Can you demonstrate how your rapid response team has impacted care?

Use the right measures to get meaningful data

Is your organization's rapid response team getting enough calls? Are the calls coming early enough to make a difference? Are outcomes such as mortality rates improving?

To date, 1,770 hospitals have implemented or intend to implement rapid response teams, as recommended by the Institute for Healthcare Improvement's (IHI) 100,000 Lives Campaign. Improving the response to changes in patients' conditions using a designated response team also is one of the Joint Commission's proposed 2007 National Patient Safety Goals.

But what impact are these teams actually having on patient care and outcomes? It's the quality professional's job to find out and share this information with senior leaders on an ongoing basis.

Two things are essential: A clearly stated goal and a measurement strategy. "The importance of monitoring and tracking is to understand how well the team is doing," says John Whittington, MD, director of knowledge management/patient safety officer at OSF Healthcare System in Peoria, IL. "Without monitoring and tracking, you will not know if your team is effective."

At Southern Maryland Hospital Center in Clinton, a rapid response team is being implemented for stroke patients. Data are being collected in real time for response times and patient outcomes, says Vivian Miller, director of risk management and patient safety officer.

For the first quarter of 2006, approximately 60 cases were reviewed by the stroke team coordinator, who also collects and analyzes the data. The analyzed data are then presented to the stroke team and the stroke committee for evaluation and further action as appropriate.

Process changes are discussed at the team level, which includes staff from the intensive care unit (ICU), the emergency department (ED), the telemetry units, case management, and the rehabilitation therapy department. Adherence to the established care pathways and guidelines is discussed by the stroke committee, comprised of medical staff including neurologists, internists, rehabilitative medicine, interventional radiologists, and emergency physicians. The committee is facilitated by the director of accreditation and standards, with performance improvement participation.

"Unless you have medical staff involvement, you can't really assess what you are seeing," says Miller.

Your objective is to determine how well the rapid response team process is working, says Kathy Haig, director of quality resource management at OSF St. Joseph Medical Center in Bloomington, IL. "The intent of the rapid response team is for early recognition of a deteriorating or changing condition so that early treatment can be initiated to prevent a code and possibly a transfer to a higher level of care, or a downhill cascade of a worsening condition that could result in mortality," she says.

As a result of the Medical Emergency Team (MET) implemented at Tallahassee (FL) Memorial Hospital, several patients have been given medications, had oxygen changes, or gotten respiratory treatments that improved their status and reversed a downward decline. "We have seen a shift from the 'just about to code' type of call to being notified of early, subtle changes, such as the very early stages of septic shock," says Cathy Pfeil, RN, BSN, CCRN, director of critical care nursing.

In one case, the MET team was called because a patient had a very high heart rate, and they found that the patient had gone into a cardiac arrhythmia, which affected her blood pressure and oxygen saturation. The respiratory therapist changed the oxygen so the patient could breathe more easily, and the ICU nurse and physician started medication to bring the heart rate down.

"The medication is usually given in an area with cardiac monitors, but there were no available beds, so they treated the patient in her room," says Pfeil. "After an hour, the heart rate was down and the patient got moved to an ICU. Without the intervention, she probably would have arrested."

Share data with leaders

At OSF St. Joseph, measures include the number of calls per month, codes outside the ICU/ED/OR/cath lab setting, total codes, and codes per 1,000 discharges. "We show a cumulative mortality value each month for the fiscal year, raw mortality, and mortality year to date and/or a 12-month rolling mortality rate," says Haig.

The code data are obtained from the hospital's switchboard operators, who log all types of codes, warnings, and alerts. Mortality data are obtained from an internal database and stored on a spreadsheet used to report progress on multiple safety and quality indictors, known as the "quality and safety dashboard." The same data are used to provide year-to-date or rolling mortality rates.

The rapid response team and the team that reviews codes get this information, and management posts the dashboard for front-line staff and reviews findings at department meetings.

The information also is shared with the medical staff at the department quality and medical executive meetings and with the quality management council, which oversees all performance improvement activity, and is reported on monthly and quarterly reports at the system level and on corporate board reports.

At Sibley Memorial Hospital in Washington, DC, rapid response team data are collected by running a report from the computerized medical record, which lists all patients who have had a rapid response team intervention. The report gives the patient name, identification number, and date and time of event.

"We then go to the medical record for further information," says Deborah McDonough, manager of the patient safety and quality department. "We look for transfers to higher levels of care and final patient outcomes."

Currently, staff in the patient safety and quality department run this report at the end of each quarter and complete chart review to gather additional information. The organization's team consists of an ICU nurse, a respiratory therapist, and the intensivist or hospitalist, with interventions documented by the respiratory therapist. In the future, members from the rapid response team may be involved in the record review process.

"We have discussed the benefit of the rapid response team members reviewing team performance and patient outcomes. This would serve as a team evaluation session and another way to evaluate the care provided to the patient," says McDonough.

Data on rapid response team calls are shared at the hospital's Code Blue committee. Statistics on calls are included on the hospital's clinical dashboard, and those data are reviewed at the hospital's quality council. "The data Sibley has collected on our rapid response team has assisted the team to enhance documentation of the event and outcome," McDonough says.

'Pulseless' codes are best measure

Many organizations look retrospectively at codes occurring outside the ICU to assess whether a rapid response team intervention prior to having a code called would have made a difference in patient treatment or outcome. "We are currently going back to look at our codes outside the ICU in 2005, to make this assessment," says McDonough.

Sibley initially saw an increase in rapid response team calls and a decrease in Code Blue events in the first year, but the second year of statistics has not shown a consistent trend. "Our team leaders have reviewed the data and are implementing improvements in staff education, as well as documentation," McDonough says.

For example, information on the rapid response team was added to the organization's annual education day, to serve as a reminder to all staff, both clinical and non-clinical, that the rapid response team is available and on call 24 hours a day, seven days a week.

Also, patient assessment triggers were added to the report completed with each call, to assist staff in making the decision to call the team, and the form is now stored on the unit's code carts for quick access.

At Tallahassee Memorial, several processes are measured for the organization's MET team. "Our main measure is our code rate," says Pfeil. "Since we had historical data for all codes, as well as floor versus ICU codes, this was ready-made to continue to use as an effectiveness marker."

Response time, length of calls, where the calls came from, reasons for the call, interventions provided, and patient disposition are tracked, with nursing managers given copies of the calls made by their units. "This has helped us look at where to devote resources and served as an early warning system for problems," says Pfeil. "Some of the calls have led to inservices and staffing changes."

For example, there were three calls from the same nursing unit for nonacute problems, all on the same shift. "Everything turned out well, but when the nurse manager was notified, she realized she needed to ensure more experienced staff were scheduled, to help the less experienced staff manage patients better," says Pfeil.

Carbons of code sheets are collected, and the hospital operator tracks code calls throughout the day, allowing quality managers to pull charts to look at outcomes and relevant factors as needed.

"All of our MET data is reported to our oversight committee periodically, as well as the hospital safety and process improvement committees," says Pfeil. "We have quite a few senior leaders in these groups, so they stay up to date on our results."

To assess the impact of your organization's rapid response team, the IHI recommends using three key measures: codes per 1,000 discharges, codes outside the ICU, and utilization of the team. Additional measures include post-cardiac arrest ICU bed utilization, staff satisfaction with the team, and the percentage of coded patients surviving at discharge.

However, if you only measure codes that occur outside the ICU, you may not be getting meaningful data, says Whittington. "If that is all you measure, you are just moving a group of patients from one bucket to the other. You may think you are making a big difference because you are having fewer codes in the organization, but it may not be giving you a true representation."

A better measure is "pulseless" codes occurring outside the ICU, so you can determine if the number of times cardiopulmonary resuscitation was required for patients is decreasing.

"If you can decrease pulseless codes, that is a harder outcome measure," says Whittington. "If that rate has dramatically decreased, you are getting closer to a true outcome measure."

Measurement of "pulseless" codes provides a more accurate reflection in the reduction of codes that could result in death, explains Haig.

To get meaningful data from mortality rates, it's necessary to measure the data over a long period of time. Even if mortality rates do decrease, that doesn't necessarily mean that the rapid response team is making the difference. "You might have added a new service line and your acuity is rising, so mortality is going up," says Whittington. For this reason, he recommends using risk-adjusted mortality measures instead of raw mortality rates.

If your hospital has an average daily census of 100 patients, you can expect to get 10 rapid response team calls for that month, according to the IHI. "This is a ballpark number we are using for the number of calls the team should be getting," says Whittington.

If you are averaging less than that, you might want to review the mortalities for the month, cases transferred to a higher level of care, or records of patients coding to determine if there was a failure to identify, communicate, or treat a deteriorating or worrisome condition in the 24 hours prior to the code, recommends Haig.

"You can also compare your rapid response team criteria with the patient's condition in the 24 hours prior to the code or time of death, to see if there was a missed opportunity for a call," she says.

At OSF St. Joseph, a test was conducted using a certain severity score based on vital signs and severe infection criteria as a trigger for an automatic call to the team.

"After a few months of testing this process, we found there were too many unwarranted calls using this severity score as a trigger," says Haig. "To avoid the 'crying wolf' reaction to calls and to be conscious of the team members' time, the trigger for automatic calls was discontinued."

A defined severity score now triggers a patient assessment by two nurses to determine if a call is warranted.

If the number of calls is less than what it should be, this could be because staff are reluctant to call the team. The IHI recommends that specific criteria be established, such as acute changes in heart rate, systolic blood pressure, respiratory rate, saturation, consciousness, urinary output, or simply that the staff member is worried about the patient.

When managers at OSF St. Joseph analyzed rapid response team cases, they saw that support service departments such as respiratory therapy sometimes were reluctant to make the call, adds Haig.

"By reviewing cases, we found that some departments hesitated, thinking they were 'stepping over the line' and that this was a nursing responsibility and that nursing would be offended," says Haig. "We explained that we were all here for one purpose — the patient — and anyone can call the team."

With the exception of cardiac arrest when a patient's heart has stopped or the patient is not breathing, there is usually nothing that forces staff to call the team. "You need to have trained nurses who feel comfortable calling the team and members willing to come help," says Whittington. "Constant education is needed to reinforce this point."

[For more information, contact:

Kathy Haig, Director, Quality/Risk Management/Patient Safety Officer, OSF St. Joseph Medical Center, 2200 E. Washington Street, Bloomington, IL 61701. Telephone: (309) 662-3311, ext. 1347. E-mail: Kathy.M.Haig@osfhealthcare.org.

Deborah McDonough, Manager, Patient Safety & Quality, Sibley Memorial Hospital, 5255 Loughboro Road NW, Washington, DC 20016. Telephone: (202) 537-4643. E-mail: dmcdonough@sibley.org.

Vivian Miller, Director of Risk Management and Patient Safety Officer, Southern Maryland Hospital Center, 7503 Surratts Rd., Clinton, MD 20735. Telephone: (301) 877-5535. E-mail: vivianmiller@southernmarylandhospital.com.

Cathy Pfeil, RN, BSN, CCRN, Director of Critical Care Nursing, Tallahassee Memorial Hospital, 1300 Miccosukee Drive, Tallahassee, FL 32308. Telephone: (850) 431-5034. E-mail: catherine.pfeil@tmh.org.

John Whittington, MD, Director of Knowledge Management/Patient Safety Officer, OSF Healthcare System, 800 N.E. Glen Oak Ave., Peoria, IL 61603. Telephone: (309) 655 4846. E-mail: John.W.Whittington@osfhealthcare.org.]