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Article Excerpt
Patients enter hospitals expecting treatment for chronic or acute conditions, but few expect to experience an adverse event. However, aging of the U.S. population (U.S. Census Bureau, 2001), greater acuity of patients admitted to hospitals, and ongoing shortages of health care workers (Fleming, Evans, & Chutka, 2005) increase the likelihood of adverse events in today's acute care environments. Health care providers and consumers are concerned with adverse events during hospitalization from both economic and ethical standpoints.
A fairly common adverse event that can affect costs and mortality/morbidity is failure to rescue. Failure to rescue, or inability to successfully intervene after complications have developed, has been cited as the most frequent cause of preventable hospital death (Health Grades, Inc., 2004). Hodgetts and colleagues (2002) identified delays in diagnosis as a contributing factor to preventable in-hospital cardiac arrests. Other investigators (Clarke & Aiken, 2003; Franklin & Matthew, 1994) suggested that delays in emergency treatment occur when (a) there is failure to recognize or to act on a patient's change in status, (b) critical changes are noted but interventions are not started or are started too late, (c) providers do not possess adequate knowledge, or (d) needed technology is not available. One study (Young, Gooder, McBride, James, & Fisher, 2003) found a significant impact (RR=3.5; CI=95%) of a delay of greater than 4 hours in transferring a critically ill patient to the intensive care unit (ICU) and an increase in morbidity, mortality, and costs.
Physiologic instability, such as changes in heart rate, respiratory rate, and oxygen saturation, was present within 6-8 hours of the event in more than half in-hospital cardiac arrests (Baldisseri, 2006; Buist et al., 2002). Early identification of health status changes and appropriate intervention are critical because survival-to-discharge rates after hospital cardiopulmonary arrest remain low, with some estimates at 15% (Brindley, Markland, Mayers, & Kutsogiannis, 2002). Because Peberdy and colleagues (2007) presented a comprehensive review of literature regarding rapid response systems, no additional elaboration is included here. In this article, one hospital's implementation of a rapid response team (RRT) to enhance recognition and timely response to patients' deteriorating conditions is described.
Setting
The setting for this project was a 620-bed, not-for-profit hospital in an urban area of Arizona. The wide range of health services included emergency and ACS-certified Level 1 Trauma services, general and intensive adult and pediatric care, neonatal intensive care, normal and high-risk maternal-fetal care, advanced oncology services, orthopedics, invasive and non-invasive cardiovascular care, and neurology and neurosurgical services. The facility is one of 41 hospitals within the larger parent organization.
Hospital leaders took part in the non-profit Institute for Healthcare Improvement (IHI, 2003) collaborative efforts to reduce non-ICU cardiac arrests with emphasis on reducing in-hospital deaths. Elements of the IHI Saving 100K Lives Campaign were drawn from studies suggesting that considerable variability in mortality rates (range = 3.4%-13.6% per 1,000 admissions) is present in acute care hospitals, even when patient risk factors and available technology are considered. IHI investigators concluded that system-wide issues, such as lack of planning, communication failure, and failure to recognize patient deterioration, were prime areas for improvement. Based on results in the literature (Bellomo et al., 2003; Goldhill, Worthington, Mulcahy, Tarling, & Sumner, 1999), the hospital developed structures and processes for deployment of a RRT, with the intent of reducing preventable patient deaths outside the ICUs.
Planning
The RRT was conceptualized as a consultative service bringing critical care expertise to the medical-surgical patient's bedside. Initiation of the RRT was designed to occur with one phone call to the house manager, a seasoned registered nurse charged with assuring staffing adequacy/patient placement and facilitating inter-departmental communication. When the house manager would receive a RRT call, he or she would activate the paging system for RRT responders. RRT members can provide necessary intervention and, if needed, assist with the patient transfer to a higher level of care. Provision of additional skills, as well as early intervention and management, was believed to lead to fewer emergency calls outside the ICUs.
Critical components of the RRT deployment included determining the structure of the RRT, clarifying criteria for summoning the RRT, designing a documentation method for RRT calls, educating physicians...
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