As health care goals go, it’s hard to beat “reducing mortality” for its combination of simplicity and power. At Baptist Memorial Hospital-Memphis (Memphis, Tennessee, USA), mortality rates have been slowly but steadily dropping, due in part to the implementation of a new program that has helped staff prevent medical crises and reduce patients’ risk of dying.
Baptist Memorial Hospital-Memphis is the flagship of the Baptist Memorial Health Care system, which serves the Mid-South with 17 hospitals. With 736 beds and an average daily census of 600, Baptist-Memphis is a busy hospital serving a large city and its surrounding area.
As members of IHI’s IMPACT network, Baptist-Memphis has a long and impressive record of improvement work. They’ve participated in IHI Collaboratives in critical care, patient safety, flow, and now are part of the Innovation Community on Reducing Mortality Rates, as measured by the Hospital Standardized Mortality Ratio
(HSMR), a risk-adjusted mortality rate that provides one means of measuring the quality and safety of care in a hospital.
As part of a prototype group for the HSMR Innovation Community, a group of six US hospitals and two in the United Kingdom has been working together to test innovative strategies designed to decrease mortality in each hospital by 25 percent in six months.
Even prior to the Community’s inception, says Kathy Duncan, RN, director of critical care at Baptist-Memphis, staff there was exploring ways to provide better care for unstable patients. “We knew there were some areas where we could improve,” she says.
They knew, for instance, that they were doing a pretty good job helping patients survive a Code Blue — they were reviving more than 60 percent of patients who had heart attacks — but in the days following the incident, about 85 percent of those patients died. “We were good at getting patients through a Code,” she says, “but not as good at getting them home.”
Implementing Rapid Response Teams
One of the concepts the Innovation Community discussed, and Baptist-Memphis piloted, is known variously as Rapid Response Teams
, Medical Emergency Teams, or, as Baptist-Memorial prefers, Medical Response Teams. With research showing that virtually all critical inpatient events are preceded by warning signs for an average of 6.5 hours, Rapid Response Teams take the idea of rescuing patients in trouble and move it forward in time, forming a sort of SWAT team designed to intervene with patients before
they develop serious medical problems.
“As doctors who respond when Codes are called, we recognized that a lot of patients could be helped more if we had been called 30 minutes earlier,” says Sonny Golden, MD, Baptist-Memphis’ ICU director.
Typically, says Golden, he or his colleagues might get calls about patients experiencing breathing difficulties. “But so often the information about the patient’s condition was incomplete, or too vague to make a rational conclusion, or by the time we got the call, the patient was in or near a crisis point.” This, says Golden, often led to bad outcomes. “We were really ripe for a rescue team that would come on the scene earlier.”
The Rapid Response Team is designed to do just that. The concept is relatively simple: create a small but powerful team experienced at assessing patients’ symptoms and the trajectory of their health, and make that team continuously and readily available to any provider who wants a second opinion about a patient, particularly a patient showing signs of potential decline.
At Baptist-Memphis, where Rapid Response Teams were introduced in August 2003, the team consists of an experienced critical care nurse (from a pool of ICU nurses who rotate on and off the team), a respiratory therapist, and/or an Intensivist when available (typically at night). A team is always available, and typically responds to calls within five minutes.
Listening to a Gut Feeling
Anyone can call the Team to consult on a patient, says Duncan, and the team averages about 21 calls a week. Calls come primarily from floor nurses, based on specific symptoms they observe or simply on a gut feeling that the patient may be headed for trouble. As a guide for staff, the team issued the following “trigger” list:
- Staff member is worried about the patient
- Acute change in heart rate
- Acute change in systolic BP
- Acute change in respiratory rate
- Acute change in O2 saturation
- Acute change in level of consciousness
“We don’t take over the patient’s care,” says Michelle Peck, RN, head nurse in the ICU and a Team member. “We try to gather complete information about the patient’s situation, and contact the doctor if necessary with all the information and a recommendation. If we think the patient needs to be transferred to the ICU, we can start that process.”
Trudy Beyersdorf, RN, is also a head nurse in the ICU and a member of the Team. She says the team has had a number of positive impacts on nurses and their patients. “The floor nurses and the ICU nurses didn’t used to even know each other,” she says. “We were two separate entities. Now we are working together.”
Mutual respect between the ICU and the floor nurses has grown with the program, says Jan Padgett, RN, manager of critical care. “The floor nurses respect the ICU nurses’ critical care skills, and the ICU nurses respect that the floor nurses handle a heavier patient load and are skilled at assessing symptoms without sophisticated monitors and equipment.”
The Real Bottom Line
The Team’s more important impact, however, is on patients’ health and outcomes. The total number of Codes at Baptist-Memphis has dropped about 28 percent since the program was implemented. The location of Codes has also changed. “Before, about 65 percent of our Codes were outside the critical care areas,” says Duncan. This suggests that patients may have been in the wrong setting for their condition. “Now, the majority of Codes are in the ICU, which tells us the highest risk patients are getting the highest level of care possible,” she says.
Most important of all, however, is the fact that the hospital’s mortality rate has declined from an HSMR of 109 when the program started to 75 today. A rate of 100 is the statistical average.
Additionally, through working with their critical care colleagues, the floor nurses have learned about ways to prevent more serious problems for patients. “Historically nurses have not gotten a lot of education about rescuing patients,” says Duncan. “Our floor nurses have learned to be more sensitive to opportunities to rescue patients before they get into serious trouble.”
Now, says Duncan, when the Rapid Response Team arrives on the scene, the nurses have already done much of what the Team would have done. “Since we started the program, the acuity of the calls has decreased not only because the nurses are better at reading symptoms and are calling earlier, but also because they are starting interventions earlier.” This observation is supported by data: the percent of patients transferred to the ICU after a consult with the Team has dropped from 82 percent to 46 percent.
Though Duncan says they initially had to “market” the program to floor nurses, now its merits are clear. “Some of our nurses say they could never work in a hospital that doesn’t have this program,” says Duncan. And because the Team follows up on each case it reviews, and reports back to nurses on the patients who are transferred to the ICU, nurses continually learn from their experiences. “Sometimes our directors will send a note to a nurse, saying ‘You saved this patient’s life.’ That kind of feedback is invaluable. That’s what our work is all about, after all.”