Rapid response teams can help reduce mortality, 'code' rates
Rapid response teams can help reduce mortality, 'code' rates
IHI says as many as 1,600 facilities have signed up for campaign
Rapid response teams, one of the six initiatives in the Boston, MA-based Institute for Healthcare Management's (IHI) "100,000 Lives" campaign, have proven to be a valuable tool for quality managers looking for new strategies to get mortality rates under control. Consider the following:
• Since implementing rapid response teams, Seton Healthcare Network in Austin, TX, has seen its mortality rates drop 60%. This is not entirely attributable to the teams, notes Alice Davis, RN, BSN, senior project coordinator, medical staff services, noting that other initiatives are underway, but she adds that nonetheless the rapid response teams played a big role in the reduction.
• At Missouri Baptist Hospital in St. Louis, MO, the total number of "codes" has dropped about 28% since the program was implemented.
"My observation is that it usually takes a little while to see a drop in mortality, but it seems to drop at about six months or so," notes Kathy Duncan, RN, the point person for the IHI's Rapid Response Team Intervention. "Several hospitals I know of say they've seen about a 10% drop in mortality. Some who have more mature programs and have gone through the process for years — and who also have other initiatives — are seeing upwards of 22%-23%."
"You can achieve great things when leadership sets the stage and you engage the right clinical people to plan and implement [the initiative]," adds Davis.
What is a rapid response team?
The forerunners of rapid response teams were developed in Australia, says Joe McCannon, IHI's campaign manager for "100,000 Lives." "They were called medical emergency teams and were introduced there as a way to respond more pre-emptively to patient distress," he says.
In many hospitals, he continues, staff have to wait for a catastrophic cardiac or respiratory event to take action. "This is a way to get to people further upstream, to detect signs of deterioration earlier to help save lives," McCannon explains. "It's about solving the problem of failure to rescue."
There is no hard and fast model for how the team is to be comprised, he says. "There are all different shapes and sizes, as there are all different kinds of hospitals — rural hospitals, teaching hospitals, and so forth," McCannon notes. "We welcome that as part of the improvement process."
There are, however, criteria, which are provided in a "how-to' guide on the 100,000 Lives campaign web site (www.ihi.org/IHI/Programs/Campaign/), he says.
"For example, you need to raise awareness about what rapid response teams are and be sure people know who to call and when," he points out.
As for who should be on the team, "It's a decision that has to be made as a function of the resources available, and of what other facilities have done," McCannon continues. "The web site includes names of mentor hospitals that are willing to share their experiences."
There are also web discussions for each of the interventions, says Duncan, who helps manage the rapid response team segments. "Right now there are 55 'threads' of questions," she says. "Hospitals who are part of the campaign can e-mail random questions, ask their peers, and it is my responsibility to guide them and help them." Duncan also helps with recruiting mentor hospitals, or finding other colleagues to discuss issues.
Duncan is also struck by the diversity of programs hospitals have developed. "Hospitals range from 10 beds to 1,000," she notes. "What's exciting to me is to see the different hospitals implement rapid response teams in 100 different ways."
Having worked in a large hospital, Duncan says her experience is that the key members "seem to be a critical care nurse, a respiratory therapist (about 50% of all calls are respiratory in nature) and a physician, if you have that availability." The team size, she notes, "Can go from one person to seven or eight."
As to who can call the team, this varies as well. For example, at Missouri Baptist anyone can call the team to consult on a patient. Calls come primarily from floor nurses, based on specific symptoms they observe or simply on a gut feeling that the patient may be headed for trouble. As a guide for staff, the team issued the following "trigger" list:
- staff member is worried about the patient;
- acute change in heart rate;
- acute change in systolic BP;
- acute change in respiratory rate;
- acute change in O2 saturation;
- acute change in level of consciousness.
Duncan says there is even variety in how the teams are called. "People use overhead pages, and beepers are also very common," she says. "Some hospitals use Nextel walkie-talkie phones, others use systems like Vocera." Whatever you use, says Duncan, "It must be easy, and it should involve only one number, so you get the team there quickly."
She also agrees with Missouri Baptist's approach concerning who may call. "Anybody who is worried about a patient should be able to call," she says.
Duncan says some people exaggerate the potential danger of someone who is not medically trained calling when they shouldn't. "I used to be very cynical about that, but it really doesn't seem to happen," she says. "When you expand outside nursing, I encourage people to put the criteria in their language; for example, when teaching radiology about the availability of the team, tell them if they are worried about a patient they can call."
If you educate non-clinical staff and lower the bar to call, calls will go up, says Duncan, "And that's a good thing; there is a greater opportunity to rescue more people." So for example, someone in radiology may see that the patient can't lie flat on the table because of shortness of breath. "Or, maybe they are scared because their lips are gray," she offers."
Several keys to success
What makes a successful rapid response team? "Like any change in process improvement, it is critical to have senior leadership endorsement," says McCannon. "Spend some time raising awareness, and some time educating people about it — but you have to make a commitment to get started on it, instead of planning indefinitely. I do not mean to sound reckless, but you need to just start. As you progress, you learn and make adjustments from there."
Your process, for example, might start with a pilot unit, during which you can work out who needs be on the team, how they are to be called, and so forth. Davis says she has seen the process spread through nursing units and then to radiology, physical therapy, and even the cafeteria and gift shop. "At each step, you educate people about warning signs and who to call if you have a concern," she explains.
"To me, the key is a culture of really trying to rescue that patient beforehand," says Duncan. "I have been a nurse for 25 years, and everybody who works in a hospital — whether they touch a patient or not — most likely first came to work to try to help people. You can help them do that by putting this process in place and educating them as to what warning signs might be indicative of a bad event — like a drastic drop in blood pressure or a change in their heart rate, which may a be key signal that something may happen later. If you give them the tools to implement the process, they will do it about 100% of the time — and they'll feel valued for what they've done, so they'll do it again and again."
For hospitals not yet involved in the campaign, Duncan says enrollment is easy — and free. "Just go to the IHI web site and fill out the form, which is mainly demographics," she says. Hospitals are also asked to submit mortality data to serve as a baseline for later comparisons. IHI provides all teaching and learning exercises free of charge. "Our purpose is to improve care and keep people from dying in their hospitals," Duncan explains.
How many hospitals have signed up? "We have 3,069 hospitals signed onto [the 100,000 Lives] campaign, which represents about 75% of the acute care discharges in the country," Duncan says. "We ask them to sign up for at least one of the six initiatives — and 60% of them [approximately 1,600 hospitals] have signed up for a commitment to start rapid response teams before June 14 — our big milestone for the campaign."
For more information, contact:
Kathy Duncan, RN, Institute for Healthcare Improvement, 20 University Road, 7th Floor, Cambridge, MA 02138 USA. Phone: (870) 739-3193.
Joe McCannon, Institute for Healthcare Improvement, 20 University Road, 7th Floor, Cambridge, MA 02138 USA. Phone: (617) 301-4836.
Alice Davis, RN, BSN, Senior Project Coordinator, Medical Staff Services, Seton Healthcare Network, Austin, TX. Phone: (512) 324-1000, ext. 7323.
Rapid response teams, one of the six initiatives in the Boston, MA-based Institute for Healthcare Management's (IHI) "100,000 Lives" campaign, have proven to be a valuable tool for quality managers looking for new strategies to get mortality rates under control.Subscribe Now for Access
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