Critical Care Nurse. 2009;29: 66-75 doi:10.4037/ccn2009802
Copyright © 2009 by the American Association of Critical-Care Nurses.
Clinical Article
CE Article
Implementation of a Rapid Response Team: A Success Story
Susan S. Scott, RN, MSN, CCRN
Sheila Elliott, RN, BSN, MBA, CNA, BC
Susan S. Scott has been a critical care nurse for 25 years and the nurse educator in the intensive care unit at Baystate Medical Center in Springfield, Massachusetts, for 15 years. She has been a member of the rapid response team at Baystate Medical Center since the team’s inception in 2006.
Sheila Elliott has been a critical care nurse for 22 years and manager of the intensive care unit at Baystate Medical Center for 4 years. She was on the task force charged with developing and implementing the rapid response team at Baystate Medical Center.
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To learn more about rapid response teams, read "Rapid Response Team: Challenges, Solutions, Benefits" by Kim Thomas et al in Critical Care Nurse, February 2007;27:20–27. Available at www.ccnonline.org.
Financial Disclosures
None reported.
This article has been designated for CE credit. A closed-book, multiple-choice examination follows this article, which tests your knowledge of the following objectives:- Discuss a plan for implementation of a hospital-based rapid response team (RRT)
- Summarize preimplementation planning that will result in a successful RRT program
- Recognize the improved patient outcomes that are associated with an ongoing evaluation of RRT use
Corresponding author: Susan S. Scott, RN, MSN, CCRN, Baystate Medical Center, 759 Chestnut St, Springfield, MA 01199 (e-mail: susan.scott{at}bhs.org).
Hospitals throughout the United States have been implementing rapid response teams (RRTs), also referred to as medical emergency teams. In 1995, Lee et al1 published one of the first descriptions of the outcomes of using an RRT. In 1999, Goldhill et al2 reported that implementation of an RRT was associated with a 26% reduction in cardiac arrests before patients were transferred to the intensive care unit (ICU). In 2000, Bristow et al3 compared 1 hospital that had an RRT with 2 other hospitals that had conventional cardiac arrest teams. In that study, the hospital with the RRT had fewer unanticipated ICU admissions and a lower death rate for patients who did not have "do not resuscitate" orders than did the other hospitals. In 2002, Buist et al4 reported that implementation of an RRT was associated with a 50% reduction in cardiac arrests outside of the ICU. Bellomo et al5 reported a decrease in unexpected ICU admissions and a significant reduction in the number of adverse events after an RRT was implemented.
Use of RRTs has resulted in a significant reduction in the number of codes called in units other than the ICU, as well as a decrease in the overall code rate in hospitals that use these teams.6–8 RRTs have had such a marked effect on the reduction of in-hospital emergencies that the Institute for Healthcare Improvement has embraced the implementation of these teams, setting a goal of 25 calls per 1000 discharges of patients.9
Unlike traditional "code teams," the purpose of RRTs is to identify and treat patients before the patients’ condition deteriorates to the point that cardiopulmonary resuscitation is needed. Research by Schein et al10 in 1990 and by Franklin and Mathew11 in 1994 identified certain signs and symptoms that are evident up to 8 hours before a patient has a serious cardiac or respiratory event:
- Mean arterial pressure less than 70 mm Hg or greater than 130 mm Hg
- Heart rate less than 45/min or greater than 125/min
- Respiratory rate less than 10/min or greater than 30/min
- Chest pain
- Altered mental status
These indicators helped form the rationale for RRTs, because the role of the teams was to intervene before a patient had a catastrophic event.
In this article, we describe the planning, implementation, and evaluation process used for the successful implementation of an RRT at Baystate Medical Center, a large teaching institution in Springfield, Massachusetts.
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Operationalizing the Process
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The makeup of RRTs varies from one hospital to another, and the specific implementation process varies depending on the available resources and personnel, as well as the type of institution in which the RRT is being implemented. A 600-bed teaching hospital with high-acuity patients and medical staff and midlevel providers on site 24 hours a day, 7 days a week would most likely have different needs and issues than would a 200-bed community hospital with lower acuity patients and only an emergency department physician on site at all times.
When the leadership at our 640-bed teaching institution committed to the development of an RRT, leaders from the ICU and the cardiac ICU were put in charge of operationalizing the process. One of the initial resources used in the planning process was the Web site for the Institute for Healthcare Improvement, which contained an extremely useful guide for establishing an RRT.9 After reviewing what other institutions were doing, collaborating with the medical staff and our department of health care quality, it was established that the members of our team would be an experienced critical care nurse, an infusion nurse, and a respiratory therapist. The decision not to include a physician on the RRT was made because physicians are present "in house" and we have physician coverage for all patients on the nursing units. A patient’s physician would be called simultaneously with activation of the RRT, so that the RRT nurse (in collaboration with a unit nurse) could consult a physician and provide immediate interventions that could be provided only by a nurse with critical care skills (eg, initiating and titrating vasoactive medications).
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Preparing for Implementation
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In preparation for implementation of the RRT, a number of pieces had to be put in place for the program to succeed: staff meetings to clarify the role of the members of the RRT, a pilot test to project the number of RRT calls, and education of hospital-based care providers and community physicians.
Staff Meetings
During the months before implementation, staff meetings were held to familiarize the critical care nursing staff with the RRT documentation tool, RRT protocol orders, roles of the RRT members, and the criteria for being an RRT nurse. Respiratory therapy staff were taught about their role on the RRT via staff meetings held by the respiratory therapy department. Critical care nurses were taught that the RRT nurse would act in a "consulting" capacity and that primary care of the patient would remain with the nurse who was caring for the patient and with the respiratory therapist who was assigned to that particular nursing unit. The exception was if the patient’s condition deteriorated to the point that the care required could be provided only by a critical care nurse (eg, use of vasoactive medications); in this case, the RRT nurse would remain until the patient’s condition improved. If the patient’s condition did not improve, the critical care nurse would accompany the patient to a critical care unit.
Concern About Understaffing
The Institute for Healthcare Improvement9 recommends a light patient assignment for the nurse who is assigned to the RRT. Our implementation team informally surveyed other institutions to gain insight as to how their teams were operationalized. Some of the hospitals did not provide an RRT 24 hours a day, 7 days a week. Instead, they provided the service when staffing of the ICU was sufficient to do so. When staff was not available, the team did not operate. Other institutions used staff members who did not provide direct patient care (eg, unit educators or managers) and were able to leave what they were doing, respond to the RRT call, and then resume their activities after returning from the RRT call.
Our critical care nurses were concerned about patient safety; they were reluctant to leave their patient assignment to respond to an RRT call. Leaving their patient assignment could create an understaffed critical care unit. The literature supported their concern about patient safety and understaffing. In 2002, Aiken et al12 published a landmark study that correlated high nurse to patient ratios in surgical patients with higher failure to rescue rates and greater mortality. Dang et al13 concluded that decreased staffing in an ICU was significantly associated with postoperative complications. In a study by Dimick et al,14 the incidence of pulmonary complications and the risk for intubation both increased when the nurse to patient ratio increased from a 2-patient assignment in the ICU to a 3-patient assignment.
Nursing leaders recognized short staffing as a potential issue, but before implementation of the team, it was not clear how many RRT calls would actually take place or how long each call would take.
Strategy 1: Pilot Period
In the attempt to project the amount of time and number of calls that might occur once the team was in place, a 10-day pilot study was done before implementation of the team. Unfortunately, the pilot study yielded little insight because it covered only 2 of the 14 nursing units in the hospital, was held only on the day shift, and did not include weekends. Because of the limited information from the trial, it was difficult to predict how many calls would actually take place. Because of this problem, it was deemed premature to create a budgeted position for an RRT nurse before the team was fully implemented.
Strategy 2: Reassessment After 1 Month
The implementation team recognized that the pilot study did not provide the necessary insight and developed a plan to review the nursing time required to cover RRTs after the first month of implementation. They would assess the mean amount of nursing time required and determine whether it warranted a budgeted position. By the end of the month, a mean of 1 RRT call occurred per shift, which did not support the creation of a budgeted RRT position.
Strategy 3: Education of Care Providers
Hospital-wide education of unit staff and all levels of management and physicians included explaining the purpose of an RRT and how to activate the team. Information was disseminated via e-mail, multiple meetings, and communication boards during the month before "going live." Posters and pocket cards with the criteria for calling an RRT, along with the team’s beeper number, were posted in prominent places on all adult nursing units (Figure 1
). Critical events and resuscitation of children were already covered by the nurses and physicians in the pediatric ICU. Therefore, it was decided that the RRT would serve only adult patients. The criteria for calling the team included a number of physiological indicators such as decreased oxygen saturation and changes in neurological status, but the first indicator on the list of criteria was concern that something was wrong.
At the same time, the information was disseminated to the local medical community to inform the physicians who admitted patients to our institution that an RRT was being implemented.
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Outcomes After 2 Years
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The champions of the implementation process, in collaboration with the health care quality department, review monthly data for the RRT. Included in the monthly data are the number and nature of RRT calls, the number of codes, and the duration of RRT calls.
Number and Nature of RRT Calls per Month
The team has received a mean of 51 calls per month (the numbers have gradually been increasing), but the goal is 80 calls per month. That goal is based on the Institute for Healthcare Improvement recommendation of 25 calls per 1000 patient discharges.9 The most common reasons for RRT calls have been respiratory and cardiovascular problems, in that order (Figure 2).
Number of Codes per Month
The number of codes called has been decreasing since implementation of the RRT. In the year before implementation, a mean of 22 codes were called per month; now the mean is 14 per month (Figure 3). Common practice before having an RRT program was to call a code blue when a patient required intubation. Since implementation of the RRT, codes are seldom called for an intubation, because the RRT is called before the patient’s condition deteriorates to the point of cardiorespiratory arrest. The team is able to intervene sooner to implement respiratory interventions such as non-invasive ventilation to optimize ventilation and oxygenation and to facilitate the intubation procedure as the need arises.
The overall code blue rate has decreased from 7 per 1000 patient days to 2 per 1000 patient days, and the data trends indicate improvement, but we do not have enough data yet to confirm the success of the program statistically from an outcomes perspective.
Duration of RRT Calls
The RRT was implemented in March 2006, and we think that it was successful partly because we evaluated it on an ongoing basis and improved it as soon as any issues were identified. Shortly after implementation, it became clear that the amount of time the nurses were off the unit responding to RRT calls warranted additional nursing resources. In the first month of implementation, the average call lasted 60 minutes; since then, the length of each RRT has been 53 minutes. A single call in January 2007 skewed the data; that call lasted more than 2 hours because the critical care nurse remained with the patient until a critical care bed was available (Figure 4).
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Optimizing the Program
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On the basis of our outcomes, we made several modifications to optimize the RRT program. These modifications involved RRT nursing coverage, physician coverage, the role of the RRT nurse during down times, unit coverage, and documentation.
Modification 1: RRT Nursing Coverage
Over time, it was clear that increased staffing was needed. Nursing leaders allocated additional funds to existing budgets so that critical care nurses could voluntarily sign up to be the RRT nurse (beyond the nurses’ regularly scheduled shifts) as a way to staff the RRT without pulling staff away from patients’ bedside. Most shifts were covered by nurses who signed up, but for some shifts no one signed up, or an extra nurse was not available because of a sick call. In these isolated instances, we had to be more creative in our RRT coverage. If an RRT nurse with a patient assignment had gone to one RRT call and received another RRT call after returning to the ICU, the role of RRT was reassigned so that the same nurse was not pulled away from the bedside a second time.
We also addressed this problem by calling on the cardiac ICU to cover the RRT for the shift. On rare occasions, the ICU was unable to cover the RRT because of an unusual number of sick calls on a shift. When this situation has occurred, the ICU charge nurse has called the cardiac ICU and explained the situation, and the cardiac ICU would respond to the RRT calls for that shift. As we routinely alternate coverage of RRT between the ICU and the cardiac ICU, the 2 units have been able to reciprocate when the need has arisen.
Modification 2: Physician Coverage
After the RRT was implemented, the issue of physician availability, or lack of availability, became evident. Most patients at Baystate Medical Center are treated by house staff and/or hospitalists, but a small number are treated by community physicians. During an RRT call, a patient’s physician may not return the nurse’s call in a timely manner. In these rare situations, the team collaborates with the intensivist who is responsible for ICU triage at that time. This arrangement has yielded multiple benefits. Not only do the patients’ urgent medical issues get addressed, but a number of the patients who are seen by the RRT require admission to critical care. Contacting the triage intensivist provides a "heads up" for a potential ICU admission.
Modification 3: Role of the RRT Nurse During Down Time
The mean length of the RRT calls has been 53 minutes, but the mean number of calls per 24 hours is still only 2. In addition to the time required for the RRT call, the RRT nurse revisits the nurse who initiated the call to address any questions that nurse may still have. Despite this added nursing time, the RRT position still does not warrant a full-time nurse; therefore, a full-time RRT position was not created. When the RRT nurse is not responding to calls, he or she acts as a "STAT nurse," assisting colleagues in their patient care. An informal survey of the ICU staff revealed that the nurses are pleased to have an additional nurse available to assist with patient care.
Modification 4: Unit Coverage
Another change we made after implementation of the RRT was alternating RRT coverage between the ICU and the cardiac ICU. Before implementation, the plan was that all codes and RRTs would be covered by a single unit (ICU or cardiac ICU) alternating monthly. This move was considered logical because the ICU and the cardiac ICU alternated code coverage up until that time and the expectation was that fewer codes would be called. After the first month, however, alternating RRT staffing was identified as a burden to the covering unit because of a number of simultaneous codes and the duration of RRT calls. Since that time, in the months that one unit is responsible for codes, the other is responsible for RRT calls.
Modification 5: Documentation
The documentation form initially developed for the RRT calls has been modified several times on the basis of feedback from the nurses who used the form (Figure 5). The documentation form includes space to note results from a point-of-care testing device that the RRT nurse brings to the call. Although sepsis has not been as common a reason as respiratory or cardiac problems to call the RRT, the focus on early intervention for the treatment of sepsis led to the addition of early sepsis indicators and inclusion of checking the lactate level those patients who had these early indicators. Thus, the nurse can obtain a number of laboratory results listed in the protocol, including a lactate level on patients who have some of the indicators of sepsis.
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RRT and Continued Awareness
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After the initial implementation of the RRT, the number of RRT calls decreased late in 2006 (Figure 6). We attributed this decrease to waning awareness of the availability of RRT support among staff. The number of calls increased when we implemented an ongoing, multi-pronged communication program to maintain nurses’ awareness of the availability of the RRT. We publish a quarterly RRT newsletter that is distributed to the nursing units. It contains educational information and case studies that are based on actual RRT calls. Thank-you notes are given to the nurses who made the calls (Figure 7). The RRT nurse also personally thanks the nurse who made the call.
The role of the RRT is described during orientation for new employees and for all staff who attend classes on cardiopulmonary resuscitation (required by all personnel who provide direct patient care). Semiannual presentations consisting of utilization data, updated processes, and staff responses are carried out by the RRT oversight team to maintain awareness of the RRT. The oversight team is made up of the managers from the ICU and the cardiac ICU, the manager of respiratory therapy, and 2 members of the Division of Healthcare Quality. Staff comments both in and out of critical care areas about the debut of the RRT have been overwhelmingly positive. Many of the unit nurses appreciate having a "second set of eyes" looking at patients who are not doing well. After a patient’s acute event has been addressed, the RRT nurse discusses the situation with the patient’s nurse. The 2 nurses review what occurred and why particular interventions were instituted during the RRT call. These teaching sessions are especially helpful for newer nurses who lack the clinical skills of more experienced nurses. Also at this time, the RRT nurse expresses appreciation for being called, in an effort to support the decision by the unit nurse who made the call.
Our RRT program has been successful in part because we have a dedicated, knowledgeable team who introduced, implemented, and evaluated the RRT to ensure that it is the best program possible. In addition, the implementation team became an interdisciplinary oversight team that continues to evaluate and improve the program on the basis of the evidence and recommendations from the RRT staff. A formal reporting structure exists for the RRT through the Critical Care Practice Committee for Quality reporting. Finally, we have a superb group of professionals, both on the RRT and on the patient care units, whose focus is providing high-quality care for patients all across the medical center.
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PRIME POINTS
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- In-service training sessions, posters, and e-mail were used to familiarize staff with the rapid response team and its purpose.
- The number of calls the team gets per month is tracked.
- Continued calling of the team is encouraged through a newsletter and acknowledgment of staff who call on the team.
- The institution allocated funds to support the needs of the units that supplied staff for the team.
- Feedback from unit staff who call on the team and from team members has been overwhelmingly positive.
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Acknowledgment
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The authors would like to thank Jan Fitzgerald, RN, MS, from the Division of Healthcare Quality, and Paula Lusardi, RN, PhD, CNS, at Baystate Medical Center, for their contributions and support in the writing of this article.
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References
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- Lee A, Bishop G, Hillman KM, Daffurn K. The medical emergency team. Anaesth Intensive Care. 1995;23(2):183–186.[Medline]
- Goldhill DR, Worthington L, Mulcahy A, Tarling M, Sumner A. The patient-at-risk team: identifying and managing seriously ill ward patients. Anaesthesia. 1999;54(9):853–860.[CrossRef][Medline]
- Bristow PJ, Hillman KM, Chey T, et al. Rates of in-hospital arrests, deaths and intensive care admissions: the effect of a medical emergency team. Med J Aust. 2000;173(5): 236–240.[Medline]
- Buist MD, Moore GE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study. BMJ. 2002;324(7334):387–390.[Abstract/Free Full Text]
- Bellomo R, Goldsmith D, Uchino S, et al. Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med. 2004;32(4):916–921.[CrossRef][Medline]
- Offner PJ, Heit J, Roberts R. Implementation of a rapid response team decreases cardiac arrest outside of the intensive care unit. J Trauma. 2007;62(5):1223–1228.[Medline]
- Dacey MJ, Mirza ER, Wilcox V, et al. The effect of a rapid response team on major clinical outcome measures in a community hospital. Crit Care Med. 2007;35(9):2076–2082.[CrossRef][Medline]
- McFarlan SJ, Hensley S. Implementation and outcomes of a rapid response team. J Nurs Care Qual. 2007;22(4):307–313.[Medline]
- Establish a rapid response team. Institute for Healthcare Improvement Web site. http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/EstablishaRapidResponseTeam.htm. Accessed March 15, 2009.
- Schein RM, Hazday N, Pena M, Ruben BH, Sprung CL. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest. 1990; 98(6):1388–1392.[Abstract/Free Full Text]
- Franklin C, Mathew J. Developing strategies to prevent in hospital cardiac arrest: analyzing responses of physicians and nurses in the hours before the event. Crit Care Med. 1994;22(2):244–247.[Medline]
- Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):1987–1993.[Abstract/Free Full Text]
- Dang D, Johantgen ME, Pronovost PJ, Jenckes MW, Bass EB. Postoperative complications: does intensive care unit staff nursing make a difference? Heart Lung. 2002;31(3):219–228.[CrossRef][Medline]
- Dimick JB, Swoboda SM, Pronovost PJ, Lipsett PA. Effect of nurse-to-patient ratio in the intensive care unit on pulmonary complications and resource use after hepatectomy. Am J Crit Care. 2001;10(6):376–382.[Abstract]
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Operationalizing the Process
Preparing for Implementation
