Medical-Legal Topics

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.

Failure to rescue is a term that describes the outcome when a patient’s condition deteriorates before the changes are recognized and acted upon. Failure to rescue is a nursing-sensitive performance measure on the list of 15 identified by the National Quality Forum in 2004 to be collected by CMS (Centers for Medicare and Medicaid Services). A 2009 study performed by HealthGrades showed that patient safety incidents with the highest incidence rates were failure to rescue. There were 92.7 incidents (per 1,000 population). Starting June 1, 2010, CMS began collecting data about a facility’s failure to rescue rates.

The use of rapid response teams (RRTs) to provide timely rescue efforts in hospitals has gained momentum and popularity, although not all hospitals have them. The concept originated with a critical care nurse from New Zealand who recognized the need to bring resources to the bedside of a patient whose condition deteriorated before more serious events occurred. 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. 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.

Is the RRT system working? A survey of 56 staff nurses identified the three categories of reasons for why the RRT was activated:

• The patient exhibited signs and symptoms that were either unexpected or significantly different from baseline.
• Despite the absence of objective data, the nurse had a “gut feeling” that “something was wrong.”
• The nurse was convinced that the patient needed immediate evaluation and was unable to get the treating physician to respond as the nurse thought necessary. This is what one nurse said:

“It’s during shift change so everybody’s calling and running and doing this and that, and we called the doctor and he said, ‘Well, she’s got a pulmonologist on the case, call them.’ He gave us nothing. No orders. No meds. No, no nothing. . . At that point we decided we’re not going to wait for anybody else, we’ll just call rapid response and get them down here.”

Consider this comment in comparison to the often slow process of obtaining medical attention when a facility does not have a RRT. In addition to the direct patient safety benefits of such teams, RRTs empowered nurses and gave them a sense of control over the patient situation, identified other processes negatively affecting patient safety, and improved communication and respect between disciplines, thereby raising job satisfaction.

Sources: Shapiro, S, Donaldson, N, and Scott, M. “Rapid response teams: seen through the eyes of the nurse”, AJN, June 2010, 110 (6), 28-34
www.healthgrades.com/media/dms/pdf/patientsafetyinamericanhospitalsstudy2009.pdf

Extracted from Patricia Iyer, Roots of Patient Injury, in Patricia Iyer, Barbara Levin, Kathleen Ashton and Victoria Powell, Nursing Malpractice, Fourth Edition, in press.

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