Rapid Response Team to the Rescue

Submitted by Marina E. Bitanga BSN, RN, CCRN

Tags: Ambulance cardiac Doctors EMS Follow-Ups patient patient safety Rapid Response rapid response team rapid response team benefits Rescue Rescue Team RRT RRT Nurse RRT Nursing Team treatment working together

Introduction: What Is an RRT Nurse?

Rapid response team (RRT) is a group of clinicians who provide a rapid response to hospital patients showing objective or subjective signs of clinical deterioration. By identifying these patients, adverse clinical outcomes including cardiac arrest and death maybe prevented[5]. It is based on the concept of failure to rescue, which refers to occasions in which clinicians do not act on signs of deterioration in a patient’s condition soon enough to prevent death. Several studies have established that up to 84% of patients show signs of clinical deterioration 6 to 8 hours preceding cardiac arrest. Failure to rescue can be a result of planning failures (a patient receives inadequate treatment or assessment), a breakdown in communication between staff members, or a failure to recognize early or vague signs of deterioration in the patient. Too often, nurses have gut feeling that something is not quite right with a patient but unless the patient displays definitive signs of distress or goes into cardiac arrest, the nurse has little recourse. Hospital staff nurses have long tradition of turning to each other when they’re worried about a patient. Confirming a colleague’s judgement, or offering guidance or another pair of hands, are just some of the way nurses support each other in their challenging and high-stakes jobs. The rapid response teams can help the nurses way to get help to honor those instincts and gut feelings. By calling a hospital’s Rapid Response Team when a patient first begins to show signs or symptoms of deteriorating health, nurses and other clinicians can quickly benefit from the expertise of other colleagues before things get worse. Nurses are encouraged and empowered to ask for help without fear of appearing incompetent, there’s more emphasis on shared learning and everyone gets the message that support is a critical component in clinically challenging situations. This has a positive impact on nursing recruitment, retention, and satisfaction.

The start of rapid response teams began in Liverpool, Australia in 1995 with the first pediatric rapid response team. In 2005, the Institute for Healthcare Improvement (IHI), a healthcare organization whose mission is to improve health and health care worldwide, implemented the rapid response systems a key part of the 100,000 Lives Campaign to improve the quality of care in hospitals and reduce the mortality rates[2].

By 2007, 1,500 hospitals had reported putting rapid response teams into action, and in 2008, rapid response teams became part of hospital accreditation by the Joint Commission on Accreditation of Healthcare Organizations.

The results from implementing an RRT have been mostly good with some studies citing the lack of cost effectiveness and which model of RRT is better over another. In 2013, a study by Leach and Mayo cited the need for improvement of regular team training to build cohesion when working together. Most part of the study has been a positive outcome for both the staff and patients; with one qualitative study citing improved morale and teamwork, improved education for nurses and physicians, a positive redistribution of workload for nurses and physicians. This results in reduced code blues outside the intensive care units, decreased length of stay and decreased morbidity and mortality. The studies done by the Institute for Healthcare Improvement (IHI 2014) revealed that in one hospital, when rapid response teams were in place that the number of code blues dropped while the survival rate increased from 40% to 60%. A study by Lakshminarayana et al, (2014) 8% of rapid responses called were either for patients in the hospital for outpatient visits or for outpatient procedures and majority of those patients were admitted to the hospital once the rapid response was resolved. Rapid responses are called as well for visitors in the hospital that experience significant event (Wittenauer, 2014).

This article will explore the goals of the RRT, benefits to the organization, team members, nurse leaders, staff, and patients, what are the criteria to activate rapid response team, who are the members of the rapid response team, and review of literature's.

Goals of Intervention by an RRT:

The major goal of intervention of rapid response system is to react promptly and appropriately to deteriorating clinical status such as respiratory failure, cardiac failure, altered consciousness, hypotension, arrhythmia, pulmonary edema, and sepsis. The goal of early intervention during clinical deterioration is to improve outcomes. An RRT functions within the rapid response system, which has two main functions: recognize urgent unmet patient needs and activate the RRT (afferent arm); and initiate an RRT response for assessment, intervention, and patient triage (efferent arm).

1. Identify patient at risk

Rapid response team assess patients in whom respiratory, cardiac, or neurologic deterioration is developing like any vital sign changes or altered mental status. They are put in place to intervene and prevent deterioration that might lead to cardiac arrest, as the survival of inpatients with cardiac arrest is low; with risk greater than 80% after in-hospital cardiopulmonary resuscitation for cardiac arrest.

2. Communicate change in patient status

Rapid response systems mandate and accelerate communication among team members caring for the patient. Cardiac arrest due in part secondary to poor communication can be prevented and avoid delay in the physician responding to the nurse’s request.
Communication at both the nursing and physician levels by systematic activation of a team of providers and ensuring no negative feedback for appropriate activation.

3. Provide effective and timely interventions

The quality of care of critically ill patients prior to Intensive Care Unit transfer maybe suboptimal and associated with increased hospital mortality. Lack of knowledge or experience by the treating clinician, failure to appreciate urgency, and failure to seek advise are the common cause of suboptimal care.

4. Avoid delays in Intensive Care Unit (ICU) transfers

Rapid response systems facilitate early transfer of patients to the ICU when needed. Mortality rates are higher when patient transfer to higher levels of care are delayed. Delay in activation of the rapid response system for decompensating patients is independently associated with increased mortality.

Benefits of Rapid Response Teams (RRTs):

Nurse leaders’ perceived benefits of RRTs likely influence their support for RRTs, crucial for sustained RRT use. The continuation of programs is likely to be valued by staff members and considered needed when the staff perceive the programs to foster their own goals and aspirations.

The sustained use of RRTs in hospitals is largely dependent on staff member’s ability to recognize the need for an RRT and their willingness to activate an RRT call. These staff members may not be aware that organizational data on the effectiveness of the RRT program, (e.g., patient mortality rates, unanticipated intensive care unit [ICU] admissions, and cardiac arrest rates outside of the ICU) are being collected, and the results may not be communicated to them on a regular basis. The staff decisions to call the RRT may depend largely on their perception of RRT benefits, to themselves and their patients, when activating RRT calls rather than on objective measures of effectiveness.

Sarani et al (2009) reported that the physicians and nurses who perceived RRTs to improve patient safety were more likely to activate and call the RRT than those who did not perceive these benefits. Davies, DeVita, Ayinla, and Perez (2014) found that as the perception of benefit from RRT activation increased, adherence rates to activation criteria increased.

Perceived benefits of RRTs and RRT Nursing to the organization:

1. Promoting positive patient and organizational outcomes.

These outcomes include reduced ICU admissions and patients’ length of stay, and improved patient safety as reflected by reduced patient morbidity and mortality following RRT adoption and implementation.

2. Enhancing community perceptions.

Patients who experienced an RRT intervention while in the hospital were likely to share their experiences with others in the community. The positive patient experiences with RRTs would enhance patients’ outlook on the hospital and the care they received which would increase their comfort to return for care to the same facility.

3. Reducing cost, improving satisfaction.

RRTs reduced cost and improved the cost-effectiveness of care because of reduced cardiac arrest rates and the need for subsequent critical care.

Perceived benefits of RRTs to staff members:

1. Getting expert help.

Staff members benefit because they know that an experienced critical care nurse is available when they have questions, someone that they can have confidence in, and that they can get a second opinion when they need one.

2. Learning, gaining knowledge, skills, and expertise.

Learning occurs during RRT calls through instructions and observations. This is a learning opportunity for RRT to teach and explain to the nurses on the floor what they are doing for the patient and the rationale and they watch them do an assessment and how RRT communicate with the physician. RRT teaches staff how to better manage deterioration, and help them how to reduce the workload associated with care of acutely ill patients. RRT involvement in end-of-life care provides opportunities for staff to gain confidence and skills in these difficult matters.

3. Supporting end-users.

The presence of RRT gives the staff the comfort they need that help is always available and they feel supported that a specialized person is there. The availability of RRT offers mental or psychological support to the staff and gives them a sense of security and help them to reduce their work stress. There is a critical care expert to stepped in to help manage the patient in crisis.

Perceived Benefits of RRTs to Patients:

1. Early recognition and intervention.

A nurse leader noted that patients are assessed by an advanced care professional, so occasionally they’re able to intervene before a crisis happens. The patients get a much more rapid treatment than waiting on a physician to maybe come from their office. The Rapid Response Team has standing orders that they can initiate like blood works, order a chest xray, and blood gases and facilitate patient transfer to higher levels when needed.

2. Better patient care.

Nurse leaders perceived RRTs to enhance patient care because early RRT interventions help to reduce complications.

3. Enhanced patient safety.

The staff feels patients receive improved care with improved outcomes with the presence of RRT. Safety is enhanced by providing the right level of care to the patients when in crisis. RRTs are perceived to enhance patient safety because complications and trauma to the patient are prevented.

Nurse leaders’ perceptions of benefits of RRT implementation were more at the macro-level of the organization than at the micro-system or intervention level. Nurse leaders perceived RRTs to improve patient outcomes such as length of stay and reduced ICU admissions. Nurse leaders are more likely to receive information on RRT call trends and outcomes on a regular basis, increasing their awareness of the impact of RRTs on the outcomes such as length of stay and ICU admission rates. They are also more likely to be cognizant of patient/family and nurse satisfaction, measures that are key indicators of the hospital’s and unit’s performance and the nursing work environment. The nurse leaders develop increase awareness of staff nurses’ work stress and their need for additional support and guidance for caring for higher acuity patients with acute, critical needs.

The members of the RRT focused more on the learning opportunities RRTs offer. When debriefings were conducted after RRT calls, the RRT members provide feedback to the staff to enhance their knowledge and skills and better prepare them for subsequent RRT calls.

The staff highlighted the psychological support that RRTs offer because a critical care expert can intervene on their behalf, activating RRT call gives them sense of security and support and reduces their work stress.

Criteria for Calling Rapid Response Team:

Each healthcare institutions establish their criteria when to activate the rapid response team but most of these criteria include:

Heart rate less than 40 beats per minute
Heart rate greater than 130 beats per minute
A change in the systolic blood pressure to less than 90 mmHg
Systolic blood pressure that is greater than 180 mmHg
SPO2 change to 90% despite initiating oxygen therapy
Any change in mental status
Urinary output of less than 50 ml in four hours
Signs or symptoms of a cerebral vascular event
Pending respiratory failure; possible endotracheal intubation
Seizure activity; this can be new activity, repeated seizures or a prolonged seizure in which airway compromise a concern
Chest pain that is unrelieved by the administration if nitroglycerin or any new chest pain complaints
Significant bleeding
Agitation and/or delirium
Uncontrolled pain

Optimum patient care relies on timely identification of clinical deterioration and prompt activation of the team. Delays in activation, known as afferent limb failure, are still a problem and the frequency of delays, which range from 21% to 56% of all calls, can increase mortality and morbidity. The reasons for these delays fall into three main areas:

1. Failure to monitor

Identification of clinical triggers either physiologic such as HR, BP, and respiratory rate or diagnostic information such as lab values.

2. Failure to recognize

Some institutions have incorporated “worried/concerned” criteria, based on nurse intuition into RRT activation criteria which include such indicators as pain, agitation, patient not progressing, and patient indicating he or she isn’t feeling well.

3. Failure to escalate

Factors that lead failure to escalate clinical deterioration to the RRT includes lack of information, scarcity of resources, informal hierarchical culture, fear of criticism that the patient wasn’t sick enough, and calling the provider before activating the RRT.

Nurses should be empowered to make an RRT call, and they need support from their managers when they do call the RRT. Leaders should also support attainment of formal education and certifications among their nurses to improve patient outcomes. The education enables the nurses to recognize and treat a deteriorating patient before or when an RRT is required. Increasing nurses’ educational attainment and self-awareness of decision-making process is key to enhance RRT utilization. Nurse leaders have an obligation to encourage this dialogue and remove barriers that prevent appropriate RRT activation.

Who Can Call Rapid Response Team:

Nurse taking care of the patient
Respiratory therapist involves in care of patient
Physicians
Family members
Any staff members concerned over the patient especially if that patient has failed to respond to prescribed treatment by the medical / nursing team

Rapid Response Team Members:

RRT members depend on the institution maybe made up by different personnel including:

1. A rapid response nurse

Usually an intensive care nurse, will assess the patient to include most recent vital signs, labs, and medications given, blood glucose. Connect patient to the monitor and monitor patient’s cardiac rhythm, make sure there is appropriate IV access and administer ordered intravenous medications.

2. Respiratory Therapist

Most patients develop respiratory distress, needing nebulizer treatment, need asses lungs sounds, do arterial blood gas, and assist with intubation
if needed.

3. Physician: either the hospitalist or an intensive care specialist or both

Will review the report from the patient’s nurse to include pertinent history of the patient and the immediate problem at that given time, do a detailed assessment and give appropriate orders for treatment, and reassess once those orders are carried out. Intensive care specialist maybe asked for central line placement for medication administration.

4. Nurse assigned to that person

Needs to stay with the patient to give patient history and the events leading
up the rapid response

5. Nursing house supervisor

Facilitate bed as needed

6. Assistant nurse manager

7. Clinical Nurse Specialist

8. Clinical Pharmacist

Will be on standby to ensure that any medications needed for the patient are readily available, and assist with verifications of compatibility of medications.

Five Keys to Success:

1. Organizational Culture

People who work in the hospital are aware of the mission of the institution they work for and they are committed to care for their patients and for their purpose. There is a need for leadership and active support for change when innovations in care delivery are introduced. The patient safety was a recognized priority and that the organizational resources would be applied to achieve successful approaches to patient care. Organizational leadership support meant backing and reinforcement from administrative and clinical leaders to organize and manage the development and use of an RRT and create teamwork between RRT members and the staff.
The role of nursing administration is significant in the daily implementation of the RRT. Without proper guidance, the team can’t be effective with its interventions. Regular monitoring and RRT evaluation should be under the direction of nurse leaders. Nursing administrators bear the responsibility for evaluating the RRT implementation process and proposing changes as needed for continued success.

2. Team Structure

This includes the function of an RRT, the design of the team, and the description of the role of each team member. RRT members usually include RRT nurse, a respiratory therapist, a bedside nurse, a patient’s primary physician and intern.

3. Expertise

Expertise meant being highly skilled, using a proactive approach by making rounds to identify at-risk patients early, being good at identifying potential problems, and being able to rapidly respond (within 5 minutes). Additional descriptions included excellent assessment skills and ability of team members to focus on the crisis and manage it to prevent further worsening of a patient’s condition. Expertise was described as clinical knowledge and experience necessary to respond to the patient’s situation and provide a basis for a team member’s clinical judgment and reasoning. Clinical knowledge was described as able to assess the patient quickly; excellent assessment skills applied very rapidly. An effective team member will be able to apply their knowledge and expertise to anticipate patient needs, identify risks, assess and monitor the patient.

4. Communication

Communication included seeking and reporting information. Effective communication is described as “the style of response is one that allows people to give information and doesn’t shut them down … being an information gatherer and willing to have a dialogue”[7]. Communication was at its best when individual team members were perceived as not intimidating and the dialogue was focused on the patient.

5. Teamwork

Teamwork is the coordination among team members working toward the common goal of addressing a patient’s immediate needs. Teamwork was viewed as working well together, understand the purpose of an RRT and the reason the members came together as a team.

Conclusion:

By calling hospital’s RRT when a patient first begins to show signs and symptoms of deteriorating health, nurses and other clinicians can quickly benefit from the expertise of the other colleagues before things get worst. The idea for the team is to assess the patient’s condition and to determine the next best step.

In addition to their significant value of a clinical tool, RRTs are also changing hospital culture. Nurses are encouraged and empowered to ask for help without fear of appearing incompetent, there’s more emphasis on shared learning, and everyone gets the message that support is a critical component in clinically, challenging situations. All these benefits are expected to have a positive impact on nursing recruitment, retention, and satisfaction.

New nursing graduates who get their first job are concerned about doing the right thing, and most of all, they do not want to hurt a patient. Having access to the RRT is very reassuring to them and provide them a strong support system.

Many recent graduates report they only considered job that have RRT and they considered this a strong support system. The appeal of the RRT is that the nurses don’t have to go do it alone anymore. They don’t have to feel alone when they have an inkling that something might be wrong. It means they can get a colleague or several to validate their concerns or put them to rest.

The effective performance of an RRT at a patient’s bedside is viewed as means to minimize delay in treatment to prevent worsening of the patient’s condition by bringing critical care expertise to the patient. Along with the call for increased patient safety in acute care hospitals, a critical need for responsive systems that address the increasing complexity of health care delivery may have influenced the development of RRTs. Studying the nature of teams that come together and dissolve quickly and carry out their work in high-risk situations is important for optimizing safe hospital systems. Members of an RRT need to understand the contributions and role of each member, the meaning of the members’ partnership in dealing with a critical situation, and how knowledge is shared. Evaluation that includes each team members’ assessment of the team’s performance and observation of the team applying the knowledge and skills from training to clinical practice in actual response situations is needed. Team functioning and what a team needs to function effectively, including qualities such as expertise, behaviors such as communicating, and influences of the environment in which the team functions must be evaluated to determine the effectiveness of the team and any improvement that needs to be done.

The availability of a dedicated RRT nurse who can round on units and collaborate with staff nurses in the care of high-risk, high-acuity patients may help to offset the staff work stress and enhance their feelings of support. The recruitment of a dedicated RRT nurse who respond to RRT calls and round on units in between calls should be considered.

References:

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