Evidence Based Practice: Implementation of a Rapid ...



Evidence Based Practice: Implementation of a Rapid Response Team

Angela Baird, Angela Delo-Miller, Keisha Doolan, Sherrie Moseler , and Chad Wolinski

Ferris State University

Research in Nursing

Dr. Baker

Abstract

In an effort to improve quality of care and decrease mortality, healthcare delivery systems are developing medical emergency teams. These medical emergency teams are also known as rapid response teams. This is a group of clinicians trained to treat critical patients at the bedside, outside of the intensive care unit. Establishing a rapid response team may affect patient mortality by allowing the healthcare provider the opportunity to intervene in a more expedient nature to a deteriorating patient’s status. The initiation of a rapid response team has proven to be successful in many healthcare organizations. There is evidence showing a reduction in the occurrences of non-intensive care unit arrests as well as decreased mortality from such adverse events.

Evidence Based Practice: Implementation of a Rapid Response Team

The research of the “5 Million Lives Campaign” presented by the Institute for Healthcare Improvement will be demonstrated. In addition, the data that demonstrates the benefit of the establishment of these types of response teams in a healthcare system will be provided. Intensive surveys of specific healthcare organization’s research regarding the development of these types of response teams will be reviewed. Testimonials from healthcare organizations will be discussed, which includes the analysis of outcomes of decreased mortality rates specifically found in their healthcare organization. Lastly, legal implications that affect our nursing practice will be discussed. The term “failure to rescue” will be introduced with the supporting data and research. The research will reveal that healthcare organizations need to make changes to become more assertive and aggressive to help protect the patients from preventable mistakes that could potentially cause life-threatening events.

There are differences in both quality of care and the safety of patients in healthcare today. This variability is evident in hospital mortality rates. Vital improvement for patient safety has triggered an enormous amount of positive change in healthcare systems. Patient care is evolving in the healthcare setting and we are beginning to see more critical patients on medical and telemetry units. With an overwhelming change in acuity, the floor nurses are impacted greatly by these changes and honestly, at times, finding it difficult to keep up with the fast pace. Consequently, this trend is causing many medical errors related to several variables. To mention a few, the nurses are experiencing not only higher acuity, but staffing issues (Aleccia, 2008). To add more fuel to the fire, the healthcare industry is facing financial challenges, which directly affects patient flow. Hospitals are pushing to get patients into the hospital and to a hospital bed. The basis of financial reimbursement is on the amount of admissions and length of stay for the hospitalized patient, thus causing the focus placed on the amount of patients admitted. As a result, the nurses are being pushed to quickly get patients through the doors and potentially causing medical errors. In addition, some of the floor nurses have limited critical thinking skills and at times rely on more experienced nurses to help problem solve. As a result, the floor nurses could be at risk for being unable to recognize signs and symptoms of a patient’s declining status related to all of these reasons mentioned (Clarke, 2003).

Definitions

Rapid Response Team

A rapid response team (RRT) provides assistance to the floor nurses who may be unable to handle developing crisis with the patient and is a group of clinicians that are trained to treat critical patients at the bedside, outside of the intensive care unit (Institute for Healthcare Improvement). Establishing rapid response teams has been shown to impact patient mortality by allowing the healthcare provider to intervene more quickly to a patient’s deteriorating status (Gould, 2007). Normally, if a patient’s condition deteriorates, the patient would wait until he/she would get to intensive care in order to receive critical bedside nursing. It is documented that a patient usually will exhibit signs and symptoms of impending cardiac or respiratory arrest 6-8 hours before the arrest actually occurs (Institute for Healthcare Improvement). If these signs and symptoms are identified early, the rapid response team could provide critical bedside consultation and the outcome for the patient could be immensely affected. Once a patient goes into a cardiac or respiratory arrest, the survival rate is less than 15% (Krysl, 2007). Early intervention at the first sign of symptoms is vital.

Failure to Rescue

Failure to rescue is a term heard in the legal arena. According to an article posted in the Executive Post, for the straight fifth year, an analysis of errors in our nation’s hospitals found that the most reported patient safety risk was “failure to rescue.” The term “failure to rescue” refers to cases where hospital doctors, nurses, or caregivers fail to recognize symptoms, or do not respond adequately or swiftly enough to clinical signs, when a patient is dying of preventable complications in a hospital (Morse, 2008, p.2). Dr. Jeffery H. Silber, Director of the Center for Health Outcomes and Policy Research first coined the term “failure to rescue” in the 1990’s when he was looking for a way to characterize the matrix of institutional and individual errors that contribute to patient deaths (Aleccia, 2008).

Save Five Million Lives Campaign

The Institute for Healthcare Improvement launched an impressive campaign to “save 5 million lives” in 2006. This campaign was a voluntary initiative to protect patients from five million incidents of medical harm over a two-year period (December 2006-December 2008). There were 3,700 hospitals enrolled nationwide in the initiative to save lives. Guidelines from several organizations have been recognized as best practice and healthcare delivery systems are putting actions into place to address these guidelines. One of the guidelines was the initiation of a rapid response team in order to assist with all of the expectations set forth to improve patient safety. The precursor to this campaign was the “save 100,000 lives campaign” (Institute for Healthcare Improvement). The notion that healthcare providers are displaying efforts to improve patient safety is applauded. This sets an enormous example for healthcare delivery systems and practicing healthcare providers, as patient safety and well-being should be at the forefront of healthcare improvement. After all, we all live by the Hippocratic Oath: “Above All, Do No Harm” (Gould, 2007, p.26).

The Institute of Healthcare Improvement shared data regarding the implementation of rapid response teams. A study revealed before and after results assessed with a clinical trial of rapid response teams (Institute for Healthcare Improvement). The research found was as follows:

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Tables adapted by Table adapted from Bellomo R., Goldsmith, D., Uchino, S., et al (2003). A Prospective Before and After Trial of a Medical Emergency Team. Medical Journal of Australia, 179 (6), 283-287.

Literature Review

The research shared provided significant support for the development and utilization of rapid response teams. The statistics revealed an appreciation for the impact that these types of interventions can have on improved patient outcomes. The Institute for Healthcare Improvement (IHI) has been at the forefront of research and communication of rapid response teams. The organization frequently posts latest research at the web site. Since the initial research from IHI, other hospitals have conducted their own studies as well. This report will provide some of the research and data regarding rapid response teams and the success organizations have discovered.

To review the documented research, a study published by the Journal of American Medical Association reviewed the implementation of rapid response teams and its effect on hospital wide mortality rates and code rates. The design included a 264-bed hospital with a total of 136,957 patient days that were assessed pre-intervention and post intervention (Sharek, 2007). According to this study, hospital mortality rates were found to decrease by 18% (1.01 total deaths per 100 discharges). The monthly code rate, per 1000 patient days, was decreased by 71.2%. The conclusion was determined that a rapid response team statistically reduced hospital wide mortality and code rate.

Henry Ford Hospital in Detroit, Michigan found that a rapid response team reduces mortality. Henry Ford Hospital set forth the goal to reduce the hospital mortality rate by 25% in one year, with the initiation of a rapid response team (Institute for Healthcare Improvement). After the development of a rapid response team, Henry Ford Hospital did a comparative research analysis to review the data. It was found that first, the goal was achieved, and secondly, they found that early intervention reduces hospital mortality rates. The development of a rapid response team was important and directly related to the improvement. The finding that early intervention was greatly influential to the mortality rate was noteworthy as well. Early intervention is vital to improved outcomes (Aleccia, 2008).

Sutter Solano Medical Center (Sutter Solano Medical Center, 2007) revealed that implementation of a “rapid response teams enhanced patient care.” During the first year of the utilization of rapid response teams the “number of cardiac arrests outside of the intensive care unit declined by 34%” (Sutter Solano Medical Center, 2007). The implementation of a rapid response team at Sutter Solano Medical Center revealed the following: (1) Improved patient care by rescuing patients prior to cardio-pulmonary arrest, (2) Expedited transfer of patients to ICU, when appropriate, (3) Demonstration to the community that the hospital is committed to patient safety, and (4) Enhanced ability for the hospital to recruit and retain nurses (Sutter Solano Medical Center, 2007).

Yale-New Haven Hospital discovered a “50% reduction in cardiopulmonary arrests outside of the pediatric intensive care unit” (Medical News Today, 2006). Yale-New Haven Hospital is cited as being one of the first pediatric hospitals to implement a rapid response team. Related to their success, they have been recognized as a “Mentor Hospital by the National Association of Children’s Hospitals and Related Institutions.” As a result, faculty members in pediatrics will serve as a “resource for training in this area to other children’s hospitals around the country” (Medical News Today, 2006).

An article written in Critical Care Medicine (2007) reviewed the data of a research project that determined the effects of a rapid response team on the rates of in-hospital cardiac arrests, total and unplanned intensive care unit admissions, and hospital mortality. The design was a before and after perspective. The setting was a 350 bed community hospital. The results revealed that post RRT implementation, the in house cardiac arrests dropped from 7.6 to 3 per 1000 patients studied and the overall hospital mortality rate decreased from 2.82% to 2.35%. The incidence of unplanned intensive care admissions decreased from 45% to 29%. The conclusion of the study revealed that the implementation of a RRT significantly was associated with the observed decline in rates of in-hospital cardiac arrests and unplanned intensive care admissions (Dacey, 2007).

Trillium Health Centre, in Mississauga, Ontario, Canada performed a survey as well, regarding the initiation of a rapid response team. Their survey revealed an interesting point: they discovered in their research that using a rapid response team will result in earlier identification of a patient’s risk of deteriorating status (Institute for Healthcare Improvement). Timely intervention should result in a decreased incidence of cardiac arrest. In addition, the ability to have trained critical nurses at the bedside to assess and assist the medical nurses was a great asset which also lead to the medical nurses feeling supported and mentored by the more trained and experienced nurses. Another example is Mercy Medical Center in Sioux City, Iowa which has developed a rapid response team. They, also, have discovered that this has improved patient outcomes and saved lives (Krysl, 2007). Children’s hospital in Central California has established a rapid response team. They had found the benefits of the development and discovered a link between early intervention and outcomes. It was the early detection of a patient’s declining status and intervention that lead to a more positive improved outcome (Golden, 2008).

Clinical Significance

Usually when a patient begins to develop medical complications, their internal compensating mechanisms will begin to respond. A patient may display an increased heart rate to compensate for decreased oxygenation or they may be bleeding internally. The cause of the progressive complications certainly needs correction. As healthcare providers, we may not be able to visualize the exact cause of distress, but we must recognize the signs and symptoms of the impending complications. With the recognition of the signs and symptoms of complications, it is imperative that the healthcare provider address them and investigate their cause. This is the early detection and intervention phase. If a healthcare provider allows the early signs and symptoms of complications to continue, the body will compensate for only a short period. Consequently, the body will then decompensate and possible cardiac and/or respiratory arrest most likely will occur. Experienced practitioners understand that signs and symptoms need investigation to rule out all causes in order to provide the highest quality care to our patients. Early signs and symptoms are nature’s way of speaking out for help and we need to take them seriously.

Critical Appraisal of the Evidence

Upon review of the literature, the best practice identified was the initiation of an emergency response team. Rapid response teams have been discovered to have colossal impact on the quality of patient care and outcomes.

A Prospective Before and After Trial of a Medical Emergency Team

The findings from this research study were clearly presented. The research question was whether a rapid response team contributes to decreased mortality and cardiac arrests. The study by Bellomo (2003), revealed impressive statistical findings using the Fisher’s extract test. P value was stated to demonstrate the research and reject the null hypothesis (RRT does not impact mortality). This statistic P< 0.001 was in the study to demonstrate the number of cardiac arrests decreased from 63 to 22. A concrete difference was described after the introduction of a rapid response team. P ................
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