SDS Accreditation Update

Rapid response teams are not just for inpatient units

Education, support from RRTs part of patient safety culture

Rapid response teams are a strategy that relies on a team called to a patient’s bedside to investigate potential problems that might lead to a Code Blue, and this strategy is proving effective in reducing patient deaths.

Rapid response teams are one component of a total patient safety culture that the Joint Commission on Accreditation of Healthcare Organizations is considering for inclusion in the 2007 National Patient Safety Goals for hospitals.

This strategy works great for inpatients and critical care patients, but do rapid response teams apply to the outpatient surgery setting? Absolutely, according to experts interviewed by Same-Day Surgery.

"It is very important for an outpatient surgery center that is linked to a hospital to be involved with the rapid response team set up within the hospital," says Danita R. Turner, RRT, manager of the respiratory care department at Gwinnett Health System in Lawrenceville, GA. "Our medical response team [MRT] is getting more calls from outpatient departments as we’ve expanded our educational efforts and as employees are more aware of what we can do to help them," she says.

Gwinnett’s MRTs are comprised of one intensive care unit (ICU) supervisor or charge nurse and one respiratory care supervisor. The combination of these two disciplines is important because before the establishment of a MRT, when staff members asked an ICU nurse to assess a patient who appeared to show signs of distress, the nurse often would arrive to discover that the problem was respiratory and a respiratory therapist would have to be called, says Joanne M. Culvern, RN, CCRN, manager of the hospital’s ICU department. "By having both departments respond, we can make sure that no time is lost in assessing the patient," she explains.

The MRT at Gwinnett does not include a physician in the initial call because there often is no need for one, says Turner. "If we do reach the patient and we determine that a physician is needed, we call one of our hospital-based physicians," she says.

Physicians like the concept of the MRT because there is an established relationship with the ICU nurses and a high level of trust in the nurses’ ability to assess and evaluate a patient’s condition, reports Turner.

"Many times we don’t have to do much more than reassure the nurse who called that he or she is doing the right thing for the patient," points out Turner. "Our primary purpose is to be an extra pair of hands and extra experience to help the nurse who is concerned about a patient," she says. The MRT members do not take over care of the patient but they do assess the condition and recommend a course of action to address the patient’s new symptoms, Turner adds.

Size of team not important

Kathy D. Duncan, RN, a faculty member at the Institute for Health Improvement (IHI) in Cambridge, MA, and the key IHI consultant for rapid response teams, isn’t aware of a freestanding surgery center that has established a rapid response team. However, Duncan points out that the concept of rapid response is "not about the team as much as the philosophy of rescuing people earlier than a Code Blue situation."

"I’ve seen large hospitals with large rapid response teams, and I’ve seen critical access and specialty hospitals with a rapid response team’ of one person," says Duncan. A small facility does not need a large team — just a well-qualified person who is experienced in assessing critical patients and is designated as expert backup in a situation in which a nurse needs an extra pair of eyes and a second opinion, she adds. "Because situations in an outpatient surgery program may be related to respiratory distress due to anesthesia, look for someone who can handle respiratory problems," she suggests.

"I encourage outpatient surgery departments within a hospital to make sure they are included in rapid response team coverage and educate staff members about the existence of a team," says Duncan. "It is probably more critical for outpatient departments to increase staff awareness because outpatient staff members are accustomed to healthy patients and routine procedures."

A relatively healthy patient will compensate longer than a chronically ill patient, says Duncan. "This means that a healthy 50-year-old man who comes in for a hernia repair will hold his oxygen saturation level longer and will be able to maintain his respiratory rate longer, even when there is a problem, than a 60-year-old with chronic renal failure," she says.

The decline of the chronically ill person will be much slower and will be noticeable sooner than the decline of the healthy patient because the signs of the healthy patient’s decline are subtle, Duncan explains. "Once he demonstrates obvious symptoms of decline, the decline will be fast, and he will be harder to rescue," she adds.

The main benefit of a rapid response team is the increased awareness of patient safety and the emphasis on calling for assistance even when there may not be significant changes in a patient’s condition, says Duncan. "Some facilities hand out protocols that list specific parameters that indicate a need to call a rapid response team, and a few just suggest that staff members call if they think something is wrong," she says. "The most effective approach is a combination of both."

The criteria for call Gwinnett’s MRT is very broad, but it is printed on a small card that is given to all staff members at educational meetings about the MRT, says Culvern. "We have a set of triggers such as heart rate below 40, abnormally high or low blood pressure, and decreased urine output so that nurses do have some guidelines," she says. "Because every patient’s normal rate for different vital signs is different, we did not want a nurse restricted to specific numbers, so we emphasize that if the nurse has a concern, even if the patient’s condition is not changing rapidly, the MRT can be called."[Editor’s note: This card is available on-line. If you’re accessing your online account for the first time, go to www.ahcpub.com. Click on the "Activate Your Subscription" tab in the left-hand column. Then follow the easy steps under "Account Activation." If you already have an on-line subscription, to go www.ahcpub.com. Select the tab labeled "Subscriber Direct Connect to Online Newsletters. Please select an archive." Choose "Same-Day Surgery," and then click "Sign on" from the left-hand column to log in. Once you’re signed in, select "2006" and then select the April 2006 issue. For assistance, call Customer Service at (800) 688-2421.]

With the emphasis on development of a patient safety culture within accreditation organizations, strategies such as rapid response teams will provide a safe, nonpunitive way for nurses to "raise the red flag" and ask for help, says Duncan. "The key is to help the patient before the Code Blue’ must be called," she says.

Sources/Resource

For more information about rapid response teams, contact:

  • Kathy D. Duncan, RN, Faculty, Institute for Healthcare Improvement, 20 University Road, Seventh Floor, Cambridge, MA 02138. Telephone: (866) 787-0831 or (617) 301-4800. Fax: (617) 301-4848. E-mail: kdduncan@midsouth.rr.com.
  • Danita R. Turner, RRT, Manager, Respiratory Care, Gwinnett Health System, 1000 Medical Center Blvd., Lawrenceville, GA 30045. Telephone: (678) 442-2388. E-mail: drturner@ghsnet.org.

For information on rapid response team development, go to www.ihi.org, choose "topics" on left navigational bar, then click on "improvement" and "move your dot." Then choose, "improvement stories" and scroll down to stories that describe rapid response team development.