Improve impact of rapid response with these steps

Effective teams help 'every patient in the building'

When it comes to implementation of rapid response teams, organizations fall into three distinct groups, says Kathy Duncan, RN, the Institute for Healthcare Improvement's faculty expert for the rapid response intervention. Here are her tips for each stage:

Organizations that have not started at all

"I think there is a huge audience out there that just hasn't been exposed at all to this concept. There are people who, for whatever reason, are just not going there," says Duncan. "They have decided they're good enough, and they really don't have any indication that they are going to do anything in the near future."

Duncan challenges these organizations to look at the last 20 codes in their building and do an objective review. "Did you miss an opportunity to rescue this patient? Did you fail some sort of communication piece? Or did some other process fail?" she asks. "Every time someone does that exercise, what they find out is that they are not as good as they think they are."

Organizations that are still early in the process

"They have figured out this is a good thing, and are trying to get started — but they're still fumbling with some of the operational pieces," says Duncan. If this describes your organization, have a small group of people meet, ideally front-line staff from medical/surgical or critical care areas.

"They can work out details such as how to activate the team, and how to educate people so that it means something to them and is not just a poster on the wall," says Duncan. "People care what happened on the floor last night, so use examples from your own hospital."

Work on encouraging phone calls to the team by building a trustworthy system, so staff know that not only is someone going to come, they are going to come with a smile on their face. "The team has to break up those old myths we have in the hospital," says Duncan, about being reluctant to give staff "extra" work. "If I have an inkling of something going wrong, I can call one number and get three or four of my colleagues to help me take care of that patient."

Weekly meetings for 30 minutes are best, says Duncan — not to go through piles of data, but to look at what went well during the previous week and what didn't, and how problems can be fixed for the following week.

Organizations that are further along in the process

For the rapid response system to be reliable, it must work 100% of the time, says Duncan. When it does, the next step is to learn what the calls to the team really mean.

"Our STAT team has looked continually at the number of codes outside of the [intensive care unit]," says Kim Barnhardt, RN, performance improvement specialist at Carolinas Medical Center–Northeast in Concord, NC. "This has really been our target. We have decreased our codes per 1,000 discharges by about 60-65%."

Quality professionals review the codes to see what is being missed, and are considering doing a root cause analysis on each code outside the ICU, says Barnhardt. "We want the culture here to know that it is a very big deal when we have an arrest," she says.

To be more proactive, a new process has been implemented, with the ICU charge nurse, who is also the STAT team leader, asking every charge nurse at the "bed huddles" that occur at 9 a.m, 4 p.m., and 3 a.m., "Who are your sickest patients, and what are your concerns?"

"This has not been going on very long, so we are really just starting to see if it is making the impact we were hoping for," says Barnhardt. "We have re-structured the steering committee for this and changed leadership in the director role."

The hope is that this will bring a new perspective and insight to the STAT team, says Barnhardt. "Future plans are to have the team leaders out rounding in units each shift, and maybe even have a designated team of responders that are not in direct care in the ICU," she says.

This would allow the STAT team to evaluate the patient early, and keep in contact with the patient's primary nurse throughout the day, to get a baseline picture of what the patients of concern look like.

"Eventually, we would like to delve into the transfers into the ICU as well," says Barnhardt. "We feel that if someone is sick enough to transfer to the ICU, that the nurses should have called for a STAT response before calling and asking for a bed."

Once operational issues are working like clockwork, trends may become apparent, such as many calls for respiratory issues. Duncan recommends picking one area at a time and working on it for several months. Put every call in "buckets" — such as "Failure to Communicate," "Failure to Recognize," or "Failure to Plan." Then begin to work on them as if they are system failures.

"One of the things that pops out a lot of the time is patient respirations are shallow after being sedated after surgery, so the team is called and they give a reversal agent," says Duncan. "If you have several of those, start trending the numbers and ask, 'How do we put a process in place so we don't over-sedate people in the first place?'"

Patient-controlled analgesia pumps or protocols for postoperative orders may need to be changed. Or, calls may involve use of different or newer narcotics with doses not as understood, such as when an internal medicine provider is ordering pain medications, which may need to be brought up with the medical executive committee.

Only a few hospitals are at an advanced stage with rapid response teams. "They don't just have a team and check it off the list and say they are done with that," says Duncan. "They are focused on every missed opportunity in their building. They have gotten codes way down to single digit numbers, and may go a month or two without a code at all."

These organizations look at every unscheduled trip to the ICU as a missed opportunity to rescue that patient. "These hospitals are really looking at it through different colored glasses, saying they want to focus on every failure," says Duncan. "They know that 99 times out of 100 it's not a person failure, it's a process failure. They drill down to fix that process failure, so they can guarantee their patients, 'If you start failing, we are going to recognize it and do something about it.'"

The ultimate goal of implementing a rapid response team is that five or six years from now, you will have corrected on system failures so that patients "never have to go down that trail," says Duncan. "Or, if they start deteriorating, you notice it in 10 minutes instead of five hours," she says. "You are not just helping that handful of patients, you are helping every patient in your building."

[For more information, contact:

Kim Barnhardt, RN, PI Specialist, Carolinas Medical Center-Northeast, 920 Church Street North, Concord, NC 28025. Phone: (704) 783-3232. E-mail: kbarnhardt@northeastmedical.org.

Kathy Duncan, Faculty Expert, Rapid Response Teams, Institute for Healthcare Improvement, 20 University Road, 7th Floor, Cambridge, MA 02138. Phone: (617) 301-4800. Fax: (617) 301-4848. E-mail: kathydduncan@comcast.net.]