You are a floor nurse on a medical/surgical ward, and you are worried about a seriously ill patient whose condition is slowly worsening. Typically, your only option for help is to go up the chain of command in your hospital — often a very slow process.
But Austin Hospital (Heidelberg, Victoria, Australia) offers a quicker choice to nurses or other staffers. They can simply go on their intuition, or check to see if the patient meets certain criteria of instability, and call in the hospital’s Medical Emergency Team (MET).
The MET includes the intensive care unit doctor on duty plus an intensive care nurse who brings a rescue pack. The patient’s doctors and primary care unit are alerted. The team assesses the patient and makes appropriate interventions, and the patient is admitted to the critical care unit if needed.
While standard treatment procedures are followed, “instead of happening within two or three hours, it’s happening in two or three minutes,” says Rinaldo Bellomo, MD, director of intensive care research at Austin Hospital and professor of medicine at the University of Melbourne.
This speedy reaction has dramatically reduced serious adverse events for surgery patients hospitalized for more than two days at Austin Hospital, reports Graeme Hart, MD, deputy director for intensive care. Results include a 37 percent relative reduction in mortality, a 65 percent drop in cardiac arrests, and an 88 percent reduction in overall hospital post-cardiac arrest bed days.
Hospitals around the world are starting to create their own intensive care Rapid Response Teams.
“The idea is to catch patients before they start this terrible downward spiral,” says Kathy Duncan, director of nursing for critical care services at Baptist Memphis Hospital (Memphis, Tennessee, USA). After setting up a team approach, Baptist Memphis found that the number of cardiac arrests dropped by 26 percent, and survival rates almost doubled, from 13 percent to 24 percent.
Making the Case
The Austin Hospital initiative is a continuation of work in Australia pioneered by Ken Hillman, says Hart. Austin Hospital began by studying patients who had major surgery at the hospital and then suffered significant complications such as reintubation, cardiac arrest or renal failure. The study found complication rates of 16 to 17 percent, consistent with research elsewhere. “This was not acceptable and we could do better,” Bellomo declares.
Proponents of a Rapid Response Team spent months presenting their case to surgical and medical units throughout the hospital. They established straightforward criteria of clinical instability, beginning simply with the staff member being worried about the patient and including other indicators such as acute changes in heart rate, blood pressure, or conscious state.
Testing the Rapid Response Team on a population of more than 1,000 post-surgery patients, the team found “very successful changes that very directly reduced the level of complications in surgical and medical patients,” Bellomo says. In addition to slashing rates for mortality and cardiac arrest, as reported in a Critical Care Medicine article (April 2004;32(4):916-921)
the team reduced relative risks by:
The team empowers nurses, who can activate a support system without needing to track down doctors who may be in the operating room or otherwise not immediately available. “The nurses just love it,” Bellomo says. “The Medical Emergency Team is now deeply embedded in the culture of the hospital.”
Combined with other hospital trends, such as the growing number of inpatients with multiple serious medical issues, the team approach has intensified workload issues, cautions Hart. “From our perspective, we’ve been victims of our own success.” The hospital may provide some help as it pushes initiatives in tracheotomy care and in follow-up of patients discharged from intensive care.
Nursing Team Success
In June 2003 Baptist Memphis Hospital participated in an Institute for Healthcare Improvement Collaborative meeting in which faculty member, Roger Resar, discussed failures to rescue patients. That dovetailed with the hospital’s reviews of its resuscitation efforts, says nursing director Duncan: “When you looked back through the data you could see things that you didn’t notice at the time.”
The IHI meeting also highlighted experience with Rapid Response Teams, and Baptist Memphis decided to try a brief experiment in August, making an intensive care nurse available to the medical/surgical floors. “I was afraid that we wouldn’t get any response, but we got 10 calls in three days,” Duncan says. “We looked at the results and found we probably saved several patients.”
The following week Duncan was making a presentation to the hospital’s medical board about mortality rates. She described the experiment and noted the success of Rapid Response Teams elsewhere. The medical board “kind of rolled their eyes” until she described what had happened with each of the 10 patients, she says. Then it gave a go-ahead.
Baptist Memphis’s team is headed not by a physician but by an experienced critical care nurse, who works along with a lead respiratory therapist. While on the team, the nurse ideally does not have any other patient responsibility but will work on the medical/surgical floor checking central lines, following up on patients discharged from the intensive care unit, and handling other tasks.
“When we started up, I was just trying to keep them busy,” Duncan says, but keeping a nurse active on the floor in this way showed major benefits. “She’s not a stranger; she’s got a rapport with the folks on the floor. It’s more collaborative.”
“The floor nurses feel safer at work,” adds supervising nurse Trudy Beyersdorf. “They know they have a safety net.”
Baptist Memphis calls this a “Medical Response Team” rather than “Medical Emergency Team,” because it is trying to respond before the emergency, Duncan says. “The whole idea is to notice a subtle change in the patient.” The medical/surgical nurses are not given a set list of criteria. “I want them to call when they get that gut feeling to call,” she explains. “That has worked out well for us.”
“I’m confident that this is assisting us in cutting mortality,” Duncan says. As they gain more experience with the team approach, floor nurses are calling earlier, giving more opportunity to readmit patients to the intensive care unit before a crisis hits. The percentage of patients who suffer cardiac arrest in the intensive care unit, where their chances of survival are much greater, has climbed from 36 to 64 percent.
The team’s incident reports also aid the hospital’s training efforts, for instance pinpointing the need for greater staff development on respiratory issues.
Different organizations will set up critical care rapid response teams in different ways and with different procedures, says Austin Hospital’s Bellomo. “Whatever works in the particular institution, let it work,” he advises. “This is not rocket science. It’s a cultural change.”
The change can fly in the face of the traditional environment in which a single physician is in charge of the patient. But that paradigm no longer works so well in hospitals filled with patients suffering from multiple serious conditions, Hart says. For instance, he says, a surgeon who is in the operating room eight hours a day can’t also actively take care of recovering patients.
To implement Rapid Response Teams, “you really need to have the political support of your colleagues and you really need to be careful about how you conduct these changes,” Bellomo emphasizes. “You’ve got to have protagonists — a nursing protagonist and a medical protagonist — who have high profiles and the respect of their peers. If you don’t have that, forget it.”
Bellomo also underlines the importance of gathering evidence for the team effort. “You’ve got to collect data before you implement it, and you’ve got to collect data after you implement it.” If data show that you can cut cardiac arrests in half, for example, the discussion shifts from whether to make the change into how to accomplish it.