Directors of RRS at fifteen AMCs responded to our inquiries (14 adult focused centers, 1 oncology center). The mean size of the medical centers included was 710 beds (range 398 to 1228 beds). Four centers had a strictly critical care fellowship program and the remaining (11) had a combined pulmonary/critical care fellowship program. The centers included showed broad geographic differences, had RRS in place for a mean of 18 months, and used a variety of team structures used as shown in . The “Trigger” structure of RRS used at two centers does include all four arms defined as mandatory components of a RRS (event detection, response triggering, crisis response, and process improvement); however, once the trigger system is activated, it utilizes a physician-led response team comprised of physicians who already have responsibility for the patient.28
Endpoints that centers used to gauge success were varied and are also presented in .
Demographics of Academic Medical Centers in Sample (N=15)
How Calls are Initiated
The criteria differed slightly between centers but generally included all criteria listed in . The most frequent reasons reported for RRS calls fell into two main categories: respiratory (70%) or nurse concern (30%). Once criteria were met to activate the RRS, calls were initiated in a variety of ways. Most (75%) centers used a system where the bedside nurse (or unit secretary) notified either the medical center switchboard or a unique number which in turn activated pagers/cell phones of team members. Overhead pages were used by all centers initially, but these led in many centers to crowds and confusion at the bedside. Bedside crowds were found to be intimidating and served as a disincentive to call the RRS again.
Criteria for Calling the Rapid Response Team
After assessment of the unstable patient, the RRS team leader had the responsibility to notify the on-call resident for the primary team. In the two centers using the Trigger system, the on-call physician for the primary team carried out the initial assessment. Four centers not using the Trigger system required the bedside nurse (or unit secretary) to simultaneously notify the RRS as well as the primary team physician on call. Notification of the primary physician by the bedside nurse gave the physician the option to participate if he or she so chose or to temporarily transfer patient care to the RRS response team. All centers expressed difficulties with this process initially as multiple primary physicians were reluctant to cede control to the RRS, and often chastised bedside nurses for activation of the RRS. One center shared their script that provided confidence to the bedside nurse when notifying the primary physician and increased acceptance of the RRS intervention by physicians in the medical center: “I needed another pair of hands to help the patient in this situation, so I activated the RRS.” Four centers found it more efficient and successful to contact the primary physician only after the RRS team’s assessment was complete, similar to the process following a cardiopulmonary arrest.
Over time however, centers with longer running RRS noted the primary physicians came to trust members of the response team and expressed not only relief and appreciation, but also a desire for intervention by the RRS. Centers with mature RRS discussed the success of marketing the RRS as a strategy to protect the primary physicians’ time and improve care of their patients.
All centers reported RRS calls were initiated mainly by nurses, although one center reported that as the RRS had matured, 20% of their calls came from interns and residents. One AMC allowed families to activate the RRS. Usually initiated by a parent or family member of the patient, these calls were not as frequent as initially predicted. Allowing families to call the RRS was a feature that the center initiated after painstaking discussions between AMC providers and administration. Successful outcomes of these family-initiated RRS events encouraged the AMC to use this feature in the public marketing of their center as an added safety feature.
Barriers to RRS Success
The most common barrier to success with implementation of a RRS was the lack of funding for full-time staff positions. Most centers reported difficulty achieving success when forced to operate the RRS with staff who had other full-time responsibilities. Funding sources varied, yet became less problematic as call volume increased and successful data outcomes could be reported. Financial benefits of the RRS program consistently were reported as nebulous and difficult to quantify, yet as programs became more active, this evidence became obvious. Another common barrier reported was perceived lack of support from administration. If hospital administration was weakly supportive or a physician champion was not initially involved, then success was more difficult to attain and functioning of the RRS was greatly compromised.
Changes in RRS over Time
Directors at 86% of the seven nurse-led RRSs reported that their center had started with a different team structure than what was currently in practice and that these changes were made due to perceived underutilization of the prior team. Centers whose teams changed their structure changed in one of two ways: (1) they started with a full cardiopulmonary arrest physician-led team and evolved to a nurse-led team with much more frequent, proactive functions; or (2) they started with a RRS nurse and/or respiratory therapist who worked on the RRS team in addition to their regular jobs then changed to a fulltime RN position or RN plus respiratory therapist on the response team. Due to the high prevalence of RRS calls related to respiratory events, having a respiratory therapist on the team as an initial responder was reported to be more efficient than having to page them separately.
The number of RRS calls were reported to increase the longer the RRS was in existence; however the rate of increase varied widely. There was a mean of 45 RRS calls per month (range from 5–166 calls/month) reported. While only 20% of centers noted a decrease in hospital mortality as RRS call volume increased, 60% of centers did report a corresponding decrease in codes outside the ICU. All centers using proactive rounding spoke of seeing the call volume increase with more frequent, proactive functions such as regular patient rounds and noted that this was more feasible once the full-time RRS positions were established. Proactive rounds were expanded in many of the centers who had successful RRS to include any patient who was: transferred out of an ICU whose ICU stay was ≥ 3 days; admitted with a primary or secondary diagnosis of sepsis; and receiving high flow oxygen and/or nebulizer treatments. Identification of the most seriously ill patients on each unit also became part of expanded rounds over time. This ability to identify potential patients early in anticipation of their deterioration also served to improve patient outcomes.
Funding positions for data management personnel who would maintain the RRS call database was a challenge at all organizations. In 31% of centers RRS nurse coordinators were responsible for managing the RRS call data, especially while call volume was low. This responsibility in other AMCs fell to staff managing cardiopulmonary arrest data for the AMC, or to the ICU director’s administrative staff. Other responsibilities for nurse and physician response team members included development of and teaching the RRS content for educational classes, as well as frequent lectures at hospital employee orientation and nursing unit inservices.
The patient areas covered by the RRSs expanded over time. All inpatient medical and surgical patient care units, as well as procedural units holding admitted patients awaiting inpatient beds were covered at all AMCs. Most centers (75%) had the team cover the emergency department; however four centers did not. Ten medical centers (67%) provided RRS coverage to inpatients and outpatients in the areas of endoscopy, cardiac catheterization, stress testing, dialysis, bronchoscopy, and interventional radiation. Four (27%) of these centers reported that their RRS also covered the general population of outpatients and visitors in the outpatient clinics, parking garages, outpatient pharmacy, cafeteria, and physician offices.
Six centers (38%) were considering expanding the functions of the RRS to include proactive management of acute myocardial infarction and sepsis patients in the emergency room awaiting treatment or a critical care bed. Standing medical order protocols for similar types of urgent patient situations were developed at these AMCs to enable faster patient intervention.
Strategies for Success
Discussion of the role, criteria, and success stories of the RRS during initial hospital personnel orientation served as a crucial factor in success for 67% of centers. Presentation of this content during orientation of new employees and medical trainees served to develop awareness of the RRS, as well as widespread understanding of the criteria for impending patient deterioration. The educational piece of building RRS awareness in all hospital staff was linked by these centers to increased call volume and improved patient outcomes. All centers agreed that the importance of RRS members being approachable and developing a good rapport with staff on the nursing unit cannot be underestimated if the RRS is to succeed. Any negative feedback directed to the bedside nurse that the call was inappropriate, or questions regarding the nurse’s judgment were found to severely hamper the success of the RRS.
Also of note as a strategy for success was establishment and growth of the process improvement arm of the RRS. Follow-up surveys, completed within 24–48 hours of the event by the initiating staff member, were crucial to identifying and correcting antecedents to the event. Eighty percent of centers used this method of evaluation, leading to novel ideas for improvements within the RRS and served to increase levels of satisfaction among the nursing staff. Additionally, directors at all 15 centers reported weekly, biweekly, or monthly meetings of the multidisciplinary RRS committee for detailed evaluation of each RRS call. Information about the clinical situation and interventions were reviewed for appropriateness and success. These debriefing sessions served as an educational opportunity for team members, maintained the motivation of the team, and provided data for improvement of other systems throughout the medical center.
Nine centers (60%) reported that as the RRS matured and achieved success, other system issues within the organization came to light. For example, one center reported a majority of RRS calls from a certain nursing unit were repeatedly due to undetected hypoglycemia. After identifying of a lack of glucometers on the unit as the problem, additional equipment dramatically decreased the number of RRS calls due to hypoglycemia. Another center reported repeated respiratory RRS calls on two units. Those particular units were found to be ill-equipped with respiratory supplies and have several new graduate nurses with little expertise in managing respiratory equipment. Additional content on respiratory equipment was added to nursing orientation classes, along with clarification of respiratory job responsibilities of daily checks on respiratory equipment in each room, and repeated pulmonary inservices for all nursing units. These steps significantly decreased RRS call volume for that specific reason on those units. Another center reported RRS calls related to issues of miscommunication between primary physicians and nurses on certain floors. Those units adopted the SBAR (situation, background, assessment, recommendations) communication system through educational sessions for staff, use of tip cards, and posters in the nursing lounge. The result was a decrease in RRS calls related to communication issues and an increase in nurse and physician satisfaction. These process changes are examples of how the quality improvement limb of the RRS can assist in preventing future events by creating a culture of safety at the organization.
Impact on Patient Safety
Two centers successful MET centers reported eliminating cardiac arrest teams due to the success of the RRS. The MET answered all RRS and cardiopulmonary arrest calls with higher efficiency and less duplication of services. A decrease in the percent of patients moving to a higher level of care was reported as an important marker of success. Since the initiation of the RRS, a mean of 50% (range of 40%–70%) of patients were now cared for at the bedside instead of needing an ICU bed across all centers.