A 73-year-old woman was recently recovering from abdominal surgery in the hospital. She seemed to be doing well, but two days after the operation her heart rate rose and her blood pressure dropped. Her color was a little off, too.
The nurse caring for the patient recognized these changes as early signs of a potential downward spiral, and called in the hospital’s
Rapid Response Team, a group of critical care specialists available to rush to the bedside of any patient who seems to be heading for trouble. The team quickly determined the patient was experiencing atrial fibrillation, and in consult with the bedside nurse and the attending physician, immediately started the woman on medication not typically available on units outside the ICU. Her heart rate dropped, her blood pressure rose, and she was transferred to the Cardiac Intensive Care Unit.
This is a story the staff at Tallahassee Memorial HealthCare, a 770-bed acute care and extended care facility in Tallahassee, Florida, share with pride. They hope it will convince other hospitals to adopt this critical, life-saving intervention.
The use of Rapid Response Teams is perhaps the most dramatic of the six strategies at the heart of IHI’s 100,000 Lives Campaign. Based on research showing that patients often exhibit signs and symptoms of increasing instability for several hours prior to a cardiac arrest — changes in breathing, heart rate, or mental status, for example — the idea is to rescue patients early in their decline before a crisis occurs.
Although Rapid Response Teams were pioneered in Australia, by February 2007 more than 2,100 US hospitals had pledged to implement Rapid Response Teams as part of the Campaign, with more than 1,500 reporting that teams had been put into action. Hospitals using Rapid Response Teams typically observe reductions in the number of cardiac arrests, unplanned transfers to the ICU, and, in some cases, the overall mortality rate.
In most hospitals, the Rapid Response Team is different from the Code Blue Team that responds to a patient experiencing a cardiac arrest. The Rapid Response Team intervenes upstream from a potential code situation, relying on bedside nurses who are highly sensitive to signs that a patient’s condition is deteriorating, and empowered to call others into action. In hospitals that have fully implemented them, Rapid Response Teams are typically called about 10 times a month for every 100 occupied beds.
The composition of Rapid Response Teams, and even the name itself, vary from hospital to hospital, with some calling it a Medical Emergency Team or a Rapid Assessment Team. Bedside nurses call teams by phone, beeper, or overhead page, and team members are alerted simultaneously or sequentially. In some hospitals, calling the Rapid Response Team is an option; in others, it’s required if patients exhibit specific symptoms. These differences reflect the varied settings, cultures, and resources in which the teams operate, and highlight the flexibility of the core concept, says Kathy Duncan, RN, formerly Director of Critical Care Nursing at Baptist Memorial Hospital-Memphis, and now working with the 100,000 Lives Campaign as a Rapid Response Team expert.
“Most hospitals can’t go out and hire a team specifically for this purpose, nor should they. The experts are already in the building,” says Duncan. “There are plenty of variations in terms of who's on the team, but if the core ideas of early assessment and intervention are followed, they all can save lives.”
For example, at UPMC McKeesport, a 219-bed University of Pittsburgh Medical Center hospital located 10 miles southeast of Pittsburgh in McKeesport, Pennsylvania, the Rapid Response Team and the Code Team, which includes eight people, are one and the same. “We’ve empowered our nurses and others to call the team for whatever level of help they need,” says T. Michael White, MD, FACP, and Senior Vice President for Value and Education at UPMC McKeesport. “We don’t want the clinician at the bedside to spend any time trying to decide which team to call.”
McKeesport introduced the Rapid Response Team concept about three years ago, inspired by the success of Rapid Response Teams at the system’s flagship hospital, UPMC Presbyterian, where Dr. Michael DeVita had championed the idea. McKeesport has seen a steady increase in what they term “Condition C” calls (for early intervention) and a decrease in Condition A, or traditional Code Blue, calls.
More typically, however, Rapid Response Teams are smaller and distinct from Code Teams. Some include an intensivist or physician’s assistant, but most teams are anchored by an ICU nurse, whose experience with vulnerable patients can help guide bedside nurses in their assessment and response to the patient, and a respiratory therapist, because the majority of patients showing early signs of distress have breathing difficulties.
In the Old Days
“In the old days, a nurse could struggle for 90 minutes with a failing patient,” says White in McKeesport. While doing all the right things — working to assess what is going on with the patient, trying to reach the patient’s physician, perhaps waiting for test results or physician’s orders — she may not actually be advancing care, says White.
In addition to potentially delaying important interventions for a “crashing” patient, White says these scenarios often “create high anxiety and frustration for the nurse, and interfere with her ability to care for the rest of her patients.” For this reason, says White, nurses at McKeesport are required to call the Rapid Response Team whenever a patient experiences a significant change in status.
The idea is not for the team to supplant the patient’s doctor (in most hospitals, the nurse is expected to call the patient’s physician or the attending physician as well as the Rapid Response Team), or to sweep in and take over for the nurse, but rather to work side-by-side with him or her. “ICU nurses are likely to be long-term nurses who have gained highly effective assessment skills,” says Diane Sanders, RNC, MN, Director of Patient Care Services at Kadlec Medical Center, a 153-bed acute care hospital in Richland, Washington, where Rapid Response Teams have been in use since the beginning of 2005. “They can be enormously helpful to the floor nurses, especially for recent nursing school graduates who are still developing their critical care assessment skills.”
This is really just an extension of the mentoring that has always been part of nursing, says Sanders. “Nurses have always relied on each other unofficially for help. Now we are saying not only that it’s okay to do that, but it’s good care.”
In the 100,000 Lives Campaign
Rapid Response Team How-to Guide, IHI lists specific recommended criteria for calling the team — acute change in heart rate to less than 40 or more than 130 beats per minute, or in systolic blood pressure to less than 90 mmHg, for example — but in most hospitals nurses are encouraged not to rely too literally on the criteria, and to call the Rapid Response Team if they simply have a gut feeling that something’s wrong. “If we get too tight with the criteria, and don’t encourage people to trust their instincts, we might miss opportunities to help patients,” says Kathy Duncan. “Nurses need to be able to say, ‘Gee, I checked him at 7:30 and now he just doesn’t look right,’ and have someone value that judgment.”
“Nurses usually know when something’s not right,” agrees Cathy Pfeil, RN, Nurse Manager for the Medical/Surgical and Cardiovascular ICUs at Tallahassee Memorial HealthCare (TMH). “They just can’t always articulate it.”
Learning to Love It
The stories of how Rapid Response Teams are implemented in hospitals vary as much as the design of the teams themselves. Sometimes a quality officer or physician champion gets the ball rolling. In other settings it’s a nurse-led initiative. Either way, getting key people to support the concept is important, as are ongoing reminders about its value.
At UPMC McKeesport, Michael White experienced a proverbial smack of the palm on the forehead when he first learned about Rapid Response Teams, which had been implemented in his system’s flagship hospital, UPMC Presbyterian in Pittsburgh. “As soon as I heard the concept, I knew I should have thought of it a long time ago,” he says. “I began immediately to learn more so I could bring the concept to our institution.” White recruited important internal champions from emergency services, respiratory therapy, and critical care nursing. “They loved the idea right away,” he says.
To train hospital personnel about when and how to use the Rapid Response Team, White and his team put together a teaching/learning packet that walks learners through the Rapid Response Team concept and the steps involved in its use, and includes case examples and a self-assessment. Every clinician is required to complete and sign the packet. “We used the packet to teach 30 people at a time, or one person at a time,” says White. “It’s very simple, but very effective.” So effective, in fact, that McKeesport’s use of this and other quality- and safety-related teaching/learning packets won it the 2004 John M. Eisenberg Patient Safety Award for Innovation at a Local or Organization Level.
At Kadlec Medical Center in Washington State, leaders were worried about adding “one more thing” to the nurses’ already full plates. “We purposely chose to call it the Rapid Assessment Team, or RAT, so it would be memorable and we could sell it more easily,” says Patient Care Services Director Diane Sanders. Signs, tee shirts, even toy rats on the units remind nurses to “Call the RAT” if they need help.
Sanders says now they needn’t have worried: the concept sold itself. “We completed the training for staff, and in the week before we even went live with the RAT, we got seven calls,” she says. The hospital now averages between five and ten calls per month.
Individual concerns about Rapid Response Teams — ranging from physicians who worry they will be left out of the loop to nurses who fear they will seem unskilled if they call for the Rapid Response Team — often fade once the team is in use. Still, most hospitals find they must wage an ongoing internal “marketing” campaign until use of the Rapid Response Team becomes ingrained. “You have to keep it in the forefront of people’s minds,” says Nancy Sanders, RN, BSN, Performance Improvement Coordinator at Missouri Baptist Medical Center, a 489-bed acute care community hospital in St. Louis, Missouri. “We send copies of the
Rapid Response Team Record to the nursing managers weekly, so they can share the purpose and the results of each Rapid Response Team call with the nursing staff.”
Sometimes Rapid Response Team members themselves must adjust to a new way of thinking. At Missouri Baptist, a physician assistant (PA) heads the Rapid Response Team. “PAs are accustomed to working independently,” says Nancy Sanders. “On the Rapid Response Team they work in partnership with an ICU nurse and a respiratory therapist. Sometimes this can be a challenge for the Rapid Response Team members.” Sanders also reported that in the early stages of the Rapid Response Team implementation, the Rapid Response Team requested that a written survey be completed about the benefits of the Rapid Response Team and asked for any additional comments after each Rapid Response Team call. Sometimes these comments prompted further coaching of the bedside Rapid Response Team providers to better meet the needs of the nursing and hospital staff.
In the end, though, positive experiences with the Rapid Response Team are the best advertising. At 370-bed McLeod Regional Medical Center in Florence, South Carolina, Medical ICU Nursing Director Mark Williams, RN, MBA, says that even long-time nurses, initially reluctant to call in the Rapid Response Team, became converts quickly. “Once they use the Rapid Response Team, they say they wish they had started using it sooner,” says Williams.
The Bottom Line
The use of Rapid Response Teams is producing positive clinical results, and is benefiting hospitals’ organizational cultures and staff morale as well.
“In the old days, calling for help was misconstrued as a sign of weakness. This turns that thinking upside down, and reminds everyone that the most important thing is caring for the patient,” says Michael White at McKeesport.
“Our nurses are recognizing people in trouble more quickly, and intervening sooner,” says Cathy Pfeil in Tallahassee. “For the first few months, we’d get calls about patients who were 15 minutes away from a Code. Now the calls are for lower-acuity issues.”
Adds Nancy Sanders from Missouri Baptist, “We believe it will help with nursing recruitment and retention. Nurses like knowing there is always someone to call.”
Moreover, many hospitals report that their Rapid Response Team has rescued patients and visitors in settings other than acute care beds, including outpatient testing areas, the cafeteria, and even the gift shop. “Everyone knows they can call the team whenever there is someone in trouble,” says Cathy Pfeil.
All the hospitals are collecting clinical data about outcomes to gauge the impact of the Rapid Response Team, including number of calls, number of Codes, and outcomes. “We have gone from about eight Codes per month to about six, and the survival rate has increased from 40 percent to 60 percent,” says White at McKeesport. “This suggests to me that people are calling Codes sooner.” White says about half of the approximately 25 non-Code, early intervention calls the team gets each month result in the patient moving to a higher level of care.
At Missouri Baptist, which implemented Rapid Response Teams in April 2004 and now averages about 65 calls per month, cardiac arrests dropped in 2004 by 31 percent from the year before. Tallahassee has experienced a 33 percent drop in Codes since implementing Rapid Response Teams in August 2003. At McLeod, Codes dropped by 35 percent in a recent three-month period compared to the same period in 2004, prior to the hospital’s use of Rapid Response Teams.
