Rapid Response, Better Outcomes

Jan. 1, 2009

A Texas VA improves ICU outcomes with an automated clinical data surveillance application.

The case for implementing rapid response teams (RRT) remains in question since 2005, when the results of the MERIT trial were published. Nevertheless, the non-profit Institute for Healthcare Improvement has aggressively promoted RRTs, making them an important part of its 5 Million Lives Campaign.

A Texas VA improves ICU outcomes with an automated clinical data surveillance application.

The case for implementing rapid response teams (RRT) remains in question since 2005, when the results of the MERIT trial were published. Nevertheless, the non-profit Institute for Healthcare Improvement has aggressively promoted RRTs, making them an important part of its 5 Million Lives Campaign.

The formation of the RRT stems from the fact that most patients have abnormalities of vital signs, laboratory or some other aspect of their condition in the eight hours prior to cardiopulmonary arrest. It is thought that early intervention in these patients would prevent the subsequent arrest. More specifically, if a nurse or other caregiver on the general ward could summon an RRT, aka a medical emergency team (MET), to intervene and stabilize patients in the early stages of clinical decline, that action could reduce admissions to the intensive care unit (ICU). The hope would be that the RRT intervention might decrease inpatient mortality and cardiopulmonary arrests, improving the patient’s chance for survival. It’s probable that lives could be saved and outcomes improved if RRTs were dispatched to the bedside at the first sign of patients experiencing a clinical decline, thereby preventing a cardiopulmonary arrest or Code Blue.

Swayed by the argument, approximately 1,800 hospitals nationwide, including VA North Texas Health Care System, have created RRTs. Although RRTs have lowered mortality and arrests outside the ICU in single-center, non-randomized studies, they nonetheless have proven to be ineffective in the large randomized study. We think this is because their design is flawed; RRT activation revolves around nurses and other caregivers recognizing that a patient’s condition is deteriorating.

Sometimes that occurs, but more often than not they miss the warning signs for several reasons including lack of time and a heavy workload. By definition, the clinical decline is unexpected and therefore vigilance for the decline is not high. For RRTs to work successfully, the early warning system triggering them must be driven by information technology, not the vigilance of a caregiver.

To better support RRTs and avoid compromising care, caregivers must electronically enter vital signs or hospitals must interface vital signs devices to transmit data to the EMR in close to real time.

That’s why VA North Texas Health Care recently initiated interfacing its Computerized Patient Record System (CPRS) with its existing Essentris OnWatch automated data surveillance application from CliniComp Intl.

The Case for IT

RRTs are part of a national patient safety initiative for VA facilities. Since we implemented RRTs earlier this year, we have found that RRTs can be an effective patient care tool, but only if deployed. Unfortunately, reflecting the results of the MERIT study in Australia where METs were pioneered, that doesn’t happen very often. The study, published in the June 18, 2005 issue of The Lancet, found that the 12 facilities that introduced METs were more likely to call an emergency team for help than the 11 hospitals that did not have them (3.1 calls versus 8.7 calls per 1,000 admissions).

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Additionally, only 30 percent of patients who met the criteria for a call received MET care and subsequent transfer to the ICU. Study results also show that facilities failed to activate a MET for 30 percent of patients who met the calling criteria prior to cardiac arrest, 51 percent of ICU admissions were unplanned, and, 50 percent of patients died unexpectedly. Clinicians also tended to monitor patients more closely during the day than the evening, while providers were more likely to keep closer tabs on patients on weekdays than weekends.

RRTs are underutilized, we believe, primarily because clinicians are very busy and expected to take care of a greater number of patients than ever before, creating an environment that is more vulnerable to lapses in patient care. In addition, there are more than 10,000 medications worldwide, making it impossible for clinicians to remember all the side effects and ways these drugs can interact with each other. Also, because of the increasing use and reliance upon hospital clinical information systems over the past decade, an unintended consequence is that many nurses and caregivers have come to rely on them to such a degree that they are neglecting critical thinking.

Who Helps the Watcher?

Given the complexity of today’s inpatient environment, RRT programs in their current structure are doomed to fail because they demand a level of perfection that is impossible for the current system to attain. Electronically monitoring patients’ physiological, laboratory and other data in real time and relaying an alert when the data shows clinical decline would provide the reliability and consistency that RRTs lack in their present form.

Unlike human beings, computers can be programmed to monitor patients 24 hours a day, seven days a week based on the same criteria. As a result, computers deliver the same level of performance regardless of whether it’s a weekday, weekend, daytime or evening.

In November 2008, the VA North Texas Health Care System rolled out this system in all of its ICUs. By interfacing vital signs, laboratory and medications, the system quickly identifies patients who are in trouble based on their blood pressure, heart rate, respiratory rates and other vitals. These patients can be identified by glancing at a “dashboard” screen within the Essentris program.

While our organization is initially using the system to identify patients doing poorly in the ICU, our next plan is to push it out to monitor the patients on the wards to anticipate and prevent adverse events from occurring.

Preventative Algorithms

In medicine, there are well-known protocols determining when it is appropriate to administer certain medications to patients based on their vital signs, laboratory values and what other drugs they may be on. For example, nurses should not administer digoxin when the heart rate is too low or give an antihypertensive to patients whose blood pressure is already low. However, busy nurses may forget that, because the order they are executing involves the right patient, right drug, right dosage, right time, right documentation and right route.

For RRTs to work successfully, the early warning system triggering them must be driven by information technology, not the vigilance of a caregiver.

The only element missing from that equation is critical thinking at the point of care — should the medication be administered and why or why not? This is the critical juncture where the algorithms play an important role in reminding and prompting people at the point of care to put on their thinking caps.

A major challenge facing VA North Texas Health Care or any other facility seeking to achieve the same care goals will be entering vital signs into their electronic medical record (EMR) on a timely basis so that data can be transmitted immediately to the interfaced system. To better support RRTs and avoid compromising care, caregivers must electronically enter vital signs or hospitals must interface vital signs devices to transmit data to the EMR in close to real time.

Striking the Right Balance

Another challenge will be writing algorithms as we move forward evolving our system. The VA North Texas Health Care System must strike the right balance to avoid generating either an inadequate or excessive number of alerts. The former will essentially mirror what already occurs in a non-automated environment in which RRTs are never called to the bedside of the majority of patients needing them. On the other hand, the latter will overwhelm RRTs with so many false positive warnings that clinicians will eventually ignore or respond slowly to them because of the “cry wolf” syndrome.

Any organization that already has an EMR and bar-code medication administration system can build a solution like ours with a modest investment. The technology by itself won’t cure the problems preventing RRTs from fulfilling their potential. By combining IT with human critical judgment, hospitals can better position themselves to maximize return on investment and resource allocation and more importantly, accelerate patient safety across their enterprise.

William C. Yarbrough, M.D. (left), is an intensivist and chief of ICU informatics at the VA North Texas Health Care System in Dallas. Steve Rypkema, RN, is clinical information system administrator at VA North Texas Health Care System in Dallas. Contact them at [email protected]  and [email protected]

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