Catholic Medical Center Rapid Response Teams Peggy Lambert

Catholic Medical Center Rapid Response Teams Peggy Lambert RN, MS, MBA Beatriz Jauregui RN, BS

IHI MOVE YOUR DOT Deploy Rapid Response Teams SAVE 100 K LIVES CAMPAIGN Deliver Reliable Evidence-based Care for AMI SBAR TM Prevent Central Line Infections Prevent Surgical Site Infections Prevent Adverse Drug Events (ADE) Prevent Ventilator Associated Pneumonia

Why Rapid Response Teams Three fundamental problems often lead to failure to rescue: • Failures in planning • Includes assessments, treatments, goals • Failure to communicate • Patient-to-staff, staff-to -physician, etc. • Failure to recognize a problem

Clinical Instability Prior to Arrest Warning signs within 6 hours of event: • MAP <70 or >130 mm. Hg • Heart rate <45 or >125 per minute • Respiratory rate <10 or >30 per min • Chest pain • Altered mental status Franklin. Crit Care Med. 1994; 22: 224 -247.

CMC’s RRT • • • Primary nurse Charge Nurse on unit ICU Clinical Leader or charge nurse Respiratory Therapist Nursing Coordinator (off shifts)

Role of the team • RRT is not intended to take the place of immediate consultation with the physician if needed. • After consultation with the RRT, a call is placed to the appropriate physician. The intention is to help patients in the time of clinical instability and not to replace physician involvement in that process.

Role of the team • • • Assess Stabilize Assist with communication Educate and support Assist with transfer to a higher level of care if necessary

SUCCESS STORIES Among surgical patients, the deployment of RRT’s has been associated with a reduction in the incidence of respiratory failure, stroke, severe sepsis, and acute renal failure as well as a reduction in the number of ICU admissions, length of stay, and postoperative mortality. Crit. Care Med. 2004; 32: 916 -921

SUCCESS STORIES Sites that have implemented RRT’s have reported a reduction in cardiac arrests and deaths, as well as a reduction in ICU and hospital bed stays among survivors of cardiac arrest. BMJ. 2002; 324: 387 -390

Catholic Medical Center Rapid Response Team Update January- December 2006

RRT Analysis Total RRT Calls Per month • We monitor number of calls per month and have seen a significant growth in the number of calls over the past 2 years • When we see a down trend in numbers we re-educate Staff to remind them to think of the RRT • Post stickers with the RRT telephone number on phones

Code Blues • Increased number of Code Blue occurring in the ICU and decreased numbers occurring on the Med/Surg & Telemetry Units

RRT Occurrences • RRT calls occur most frequently between the hours of 8 PM to 7 AM • There are no patterns/ trends as to any particular day of the week

Precipitating Event CMC’s experience follows the literature. The majority of calls are respiratory related followed by cardiac then neurological events

Rapid Response Team Arrival • Average Rapid response team arrival is 4 minutes from initial call.

Disposition • Most patients were transferred to a higher level of care after RRT deployment- 48. 6% • 35. 5% remain on their current unit with specific follow up identified Unadjusted Mortality • We have observed a decrease in unadjusted mortality. With the number of concurrent quality improvement processes it is difficult to determine the exact role of the RRT in this, however we do believe that it has played a role in the decrease.

Rapid Response/ Code Correlation • 38% Code Blue calls occurred outside of the ICU. Since the initiation of the RRT, Codes occurring outside of the ICU has decreased

CMC has used the IHI 2 x 2 Matrix to analyze 50 deaths by Comfort Care Type and Unit of Admission. This is helpful in determining right care, right nursing unit. Based on 50 consecutive Mortalities from 7/1/06 - 9/30/06 Comfort Care Non Comfort Care ICU Admit Non-ICU Admit IHI Aggregate 3% IHI Aggregate 13% IHI Aggregate 37% IHI Aggregate 48% IHI Aggregate- N- 64 acute care hospitals

IHI 2 x 2 Matrix Change Ideas Box 1 suggestions: • Maintain pressure on the system to avoid inappropriate ICU admissions. • A discussion to understand the limits of care should occur on admission Box 2 Suggestions: • Advanced Directives • Alternatives to hospital care at the end of life • Palliative Care Team • Community outreach for Advanced Directives Box 3 Suggestions: • Glycemic Control • Sepsis Intervention • Ventilator Bundle • Coordination of care in the ICU by an Intensivist • Daily goal sheets • Communication and Handoffs • Central Line Bundle Box 4 Suggestions: • Rapid response Team • Communication and Handoffs • Early Warning System • Multidisciplinary Rounds in the ICU • Central Line Bundle outside of the ICU • Advanced training for Rapid Response Team incorporating Sepsis and Early Warning