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When seconds matter: Rapid response teams and nurse decision making

McColl, Alma MSN, RN; Pesata, Virginia DNP, ARNP, NEA-BC, FNAP

Nursing Management (Springhouse): February 2016 - Volume 47 - Issue 2 - p 34–38
doi: 10.1097/01.NUMA.0000479446.20286.83
Feature

Empower yourself with analytic thinking, education, and teamwork to take full advantageof RRTs and improve patient outcomes.

At South University in Tampa, Fla., Alma McColl is an assistant professor and Virginia Pesata is DNP faculty.

The authors have disclosed no financial relationships related to this article.

Figure

Figure

Currently, most acute care hospitals have a rapid response team (RRT) to assist medical-surgical nurses in managing patients during crises.1 But despite the potential efficacy of RRTs, patients on these units continue to experience preventable adverse events. The underutilization of RRTs is linked to higher mortality from increased cardiac arrests, and can also impact patient length of stay.2

We present a review of the current literature on RRTs and nurse decision making to demonstrate how nurses can empower themselves with analytic thinking, education, and teamwork to take full advantage of their RRT and improve patient outcomes. We encourage nursing leadership to support staff in these efforts and ensure continual RRT evaluation and improvement.

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Methods

We reviewed literature from 2010 to 2015 using various databases, such as CINAHL, PubMed, Cochrane, and JSTOR. The search was limited to full-text, peer-reviewed articles and dissertations written in English. Key terms used were “rapid response teams” and “nurses decision making.” In addition to automated searches, a manual search of key article bibliographies identified other possible studies relevant to the topic.

The original search yielded 261 articles and one dissertation. Ultimately, 50 articles were considered for inclusion. Of these, eight studies on RRTs and eight studies on nurse decision making were included in this review.

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Nurses to the rescue

The implementation of RRTs in 2004 was a result of the Institute for Healthcare Improvement campaign to reduce mortality and morbidity in healthcare.3 The RRT customarily consists of a critical care nurse, a respiratory therapist, and a nursing supervisor. Each hospital sets its own criteria for RRT activation, which results in some variation in implementation across settings.

In 2008, The Joint Commission mandated that nurse leaders in acute care institutions monitor patient outcomes and improve processes to rescue deteriorating patients.4 National benchmarks for mortality and morbidity are now public, and hospitals are held accountable for their quality outcomes.5 Acute care hospitals are also required to provide failure to rescue rates, defined as the number of inadequate or delayed responses to a deteriorating patient.6 This is a vital measure of how nursing surveillance is assessed and evaluated in each facility.

The effectiveness of the RRT in reducing cardiac arrests, as well as the associated reduction in mortality, has been established in many studies.7,8 One integrated review of RRT implementation literature reported a reduction in all cardiac arrests in 60% of the studies and associated mortality in 40% of the studies reviewed.7 However, cardiac arrests that occurred in an uncontrolled environment, such as a medical-surgical unit, demonstrated poorer outcomes than those in a controlled environment, such as an ICU.8 These findings support continued utilization of RRTs, but highlight the need for standardized interventions for specific clinical scenarios of patient deterioration.

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Lost opportunities

Recognition of deterioration is a complex process; there are instances when a nurse fails to respond to a patient deterioration, resulting in underutilization of the RRT. A multicenter, mixed-methods study addressed three key considerations for how nurses can improve RRT utilization: better assessment of the problem that necessitates RRT activation, identification and elimination of barriers to calling the RRT, and interventions to improve the effectiveness of the team.9 The following sections examine each of these considerations in further detail.

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Continuing education

Several articles identified nursing-specific factors for RRT underutilization. A leading factor is the need for increased nursing knowledge and skill. A pre- and postimplementation survey evaluated the relationship between nurse demographics and identification of clinical situations warranting specific actions. These actions include RRT activation, which is influenced by factors such as level of education and CPR course attendance.10 Therefore, nurses should develop advanced clinical assessment and communication skills during formal and continuing education.11

Underutilization was recently quantified by a retroactive chart review that determined one in seven patients fulfilled the criteria for RRT activation during their hospital stay. Only three of the seven identified patients meeting the criteria for activation were referred to the RRT. Conclusions suggest that nurses may not consistently recognize the clinical significance or the urgency of aberrant vital signs, requiring further educational efforts.12

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Activation barriers

Examining the perceived barriers to activation is crucial to understanding RRT underutilization. A recent cognitive work analysis explains that some of the omnipresent conditions within a hospital system shape medical-surgical nurse reluctance or inability to call the RRT. Barriers included subtle or gradual clinical changes, inadequate information, availability of alternate health improvement strategies, the need to justify RRT activation to responders and physicians, a scarcity of human resources, and informal hierarchical hospital culture.13

Interactions between RRT nurses and medical-surgical nurses were also a large factor in decision making. When the medical-surgical nurse consulted with the RRT nurse and collegiality and role support were demonstrated, medical-surgical nurses made better RRT activation decisions and the outcome was better for the patient.14 An unexpected finding was the reluctance of the medical-surgical nurses to activate the RRT when they perceived that the ICU nurses were too busy to respond.15

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Decision-making skills

Researchers use the Nurse Decision-Making Instrument (NDMI) to identify and classify what decision-making models nurses use when faced with specific clinical situations. The instrument consists of 24 factors scored from 1 to 5. A low score describes an analytic approach to decision making, a high score an intuitive approach to decision making. The three decision-making models measured by the NDMI are analytic, intuitive, and mixed-method (analytic and intuitive).16

In one study, the NDMI was utilized to determine nurses' decision-making model as they responded to a deteriorating patient. The research then correlated the frequency of RRT calls to the type of decision making used by the nurses, and concluded that analytic decision makers had a higher incidence of RRT calls than intuitive decision makers.17 Therefore, analytical thinking is important for all nurses. Simulations and case study discussions are effective tools for developing analytical thinking.18

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Administration

Nurses should be empowered to make an RRT call, and they need support from their managers when they do call the RRT. Leaders should also support attainment of formal education and certifications among their nurses to improve patient outcomes. As previously discussed, this education enables nurses to recognize and treat a deteriorating patient before or when an RRT is required.

Teamwork is an important component of education and success that nurse administrators can cultivate. The use of interdisciplinary teaching in hospitals to increase nurse awareness of each clinician's role in the care of the patient is critical to effective RRT training. This in turn increases teamwork, which is especially important in critical situations.19

The role of nursing administration is significant in the daily implementation of the RRT. Without proper guidance, the team can't be effective with its interventions. Further, regular monitoring and RRT evaluation should be under the direction of nurse leaders. Ultimately, nursing administrators bear the responsibility for evaluating the RRT implementation process and proposing changes as needed for continued success.

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Room for improvement

The literature reviewed for this article included some gaps, indicating areas for potential further study and improvement. First, this systematic review exposes the lack of information standardization that nurses need to make decisions. Although we were able to compile general clinical criteria from these studies (see Table 1), national clinical practice guidelines and RRT activation protocols should be established and approved by regulatory agencies. After an organization implements these standards, education for nurses and responders should follow.

Table 1

Table 1

No benchmark data were identified in the literature. Benchmarks for hospitals to measure their utilization rates against other hospitals are necessary to improve outcomes and assist in the dissemination of best practices. Additionally, there are potential health information technology solutions to improve nurse surveillance. Hospitals that use the track and trigger tools tied to the patient's electronic healthcare record can actually alert the nurse to activate the RRT.12

The differences between analytical thinking and intuitive thinking require further research as well. Understanding all of the data that nurses need and use to respond correctly to a deteriorating patient is paramount.

Varying RRT composition also needs to be studied to compare effectiveness; identifying new roles for nurses in RRT activation warrants exploration. In fact, the perception that the RRT responders possessed specialized training and expertise served as a major facilitator.14 Therefore, advanced practice nurses may be a good addition to the RRT and prove effective in standardizing protocols as leaders of the RRT. A study defining the potential role of clinical nurse specialists in facilitating RRTs suggested that they're uniquely qualified to provide leadership in the development and implementation of RRTs.20

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Enhanced utilization

Nurses spend more time with patients than any other members of the healthcare team. This means that nurse surveillance is critical to recognizing and preventing patient deterioration. With increased surveillance, quick responses, and early interventions, patient outcomes and nursing care quality improve.

Increasing nurses' educational attainment and self-awareness of decision-making processes is key to enhanced RRT utilization. Nurse leaders have an obligation to encourage this dialogue and remove barriers that prevent appropriate RRT activation.

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