Getting Started Kit: Rapid Response Teams

Getting Started Kit: Rapid Response Teams free pdf ebook was written by Jendo on April 13, 2006 consist of 27 page(s). The pdf file is provided by www.rtjournalonline.com and available on pdfpedia since May 16, 2011.

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Getting Started Kit: Rapid Response Teams pdf




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Getting Started Kit: Rapid Response Teams - page 1
Getting Started Kit: Rapid Response Teams How-to Guide 100,000 Lives Campaign ! ! ! ! )* * "# # # !# # * ! * + $ * %# #& ( * $ %#! #' ! !*, *+ ) ) 1 1 ) - # ** *. * * ) -/ ) ) - - ) -/ 0 - ) 1 - - ) - ) ) - ! #% ' ( " $& ) " - ) -/ ) - 1
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Getting Started Kit: Rapid Response Teams - page 2
100,000 Lives Campaign How-to Guide: Rapid Response Teams What Is a Rapid Response Team? A Rapid Response Team – 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). Why Do We Need Rapid Response Teams? People die unnecessarily every single day in our hospitals. It is likely that each clinician can provide an example of a patient who, in retrospect, should not have died during their hospitalization. The goal is to respond to a “spark” before it becomes a “forest fire.” Analyzing Hospital Deaths The purpose of this diagnostic is to get a clearer understanding of local conditions that contribute to mortality. Mortality Diagnostic – 2 x 2 Matrix ICU Admission ? Yes No Yes Comfort Care Only? No Box #1 Box #2 Box #3 Box #4 2
Getting Started Kit: Rapid Response Teams - page 3
100,000 Lives Campaign How-to Guide: Rapid Response Teams These cases are often seen when retrospectively reviewing inpatient hospital deaths using a simple diagnostic tool called the “2 x 2 Matrix” – or “3 x 2 Matrix” for our colleagues in the United Kingdom. This diagnostic consists of analyzing the patient records for 50 consecutive patients who died in the hospital and placing them into one of the four boxes in the 2 by 2 Matrix. This is done by asking the following questions: - - Was the patient hospitalized for comfort care only? Was the patient initially placed into an intensive care unit? If the answer is yes to both questions, is the death is counted in Box 1. If the answer is no to the ICU but yes for comfort care, the death is counted Box 2. If the answer is yes to ICU but no to comfort care, the death is counted in Box 3. If the answer is no to both, then the death is counted in Box 4. Box 4 should be further analyzed by asking if there was any evidence of communication failures, planning failures, or failure to recognize a deteriorating patient condition, which often leads to situations of failure to rescue. Finally, deaths in Boxes 3 and 4 should be reviewed using the Global Trigger Tool (on the web at www.ihi.org), looking for any evidence of adverse events. Mortality Diagnostic: Aggregate Results for 64 US Hospitals ICU Admission Comfort Care 86 / 3175 3% (0-14%) 1161 / 3175 37% (10-72%) No ICU Admission 402 / 3175 13% (0- 40%) 1526 / 3175 48% (18-76%) Non Comfort Care 3
Getting Started Kit: Rapid Response Teams - page 4
100,000 Lives Campaign How-to Guide: Rapid Response Teams As of October 2004, 64 US hospitals have shared the results of their mortality reviews using the 2 x 2 Matrix. The table represents their data in aggregate. On average, 48% of all deaths are found in Box 4: patients who were admitted to a non-ICU setting and were not expected to die. Some percentage of the deaths in Box 4 are indeed unnecessary deaths – ones a Rapid Response Team can have an impact on. Three Fundamental Problems There is a large amount of variability in health care today. Numerous articles have shown that this variability exists across both quality and safety. Fairly recent work by Sir Brian Jarman, Emeritus Professor of Primary Health Care at Imperial College School of Medicine (London, UK), indicates that this variability exists in hospital mortality rates. Even when multiple risk factors and community factors are taken into consideration, there is no clear explanation for differences from hospital to hospital. And yet, an opportunity exists to reduce this variability by improving hospital care. During the past 18 months, work has been carried out to understand the causes of the problem and to develop potential improvement strategies. The conclusions from this work and a review of the literature are that three main systemic issues contribute to the problem: Failures in planning (including assessments, treatments, and goals) Failure to communicate (patient-to-staff, staff-to-staff, staff-to-physician, etc.) Failure to recognize deteriorating patient condition These fundamental problems can often lead to a failure to rescue. 4
Getting Started Kit: Rapid Response Teams - page 5
100,000 Lives Campaign How-to Guide: Rapid Response Teams Clinical Instability Prior to Arrest Several studies indicate that patients often exhibit signs and symptoms of physiological instability for some period of time prior to a cardiac arrest: 70% (45/64) of patients show evidence of respiratory deterioration within 8 hours of arrest Schein RM, Hazday N, Pena M, et al. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest. 1990;98:1388-1392. 66% (99/150) of patients show abnormal signs and symptoms within 6 hours of arrest and MD is notified in 25% (25/99) of cases Franklin C, Mathew J. Developing strategies to prevent in hospital cardiac arrest: analyzing responses of physicians and nurses in the hours before the event. Crit Care Med. 1994;22(2):244- 247. Franklin’s article identified several warning signs present within six hours of arrest: MAP <70, >130 mmHg Heart rate <45, >125 per minute Respiratory rate <10, >30 per minute Chest pain Altered mental status 5
Getting Started Kit: Rapid Response Teams - page 6
100,000 Lives Campaign How-to Guide: Rapid Response Teams What Difference Can a Rapid Response Team Make? What difference can it make? Before After No of cardiac arrests Deaths from cardiac arrest No of days in ICU post arrest No of days in hospital after arrest Inpatient deaths 63 37 163 1363 302 22 16 33 159 222 RRR 65% P=0.001 RRR 56% P=0.005 RRR 80% P=0.001 RRR 88% P=0.001 RRR 26% P=0.004 Bellomo R, Goldsmith D, Uchino S, et al. A prospective before-and-after trial of a medical emergency team. Medical Journal of Australia. 2003;179(6):283-287. 50% reduction in non-ICU arrests Buist MD, Moore GE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study. BMJ. 2002;324:387-390. Reduced post-operative emergency ICU transfers (58%) and deaths (37%) Bellomo R, Goldsmith D, Uchino S, et al. Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med. 2004;32:916-921. Reduction in arrest prior to ICU transfer (4 % vs. 30 %) Goldhill DR, Worthington L, Mulcahy A, Tarling M, Sumner A. The patient-at-risk team: identifying and managing seriously ill ward patients. Anesthesia. 1999;54(9):853-860. 6
Getting Started Kit: Rapid Response Teams - page 7
100,000 Lives Campaign How-to Guide: Rapid Response Teams Sample Results Hospital Codes per 1000 Discharges Hospital Codes per 1000 Discharges (u-chart) 30.0 25.0 20.0 15.0 10.0 5.0 0.0 Rapid Response Team (RRT) implemented August 2003 Codes per 1000 Discharges UCL Average 23% decrease LCL Apr-02 Aug-02 Apr-03 Aug-03 Apr-04 Aug-04 Jan-02 Sep-02 Feb-02 Oct-02 Jul-02 Dec-02 Jun-02 Jan-03 Sep-03 Feb-03 Oct-03 Jul-03 Dec-03 Jun-03 Jan-04 May-02 Nov-02 May-03 Nov-03 This chart represents one hospital’s results after implementing a Rapid Response Team. This hospital is a 750-bed non-teaching community hospital. Their Rapid Response Team consists of a critical care nurse and respiratory therapist, with intensivist backup. They have seen a 23% decrease in their overall code rate per 1,000 discharges. H ospital Codes O Outside Hospital Codes utside ICU the ICU 40 35 Number of Codes 30 25 20 15 10 5 0 44 % decrease Rapid Response Team (RRT) implemented August 2003 Aug-04 Jul-04 Aug-03 May-04 Sep-04 Nov-03 May-03 Mar-03 Mar-04 Nov-02 Apr-03 Apr-04 Jun-03 Dec-03 Dec-02 Feb-03 Feb-04 Jun-04 Sep-03 Oct-03 Oct-02 Jan-03 Jan-04 Oct-04 Jul-03 May-04 (u-chart) Sep-04 Feb-04 Mar-04 Jun-04 Mar-02 Mar-03 Oct-04 Jul-04 7
Getting Started Kit: Rapid Response Teams - page 8
100,000 Lives Campaign How-to Guide: Rapid Response Teams The same organization observed a 44% decrease in the codes occurring outside their ICU. Their hypothesis: Patients were being identified prior to cardiac arrest and either never coded at all or were moved to the ICU prior to their arrest. Percent of Coded Patients Percent of Coded Surviving Patients Discharge at Surviving at Discharge 40% 35% 30% 25% (p-chart) UCL Rapid Response Team (RRT) implemented August 2003 Average Percent 20% 15% 10% 5% 0% Jun-04 Aug-02 Aug-03 May-02 May-03 May-04 Mar-02 Mar-03 Mar-04 Aug-04 Nov-03 Nov-02 Apr-02 Apr-03 Apr-04 Jan-04 Jun-03 Jun-02 Feb-02 Dec-02 Feb-03 Dec-03 Feb-04 Jan-02 Sep-02 Oct-02 Jan-03 Sep-03 Oct-03 Sep-04 Oct-04 Jul-02 Jul-03 Jul-04 48 % increase LCL P A Average A This same hospital saw a 48% increase in the percentage of coded patients surviving at discharge. Once again, their hypothesis: Patients who coded did so in a monitored setting such as an ICU, thereby increasing the likelihood of their surviving. Codes per 1000 Discharges 8
Getting Started Kit: Rapid Response Teams - page 9
100,000 Lives Campaign How-to Guide: Rapid Response Teams Another organization, a smaller community non-teaching hospital with an average daily census of around 225 patients, has seen similar results in their overall reduction in codes per 1,000 discharges. What Is the Role of the Rapid Response Team? Assess Stabilize Assist with communication Educate and support Assist with transfer, if necessary The Rapid Response Team has several key roles. The team assists the staff member in assessing and stabilizing the patient’s condition and organizing information to be communicated to the patient’s physician. The Rapid Response Team member also takes on the role of educator and support to the staff. Initially, organizations may fear that the introduction of the Rapid Response Team will lessen the clinical skills of the non-ICU staff. In fact, quite the opposite appears to be true. In their role as educators, the Rapid Response Team nurses have a unique opportunity to educate the non-ICU staff at the time of the call, assembling the various pieces of clinical information and pulling the pieces of the puzzle together. If the circumstances warrant, the Rapid Response Team assists with the patient transfer to a higher level of care. 9
Getting Started Kit: Rapid Response Teams - page 10
100,000 Lives Campaign How-to Guide: Rapid Response Teams Rapid Response Team Considerations Prior to testing and implementation of a Rapid Response Team, organizations may wish to consider the following: Engage senior leadership support. Determine the best structure for the team. Provide education and training. Establish criteria and mechanism for calling the Rapid Response Team. Use a structured documentation tool. Establish feedback mechanisms. Measure effectiveness. Engage Senior Leadership Support Engage senior leadership (executive and physician) support and buy-in, i.e., “We are going to do this; this is important and the right thing to do for our patients.” Make an explicit organizational commitment to establishing the Rapid Response Team. Educate the medical staff about the benefits of Rapid Response Team and put the myths to rest. Craft a very clear and widely disseminated communication message from senior leadership. Determine the Best Structure for the Team First, who will comprise the Rapid Response Team? Our experience shows that multiple models work well, including the following: ICU RN and Respiratory Therapist (RT) ICU RN, RT, Intensivist, Resident ICU RN, RT, Intensivist or Hospitalist ICU RN, RT, Physician Assistant Select each member (physician, RN, RT) of the Rapid Response Team carefully. The physician team member should be one who is respected by both nurses and physicians and perceived as a good communicator and team player. 10
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