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System shows diversity in rapid response teams
Facilities find ways to make the approach work
The implementation of rapid response teams in seven different facilities in the Seton Healthcare Network in Austin, TX, is a virtual "living laboratory" of the many different ways hospitals can create and implement rapid response teams — and they all seem to be working, says Alice Davis, RN, BSN, senior project coordinator, medical staff services.
"Seeing seven different facilities do this — with all of them staffed differently, with each facility unique — and seeing it work everywhere — that's the thing that amazes me," she says.
In fact, the teams seem to touch both ends of the spectrum. For example, Davis notes, the first teams started in early 2004 at Brackenridge Hospital, a 150- to 200-bed facility. "They have a residency program and are a city/county trauma center, and they literally flipped it out there," she recalls. "It was not a methodical approach at all; they thought it was a great idea, they talked to the critical care nurses, sent out fliers, gave everyone the number to call, and started it up."
The team has worked well, Davis reports. Yet at Seton Medical Center, which is the largest of the facilities with about 400 beds, the approach was very methodical. "We took it to a committee, formed the team, had great representation, really deliberated a lot to try to identify all the various pitfalls that might occur, and rolled it out one unit at a time starting in July 2004," she says. In preparation, they used flow diagrams, created different scenarios that might warrant a rapid response team call, and educated every nurse on every unit. All units were rolled out by November 2004, "and it's become so firmly entrenched that the people just love it," Davis recalls.
Davis and her colleagues heard about the rapid response team concept from another hospital within Seton's national network and reviewed the early literature. "Our medical director came back from an off-site visit and shared that this was an initiative that would definitely be beneficial," Davis recalls. Later that same year, they joined the Institute for Healthcare Improvement's 100,000 Lives Campaign and subsequently "sequenced" each of the 100,000 Lives initiatives to assure every site had implemented each of the six strategies for improvement. "This strong message from our leadership, as well as the timeline for implementation, helped everyone focus," she says.
Davis notes that the diversity of the seven different facilities was one of the largest implementation challenges. The hospital network is comprised of one large tertiary care facility, one city/county trauma center with a residency program, two smaller facilities with surgical services but somewhat lower acuity, one children's hospital, and two critical access hospitals.
"We quickly identified that implementation across such a wide range of facilities needed localization," she says. After identifying the importance of the concept, it was adapted to the unique population and resources available locally. "In hospitals with a critical care unit and 24/7 respiratory therapy it posed primarily a staffing challenge," she notes. In these facilities, the staff quickly identified that an earlier response to a challenged patient was important and yielded an improved outcome.
At the other end of the continuum were the critical access hospitals in small communities, and the smaller sites without critical care. "They needed to be especially creative and identify all possible responders with the critical thinking and communication skills necessary to be a rapid response team responder," Davis says.
There was some commonality, where possible. "Uniformly, if a site had critical care services, they chose the critical care nurse and the respiratory therapist," Davis shares. "We did not have any physicians on our team, so you don't get hospitalists or residents."
At one of the smaller critical care facilities, they decided to rotate in different staff in the beginning, based on who was on shift. "It might be an ED nurse, a PACU nurse, or a clinical manager, based on their particular skills," Davis says. "They quickly evolved to fill the position, which was a house supervisor, and hired someone who had critical care experience and rotated out the rest of the time," she explains.
In all cases, choosing team members always began by identifying nurses who could think critically and had good communication skills. "In sites with critical care and respiratory therapy, it was obvious that those two specialties were needed to staff the team," adds Davis.
The planning and implementation processes also varied across the range of sites. At Seton Medical Center, for example, the planning team that was formulated had representation from each area and included key physician champions. "We put articles in our medical staff newsletter and nursing monthly newsletter and informed our medical executive committee and nursing leadership team of the concept and plan," says Davis. "Our work team then identified a specific unit whose acuity was high and where, at times, we had some physician reluctance to transfer to a higher level of care."
As mentioned previously, the program was spread a unit at a time. "As we spread to each unit, we educated the nurses about the rapid response team concept and the various scenarios that would warrant calling the team," says Davis. "We eventually included areas such as endoscopy and radiology." She adds that she met very little opposition from either staff or physicians.
"We worried about meeting resistance from physicians, but they have totally appreciated having an additional skilled nurse and respiratory therapist assess and intervene on their patients and communicate clearly the patient's need," says Davis. "We also worried about communication and turf battles between the critical care responder and patient care nurse, but the rapid response team has brought increased communication and teamwork between critical and acute care. Nurses actually assemble to see what the responders think, and it's become a teaching opportunity for critical thinking skills and advanced expertise."
The nurses calling the rapid response team quickly saw it as a much needed and valuable service to summon extra help when required, adds Davis. "The responders also recognized getting to patients early would improve outcomes and reduce codes."
In all cases, she says, developing a backup plan was helpful, so if the primary responder was not available to go, there was a backup person who could be summoned.
There also is quite a bit of variation in the way the teams are called. "Some sites overhead-page, others have special pagers that responders carry, others have a dedicated phone," says Davis. The children's hospital has a pager and an elaborate system to key in the area the team is needed. Another hospital that uses the phone finds it helpful to hear about the patient's problem as they are on the way.
The average response time is between two and five minutes — far better than the established response goal of 10 minutes.
Davis says she has learned a number of lessons from this experience. "We should implement new ideas more quickly, even though our culture is to implement new programs more slowly and methodically," she asserts. "We should recognize that all physicians and staff do have improved patient outcomes at the forefront of their priorities."
The rapid response team and its implementation are evolutionary, she continues. "The first step is to assemble appropriate resources and activate them to respond to patients' needs. The second step is to assess the need for increased resources; some of our hospitals have dedicated positions to do just this and search for patients in need. The third may be to add prescriptive authority — a physician, resident, advanced practice nurse."
An important strategy, she adds, "is to evaluate the effectiveness of your team and continue to allow it to evolve to meet the need and reduce preventable mortality and complications in our patients."
For example, her staff monitors and examines all codes that occur outside of critical care. "We review these cases very quickly after the event and search for preventability in these codes," Davis says. "Were there early warning signs that were apparent before the code? Is there something that could have been done to prevent the code from occurring?"
She reports that now her team rarely finds codes that it deems to be preventable. "We measure how many CRT calls there are each month, how many codes, were those codes preventable, what was the rapid response team response time, and how long did the team spend on the unit," Davis says. "We look at the reason for the call, did they transfer to a higher level of care, what interventions did the team perform while there, and what was the outcome for the patient?"
This information is reported on a monthly basis to leadership, site safety teams, and individual units. "When our number of rapid response team calls dwindles, we re-educate and continue to promote the program," she says.