Rapid Response Teams: Reducing Codes and Raising Morale

Hospital staff nurses have a long tradition of turning to each other when they’re worried about a patient. Confirming a colleague’s judgment, or offering guidance or another pair of hands, are just some of the ways nurses support each other in their challenging and high-stakes jobs.
Now that kind of support is becoming institutionalized at hospitals across the nation and around the world, as caregivers recognize how collaboration can head off crises in the making. By calling a hospital’s Rapid Response Team when a patient first begins to show signs or symptoms of deteriorating health, nurses and other clinicians are able to quickly benefit from the expertise of other colleagues before things get worse.
The idea is for the Team — which can vary in composition but always includes a critical care nurse, often a respiratory therapist, and sometimes an intensivist — to assess a patient’s condition and to determine with the bedside nurse the next best steps. One of the six interventions in the 100,000 Lives Campaign, launched in December 2004 by the Institute for Healthcare Improvement (IHI), Rapid Response Teams are associated with reductions in “codes,” or cardiac arrests, in many hospitals, as well as falling mortality rates.
In addition to their significant value as a clinical tool, Rapid Response Teams are also changing hospital culture. Nurses are encouraged and empowered to ask for help without fear of appearing incompetent, there’s more emphasis on shared learning, and everyone gets the message that support is a critical component in clinically challenging situations. All these benefits are expected to have a positive impact on nursing recruitment, retention, and satisfaction.

A Recruiting Tool

Long-time nurses say that the Rapid Response Team concept draws on the kind of collaboration that has always been part of the profession, but that has been harder to maintain as nurses have gotten busier with more and sicker patients. “When I began in nursing, I was surrounded by people with different levels of education and experience, and I would always ask someone to give me their opinion about things like a patient’s color or mental status,” says Mary Therriault, RN, BSN, Director of Quality and Research Initiatives at the Healthcare Association of New York State, and a faculty member in the nursing program at Maria College in Albany. “It felt like team care, and I think we got away from that. This brings back the team concept.”

For nurses new to the field, the appeal is obvious. “Our recent graduates say it feels like having a nursing instructor for a little longer,” reports Mary Therriault. “When they are students, we are at their elbow, and they ask for our opinions and help. When they get into their first job, they are concerned about doing the right thing, and most of all they don’t want to hurt a patient. Having access to the Rapid Response Team is very reassuring to them.”
So attractive is the idea to new nurses that many recent graduates report they only considered jobs at hospitals that have Rapid Response Teams, says Linda Millenbach, RN, PhD, Chair of the Department of Nursing at Maria College. “As we prepare them for the professional world we talk about the importance of support systems. We encourage them to ask questions about support when they look for a job. Many say they ask specifically if Rapid Response Teams are in place,” she says.
Mary Therriault confirms this. “I had three nursing students who took jobs specifically because the hospitals have Rapid Response Teams. It was one of the things they were looking for in a first-time nursing job,” she says. “One graduate said that it allays one of her greatest fears: working on the night shift and having no one to go to if a patient’s condition changes.”
At Richmond Heights Hospital, part of the University Hospitals Health System (UHHS) based in Cleveland, Ohio, ICU and Step-Down Units Manager Sharon Garretson, RN, BSN, says she recently interviewed two RNs who were both very excited about working in a hospital with a Rapid Response Team. “One came from a hospital that also had Rapid Response Teams, and she said she didn’t know if she would have accepted this job if we didn’t also have that kind of system.”
Nursing Program Chair Millenbach thinks the demographic make-up of the new nursing workforce is one reason that the Rapid Response Team concept is so effective. “The average age of our students is 32,” she says. “These somewhat older students may be new to nursing, but they often bring well developed critical thinking skills and many have gained self-confidence in another career and aren’t afraid to ask for help. They aren’t insecure and worried about appearing inadequate.”

An Antidote to Frustration

Kathy Duncan, RN, faculty expert on Rapid Response Teams for IHI, says there is growing excitement in the nursing community as word spreads about this new model of care. “The appeal of the Rapid Response Team is that nurses don’t have to go it alone anymore,” she says. “It means they don’t have to feel alone when they have an inkling that something might be wrong. It means they can get a colleague or several to validate their concerns or put them to rest.”

This kind of support might be the antidote to the frustration many new nurses reportedly feel, says Duncan, “when we throw them out there with several really sick patients and no tools to help them take care of those patients.” This frustration and the accompanying fear of making a mistake is likely one of the reasons that a 2001 report published in Health Affairs found about a third of nurses under the age of 30 reported plans to leave their hospital nursing jobs within a year. [Health Affairs. 2001;20(3):43-53.]
Some efforts are already underway to measure the impact of Rapid Response Teams on nurse recruitment, retention, and satisfaction. The Robert Wood Johnson Foundation (RWJF) has awarded grants to nine large hospital systems — such as Catholic Health Initiatives and Tenet Healthcare Corporation, along with academic medical centers and VHA Inc., a not-for-profit health care alliance — to introduce and spread Rapid Response Teams, and to study the impact of their use on the nursing workforce. Through IHI, Kathy Duncan is working with RWJF to provide technical support to the grantees. “We will be measuring how this intervention changes the culture for nurses, and whether it is helping keep nurses in their jobs,” she says.
Anecdotal evidence is encouraging. “One of my nurses told our Chief Nursing Officer that the Rapid Response Team is one of the best things she’s ever done for nursing and for patients,” says Barbara Rogness, BSN, Director of Quality at St. Joseph’s Hospital in Milwaukee, Wisconsin, part of the Wheaton Franciscan Healthcare System.
“Our nursing staff definitely sees this as a valuable resource,” says Cathy Pfeil, RN, BSN, CCRN, Director of Critical Care Nursing at Tallahassee Memorial Hospital, a VHA-member hospital that has had Rapid Response Teams in place since 2003. Tallahassee Memorial has also been a part of IHI’s RWJF-funded Pursuing Perfection program. Data bears out the nurses’ perception: in less than two years the hospital saw a 16 percent reduction in mortality and a 72 percent reduction in codes outside the ICU.
But just because Rapid Response Teams are growing in popularity doesn’t mean nurses always embrace the concept from the very beginning, especially if they’ve been in the nursing workforce for a while. Some feel they don’t need to call on others after years of making their own judgments; others worry that the team will swoop in and usurp their role.
Neither scenario is true, says Tallahassee Memorial’s Cathy Pfeil. “The Rapid Response Team must truly behave as a consultant. They can’t take over like a code team. They are there to support the nurse’s role.” This could mean providing help assessing a patient’s situation, or simply providing extra sets of hands when there is more to do than one nurse can reasonably manage.
Collaborating to provide care when a patient needs it most has helped bridge an age-old cultural divide between ICU nurses and floor nurses, says Lisa Leach, LPN, an ICU nurse at UHHS Richmond Heights Hospital who serves on her hospital’s Rapid Response Team. “There’s always been a little bit of tension between the two,” she says. “But with the Rapid Response Team, the ICU nurses get a better understanding of what the floor nurses are dealing with. We care for two critically ill patients in the ICU; they have a demanding patient load and it is spread throughout the floor.” Conversely, she says, the floor nurses grow to respect the expertise of their ICU colleagues, and begin to learn from them. “Now the nurses are better prepared when we get there. They are part of our team.” Leach says floor nurses will sometimes come to the ICU to check on a patient who was transferred there as a result of the Rapid Response Team call. “Before, they would never come in the ICU. It just wasn’t their territory. Now those barriers have been broken down.”
Stories such as these demonstrate why Rapid Response Teams must be thoroughly coached on their role, just as nurses need training on when to call the Team and what to expect. Hospitals that introduce Rapid Response Teams successfully provide plenty of both, along with evidence that the Teams help patients and support staff. And they focus considerable energy on creating a collaborative culture that supports nurses — or anyone — who ask for assistance.

Avoiding A Mutiny

At Richmond Heights Hospital in Cleveland, Sharon Garretson says that initial resistance there has given way to strong support. “If we said today we were going to get rid of the Rapid Response Team, we’d probably have a mutiny on our hands,” she says. Part of the key to that attitude change, says Garretson, is data showing the impact of the Team.

“We have decreased cardiac arrests per 1,000 discharges by 44 percent, and cardiac arrests outside the ICU by 67 percent,” says Mary Beth Rauzi, RN, MSN, Manager of Learning Services at Richmond Heights. “Our total mortality is down 14 percent. When nurses see results like that, they see that they are making good calls, their judgment is being validated, and they are proud to be part of this change.”
Barbara Rogness at St. Joseph’s in Milwaukee says the written comments she gets when she evaluates each Rapid Response Team call are almost universally positive. Examples include:
  • This was a great experience, with great ideas put into place quickly.
  • The team asked for my needs, and then together we dealt with the patient’s needs.
  • Several suggestions made the patient outcome improve.
  • Although this patient’s assessment was unremarkable, the x-ray the team ordered was instrumental in diagnosing his worsening heart failure.
Kathy Duncan hears these kinds of comments in hospitals all over the country. “What nurses are discovering is that this is not just a tool to rescue patients,” she says. “It’s a tool to help colleagues support one another. The more I see it in practice and the more I study it, the more convinced I am that this represents a dramatic change in the culture of nursing, and an exceptionally good teaching tool. What a new nurse can learn on one Rapid Response call will help her and her patients for the next 20 years.”​
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