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Implementing a rapid response team: A practical guide

Garretson, Sharon RN, BSc (Hons), Dip HE; Rauzi, Mary Beth RN, MSN

doi: 10.1097/01.NURSE.0000312630.04929.1a
CRITICAL CARE
Free

Learn about one facility's experience setting up a successful team.

Sharon Garretson is manager of the pediatric/neonatal air and ground transport, and manager of the communications center at Akron (Ohio) Childrens Hospital.

At the time the article was written, she was nurse-manager of the orthopedic surgical unit at University Hospitals Richmond Medical Center in Richmond Heights, Ohio, where Mary Beth Rauzi is manager of learning services.

Because patient-acuity levels have risen and treatment has become more complex, hospitals have sought ways to recognize the warning signs of clinical deterioration and to intervene early to improve patient outcomes. With experts agreeing that 50% to 70% of adverse events that occur in hospitals could be prevented, the rapid response team (RRT) is emerging as a method to avert such deterioration.1,2

An RRT usually comprises physicians and nurses who respond to calls from hospital staff for assistance with patients experiencing acute clinical changes. The RRT's primary goals are to intervene early, reducing the rate of cardiac arrest and mortality and reducing emergency intensive care unit (ICU) admissions. A traditional cardiac arrest team reacts to situations, but the RRT is proactive.

Establishing RRTs was one of six strategies promoted in the Institute for Healthcare Improvement's 100,000 Lives Campaign.3 In this article, we'll describe how we set up an RRT at our facility, including the obstacles we faced and how we overcame them.

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First things first

The first step in starting a successful RRT is to obtain support from senior leaders of both administrative and medical staff.4 Changes in a hospital's culture can be difficult without those in leadership roles championing the RRT concept. Encourage those who resist the RRT to study documented successful outcomes in other facilities for evidence that an RRT can work in your institution. If other departments are to be included as team members, get them involved early.

Many team structures can be used to form a successful RRT, depending on staff available at your facility. Teams may be led by either a nurse or a physician; the literature has shown no difference in patient outcomes between the two models.5 In hospitals that don't have 24-hour on-site physician coverage, an advanced practice nurse may lead the team.6 In some facilities, a critical care nurse follows standing protocols to direct care.7 The team should also include a respiratory therapist to manage the patient's airway and maintain oxygenation.7 All team members must be trained in advanced cardiovascular life support (ACLS).5

At our facility, team membership has evolved as our experience has grown. Initially, the team comprised two tiers: Tier one, for basic care needs, consisted of a critical care nurse, respiratory therapist, and medical intern; tier two, for more advanced interventions, added the skills of the hospitalist to the tier one members. As calls for the team increased, we noted that the hospitalist was responding to most calls on both tiers, so the tier system was eliminated. Now one team responds to all calls.

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Who, when, and why to call the RRT

At our facility, the nursing staff was taught about calling the RRT. After feedback from staff, nursing assistants and other nonclinical staff who have patient contact were added to the list of who can call the RRT.

If a patient's clinical instability isn't recognized promptly, mortality and morbidity rates rise.5,8 Researchers have developed RRT calling criteria using certain signs and symptoms commonly exhibited in deteriorating patients (see When to call for action). These signs and symptoms may include but aren't exclusive to changes in level of consciousness, respiratory rate, oxygen saturation, heart rate, blood pressure, urine output, and lab results. But staff needn't wait for clinical changes; they're also encouraged to call the RRT on the basis of “being worried” about a patient—a gut feeling that something's not right.5,7,9

A mix of objective and subjective data may increase staff willingness to activate the RRT.5 For example, the criterion “being worried” about the patient lets a staff member activate the RRT in the absence of objective, observable patient changes. In a recent study, 18% of RRT activations were initiated by nurses who were worried about a patient.9 Nurses spend the most time with patients, so they may pick up on subtle changes that others may not recognize.

In our facility, staff members were trained to call RRT using the emergency number reserved for cardiac arrest team notifications. This would guarantee priority handling from the hospital operators.

Initially, we used the pager system to alert the team of an RRT call. We'd previously established a 5-minute response time for the team's arrival at the bedside, yet we often found a 4- to 5-minute delay before the pager was activated with the RRT information. So we added an overhead page in conjunction with the pager system. This dual system guaranteed that all team members could respond within 5 minutes.

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When to call for action

At our facility, nurses are encouraged to call the RRT whenever they're worried about a patient regardless of clinical indicators or when they observe any of these signs and symptoms:

  • an acute change in heart rate (less than 40 beats/minute or more than 130 beats/minute)
  • an acute change in systolic BP (less than 90 mm Hg)
  • an acute change in respiratory rate (less than 8 or more than 24)
  • an acute change in SpO2 (less than 90% despite oxygen administration)
  • an acute change in level of consciousness
  • an acute change in urine output (less than 50 mL in 4 hours)
  • chest pain.
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Getting the staff ready

Staff education is imperative for a successful RRT implementation. At our facility, unit nurses learned when and how to call the RRT and about their roles as RRT members. We distributed a pocket card with the calling criteria on the front and an SBAR (Situation, Background, Assessment, and Recommendation) communication tool on the back, to help the calling nurse succinctly convey critical information. Documentation tools were also reviewed during this session.

Team responders, including ICU nurses, were taught about symptom review, documentation tools, and the activation process for an RRT call. (Because all RRT members were ACLS trained, they didn't need treatment and medication reviews.) We stressed that all calls were to be answered and that nurses weren't to be criticized for making “unnecessary” calls. Each call was an opportunity for education for the unit staff and was to be treated as such.

Our team's first call came from the ICU, from an experienced nurse who needed help with a critically ill patient. As a result, we expanded the RRT's role so that ICU nurses could not only respond to RRT calls, but also receive RRT assistance in the form of immediate attention from a physician and respiratory therapist. In fact, since our RRT started, the ICU staff has initiated more than 15% of all calls.

To ensure the continued success of the program, we developed flyers and placed them in each patient room. Posters were placed in all public elevators describing the team and focusing on patient safety. We published articles about the RRT in the hospital's physician newsletter and sent information about the RRT to all physicians on staff in the routine monthly mailing. We also provided speakers for nursing staff meetings to communicate about the RRT.

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Breaking down barriers

Without the support of administration and physician and nursing leaders, an RRT may fail or never get off the ground. Physicians may resist the idea of a team being called to intervene with “their patient.” The physician champions at our facility were instrumental in assuring the attending physicians that control of each patient's medical course would be immediately transferred back to them and that they'd receive immediate communication from the hospitalist after the patient was stabilized.

A negative perception by nurses is another potential barrier to RRT implementation. Unit nurses may perceive the RRT as an indication that management thinks they can't properly look after patients. They may also be concerned that their clinical skills and judgment would be evaluated and seen as lacking every time they called the RRT. They were assured that all calls would be treated in a nonpunitive and nonthreatening manner.

The ICU nurses on the RRT were concerned about leaving their patients for extended periods and increasing their coworkers' workloads while they attended the call. We evaluated the time ICU nurses spent off the unit in the first 3 months of the RRT implementation and found that additional staff wasn't necessary. This may not be feasible at a large academic medical center, but no additional staff was needed at the University of Pennsylvania Medical Center–Presbyterian in Philadelphia, arguably one of the most successful RRT programs in the United States.10

Another potential barrier to RRT formation is lack of 24-hour physician coverage. However, many successful teams around the country are nurse-led, and RRTs may include advanced practice nurses.6 Another option is to develop standard order sets for the RRT to use in lieu of an on-site physician team member. An RRT can be successfully implemented based on whatever staff resources are available.

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Measuring success

As with any new initiative, measuring outcomes is essential to demonstrate the program's success and identify areas for improvement. Our facility collected data on mortality rate, cardiac arrest rate per 1,000 discharges, and cardiac arrests occurring outside the ICU. The results were hugely encouraging: Mortality rates fell 13% in the first year and 34% in the second. The number of cardiac arrests per 1,000 discharges dropped 44% in the first year and another 2 percentage points in the second year. Even more significant reductions in cardiac arrests occurred outside the ICU, with reductions of 67% (year one) and 60% (year two).

We also found an inverse correlation between the number of RRT calls and the number of cardiac arrests: The more times the team was called, the fewer cardiac arrests were seen and vice versa. These results are consistent with evidence from other studies.2,11

Some researchers have asserted that RRTs have limited success or that research promoting them is flawed.12,13 However, limited research is available and RRTs are a new concept in health care, so we can't conclude that the teams have no value. In our experience, nurses find value, patient-quality outcomes are improving, and relationships between ICU and unit nurses are evolving in a positive manner.

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REFERENCES

1. Cretikos M, Hillman K. The medical emergency team: Does it really make a difference? Internal Medicine Journal. 33(11):511–514, November 2003.
2. Buist MD, et al. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: Preliminary study. British Medical Journal. 324(7334):387–390, February 2002.
3. Institute for Healthcare Improvement. 100,000 Lives Campaign.. Accessed November 1, 2007.
4. Scholle CC, Mininni NC. Best-practice interventions: How a rapid response team saves lives. Nursing2006. 36(1):36–40, January 2006.
5. DeVita MA, et al. Findings of the first consensus conference on medical emergency teams. Critical Care Medicine. 34(9):2463–2478, September 2006.
6. Morse KJ, et al. A new role for the ACNP: The rapid response team leader. Critical Care Nursing Quarterly. 29(2):137–146, April-June 2006.
7. Durkin SE. Implementing a rapid response team. American Journal of Nursing. 106(10):50–53, October 2006.
8. Subbe CP, et al. Does earlier detection of critically ill patients on surgical wards lead to better outcomes? Annals of the Royal College of Surgeons of England. 87(4):226–232, July 2005.
9. Cioffi J. Recognition of patients who require emergency assistance: A descriptive study. Heart & Lung. 29(4):262–268, July-August 2000.
10. Mininni NC. Rapid Response Team Seminar. Columbus, Ohio, 2006.
11. DeVita MA, et al. Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Quality and Safety in Health Care. 13(4):251–254, August 2004.
12. Smith GB, Nolan J. Medical emergency teams and cardiac arrests in hospital. Results may have been due to education of ward staff. British Medical Journal. 324(7347):1215, May 18, 2002.
13. Winters BD, et al. Rapid response teams—walk, don't run. JAMA. 296(13):1645–1647, October 4, 2006.
© 2008 Lippincott Williams & Wilkins, Inc.