment is contingent on having a staff member who can: Serve as hospital staff educator Identify and solving problems as they arise Elicit staff feedback Compile data and metrics Our RRT administrator has been essential to program success.
Calls Nov 06 Feb 07 120 100 80 60 40 20 0 2006 Nov 2006 Dec 2007 Jan 2007 Feb Total Avg/Mon 2006 Nov - 26 2006 Dec - 21 2007 Jan - 23 2007 Feb - 38 Total - 108 Avg/Month - 27
Call Dispositions 60% 50% 40% 30% 20% 10% 0% November 06 - February 07 Remained in Room - 56% To ICU - 25% To Prog - 9% To ED - 5% Admitted to Ward - 1% Remained in OR - 1% Outpatient - 2%
Reason for Activation 70% 60% 50% Staff Concerned - 68% Resp Rate > 24-18% 40% 30% 20% SpO2 < 90% w/o2-31% SBP < 90mmHg - 27% 10% 0% November 06 - February 07 Acute Mental Status Change- 21%
Call Locations 35% 30% 25% 20% 15% 10% 5% 0% November 06 to February 07 Telemetry Ward- 31% Other: Wards/Clinics- 24% General Medical Ward - 24% Prog Care - 13% Surgical Ward - 4% Dialysis Clinic - 4%
Conclusions (1/2) Institutional consensus is that: The RRT has enhanced the inpatient care provided at TAMC RRT can improve communication and empower staff and families Education and a commitment to sustainment are the keys to success RRT development requires dedicated personnel resources
Conclusions (2/2) Monthly call volume was in line with IHI estimates 10calls/100beds/month Most patients did not require transfer to a higher level of care Nearly all inpatient venues utilized the services Simple interventions applied early are superior to complex ones applied late in the course of disease
Conclusion Zero complaints from staff surgeons, or physicians. Concerns about loss of control unfounded Realization that the team is supportive Reassurance from knowledge clinical worsening is recognized earlier and addressed No degradation of resident medical education noted
Discussion For additional information contact: eric.crawley@us.army.mil (808)433-2297