But in 1988, a physician's wife who was an inpatient became critically ill while on the med/surg unit. The critical care doctor arrived and performed an intervention at the bedside. “The physician said, 'This is a great idea. Why don't we do this for everybody?'” he said.
After that, the hospital began devising ways to help patients before they decompensated. But the criteria were practitioner-centered, so only certain staff could decide to call for help. And adhering to the hospital's chain of command often meant initially calling the least-experienced person, such as an intern.
“It was 'delegation to the dumbest,'” Dr. McAdams said. “In a crisis situation, this leads to delays and disaster.”
In 1999, the hospital revised its criteria to make it more specific and to make it patient-centered; it also allowed anyone to call a code, he continued. Hospital officials also decided that neither hospitalists nor residents needed to be involved in the response; instead, the attending critical care physician answers the call.
The teams get an average of two to six calls per day, Dr. McAdams said. The hospital also has found that the more people call for an RRT—which the hospital calls a “Condition C” code—the fewer times they get “Condition A” calls, which are more serious. And although the data are not yet complete, Dr. McAdams said he suspects that the program has reduced the number of preventable deaths.
Full-Time Nurses
Kaiser Permanente in Santa Clara is one hospital that has just begun to experiment with RRTs; it fully implemented its teams in April. But Kaiser has decided to do things a little differently. Rather than having all RRT members—the RRT nurse, the respiratory therapy supervisor, and a physician—all work on the team in addition to their regular jobs, Kaiser hired RRT nurses to be on the team full-time, 24 hours a day.
“The RRT nurse has no other patient responsibilities,” explained Dr. Allison Schwanda, chief of hospital-based medicine at the facility. When the nurse is not answering RRT calls, he or she rounds on all patients transferred out of the ICU and follows up on RRT calls within 12 hours to ensure that patients remain stable. He or she also “asks the nurses if there is anyone they're worried about. We think that even gets us intervening earlier than what we might get with a call to the RRT.”
The RRT nurse must handle a delicate balancing act: keeping the primary care physicians involved in care of the patient without creating barriers to activating the RRT. As a result, the team has developed a notification system to keep doctors in the loop. “Then it's up to that [doctor] whether they want to come bedside,” she said.
If the nurse in charge needs backup, she can call in the “second tier” for help: an intensivist during the day or the hospitalist at night. So far, the RRT is averaging 21/2 to 3 calls per day, or about 1 per shift, Dr. Schwanda said. The response to each call averages 30–90 minutes.
Although several speakers were enthusiastic about the potential of RRTs, not everyone in the audience was as impressed. “I remain skeptical due to the methodologic issues [in] the studies that are out there,” said Dr. Shaun Frost, a hospitalist at HealthPartners Medical Group and Clinics, Minneapolis. “And I'm amazed at the amount of resources thrown at this activity,” such as Kaiser's hiring several full-time nurses.
Keeping Response Teams in Play
Dr. King outlined some of the lessons that hospital staff have learned about working with rapid response teams:
▸ Have needed equipment available. “We need oxygen!” “And a crash cart!” After those cries were heard several times, oxygen and crash carts were put in centralized locations and additional ones were placed near the security guards and in the lobby.
▸ Don't forget about hypoglycemia. Often, the team would see a patient and say, “He looks hypoglycemic,” but there would be no glucometer available. The team eventually added a glucometer, glucagon, and glucose tablets to its supply bag.
▸ Make detecting a problem easier. The hospital is piloting a vital signs sheet that highlights in yellow any physiologic markers of decline. “It actually says, 'MD or RRT should be called'” on the sheet, Dr. King said.