Rapid response teams prove value for safety of your patients

Latest research suggests need for more implementation

The evidence proving the value of rapid response teams (RRTs) continues to accumulate, with the latest research suggesting that this strategy can improve patient safety in a variety of clinical settings. Proponents of RRTs say risk managers may be missing an opportunity to improve outcomes if you are not using RRTs or formulating a plan to institute them in your own facilities.

Paul Sharek, MD, chief clinical patient safety officer at Lucile Packard Children's Hospital in Stanford, CA, says the benefits from RRTs have been confirmed by the experience of many hospitals that were on the leading edge of this movement. Sharek and his colleagues at the hospital and the Stanford (CA) University School of Medicine recently published the latest research that confirms the value of RRTs.1 In their case, the report showed significant benefits in a pediatric setting, complementing previous work that showed RRTs can be effective in adult populations.

The finding is the first to reveal lower death rates and cardiopulmonary arrest rates resulting from rapid response teams in a pediatric setting and could spark similar programs in children's hospitals around the country.

Sharek, who also is an assistant professor of pediatrics at the medical school, estimated that 33 lives — equivalent to an 18% reduction in the monthly mortality rate — were saved during the 19-month study period by RRTs, trained to provide supportive care before a child's clinical condition becomes life-threatening.

"We previously had evidence that RRTs could be effective in an adult population," he says. "Now with this report, we have evidence that they should be implemented in hospitals that take care of children. The benefits are very clear."

So does this mean every hospital should have an RRT now? Sharek says the evidence suggests the answer is yes, at least in terms of the potential benefits. The practicalities of implementing them, such as the costs involved with extra staffing, still have to be considered.

Good results in pediatric setting

Packard Children's hospital first considered establishing a rapid response team in December 2004 when the Institute for Healthcare Improve-ment recommended RRTs for adult U.S. patients as part of its 100,000 Lives Campaign. At the time, rapid response teams had been shown to be effective in adult care settings.

Packard Children's implemented the RRT program in 2005 to reduce the frequency of emergency codes occurring in children who are hospitalized but outside the intensive care unit. Although the most unstable children are kept in the intensive care unit, many young patients in non-ICU settings are very ill and can worsen rapidly.

"Once a child codes, the odds of long-term survival are pretty small," Sharek says. "However, there's often a period of about six to eight hours when a child who might later code begins to show subtle signs of distress. If we can intervene early in this process, the child is far more likely to improve than if we simply monitor and maintain the same approach to treatment."

Rapid response teams, made up of existing staff members, consist of a pediatric intensive care physician, an intensive care nurse, an intensive care respiratory therapist and a nursing supervisor. The teams, which are present at the hospital 24 hours a day, seven days a week, arrive at a child's bedside within five minutes after a summons to assess his or her condition. Interventions in addition to the medical management already under way include providing additional respiratory support, administering additional or different intravenous fluids or transferring the child to the intensive care unit for ongoing monitoring and more intensive therapy.

Nurses empowered to act

The researchers found that although many RRT calls were triggered by measurable changes in a patient's status — a change in breathing pattern, blood oxygen content or blood pressure — some occurred simply because the child's medical caretaker or parent felt that something just wasn't right.

"We empower the nursing staff to act on their expertise by calling for RRT involvement when they are concerned about a child's worsening clinical situation," Sharek says.

Aggressively empowering, and then supporting, the nursing staff may be one reason the RRT effort was so successful at Packard Children's, Sharek says. The researchers hypothesize that nurses at Packard Children's involved the RRT earlier in the time course of the child's deterioration than those at other pediatric institutions that have recently implemented RRTs. The fact that Packard Children's specializes in highly complex cases, which can result in a rapidly changing clinical status, may be another reason the RRT has been particularly successful at Packard Children's.

"The average level of illness at Packard Children's is substantially higher than the vast majority of other children's hospitals in North America," Sharek says. "Although the average child on our medical or surgical hospital units may not require the high nurse-to-patient ratio of the intensive care unit, he or she is still frequently quite ill."

The use of the RRT program at Packard Children's did not require any additional staffing or financial resources. The study authors added, however, that cost-effectiveness of the RRT program should be studied in more depth.

Don't stretch RRT members too thin

The way you structure an RRT can determine its effectiveness, notes Cynthia Musetti, RN, CPHQ, system director of quality management administration at New York Hospital Queens, which has seen good results from its own RRT program. The RRT was implemented in February 2006, first on two units and then adding additional units every couple of months until the whole hospital was covered by February 2007. As the RRT program grew, Musetti and Elyse Goldberg, RN, the hospital's RRT coordinator, realized that nurses assigned to the RRT were being pulled in too many directions because they had regular patient care duties that had to be put on hold when the RRT was called.

"So we went to administration and we asked for help. We were given two dedicated nurses, new staff positions, that are dedicated solely to the RRT," Musetti says. "That made a real difference in keeping the RRT effective without taking away from other patient care."

The dedicated staff can stay with the patient much longer than nurses who must return to their regular patients soon, Goldberg says. The average time spent with patients by RRT nurses at New York Hospital Queens is about 75 minutes, which Goldberg says is at least three times longer than the average time spent when nurses must return to other patients.

RRT calls now average about 65 a month, she reports. The dedicated RRT nurses stay busy between calls by rounding on units to see if nurses need any special attention for patients and by providing ongoing education about assessment and critical care skills, she says.

The RRT members also use the surgery department's simulation lab to run RRT drills in which the team responds as if on a real call, with the response videotaped and critiqued afterward.

Go with your gut

Sharek agrees that exactly how RRTs are used can have a big impact on how effective they are. For instance, he says gut feelings can save lives. Deploying the hospital's RRTs proactively at the first inkling of trouble in hospitalized children, rather than taking the standard course of cautiously watching and waiting, can significantly reduce death rates, Sharek and his colleagues found.

Even in the hospital, sick children can deteriorate so quickly," Sharek says. "They don't have the energy reserves or muscle mass that most adult patients have."

Sharek notes that the researchers considered whether the additional staff education that came with implementing the RRT program could explain the improvement in patient safety. As part of the program, clinical staff received training on how to spot a patient in decline, when to call for help from the RRT, and related issues.

"The literature is littered with studies showing that education alone doesn't result in this kind of improvement," he says. "Without the actual structure of having a team to call, we don't believe the education is enough to make sure the deterioration phase is aborted."

Reference

1. Sharek PJ, Parast LM, Leong K, et al. Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a children's hospital. JAMA 2007; 298:2,267-2,274.

Sources

For more information about rapid response teams, contact:

  • Elyse Goldberg, RN, Rapid Response Team Coordinator, New York Hospital Queens, Flushing, NY. Telephone: (718) 670-1231.
  • Cynthia Musetti, RN, CPHQ, System Director of Quality Management Administration, New York Hospital Queens, Flushing, NY. Telephone: (718) 670-1231. E-mail: clmusett@nyp.org.
  • Paul Sharek, MD, Chief Clinical Patient Safety Officer, Lucile Packard Children's Hospital, Palo Alto, CA. Telephone: (650) 736-0629. E-mail: psharek@lpch.org.