Rapid response teams (RRTs), guided by advanced electronic health record (EHR) capabilities with alerting tools, could be as big a breakthrough in saving lives as the creation of intensive care units (ICU) was in the 1950s. RRTs, which major hospitals are establishing to curb patient codes and deaths, are quickly advancing the standard of care for critically ill patients.
Rapid response teams (RRTs), guided by advanced electronic health record (EHR) capabilities with alerting tools, could be as big a breakthrough in saving lives as the creation of intensive care units (ICU) was in the 1950s. RRTs, which major hospitals are establishing to curb patient codes and deaths, are quickly advancing the standard of care for critically ill patients.
RRTs were virtually unknown just a few years ago, but that began to change when the Institute for Healthcare Improvement (IHI) launched its “100,000 Lives Campaign” in December 2004 with the goal of preventing 100,000 unnecessary in-hospital deaths. The campaign’s first of six recommended quality improvement changes was to “Activate a rapid response team at the first sign that a patient’s condition is worsening and may lead to a more serious medical emergency.” Interest soared as hospitals began to report the benefits of utilizing RRTs, including dramatic reductions in:
• Cardiac arrests;
• Deaths attributable to cardiac arrests;
• Post-operative and hospitalwide deaths;
• Length-of-stay for cardiac arrest survivors; and
• The rate of serious adverse outcomes after surgery.
In June 2006, IHI announced that more than 100 hospitals have fully implemented the RRT concept and more than 1,700 hospitals are either in the process or are committed to implementation. Also, several distinguished healthcare organizations have endorsed the campaign, including the American Medical Association, the American Nurses Association, the Centers for Disease Control and Prevention, and the Joint Commission on Accreditation of Healthcare Organizations.
An Ounce of Prevention
Even with the availability of physicians, nurses and equipment, thousands of hospitalized patients die every year from cardiac or respiratory arrest. Traditionally, hospitals have deployed “code blue” teams to resuscitate these patients after they reached a crisis stage. RRTs, sometimes known as medical emergency teams, intervene before a patient’s condition deteriorates by bringing critical care expertise to the bedside or wherever it is needed—outpatient testing areas, the cafeteria or even the gift shop—when the patient first becomes unstable. The idea behind all RRTs is to avert crises through early identification of unstable patients, with transfer to the ICU. The team helps:
• Assess and stabilize the patient’s condition;
• Educate and support staff;
• Organize information to be communicated to the patient’s physician;
• Facilitate needed patient transfers.
Currently, most RRTs are called when a nurse or other caregiver believes that a patient may be in danger. However, combining RRTs with an automated clinical surveillance system that triggers an alert before a bedside caregiver may be aware of a patient’s deteriorating condition can help RRTs prevent problems.
The automatic trigger also eliminates the stigma that some nurses may feel if they ask for help. The system should capture key patient data, monitor that best practices are being followed, aggregate key clinical information and automatically notify the RRT when results fall outside of established norms. Triggering criteria might include acute changes such as:
• Heart rate <40 or >130 bpm;• Systolic blood pressure <90 mmHg;• Respiratory rate <8 or >28 per minute;• Saturation <90 percent despite O2;• State of consciousness;• Urinary output to <50 ml in four hours.Research on clinical instability further bolsters the incorporation of automated surveillance and alerting tools into the RRT process. Usually, the clinical status of non-ICU patients doesn’t decline suddenly; there are warning signs. For example, the median duration of instability before a clinical event was six and a half hours. Furthermore, 48 percent of the time, clinical signs of deterioration were evident in the preceding 24 hours but were not acted upon. Most disturbing of all, 73 percent of arrests were avoidable. An objective, “always on” automated system provides a valuable “fail safe” for overworked caregivers.
Automated clinical surveillance requires the use of EHRs to ensure the accessibility of key patient data. Some EHRs have a clinical surveillance system option, while others require the addition of an add-on system that can seamlessly integrate with an existing EHR. Proactive clinical surveillance systems should be customizable to give caregivers and supervisors “dashboard views” that efficiently pinpoint the warning signs of clinical decline.
For instance, the computer screen might show all patients in a universal view: ICU, medical-surgical, orthopedics and telemetry, noting that a telemetry patient is experiencing respiratory distress and needs an RRT. The dashboard also can be organized by provider, so that physicians and nurses can check a patient list to see which values are sounding an alert; or by patient, providing caregivers detailed data on the patient’s current status and previous care.
To promote best practices in mobilizing RRTs, automated clinical surveillance tools save immense time in prioritizing patient care, eliminating the need to rely on notes taken during rounds or verbal information. They also must enable the hospital to accomplish the following objectives:
1. Capture and review patient data electronically from devices such as physiologic monitors and
ventilators;
2. Display information in real-time dashboard summaries based on hospital-established parameters;
3. Present actionable data for nurse approval so caregivers can easily identify decompensating
patients, based on information that is specific and focused;
4. Allow review of real-time reports to assess compliance and effectiveness of hospital protocols
and processes.
If, for example, the hospital calls for head-of-the-bed elevation to reduce ventilator-associated pneumonia, real-time monitoring can instantly display whether the protocol is being followed. If not, the correction can happen immediately, promoting best practices and maybe even avoiding sudden decompensation. In the past, it was possible to see this kind of data, but only after waiting weeks or months after periodic reporting was compiled, and far too late to prevent an adverse outcome.
Is the Effort Worth It?
Change is difficult, so it is important to determine if it is warranted. Based on data from hospitals that have implemented RRTs, they are definitely worth the effort.
Austin and Repatriation Medical Centre in Melbourne, Australia, a pioneer in RRT adoption, experienced the following reductions:
• 65 percent in cardiac arrests;
• 56 percent in deaths attributable to cardiac arrests;
• 26 percent in deaths hospitalwide;
• 88 percent in length-of-stay among cardiac arrest survivors;
• 58 percent in the rate of serious adverse outcomes after surgery;
• 37 percent in postoperative deaths.
At Missouri Baptist Medical Center in St. Louis, Mo., calls to the RRT numbered between 70 and 80 per month after only two months. The team’s average response time is 1.5 minutes. The organization experienced a 31 percent drop in cardiac arrests during 2004. Finally, the survival rate for patients assessed by the RRT is 82 percent, compared to 17 percent for codes.
Keep in mind that as RRTs gain popularity, hospitals will increasingly risk needless-death litigation, and also losses, from not implementing an RRT. In the near future, these teams will be seen as another best-practice measure that hospitals could have employed to save a life.
Furthermore, there is new evidence that RRTs may actually enhance a hospital’s bottom line. Indeed, the bond-rating firm Moody’s issued one of its periodic “Special Comments” in May. The report noted that hospitals “that eventually demonstrate a sustainable link between quality investments and better clinical outcomes will likely gain competitive advantage, thereby improving financial performance and possibly their bond ratings.”
Because RRTs have evolved without organized input from IT, many hospitals in the planning stages may not be aware of the benefits of clinical surveillance systems. IT professionals can help hospitals measure outcomes by tracking pre- and post-implementation trends in:
• Codes per 1,000 discharges;
• Codes outside the ICU;
• Utilization of the RRT;
• Post-cardiac arrest ICU bed utilization;
• Staff satisfaction with RRT;
• Percent of coded patients who survive and are discharged.
Many hospitals are in the planning stages of RRT implementation. Now is the time for CIOs to become a part of the process.
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