Feature
Designing a Critical Care
Nurse–Led Rapid Response
Team Using Only Available
Resources: 6 Years Later
ANNE MITCHELL, RN, MSN, CCRN, CEN, CNS-BC
MARILYN SCHATZ, RN, BSN, MSN, CCRN
HEATHER FRANCIS, RN, MBA, BSN
Rapid response teams have been introduced to intervene in the care of patients whose condition deteriorates
unexpectedly by bringing clinical experts quickly to the patient’s bedside. Evidence supporting the need to overcome failure to deliver optimal care in hospitals is robust; whether rapid response teams demonstrate benefit
by improving patient safety and reducing the occurrence of adverse events remains controversial. Despite inconsistent evidence regarding the effectiveness of rapid response teams, concerns regarding care and costly consequences of unaddressed deterioration in patients’ condition have prompted many hospitals to implement rapid
response teams as a patient safety strategy. A cost-neutral structure for a rapid response team led by a nurse
from the intensive care unit was implemented with the goal of reducing cardiopulmonary arrests occurring
outside the intensive care unit. The results of 6 years’ experience indicate that a sustainable and effective rapid
response team response can be put into practice without increasing costs or adding positions and can decrease
the percentage of cardiopulmonary arrests occurring outside the intensive care unit. (Critical Care Nurse. 2014;
34[3]:41-56)
ince the publication of To Err Is Human by the Institute of Medicine in 2000,1 patient
safety has become a national focus for health care, and noteworthy efforts have been
directed at reducing the number of deaths resulting from preventable errors. Many
patients experience serious adverse events while in the hospital, including cardiac arrest and unexpected admission to the intensive care unit (ICU), and research indicates that such events occur after
S
CNE Continuing Nursing Education
This article has been designated for CNE credit. A closed-book, multiple-choice examination follows this article, which tests your
knowledge of the following objectives:
1. Compare/contrast the evidence regarding effectiveness of rapid response systems to reduce the occurrence of adverse patient events
2. List benefits of rapid response systems according to the literature
3. Discuss the experience of implementing a rapid response program in a hospital setting
©2014 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2014412
www.ccnonline.org
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41
failure to rescue.2,3 Several studies have established that
up to 84% of patients show signs of clinical deterioration
6 to 8 hours preceding cardiac arrest.3-7 Clinicians often
fail to appreciate or report antecedent signs of deterioration or to intervene if signs of deterioration are indeed
recognized.3,4,8 The inability of clinicians to recognize a
decline in a patient’s condition and prevent unintended
injury or death constitutes failure to rescue, which has
been incorporated as a measure of medical and nursing
care.4,6-10 Reasons for failure to rescue include limitation
of monitoring techUp to 84% of patients show signs nology to specialty
of clinical deterioration 6 to 8 hours units; failure to
preceding cardiac arrest.
report or respond
to abnormal findings on assessment; variation in individual judgment, training, and experience; low sensitivity
and fidelity of periodic assessments in general care
areas; and inability of frontline staff to initiate early
interventions independently.8,11
Because cardiac events are often not sudden and early
signs of deterioration in a patient’s condition are not
always recognized, rapid response systems (RRSs) have
been introduced to intervene in the care of declining
patients by bringing clinical expertise and timely interventions to the bedside.3,8,12 Litvak and Pronovost13 suggest that some patients in general care areas have their
condition deteriorate despite adequate clinical care
whereas other patients may be misclassified on admission and the level of care provided is inadequate to meet
the patient’s needs, so rapid response teams (RRTs) are
necessary to rescue them.
In 2004, the Institute for Healthcare Improvement (IHI),
through its Saving 100000 Lives Campaign, challenged
Authors
Anne Mitchell is a clinical nurse specialist in the emergency department and intensive care unit at Banner Baywood Medical Center,
Mesa, Arizona.
Marilyn Schatz is a clinical manager in the intensive care unit at
Banner Baywood Medical Center.
Heather Francis is the director of nursing of the intensive care unit,
dialysis, at Banner Baywood Medical Center.
Corresponding author: Anne Mitchell, RN, MSN, CCRN, CEN, CNS-BC, Banner Baywood
Medical Center, 6644 E. Baywood Avenue, Mesa AZ 85206 (e-mail: anne.mitchell@
bannerhealth.com).
To purchase electronic or print reprints, contact the American Association of CriticalCare Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949)
362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.
42
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the health care community to create a culture of patient
safety. In 2006, the IHI recommended the deployment of
RRTs as 1 of 6 innovative strategies to improve patients’
outcomes.1,14 In 2005, the first International Consensus
Conference of Medical Emergency Teams convened
experts in patient safety, critical care, and hospital medicine to standardize nomenclature, describe patients who
might benefit from RRTs, and identify characteristics of
an RRS.2 They identified 3 models of RRSs: medical
emergency teams (MET) led by a physician, RRTs led by
a nurse (usually a critical care nurse), and critical care
outreach (CCO) teams led by a nurse, which in addition
to responding to RRT calls, provide surveillance for
patients recently discharged from the ICU. Although the
optimal composition of a RRT is not known, members
of the team typically include physician or nurse team
leads, respiratory therapists, critical care nurses, and
nursing supervisors.3,8,15
Although most RRTs are staff activated, many hospitals now provide family and patients access to the RRT
in accordance with the 2009 Joint Commission National
Patient Safety Goals.16 Family-activated RRT call rates are
reported to be low and often relate to communication
issues between providers and patients’ families or pain
management.11,17-20 In 2011, the Society of Critical Care
Medicine surveyed hospitals to determine their experience with patient and family activation of RRSs.20 Of the
25 participating hospitals, 67% used a nurse-led RRT
model and 90% afforded patients and their families
access to the RRT. The volume of family or patient calls
ranged from 0 to 24 calls per year and appeared to be
related to the size of the facility. A lack of understanding
of the plan of care or perceived lack of a quick response
to changes in the patient’s condition were reported as
primary causes for family RRT activation.20
Impact of RRTs on Patients’ Outcomes
Evidence of the impact of RRTs or METs on the safety
and survival of hospitalized patients is contradictory,
with researchers in some studies reporting decreased rates
of cardiac arrests, unplanned ICU admissions, and hospital mortality, whereas researchers in other studies
reported no difference.8,21-26 Bristow and colleagues21
reported a reduction in the number of unplanned ICU
admissions, but no difference in cardiac arrest rates
when they compared 1 hospital that had a MET with 2
hospitals that did not. In a prospective controlled trial
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that examined the effect of a MET on postoperative
patients, Bellomo and colleagues22 concluded that the
availability of a hospital-wide MET 24 hours a day, 7
days a week reduced both the incidence of postoperative
adverse outcomes and mortality rates. In an observational
study, DeVita and colleagues23 reported that use of a
MET decreased the mean monthly incidence of cardiopulmonary arrest by 17%. A single-center 5-year study
examined the effect of a MET on time to treatment and
mortality rates of patients diagnosed with shock and
showed substantial reductions in time to central catheter
placement, fluid and antibiotic administration, and
mortality rates after implementation.25 In a prospective
before and after trial in a community hospital, using an
RRT led by a physician’s assistant, Dacey et al27 reported
that cardiac arrests per 1000 discharges decreased from
7.6 before RRT implementation to 3.0 afterward.
After initiation of a CCO model, McFarlan and
Hensley17 noted a 36% reduction in the rate of non-ICU
cardiac arrest whereas Thomas and colleagues,11 using a
nurse-led RRT, reported a 56% decrease in cardiac arrest
outside the ICU. One year after implementation of an
RRT, Jolley et al18 reported a 21% decrease in the occurrence of cardiac arrests outside of the ICU but noted no
change in hospital mortality rates. After execution of a
MET in a 300-bed teaching hospital, Buist and colleagues,28 after adjusting for case mix, noted a 50%
decrease in the incidence of unexpected cardiac arrests
and a reduction in mortality from 77% to 55%. Howell
did not use an ICU-trained RRT but instead focused on
systematic detection of patients’ clinical deterioration
and notification of the usual care providers to determine
if patients’ outcomes improved.29 They reported that a
rapid response by this type of team was independently
associated with decreases in unexpected mortality and
cardiac arrests occurring outside of the ICU, proposing
this as a cost-effective option for facilities with limited
critical care resources.29 Using an intensivist-led CCO
model that also included an ICU fellow and provided 48
hours or more of post-ICU surveillance, Al-Qahtani and
colleagues30 evaluated non-ICU cardiac arrests 2 years
before and 3 years after implementation. They noted a
decrease in non-ICU arrests from 1.4 to 0.9 per 1000
hospital admissions and a decrease in hospital mortality
from 22.5 to 20.2 per 1000 hospital admissions.
In spite of strong face validity and widespread
adoption in many hospitals, measurable benefit after
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implementation of an RRT has not been reported by all
investigators. In a large, multicenter randomized controlled trial, the MERIT study investigators randomly
assigned 23 hospitals to MET implementation or usual
care for 6 months and found no reduction in cardiac
arrests, ICU admissions, or unexpected deaths.24 After a
systematic review and analysis of studies evaluating RRT
effectiveness, Chan and colleagues26 reported that implementation of an RRT in adult populations was associated
with a 33.8% reduction in rates of cardiopulmonary arrests
outside the ICU but did not decrease hospital mortality.
After completing a systematic review of RRSs, Winters and colleagues31 concluded that although METs were
associated with reductions in hospital mortality and cardiac arrest rates, the results should be interpreted with
caution because of limitations (wide confidence intervals,
lack of heterogeneity, nonrandomization) in the quality
of the studies they reviewed. However, Winters et al8
recently published a second systematic review of RRSs
as a patient
safety strategy, Evidence on the impact of rapid response
again noting
teams (RRTs) or medical emergency
that RRSs
teams (METs) on the safety and survival
decreased the of hospitalized patients is contradictory.
rate of adult
and pediatric arrests outside the ICU but benefits were
not consistently realized by all facilities. They suggested
several possible explanations for some RRSs not realizing benefits: unknown optimal team membership, ineffective monitoring and identification of patients in
deteriorating condition, and limited availability of
resources.8 However, they did conclude that the beneficial effects of RRSs are becoming more apparent with
increased implementation. Results of these studies
reporting mortality and non-ICU cardiopulmonary
arrest data are summarized in Table 1.
Some authors suggest that RRT benefits include
more than measurements of mortality rates and numbers of cardiac arrests. Rosen and colleagues32 reported
reductions in non-ICU codes and mortality rates during
a 3-year period within a 26-hospital collaborative after
each facility implemented a type of RRS. They described
unanticipated benefits related to RRS use, including
improved staff satisfaction, the opportunity to discuss
and change code status, and identification of new areas
for quality improvement.32 After comparing outcomes
for patients admitted to the ICU via RRT intervention
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Table 1
Reference
Summary of studies of rapid response systems that reported comparison data
Type of team
Findings
Bristow et al, 2000
MET
Fewer unanticipated ICU admissions, no difference in in-hospital cardiac arrest rates or mortality, higher rate of do-not-resuscitate orders
Buist et al,28 2002
MET
Reduction in cardiac arrest rate, decrease in hospital mortality rate
Bellomo et al, 2004
MET
Decrease in postoperative adverse outcomes, mortality rate, and length
of stay in hospital
DeVita et al,23 2004
MET
Decrease in cardiopulmonary arrest rate, no change in proportion of
fatal arrests
Hillman et al,24 2005
(MERIT)
MET
No significant difference in unexpected deaths, incidence of cardiac
arrest, unplanned ICU admissions
21
22
Sebat et al,25 2007
Dacey et al,27 2007
McFarlan and Hensley,
2007
MET (emergency department
physician and intensivist)
Decreased time to central catheter placement, infusion of fluids, ICU
admission, first antibiotic administration and profound reduction in
mortality for patients identified with shock
RRT led by physician assistant
Decreased in-hospital cardiac arrest rate and unplanned ICU admissions
17
RRT
Decrease in cardiac arrests in non-ICU areas
Thomas et al, 2007
RRT
Decrease in cardiac arrests on medical-surgical units, decrease in nonICU cardiac arrests
Jolley et al,18 2007
RRT
Decrease in arrests and non-ICU arrests, no difference in deaths/1000
discharges
11
Howell et al,29 2012
Patient’s usual primary care
team, no critical care training
Reduction in unexpected mortality, no difference in overall in-hospital
mortality rate, decrease in non-ICU arrests
MET
Decrease in non-ICU cardiopulmonary arrest, decrease in non-ICU
mortality rate (anticipated and unanticipated)
Rosen et al,32 2013
Variable team composition
among 26-hospital collaborative
Decrease in non-ICU arrests, nonsignificant decreases in ICU codes
and all-cause mortality rates
Jones et al,33 2010
MET (patient’s on-call physician
and ICU nurses)
Decrease in non-ICU cardiac arrests
Al-Qahtani et al,30 2013
Chan et al, 2010
Meta-analysis of 18 studies
Reduction in cardiac arrests outside ICU, not associated with lower
hospital mortality rates
Winters et al,8 2013
Meta-analysis of 18 high-quality
studies and 26 lower-quality
studies
Decrease in cardiac arrests in non-ICU areas, benefit not realized in all
rapid response systems
26
Abbreviations: ICU, intensive care unit; MET, medical emergency team; RRT, rapid response team.
versus patients transferred to the ICU by usual processes,
Jaderling et al34 suggested that RRTs represent an important mechanism for identifying complex cases in which
patients are in need of ICU care. They noted that although
30-day mortality did not differ, the RRT patients were
older, had more severe comorbid conditions, and were
almost 3 times as likely to have a diagnosis of severe
sepsis.34 Additional benefits of RRTs listed by Thomas
et al11 include improved patient safety, improved identification by nurses of signs of deterioration, increased
satisfaction of physicians and patients, and increased
job satisfaction among nurses.
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Some researchers, addressing the inconsistent results
of RRT studies, suggest that RRT benefit takes time, perhaps several years, to become evident as it involves a cultural change for an institution. RRT success also appears
to be linked to practice; if the RRT is widely adopted by
clinicians, it appears more effective.35,36 A higher call
intensity, or “dose rate,” more than 25 RRT calls per 1000
admissions, is reported to be associated with decreases
in cardiac arrest rate,37 and conversely when the RRT
rate decreases, the cardiac arrest rate increases.36 The
RRT must be used to be effective, and if it is not used,
benefits may not be manifested.3,15,24,37
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The complexity of the intervention and the lack of
benchmarking tools to facilitate comparisons of RRS
outcomes among hospitals may contribute to the inconsistent evidence of RRT effectiveness.24,38 It is assumed
but not established that RRSs are rapid and responsive.38
To that end, Olgesby et al38 proposed a “score to door
time,” the time from the first recorded abnormality that
should have triggered RRS activation to ICU admission,
as a standardized measure of RRS effectiveness. Delays
greater than 4 hours were associated with higher Acute
Physiology and Chronic Health Evaluation (APACHE)
scores at ICU admission.38
Attempting to improve the effectiveness of the RRT,
a group of investigators placed automated vital sign monitors on patients in general care areas that provided electronic prompts to escalate care when abnormalities
were detected. They reported increases in the detection
of respiratory abnormalities, increased RRT calls, and
improved survival of patients receiving RRT intervention.39
Wake Forest University initiated an RRS comprising the
patient’s on-call physician and critical care nurses hired
into RRS positions to identify patients who are not
responding to treatment.33 Owing to a 17% decline in
RRS use, policy was changed to mandate RRS activation
for any patient meeting the criteria for physiological
instability, resulting in a 34% increase in RRS calls and
a 35% decrease in cardiopulmonary arrests occurring in
the general care areas.33 The authors concluded that by
mandating RRT activation, fear of criticism on the part
of nurses initiating RRS was eliminated, resulting in
increased call rates and improved outcomes.33
In addition to vital signs criteria, judgment that
prompt assistance was needed at the bedside was emphasized to staff as an important criterion for RRT activation
by Beitler and colleagues.40 As a result, they reported
significant reductions in hospital-wide mortality, out-ofICU mortality, and out-of-ICU cardiopulmonary arrests.40
Although outcomes vary from study to study, the beneficial effects of RRTs are becoming clearer as the intervention is more universally applied. Benefit has been reported
in many hospital settings using a variety of RRS models
even though this has not firmly translated into a consistent reduction in overall hospital mortality.8,19,23,28,29,41
Perceptions and Function of RRTs
To determine the value of RRTs as perceived by
nurses and physicians using them, investigators
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surveyed staff in hospitals with established programs.
They found that nurses working in facilities with wellfunctioning and integrated RRTs did not hesitate to activate it.42-44 Conversely, teams not viewed as cohesive and
supportive were less likely to be called because the nursing staff was not confident the team would support their
decision to activate the response.42 Nurses with RRT
experience indicate that they initiate RRTs for 3 primary
reasons: (1) the patient exhibits signs and symptoms
that were either unexpected or significantly different
from baseline; (2) the nurse, despite the absence of
objective data,
The RRT must be used to be effective,
thought that
something was and if it is not used, benefits may not
wrong; and (3) be manifested.
the nurse was
convinced that the patient needed immediate intervention and was either unable to reach the physician or
unable to obtain appropriate interventions as perceived
by the nurse.42 Nurses with access to a robust RRT state
that if they were changing jobs or a family member
required hospitalization, they would select a facility
offering an RRT.32,42,43
Surveys of medical residents and nurses indicate that
both agree that the presence of a MET improves patient
safety, although the nurses perceived that more strongly
than did the residents.42-45 Benin and colleagues45 conducted qualitative open-ended interviews with nurses,
physicians, RRT members, and house staff to evaluate
their view of RRT impact within a hospital setting. Nurses
reported a sense of security and empowerment derived
from knowing that skilled backup was available, a perception echoed by physicians and administrators.45
Additional positive benefits included increased morale
among nurses, real-time redistribution of nurses’ workload, triage of patients needing intensive care, and
immediate access to expert help.45 After conducting
interviews with RRT members, physicians, and staff,
and observing actual RRT events, Leach and Mayo12
defined 5 attributes associated with well-functioning
and effective RRTs: an organizational culture supportive
of innovation and committed to patient safety, expertise
of team members, dedicated RRT positions, communication, and familiarity among RRT members. Easy
access to RRT activation and a respectful, nonjudgmental response by the RRT members have also been identified as structural elements critical to RRT success.46-48
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Development of a Facility-Based RRT
In 2005, administrators at a nonteaching, 275-bed
community hospital within a large health care system
(Banner Baywood Medical Center, Mesa, Arizona)
resolved to follow the IHI recommendations by implementing a hospital RRT. They tasked the facility’s code
blue committee with the responsibility for model selection, process development, and implementation.
Table 2
When to activate the rapid response team
Nurse is concerned about patient
Respiratory distress or threatened airway (respiratory rate
>30/min or <6/min or acute change in oxygen saturation
<90% despite administration of oxygen) or change in
breathing pattern
Acute change in blood pressure to <90 mm Hg, heart rate to
<40/min or >130/min, or 20% change from baseline
Acute change in level of consciousness
Model Selection
After a review of the literature and IHI recommendations for RRSs and evaluation of available resources, a
nurse-led RRT model was selected. The RRT implementation had to be budget neutral. No positions existed
that could be solely dedicated to the RRT, and creating
new RRT nursing positions was not an option. The
selected RRT membership included the nursing house
supervisor, the shift lead respiratory therapist, and the
nurse manager of the ICU, who was designated as team
lead. Typically none of these individuals had patient
assignments and all could respond quickly to an RRT
call. If the ICU nurse manager could not avoid a patient
assignment, they were directed to delegate another ICU
nurse to respond, assign other ICU nurses to monitor
their patients while off the unit, or notify the nursing
supervisor that they were unable to respond but were
available for phone consultation.
Procedure
Criteria for calling the RRT similar to the criteria
used by other hospitals were developed (Table 2), but
staff were encouraged to activate the RRT any time they
had concerns about a patient’s condition.3,15,18,23,27,29,30,41,47
To activate the RRT, staff called the same emergency
phone number used to broadcast a cardiac arrest. A
beeper paging system was tried about a year after RRT
implementaEasy access to RRT activation and a
tion to reduce
respectful, nonjudgmental response by
hospital noise,
the RRT members are critical to success. but overhead
paging of RRT
calls was resumed because of some dead zones within
the facility. The RRT responded to all inpatient units,
diagnostic areas, a rehabilitation unit located within the
facility, as well as outpatient areas such as endoscopy,
medication and pain clinics, and a chest pain unit. In
the event of simultaneous RRT calls, the clinical nurse
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Urine output <50 mL in 4 hours without history of renal dysfunction
Failure to respond to treatment
specialist or the ICU director of nursing would respond.
If they were unavailable, the ICU nurse manager and the
nursing supervisor decided who would respond to which
call and would request additional respiratory therapy
support if needed. An emergency protocol for orders
common to urgent patient situations was developed for
use by the RRT (Table 3). The cardiovascular, internal
medicine, surgery, and anesthesia medical committees
approved the emergency protocol and operationalization of the RRT.
As RRT lead, the ICU nurse manager was encouraged to communicate assessment findings and recommendations directly to the patient’s primary provider,
who was always contacted. However, if the RRT event
concluded before contact with the provider, and transfer
to a higher level of care was not indicated, the patient’s
primary nurse assumed responsibility for communicating findings to the responding physician. Initially, ICU
transfer was ordered by the attending physician, but
after the initiation of an intensivist program, this became
a collaborative decision between the intensivist and the
attending physician.
Documentation of RRT call data was recorded by the
nursing supervisors on a form created for that purpose
and became a permanent part of the medical record
(Figure 1). The RRT call rates, cardiac arrests outside
the ICU, and outcome data were reviewed bimonthly by
the code blue and RRT committee and reported annually
to the hospital quality committee.
Education
All hospital clinical staff and physicians were educated about the purpose and process of RRT activation
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Table 3
Rapid response team’s emergency protocol: symptomatic/unstable – systolic blood pressure ≤90 mm Hg, change in
level of consciousness, nausea/vomiting, dizziness, lightheadedness, diaphoresis, saturations decreased from normal, tachypnea
Complaint
Interventions
Sudden onset of chest pain
Call physician
Obtain stat EKG, physician to interpret
Apply O2 at 2-4 L via nasal prongs; titrate O2 to maintain SpO2 ≥92%
Nitroglycerin 0.4 mg SL for unrelieved chest pain q 5 minutes x 3
Nitroglycerin infusion for CP unrelieved by SL NTG, start 5 μg/min
Sustained symptomatic ventricular
tachycardia
Pulse present: Call physician
Titrate O2 to maintain SpO2 ≥92%
Obtain 12-lead EKG (physician to interpret), continuous monitoring
Amiodarone 150 mg in 100 mL D5W IV over 10 minutes (15 mg/min); followed by amiodarone
900 mg in 500 mL D5W IV infusion at 1 mg/min
Cardiovert if patient becomes unstable/symptomatic
If becomes pulseless, call code blue; follow ACLS guidelines
Symptomatic bradycardia
Call physician
Titrate O2 to maintain SpO2 ≥92% (flow maximum 4 L/min)
Obtain 12-lead EKG, physician to interpret
Atropine 0.5 mg IV; may repeat x 1
Apply transcutaneous pacemaker if dysrhythmia persists
Acute respiratory distress
Call physician
Titrate O2 to maintain SpO2 ≥92% (verify O2 flow with physician)
Notify respiratory therapist
Stat ABG
Call ED physician to intubate if patient’s condition critical
Order stat portable CXR if suspected pneumothorax, hemothorax, or other chest abnormality
For life-threatening dysrhythmias
associated with placement of a
Swan-Ganz catheter in the right
ventricle
Notify the physician
Withdraw Swan-Ganz catheter into the right atrium (after verifying that the balloon is deflated)
For symptomatic tachycardia
Call physician
Initiate ACLS guidelines for synchronized cardioversion if patient’s condition becomes unstable
For symptomatic hypotension
Call physician
Initiate fluid bolus of 250 mL normal saline
H/H if bleeding suspected
Abbreviations: ABG, arterial blood gas analysis; ACLS, Advanced Cardiovascular Life Support; CP, chest pain; CXR, chest radiograph; D5W, 5% dextrose in water;
ED, emergency department; EKG, electrocardiogram; H/H, hemoglobin/hematocrit; IV, intravenous; NTG, nitroglycerin; O2, oxygen; q, every; SL, sublingual; SpO2,
oxygen saturation by pulse oximetry; stat, urgent.
(Figure 2). Designated members of the RRT received
training on use of the emergency protocol and expectations of RRT roles, with a strong emphasis on providing
positive reinforcement to staff members initiating the
response. No specific education on the clinical management of urgent patient situations was deemed necessary
for the 4 ICU nurse managers. They had a mean of 21
years of ICU experience, maintained Advanced Cardiac
Life Support (ACLS) certification, and had already informally consulted on non-ICU patients in deteriorating
condition when requested by other nurse managers.
This approach allowed more rapid implementation of
the RRT program and decreased RRT initiation costs.
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Findings Before RRT Implementation
Before RRT implementation, a retrospective chart
review was conducted of inpatients sustaining a cardiopulmonary arrest during the preceding year to evaluate
the presence of antecedent physiological abnormalities.
A systolic blood pressure less than 90 mm Hg, a heart
rate greater than 100 beats per minute, and a respiratory
rate greater than 20 breaths per minute were grouped
together and considered abnormal vital signs. Oxygen
saturation less than 90% was considered abnormal, and
a level of consciousness recorded as less than the patient’s
baseline was considered altered mental status. New onset
or worsening of pain was determined by the patient’s
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RAPID RESPONSE
TEAM RECORD
Date: _______________________
Time called: __________
Team called by:
❒ Nurse
Patient label
Room#/location: __________________
Arrival time: ______________
❒ Therapist
❒ House officer
Code status_________
Event ended: ____________
❒ Attending
❒ Other ____________
PRIMARY REASON FOR CALL
❒ Staff concerned/worried:
❒ Acute significant bleed
Specify: _______
❒ Acute mental change
❒ SBP less than 80 mm Hg
❒ Failure to respond to treatment
❒ Symptomatic hypertension
❒ New neuro deficit
VITAL SIGNS:
HR____________
❒
❒
❒
❒
❒
❒
RR less than 8
Symptomatic bradycardia
RR greater than 24
Seizures
SpO2 less than 90%
HR greater than 130
BP______________
RR______________
Situation/background:
TEMP_____________
RECOMMENDATIONS/INTERVENTIONS
Airway/Breathing
❒ Oral airway
❒ Suctioned
❒ Nebulizer treatment
❒ Intubated
❒ NPPV
❒ Bag mask
❒ O2 Mask/nasal
❒ ABG
❒ CXR
❒ No intervention
Circulation
❒ Fluid bolus
❒ Blood
❒ EKG
❒ NPPV
❒ Defibrillation
❒ Cardioversion
❒ No intervention
Admitting DX:
History:
MEDICATIONS:
ASSESSMENT:
OTHER INTERVENTIONS (Specify):
Follow-up report:
Outcome: ❒ Potential code avoided ❒ Other: __________________________________________________________
❒ Stayed in room
❒ Transferred to ICU
❒ Transferred to telemetry
❒ Remote telemetry
PHYSICIAN NOTIFIED: __________________________________
Time: _______________________________
SIGNATURES OF TEAM MEMBERS:
MD:________________________________________________________
RN:________________________________________________________
RT:_________________________________________________________
Figure 1 Form used to document rapid response calls.
Abbreviations: ABG, arterial blood gas analysis; BP, blood pressure; CXR, chest radiograph; DX, diagnosis; EKG, electrocardiogram; HR, heart rate; ICU, intensive
care unit; MD, physician; NPPV, noninvasive positive-pressure ventilation; O2, oxygen; RN, nurse; RR, respiratory rate; RT, respiratory therapist; SBP, systolic
blood pressure; SpO2, oxygen saturation by pulse oximetry; TEMP, body temperature.
report of pain. Patients exhibited signs of deterioration
a mean of 4.53 hours before cardiac arrest. A change in
vital signs, occurring in 74% of patients, was the most
common abnormality noted before cardiac arrest. The
next most common abnormality was oxygen desaturation
in 42% of patients, followed by an alteration in mental
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status in 37% of patients. New or increased pain was noted
in a small number of patients. Most patients exhibited
more than 1 indication of deterioration in clinical condition. The percentage of cardiac arrests occurring outside
of the ICU was 83%. The cardiac arrest rate was 1.84 and
the hospital mortality rate was 1.42 per 1000 discharges.
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Findings After RRT Implementation
House
supervisor
Lead
respiratory
therapist
Intensive care
unit’s nurse
manager
Assessment of patient
Transfer
to higher
level of care
Collaborates
with
attending
physician
Make recommendations
and patient remains
on present unit
If patient’s condition worsens or you become
concerned—recall critical rescue
No. of inpatient codes
Figure 2 Algorithm showing the process for activating the
rapid response team.
7
17
6
14
12
5
10
4
8
3
6
2
4
1
No. of rapid response calls
In mid-February 2006, the RRT officially became
operational. By year’s end, a total of 106 RRT calls had
been made and 20 inpatients had experienced cardiac
arrest. In 2006, the cardiac arrest rate per 1000 discharges
was 1.7 and the percentage of non-ICU cardiac arrests
decreased from 83% to 12.7%, a substantial reduction.
The number of cardiac arrests declined as the number
of RRT calls increased (Figure 3). By the close of 2007,
the percentage of cardiac arrests occurring outside the
ICU was 64% and declined further to a relatively constant
rate, ranging between 45% and 53% through 2012 (Figure 4). The actual number of cardiac arrests increased
during the 6-year period, related to the addition of 68
ICU and inpatient beds and a higher patient volume.
The cardiac arrest rate initially decreased for the first 2
years of implementation to 1.7 but increased to 3.4 by
2012 after changes in the method of collecting and
reporting this data were implemented within the health
care system. Hospital mortality rate showed a small
downward trend from 1.44 per 1000 discharges in 2005
to 1.25 per 1000 discharges in 2012.
The number of RRT calls increased almost every year,
peaking at 444 calls in 2011, ending at 358 calls for 2012,
reflective of a 5% decrease in 2012 hospital discharges. The
RRT “dose” rate increased from 7.5 per 1000 discharges
in 2007, the first full year of RRT operation, to as high as
Page rapid response team
2
0
0
February
March
April
May
June
Inpatient codes
Juy
August September October November December
Rapid response calls
Figure 3 Inpatient codes versus rapid response calls in 2006. Rapid response calls started in February, and there were no
inpatient codes in December.
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Vol 34, No. 3, JUNE 2014
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90
60
80
40
60
50
30
40
20
30
20
Number of non-ICU cardiac arrests
Percentage of non-ICU cardiac arrests
50
70
10
10
0
0
2005
2006
2007
2008
2009
2010
2011
2012
Year
% of non-ICU cardiac arrests
No. of non-ICU cardiac arrests
Figure 4 Percentage versus number of cardiac arrests not occurring in the intensive care unit (ICU). Data point for the number
of non-ICU cardiac arrests in 2005 was not available.
20.3 per 1000 discharges in 2011. The RRT call duration
decreased from a mean of 40 minutes the first year to a
mean of 24.3 minutes by 2012. Telemetry activated the
RRT most often, followed by the medical and surgical
units. Although the telemetry units placed the most RRT
calls, the “other” category, which includes the outpatient
areas, rehabilitation unit, medical imaging, cafeteria, hospital lobby, and other areas, demonstrated an increased
call rate during the 6-year period, while telemetry calls
decreased
The RRT included the nursing house
slightly. Most
supervisor, the shift lead respiratory
calls occurred
therapist, and the nurse manager of the
between the
ICU, who was designated as team lead. hours of 7 AM
and 3 PM, but
calls during evening and night hours have trended upward
(Figure 5). Disposition of RRT patients after an RRT
event remained consistent during the 6 years (Figure 6).
More than half, up to 58%, of RRT patients transferred
to the ICU after an RRT event, 10% to 20% transferred
to telemetry, and 30% to 40% remained in their room.
A small number of RRT patients from outpatient areas
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Vol 34, No. 3, JUNE 2014
were taken to the emergency department. Initially the
most common reason for the RRT call was a change in
vital signs, but over time, nurses’ concern for the patient
became the most common reason and a change in vital
signs became the second most common trigger.
Discussion
Although the goal of RRT implementation was to
reduce the incidence of cardiac arrests outside the ICU,
the precipitous decrease during the first year, from 83%
to 12.7%, was greater than anticipated. Likely reasons for
this decrease included the implementation of the RRT,
the opening of a newly constructed 26-bed ICU, nearly
double the size of the former ICU, and the addition of 56
new telemetry and surgical beds. Typically many
patients in the emergency department waited from 2 to
24 hours or more for inpatient bed placement. The addition of the new beds improved patient flow, decreased
length of stay in the emergency department, and facilitated patients’ placement on monitored units.
In 2007, the second year of RRT implementation,
64% of arrests occurred outside the ICU, a 23% decrease
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80
70
Percentage of calls
60
50
40
30
20
10
0
0
2006
2007
2008
2009
Year
2010
2011
2012
2011
2012
Time of day
7 AM-2:59 PM
3 PM-10:59 PM
11 PM-6:59 AM
Figure 5 Percentage of calls and time of day.
70
60
Percentage of patients
50
40
30
20
10
0
2006
2007
2008
2009
2010
Year
Stayed in room
Transferred to telemetry unit
Transferred to intensive care unit
Transferred to emergency department (outpatients)
Figure 6 Disposition of patients after rapid response team was called.
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CriticalCareNurse
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51
from 2005, and comparable to decreases reported by
others.8,11,17,26,28 The percentage of non-ICU arrests declined
to 56% in 2008 and to 47.6% by 2009, thereafter ranging
from 45% to 48% until 2012 when it increased slightly
to 53.4%. As hospital volume increased after the addition of 68 beds, the actual number of cardiac arrests
increased and then remained fairly constant through
2012. After declining to 1.7 per 1000 discharges for the
first 2 years, the cardiac arrest rate increased, in spite of
a sustainable reduction in the number of cardiac arrests
occurring outside the ICU and a slight decline in hospital mortality rate. After the initial increase, the arrest
rate stabilized between 3.4 and 4.5 per 1000 discharges
through 2012. An aging population may have contributed
to the increase; however, changes made to definitions
and disease code classifications during the third year
were most likely responsible for the difference in cardiac
arrest rates between the first 2 years and the last 4 years.
Because the RRT dose rate was less than the recommended
25 per 1000 discharges, using the RRT more often may
have resulted in a more observable decrease in the overall arrest rate.
The number of RRT events has increased since RRT
inception while the duration of calls has decreased. Several factors influenced the increase in RRT use. Intentional
promotion of RRT by sharing its success with nursing
and medical staff encouraged RRT use, and keeping the
ICU nurse manager free of patient assignments accommodated the increased call volume. Although no formal
data were obtained, anecdotal reports from nursing staff
and managers indicated that they viewed the RRT as a
support for the bedside nurse, a patient safety measure,
a mechanism
for improving
The percentage of cardiac arrests occurring communicaoutside the ICU decreased from 83% to
tion with
12.7% in the year after implementation of
providers, and
the RRT, although a new ICU twice the size a tool for facilof the old ICU opened that year too.
itating care
and ICU transfer for a declining patient. This theme, consistent with
previously reported data, was also observed by administrators and most providers.3,35,42,43,46 The mean RRT call
duration of 24 minutes in 2012 is similar to what some
others have reported.15,32,46,48,49 Factors contributing to
shorter RRT calls include familiarity with the RRT
process, development of cohesiveness and trust among
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Vol 34, No. 3, JUNE 2014
team members, and acquisition of expertise by both
nurses from general care areas and RRT members
through repeated experience of the RRT process.12,46
This ICU consistently reports the highest mean
APACHE scores within the 24-hospital system. The 4
telemetry units, including the stroke unit, have a total
of 104 beds and receive the majority of ICU transfers,
contributing to their higher number of RRT calls. Two
things may be responsible for the decline in telemetry
RRT calls in the past few years: the addition of education
in nursing orientation focused on patients in deteriorating condition and skill gained in managing declining
patients through repeated RRT exposure.
Initially the RRT was conceived as a resource for
inpatients, although it was never specifically stated that
the team would not respond to other areas. As the RRT
has become a familiar part of the hospital culture, it has
been adopted by all areas of the hospital. The increased
volume of RRT use in “other” areas of the hospital such
as the kitchen, gift shop, lobby, as well as ancillary
departments such as outpatient diagnostics and
endoscopy is responsible for the higher number of
“other” category calls.
Multiple factors contribute to a successful RRT, but
nursing satisfaction with the process is a key factor in
developing an effective RRT. Supportive feedback from
the RRT members and favorable experiences with RRT
events reinforce staff use. Because failure of bedside staff
to call the RRT when activation criteria are present has
been associated with adverse events, the RRT should
support the staff initiating the response and consider no
call inappropriate.11,24,49 If nurses fear disapproval, believe
they have adequate resources to manage the patient, or
presume they should be able to handle the patient themselves, initiation of the RRT is unlikely.42,49
Nonjudgmental appraisal of RRT occurrences mitigates fear of reproach for unwarranted calls. An “unnecessary” call still offers opportunities for teaching and
mentoring less-experienced clinicians. The nurse may
require help even if the patient did not. Easy access to
skilled assistance, an immediate response to a patient in
unstable condition, expedited patient transfer to a higher
level of care, patient stabilization, and confirmation of
the bedside nurses’ judgment underscores the benefit
of RRT activation to staff.42,44,45 The RRT event may also
encourage discussions regarding end-of-life decisions
and facilitate a “do-not-resuscitate” order for patients
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and families struggling with end-of-life decisions.30,32,50
As nurses experience these advantages, the RRT will
become incorporated into usual nursing practice.47
Monitoring RRT data and processes are essential to preserve RRT effectiveness by confirming success or identifying deficiencies. Data analysis has confirmed the need
to exclude the ICU nurse manager from patient assignments. If RRT call volume increases, call duration
lengthens, or the RRT assumes additional responsibilities such as outreach or surveillance, back-up strategies
using the clinical nurse specialist or ICU director of
nursing may be insufficient, and dedicated positions
may be a consideration.
Implications for Practice
Our experience indicates that a team of clinical
experts responding to the bedside of patients in deteriorating condition results in a reduction in non-ICU cardiopulmonary arrests, and this reduction is sustainable
over time. Creating and maintaining a successful RRT,
without the use of additional resources, is possible if
the team members are experienced in the rescue and
management of critically ill patients and are routinely
free of patient assignments. The ICU nurses leading the
RRT should be ACLS certified and proficient critical
care nurses. Barriers that prevent bedside staff from
activating the RRT need to be identified and conquered
in order to promote its use, increase the call rate, and
realize benefits.
The RRT must be incorporated into hospital culture
to be effective. Providing repeated education and sharing RRT outcomes with nurses, clinical staff, physicians,
and administrators can perpetuate its use and achieve a
higher dose rate, which can maximize RRT impact. The
leadership team of the hospital must support an organizational culture that values patient safety and promotes
innovative strategies focused on the reduction of adverse
outcomes. Ongoing monitoring of RRT call volume, duration, and outcomes is essential to ensure that designated
resources are adequate to maintain patient flow, ICU
staff supervision, program success, and sustainability.
Conclusion
Although RRSs have been described as a “bandaid”
for managing patients in general care areas whose condition deteriorates, this patient safety strategy is contributing to the ability of hospitals to rescue patients with
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signs of deterioration and reduce the occurrence of preventable adverse events.8,13 The implementation of an
RRT program that uses the ICU nurse manager as the
team leader can produce sustainable decreases in the
percentage of cardiac arrests occurring outside the ICU
without the expense of dedicated resources. Over time,
experience with the rapid response process can decrease
the duration of the call, which allows accommodation
for increases in RRT volume. For now, the RRT seems to
be a good strategy for improving patient safety. As Don
Berwick14 stated, “the names of the patients whose lives
we save can never be known. Our contribution will be
what did not happen to them.” CCN
Financial Disclosures
None reported.
Now that you’ve read the article, create or contribute to an online discussion
about this topic using eLetters. Just visit www.ccnonline.org and select the article you want to comment on. In the full-text or PDF view of the article, click
“Responses” in the middle column and then “Submit a response.”
To learn more about rapid response teams, read “Rapid Response
Teams: Qualitative Analysis of Their Effectiveness” by Leach and
Mayo in the American Journal of Critical Care, May 2013;22:198210. Available at www.ajcconline.org.
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CCN Fast Facts
CriticalCareNurse
The journal for high acuity, progressive, and critical care nursing
Designing a Critical Care Nurse–Led Rapid
Response Team Using Only Available
Resources: 6 Years Later
Facts
• Rapid response teams (RRTs) have been introduced
to intervene in the care of patients whose condition
deteriorates unexpectedly by bringing clinical
experts quickly to the patient’s bedside.
• Evidence supporting the need to overcome failure to
deliver optimal care in hospitals is robust; whether
RRTs demonstrate benefit by improving patient
safety and reducing the occurrence of adverse events
remains controversial.
• Despite inconsistent evidence regarding the effectiveness of RRTs, concerns regarding care and costly
consequences of unaddressed deterioration in
patients’ condition have prompted many hospitals
to implement RRTs as a patient safety strategy.
• A cost-neutral structure for an RRT led by a nurse
from the intensive care unit (ICU) was implemented
with the goal of reducing cardiopulmonary arrests
occurring outside the ICU.
• No positions existed that could be solely dedicated
to the RRT, and creating new RRT nursing positions
was not an option. The selected RRT membership
Table
When to activate the rapid response team
Nurse is concerned about patient
Respiratory distress or threatened airway (respiratory rate
>30/min or <6/min or acute change in oxygen saturation
<90% despite administration of oxygen) or change in
breathing pattern
Acute change in blood pressure to <90 mm Hg, heart rate to
<40/min or >130/min, or 20% change from baseline
Acute change in level of consciousness
Urine output <50 mL in 4 hours without history of renal
dysfunction
Failure to respond to treatment
included the nursing house supervisor, the shift lead respiratory therapist, and the nurse manager of the ICU,
who was designated as team lead.
• Criteria for calling the RRT similar to the criteria used by
other hospitals were developed (see Table), but staff were
encouraged to activate the RRT any time they had concerns
about a patient’s condition.
• To activate the RRT, staff called the same emergency phone
number used to broadcast a cardiac arrest. The RRT
responded to all inpatient units, diagnostic areas, a rehabilitation unit located within the facility, as well as outpatient areas such as endoscopy, medication and pain
clinics, and a chest pain unit.
• All hospital clinical staff and physicians were educated
about the purpose and process of RRT activation. Designated members of the RRT received training on use of
the emergency protocol and expectations of RRT roles,
with a strong emphasis on providing positive reinforcement to staff members initiating the response.
• The number of RRT events has increased since RRT inception while the duration of calls has decreased. Several
factors influenced the increase in RRT use. Intentional
promotion of RRT by sharing its success with nursing
and medical staff encouraged RRT use, and keeping the
ICU nurse manager free of patient assignments accommodated the increased call volume.
• Anecdotal reports from nursing staff and managers indicated that they viewed the RRT as a support for the bedside nurse, a patient safety measure, a mechanism for
improving communication with providers, and a tool for
facilitating care and ICU transfer for a declining patient.
This theme, consistent with previously reported data,
was also observed by administrators and most providers.
• The results of 6 years’ experience indicate that a sustainable and effective RRT response can be put into practice
without increasing costs or adding positions and can
decrease the percentage of cardiopulmonary arrests occurring outside the ICU. CCN
Mitchell A, Schatz M, Francis H. Designing a Critical Care Nurse–Led Rapid Response Team Using Only Available Resources: 6 Years Later. Critical Care Nurse.
2014;34(3):41-56.
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Vol 34, No. 3, JUNE 2014
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