Collaborative model works in Knoxville RRT initiative

Competitors cooperate to achieve patient safety goal

Hospitals in the Knoxville, TN, area have joined forces in what they assert is a tremendously successful collaborative involving rapid response teams. The initiative, begun in 2005, is actually the second campaign of the Greater Knoxville Hospital Study Group (the first involved ventilator-associated pneumonia, or VAP), which in turn grew out of the local Healthcare 21 Business Coalition.

The rapid response team initiative includes Parkwest Medical Center, Fort Sanders Hospital, Methodist Medical Center, University of Tennessee (UT) Medical Center, Children's Hospital, Baptist Hospital, St. Mary's Health System, and Blount Memorial Hospital.

So far, the following results have been reported:

  • At Parkwest, the critical care unit credits the response teams for a 61% reduction in the number of cardiac and respiratory arrests. Rapid response teams were activated 201 times in the first six months and decreased the number of transfers to the critical care unit by 15%.
  • At St. Mary's, the rapid response team saved the life of one of its own nursing employees.
  • Blount Memorial successfully met its goals of a 20% reduction in overall inpatient acute care mortality, in code 99 (emergency cardiac arrest) calls, and in code 99s outside of the CCU within the first six months.

One of the most interesting aspects of the project is that facilities which normally consider each other to be competitors have readily cooperated in order to achieve a common goal.

"While on the business side, we are very competitive, on the clinical side there are deep desires to standardize care and bring the community to evidence-based practices," explains Doug Henderlight, RN, MSN, vice president of quality and continuum of care for St. Mary's. "We got together as a group of clinicians."

The original group, consisting of directors of quality and chief medical officers, started addressing VAP in late 2004. (The rapid response team initiative, he notes, was part of the Boston-based Institute for Healthcare Improvement's [IHI] 100,000 Lives campaign.)

When the facilities first met as a large group in one room, Henderlight recalls, "It was business as usual." However, as soon as just the clinical folks got together, "Those walls came tumbling down. We agreed what we wanted to work on was clinical care — for the good of the community."

Collaborating with competitors is "good in two completely opposite ways," adds Marie X. Fox, RN, MSN, director of quality management at Blount Memorial. "First, there is still that little bit of competition which says, 'I can do it just a little better than you.' I can look at the aggregate numbers and compare our performance."

The other part of the equation, she continues, is a sense of support for each other. "This is the complete opposite," she notes. "We all ask each other how we are doing and what is working. We share ideas rather than reinvent the wheel."

"We have regular meetings at one another's facilities, celebrating successes," notes Henderlight. "We've built relationships, established contact people, so we have others we can call on for a fresh 'set of eyes' or another opinion."

"We've been able to share successes and failures as we moved forward and implemented these concepts in all hospitals," adds Jack Lacey, MD, chief medical officer for the UT Medical Center and co-chair of the Greater Knoxville Area Hospital Study Group.

"Even though we are competitors, we each recognize that the others are fine hospitals and have the same goals — high-quality care and exceeding patients' expectations," he continues. "However, there are some areas where we do not compete, and patient safety is one of them. We've said to each other that we might find ourselves or a loved one in a competitor's hospital, and we want them to be safe, so common ground was not hard to establish."

While using the guidelines of the IHI to establish their rapid response teams, each facility adapted the model to its own realities.

"We implemented the IHI rapid response team concept in a way that was specific and appropriate to the needs of the individual organization," says Henderlight. "Most teams were composed of a critical respiratory therapist and a critical care nurse, but a teaching hospital might choose to substitute an internal medicine resident."

St. Mary's uses the first model. "We set up our own criteria; the basic goal is that when patients are not 'looking well' and the nurses on the unit have difficulty putting their finger on what the problem is, they can call for a second set of eyes and ears to do an assessment and discuss the case as a group of professional practitioners," says Henderlight. "This way, they can get a plan together to avoid tragedy."

"Anyone" can call the team, he says, including nurses' assistants. The team is called using a pager system, but it is backed up by an overhead page.

"Our team is a critical care nurse, a respiratory therapist, and a house supervisor," says Fox. "The rapid response team is called via overhead page, but team members also have beepers.

"Part of our primary focus with this was to be as consistent as possible," she explains, "So everyone calls rapid response the same way they call a code 99. This way, if I'm an agency nurse and I'm at Parkwest or Blount, I know what the call is. We're hoping the same goes for doctors, too."

At UT, an academic hospital, things are a bit different. "Since we are a teaching hospital, we have residents and students — and the residents thought they were the rapid response team," Lacey recalls. "We do have docs here 24/7 — we have a strong hospitalist program as well as trauma surgeons — but in truth, we know the residents are sometimes in surgery or in the ED, and we expect a response to a call within five minutes."

This clearly cannot always be done, although the resident and the attending are notified of the patient's change in status — that is, that a rapid response team alert has gone out. The team itself includes a critical care nurse and a respiratory therapist, backed up by one of the critical care physicians.

Fox says the rapid response team initiative at her facility, which started August 2005, has been "unbelievable, amazing, better than I could have believed possible."

One of the aspects of the project that has most impressed her has been the physicians' response. "You can very easily anticipate some resistance a physician might feel towarda something like this, and we really worked at identifying what the barriers might be and removing as many obstacles as we could," she says. "We had [physician] champions almost immediately, and nearly everyone else bought in." Any physicians that might have had some residual reluctance, she notes, "didn't after their first patient."

Lacey adds that one of the most important lessons he has learned is how vital it is to get physicians on board. "From the very beginning, physicians must be very much a part of defining what the system will be and how it will work and should be in a leadership role in implementing it."

Lacey, too, says the rapid response teams at UT have been "very effective." While they are very early in the data-gathering stage, he says that "The trends in our data show a decline in total codes, a shift in codes from the acute care areas to the ICU, and I believe we are also beginning to see a trend in the reduction of mortality."

Henderlight says the initiative at St. Mary's has been "very successful; we've had a number of calls [at least one a month]." The most memorable, perhaps, involved a night shift employee (a nursing assistant), who was found by a co-worker to be very ill. "They called the rapid response team and got her to the cardiac cath lab and then to surgery and avoided a heart attack," he says.

Lacey notes that the collaborative has had two additional benefits beyond patient safety. "We believe we have supplied an excellent support framework for new graduate nurses who may not have the experience of more seasoned nurses; this gives them a place to turn, an opportunity to reflect thoughts off a more experienced nursing team. I'm not sure there is an easier way to do this."

In addition, he says, it helps get nurses to focus on early recognition of a window of opportunity when patient status is changing — just by educating them to be on the alert and looking for changes in BP, pulse rate, and so forth. "Education does not hard-wire this into your system; the rapid response team does," he asserts.