Articles: Medical Topics
RRTs: Douse the spark before it becomes a forest fire
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 Imagine
this scene: You are visiting your elderly father in the
hospital when you notice his speech is becoming slurred
and he is less awake than usual. Concerned, you call his
nurse into the room. She assesses your father, then picks
up the phone and requests an emergency response team. A
team of professionals enter the room, assess and stabilize
your father, and arrange for him to be transported to the
ICU with a tentative diagnosis of rule out stroke. Your
father’s attending physician is called as the team
is completing its assessment. The critical care nurse on
the team pulls the floor nurse aside to congratulate her
on her astute assessment. The process from start to finish
has taken 20 minutes.
Rapid
response teams (RRTs) were started in Australia several
years ago, and have been implemented in large numbers of
American and Canadian hospitals and elsewhere in the world
after 2005. The genesis of rapid response teams is rooted
in the recognition that unnecessary deaths occur in hospitals
every day. Early recognition of warning signs of impending
medical deterioration reduces some of these deaths. In one
study published 17 years ago, as many as 70% of patients
showed evidence of respiratory deterioration within 8 hours
of a respiratory/cardiac arrest. 1 A study published
13 years ago reported that as many as 66% of patients showed
abnormal signs and symptoms within 6 hours of an arrest;
the physician was notified only
25% of the time. 2
The
composition of RRTs varies from hospital to hospital. A
team typically consists of 2-3 people who are assigned to
flexible responsibilities within the facility. The team
may consist of respiratory therapists, physician assistants,
nurse practitioners, critical care nurses, intensivist (critical
care doctors), hospitalists (physicians employed within
a facility to provide inpatient care) or residents. The
team’s role is to assess and stabilize the patient,
assist with communication with the attending physician,
educate and support the nursing staff and family, and assist
with transfer to another level of care, if needed.
Without
rapid response teams, nurses who recognize ominous changes
in the status of their patients are forced to contact the
attending physician and wait for a return call. Should an
attending physician refuse to deal with or minimize the
concerns of the nurse, the nurse has to use the chain of
command within a facility - in effect, to go over the head
of the attending physician with the assistance of nursing
administration, to find a physician who will respond. This
is a slow and difficult process. RRTs have the capability
of bypassing the attending physician to turn what can be
a 2-3 hour long process into a 5-10 minute arrival to the
patient’s bedside. The use of a team within a facility
empowers the staff nurse, and provides a safety net for
both the nurses and the patients. (Refer to box for typical
criteria for calling a RRT.) Implementation of RRTs has
reduced cardiac arrests, deaths, the number of unexpected
emergency admissions to ICU, and the length of a hospital
admission for cardiac arrest survivors. RRTs build teamwork
and spread knowledge and skills throughout the hospital.
“The goals of the team are to provide immediate detection
and diagnosis, to treat patients early, and to mitigate
harm by turning adverse events into ‘near misses’.
The system is designed to protect the patient from further
harm and to allow for recovery from possible medical errors
and system deficiencies.” 3
| Typical
criteria for calling the RRT
•
A staff member is concerned or worried about
the patient
•
Acute change in heart rate (less than 40 or
greater than 130 beats per minute)
•
Acute change in systolic blood pressure (less
than 90 mm/Hg)
•
Acute change in respiratory rate (less than
8 or greater than 24 breaths per minute) or
threatened airway obstruction
•
Acute changes in blood oxygen saturation (less
than 90% despite oxygen)
•
Fractional inspired oxygen (Fi02 for a patient
on a ventilator) of 50 % or greater
•
Acute changes in mental status (delirium, confusion,
decreased awareness)
•
Acute significant bleeding
•
Urine output less than 50 cc in 4 hours
•
New, repeated, or prolonged seizures
•
Failure to respond to treatment for an acute
problem or symptom |
| |
| Patricia
Iyer MSN RN, LNCC, Mary Ann Shea JD RN, and
Barbara Levin BSN RN ONC LNCC presented
a symposia at the International Council of Nurses
Conference in Yokohama, Japan on May 31, 2007,
on education of nurses about RRTs and dealing
with unexpected changes in patient’s conditions.
Their second symposia described the consequences
of a medical error. An estimated 3,400 nurses
from 109 countries attended the
conference. |
|
The
benefits seem obvious - why doesn’t every hospital
have an RRT? If the Institute for Healthcare Improvement
had its way, every one would. The use of RRTs is one of
the cornerstones of the 5 Million Lives Campaign, which
is aimed at preventing 5 million incidents of medical harm
over 2 years (December 2006 to December 2008) by use of
patient safety measures that have been proven to save lives.
Implementation of RRTs has stirred initial resistance to
change in some facilities. Some physicians have resented
the development of RRTs, fearing that a call to the team
will be viewed as a sign of inadequate medical care. In
one facility, resistant physicians were upset that the nursing
staff could invite another physician to get involved with
their patient. Some even went as far as to write formal
orders that the rapid response team could not look at their
patients. Such orders were ignored. 4 Despite initial
resistance, it is clear that RRTs are spreading and they
are saving lives.
Key
points for attorneys
1. Many hospitals have now adapted the RRT concept
to the needs of specific patients. There are trauma teams,
chest pain teams, stroke teams, shock teams, and obstetrical
teams.
2. Some
facilities have begun encouraging patients and family members
to activate a rapid response team when they do not feel
their concerns are being adequately
addressed.
3. Soon
it will be argued that having an RRT is the standard of
care.
4. Whether
or not a team is in place, failure to recognize early changes
in a patient’s condition causes many deaths.
5. Inquire
if a hospital has a RRT before someone you love is electively
admitted.
References
1. Schein, R, Hazday, N, Pena, M et al. Clinical antecedents
to in-hospital cardiopulmonary arrest. Chest 1990: 98: 1388-1392.
2. Franklin,
C, Matthew, J. Developing strategies to prevent in-hospital
cardiac arrest: analyzing responses of physicians and nurses
in the hours before the event. Critical Care Medicine. 1994;
22 (2): 244-247.
3. Baldisseri,
M. Rapid Response Systems: Have They Made a Difference?
Critical Connections, June 2006, online at www.sccm.org/SCCM/Publications.
4. Staff
education, ‘tough love’ key to RRT success,
HealthCare Benchmarks and Quality Improvement 11/01/06.
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