Clinical Roundtable: Rapid Response Teams

[proman]

In an effort to spark discussion, I'll be posting articles related to CCM periodically.

Dacey et al. The effect of a rapid response team on major clinical outcome measures in a community hospital. Crit Care Med 2007; 35:2076-82
The pdf is too big to upload, contact me for a copy via email.

In the article above, the authors evaluated the impact of a rapid response team (lead by PAs) in a nonteaching community hospital. Results included a reduction in cardiac arrests by 60%, a decrease in unplanned ICU admission from 45 to 29%. Cost of implementation was >$460,000.

There has been conflicting evidence about the efficacy of RRTs. My questions to the group:

1) What has been your experience, if any, with RRTs?

2) Is there a role for RRTs in academic centers, or in hospitals with in-house intensivists versus community non-teaching hospitals (ie the majority of hospitals in this country)?

3) Opinions on the quality of the paper?

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[chimichanga]

I don't like them so far...

On paper, they are a great idea, but 9 times out of ten, the nurse overreacts and calls one...Then 15 people show up, and it's now chaos...

And if the nurse had been more on top of (what's usually) a progressive change in condition, the whole thing could have been avoided...I believe poor nursing judgement (or lack of basic nursing intervention) is at the root of the RR...

 

[proman]

I don't like them so far...

On paper, they are a great idea, but 9 times out of ten, the nurse overreacts and calls one...Then 15 people show up, and it's now chaos...

And if the nurse had been more on top of (what's usually) a progressive change in condition, the whole thing could have been avoided...I believe poor nursing judgement (or lack of basic nursing intervention) is at the root of the RR...

What has been your experience with RRTs? Have you had the opportunity to interact with one?

I don't quite follow the comment about poor nursing judgement. It appeared according to this article that nurses requesting RRT intervention was associated with reduction in cardiac arrest and ICU admission.

 

[chimichanga]

I have experienced many of them, and they always seem to be an overreaction on the nurse's part, but this is just one hospital...Kind of a new concept seemingly...

Basically what I'm saying, is that, IMO, if the nurse triages her pts appropriately, gives the most attention to the "sickest" from moment one, she should (aside from a major acute change in condition) "see it coming" if you will, long before a rapid response is "needed"

And a good seasoned nurse, should call the charge nurse (for another opinion) and interact together, before the pt crashes...

Maybe it's not that black and white, but I've only ever seen one RR that was actually needed...

A good example (of + outcome w/ no RR): change of shift; day nurse notices new facial droop in pt x...she calls in night nurse (who had the pt the day before) and they both agree...we call PCP, get stat CT, pt has subacute subdural w/ 5mm shift...I (house sup) arrange admission to a hospital w/ neurosurg...Pt to ICU while transfer is arranged...

No drama, no fuss, no muss...we handled it well...If nurses would use available resources (charge, house sup, teach team, etc) RR 90% of the time, is not needed...

 

[southerndoc]

I have experienced many of them, and they always seem to be an overreaction on the nurse's part, but this is just one hospital...Kind of a new concept seemingly...

Basically what I'm saying, is that, IMO, if the nurse triages her pts appropriately, gives the most attention to the "sickest" from moment one, she should (aside from a major acute change in condition) "see it coming" if you will, long before a rapid response is "needed"

And a good seasoned nurse, should call the charge nurse (for another opinion) and interact together, before the pt crashes...

Maybe it's not that black and white, but I've only ever seen one RR that was actually needed...

A good example (of + outcome w/ no RR): change of shift; day nurse notices new facial droop in pt x...she calls in night nurse (who had the pt the day before) and they both agree...we call PCP, get stat CT, pt has subacute subdural w/ 5mm shift...I (house sup) arrange admission to a hospital w/ neurosurg...Pt to ICU while transfer is arranged...

No drama, no fuss, no muss...we handled it well...If nurses would use available resources (charge, house sup, teach team, etc) RR 90% of the time, is not needed...

In my institution, the RRT is activated early. It's not because the nurse can't triage the patient appropriately. Rather it's a quick way to get a hospitalist attending at the patient's bedside to determine if the patient needs something urgently. If you call the MICU or CCU resident, they are often busy seeing other patients and might be delayed an hour or two before being able to evaluate a patient for ICU admission. If the nurse tries to page the intern covering the patient, he or she may be overwhelmed with admissions and other floor work and may delay seeing the patient.

The issue of a resident not being able to evaluate the patient in a timely basis can be debated ad nauseum. There is no way to get them to evaluate them quickly. At least in my institution, the adoption of a rapid reponse team (consisting of a hospitalist attending, respiratory therapist, ICU "float nurse", and the house supervisor) allows a patient to quickly get care that is needed and a disposition to the appropriate unit if necessary.

During my months as a MICU resident, the RRT saved me from a lot of admissions by simply intervening on patients early. The rapid AFib's were given metoprolol before they had a rate of 150 for 20 minutes and developed CHF. The briefly hypotensive patients were given fluids early and assessed for sepsis before it got to the point where they needed pressors. You get the point. It's only anecdotal evidence on my part, but RRT's do work in some institutions.

 

[ibnateICURN]

RRT's have had a positive impact at our hospital. Usually a floor nurse will call an RRT. I would agree with one of the other posters to some extent that it is usually a floor nurse using "poor nursing judgement (or lack of basic nursing intervention) is at the root of the RR..." The RRT team at my hospital consists of an ICU charge nurse and team leader ICU nurse. They assess the patient, look at current labs, signs and symptoms, give fluid boluses or start dobutamine or dopamine etc if needed. If more staff is needed such as respiratory or house supervisor then they are called. MD is then called regarding patient. Either new orders are given, patient goes to ICU, or codes. Either way I think the current literature that is out supports RRT's and there cost effectiveness. Just my 2 cents!

 

[JayneCobb]

I'm conflicted about RRTs. My experience with them is akin to chimichanga's views. At one hospital I was in the RRT was made up of an ICU nurse, RT, and senior IM resident, intern, and the med students. 9 times out of 10 we'd get there and it was really just a pre-code. and reviewing the nursing data it always seems that the vitals were never progressively changed. It's amazing that the respiratory rate is always 16 and then changes in less than 30 minutes.

and currently the hospital I'm at the RR always is 18-20. shocking. It's amazing that things are so important to pt care are done haphazardly.

 

[proman]

I'm at a bit of a loss understanding the perspective that the nurse who activates an RRT has failed. If anything, I would consider it to be a pro-active move. I'd much rather deal with a peri-arrest patient than an arrest patient. The ratios that I've seen nurses staffed (6 patients at least) really limits the face time with patients.

 

[carrigallen]

The bottom line is that RRTs prevent codes. Experienced nurses know when a patient is crashing, and should have a channel to getting help if the physician on-call is tied up or not useful.
Most of our RRTs are respiratory distress. About 70% of our RRTs result in patient being moved to higher level of care. The fact is that patients can go downhill faster than the time it takes a resident to drop everything, get to the patient, eval the patient, and make a plan...and in some situations there is no substitute for experience. The disadvantage is of course that new interns and residents aren't getting as much leadership experience in emergency situations.

 

[JayneCobb]

I'm at a bit of a loss understanding the perspective that the nurse who activates an RRT has failed.

I agree with you, but I'm a bit more to the extreme. It's been my experience that most of RRT uses were to patients who are becoming septic/SIRS and should have been caught earlier had the vital sign trends been a little more diligent in their collection.

Now for MIs, aspiration, A-Fib with RVR, etc, the RRTs are great, but they should not be used as a crutch and I guess I'm more in line with saying that we could do even better about preventing RRT usage.

 

[Tigerz_Fan]

I am a resident at a large academic institution. RRT was implemented about 9 months ago, and consists of nurse practitioners only. We have had some major problems. The floor nurses activate RRT and seem to think that is a substitute for a doctor. RRT seems to think that they are the substitute, and do not notify the resident on call either. This has resulted in detrimental outcomes on at least 6 cases.

For example: On my last night float night, a code was called overhead. When I arrived to the code, RRT had been on the scene for over an hour. I never received a page from the floor nurses or the RRT. When I questioned them about this issue, their response was basically stating that I didn't need to be there. This patient had impending respiratory failure when I arrived. When I examined the chart, I found out that she had end-stage sarcoid. RRT accepted this as the cause of her intial respiratory distress. Nothing had been done to work-up the patient for other causes. No labs, CXR, nothing. The patient did not survive the code, and why? She had an aortic dissection. I did manage to get a CXR before she died, and it was quite apparent on the films that she had a dissection. A simple CXR when she first had acute SOB may have saved her. Oh, and let me mention that they also assumed she had a PE, and started her on a heparin drip. Lovely.

I know that many institutions have had great luck with their RRT. This is just my experience, and unfortuately the problem keeps occurring.

 

[southerndoc]

I am a resident at a large academic institution. RRT was implemented about 9 months ago, and consists of nurse practitioners only. We have had some major problems. The floor nurses activate RRT and seem to think that is a substitute for a doctor. RRT seems to think that they are the substitute, and do not notify the resident on call either. This has resulted in detrimental outcomes on at least 6 cases.

For example: On my last night float night, a code was called overhead. When I arrived to the code, RRT had been on the scene for over an hour. I never received a page from the floor nurses or the RRT. When I questioned them about this issue, their response was basically stating that I didn't need to be there. This patient had impending respiratory failure when I arrived. When I examined the chart, I found out that she had end-stage sarcoid. RRT accepted this as the cause of her intial respiratory distress. Nothing had been done to work-up the patient for other causes. No labs, CXR, nothing. The patient did not survive the code, and why? She had an aortic dissection. I did manage to get a CXR before she died, and it was quite apparent on the films that she had a dissection. A simple CXR when she first had acute SOB may have saved her. Oh, and let me mention that they also assumed she had a PE, and started her on a heparin drip. Lovely.

I know that many institutions have had great luck with their RRT. This is just my experience, and unfortuately the problem keeps occurring.

For what it's worth, many nurse practitioners and physician assistants with adequate experience know more than first-year residents. However, a senior resident should have been called in this case. I think this is why RRT's work in my hospital: they are staffed by an attending hospitalist.

Regarding the aortic dissection, why would anyone accept sarcoidosis as the cause of respiratory distress if the patient was having chest pain? I assume the patient was having chest pain because aortic dissections rarely, and one could argue ever, present without chest pain. I am assuming that your thoughts of her having an aortic dissection were verified on post-mortem exam? I've seen several cases of widened mediastinums (is it mediastina?) in patients who had a portable chest x-ray or underlying pathology, such as sarcoidosis. Sarcoid itself can give you a very widened mediastinum that can fake someone out into thinking the patient has an aortic dissection.

I'm not disagreeing with you, but just throwing that out on the table.

 

[elwademd]

1) What has been your experience, if any, with RRTs?

we instituted rrt over a year ago. it's been pretty good, and we've had less codes overall.

our rrt consists of: senior resident, icu charge nurse, respiratory therapist.
code team consists of: senior resident, icu charge nurse, respiratory therapist.

so, the same team, lol. the difference is the amount of time to respond. code blue-go now. rrt- you have 2-5 minutes...

in any event, i figure the patient's either going to have a rapid response called... or have a code blue called. either way, if i'm on call, i'll end up seeing the patient one way or another. in general, i'd rather see a rapid response than a code blue.

2) Is there a role for RRTs in academic centers, or in hospitals with in-house intensivists versus community non-teaching hospitals (ie the majority of hospitals in this country)?

essentially, "the powers that be" need to look at their numbers.

at my institution, i believe "they" looked at the numbers of patients that coded, and determined it was patients not on the teaching service. rrt was implemented to reduce this number.

3) Opinions on the quality of the paper?

the articles i've read are from australia, if memory serves me correctly. i have not read this paper.

 

[BMW19]

Are hospitalist attendings frequently part of this RRT? Just curious...

B-

In an effort to spark discussion, I'll be posting articles related to CCM periodically.

Dacey et al. The effect of a rapid response team on major clinical outcome measures in a community hospital. Crit Care Med 2007; 35:2076-82
The pdf is too big to upload, contact me for a copy via email.

In the article above, the authors evaluated the impact of a rapid response team (lead by PAs) in a nonteaching community hospital. Results included a reduction in cardiac arrests by 60%, a decrease in unplanned ICU admission from 45 to 29%. Cost of implementation was >$460,000.

There has been conflicting evidence about the efficacy of RRTs. My questions to the group:

1) What has been your experience, if any, with RRTs?

2) Is there a role for RRTs in academic centers, or in hospitals with in-house intensivists versus community non-teaching hospitals (ie the majority of hospitals in this country)?

3) Opinions on the quality of the paper?

 

[elwademd]

I'm conflicted about RRTs. My experience with them is akin to chimichanga's views. At one hospital I was in the RRT was made up of an ICU nurse, RT, and senior IM resident, intern, and the med students. 9 times out of 10 we'd get there and it was really just a pre-code. and reviewing the nursing data it always seems that the vitals were never progressively changed. It's amazing that the respiratory rate is always 16 and then changes in less than 30 minutes.

and currently the hospital I'm at the RR always is 18-20. shocking. It's amazing that things are so important to pt care are done haphazardly.

i too am conflicted about rrt. i've had ones where i really felt we made a difference, and thus i've seen the good... but at times, some of the calls are mind blowing: hypoglycemia (iv came out, so the nurse figured she should call), left sided weakness in someone who came in with a stroke and left sided weakness, gave morphine/dilaudid 10-15 minutes ago and patient is somnolent...

the vital signs seems to be an interesting point... either the vitals aren't truly accurate (which would seem to be every single patient with a rr of 20), or the private attending/staff not truly paying attention to the trends.


in the end, one can always say that it's better to call than to not call... but i think the care before the rrt should also be reviewed to better the physician/nurse/cna/whoever saw the patient before that point in order to address/correct any issues.

 

[JayneCobb]

the vital signs seems to be an interesting point... either the vitals aren't truly accurate (which would seem to be every single patient with a rr of 20), or the private attending/staff not truly paying attention to the trends.

Given the vitals are coming from the nursing notes, I tend to think the collection is haphazard. In reality, the Heart rate and Temp is the only thing I can semi count on. The I&Os are rarely done properly and half the time on a patient I've ordered strict I&Os, the nurses write in BRP.

And assuming we're talking about SIRS, this is a little disconcerting as the number of criteria you have to meet does have a correlation with mortality.

 

[chimichanga]

They can be haphazard...


D/T poor judgement, poor staffing, poor whatever, and et, freakin' ceterea...

Nursing failure is a nightmare, for certain, and a necessary evil...Admin failure is at the root...

 

[carrigallen]

RRTs basically are designed to compensate for ******ed residents. Tonight we had no less than 3 RRTs all on one small surgical-subspecialty floor. One was an old lady with an EF of 10% given 4 liters of LR post-op.

 

[Annette]

I'm a hospitalist in a non-resident teaching community hospital. Our RRT consists of an ICU nurse, the nursing coordinator (an experienced nurse, usually EM or ICU trained), and an RT. Physicians are called when ever a RRT is called. Hospitalist patients always have a hospitalist in house, private patients get what they get. Each RR called is evaluated after the fact to see what could have been done different/better/sooner. Personality issues haven't been too big of a problem, and when it did happen, that person was removed from the team. My hospital has had good results, but I don't know the costs/ money saved.

I like the RRT because we have a large number of fairly new/ less experienced nurses. Most hospitals have a nursing shortage. I think being able to call RR, even if they can't even say why they are worried, makes the nurses feel better supported. No one gets any flak for calling RR.

 

[core0]

The bottom line is that RRTs prevent codes. Experienced nurses know when a patient is crashing, and should have a channel to getting help if the physician on-call is tied up or not useful.
Most of our RRTs are respiratory distress. About 70% of our RRTs result in patient being moved to higher level of care. The fact is that patients can go downhill faster than the time it takes a resident to drop everything, get to the patient, eval the patient, and make a plan...and in some situations there is no substitute for experience. The disadvantage is of course that new interns and residents aren't getting as much leadership experience in emergency situations.

They prevent codes but do they change outcomes. One of the private hospitals that I worked at had a chart with Codes, RRTs, and in hospital death rates. Codes went down, RRTs went up and the death rate stayed the same. If you looked at the chart the RRT+Code was exactly the same. JHACO likes these because they "reduce codes" but do they change outcomes. Anecdotally no.

David Carpenter, PA-C

 

[Annette]

I'm not surprised RRT doesn't reduce in hospital mortality rates as the patients who code/ get RRT called are CTD anyway. With RRT, there is just less rushing around/ pandemonium.

 

[Tigerz_Fan]

For what it's worth, many nurse practitioners and physician assistants with adequate experience know more than first-year residents. However, a senior resident should have been called in this case. I think this is why RRT's work in my hospital: they are staffed by an attending hospitalist.

Regarding the aortic dissection, why would anyone accept sarcoidosis as the cause of respiratory distress if the patient was having chest pain? I assume the patient was having chest pain because aortic dissections rarely, and one could argue ever, present without chest pain. I am assuming that your thoughts of her having an aortic dissection were verified on post-mortem exam? I've seen several cases of widened mediastinums (is it mediastina?) in patients who had a portable chest x-ray or underlying pathology, such as sarcoidosis. Sarcoid itself can give you a very widened mediastinum that can fake someone out into thinking the patient has an aortic dissection.

I'm not disagreeing with you, but just throwing that out on the table.

I've been busy, so not alot of time on the forums...

Anyway, to give you more light on the case. I was the senior resident on call that evening, and I was very familiar with the patient (freq-flier). I still feel that if I would have been called earlier, I would have known she was not at her normal respiratory distress state (remember end-stage sarcoid). She did never complain of chest pain. The dissection was confirmed by autopsy.....

 

[mark2climb]

My hospital was one of the first to institute the RRTs. Our arrest rates on the general floors are so low now that nurses are having to do mock resuscitations because they are so out of practice.

We encourage our floor RNs to call whenever they are feeling uncomfortable with the patient status and unable to get the primary service to come assess the patient. When the call for RRT comes, an ICU charge RN and ICU resident respond.

We have tried hard to make the call for RRTs non-punitative. The floor RNs are often so busy already and they feel guilty for not catching a decompensating patient. So, whenever a RRT is called, the RN and MD always try to make it a point of thanking them for calling, even if it's something simple like a loose pulse ox probe or a nasal cannula that's blowing on the patient's forehead. If the RNs don't feel comfortable calling, then we'd be responding to calls for resuscitation rather than responding to prevent an arrest. Also, the floor RN does not need an MD order to call the RRT.

 

[southerndoc]

I still feel that if I would have been called earlier, I would have known she was not at her normal respiratory distress state (remember end-stage sarcoid). She did never complain of chest pain. The dissection was confirmed by autopsy.....

Then I would argue that you would not have diagnosed her aortic dissection. As mentioned previously, aortic dissections rarely present without chest pain, and you may have a case that is reportable. I would encourage you to write this up in the literature. I was unable to locate any literature where aortic dissection presented without chest pain.

Finally, I assume her aortic dissection ruptured. An aortic dissection without rupture is rarely fatal unless a clot dislodges and causes massive stroke, carotid artery dissection occurs, etc.

 

[deleted6669]

we have 1 at my facility. mostly what they do is common sense stuff:
hypoxia:give o2, suction secretions
hypotension: give fluids
aloc: check glucose, give narcan, etc
psvt: give adenosine

a lot of what they do could be done by the floor nurses if they were on top of things better. if you are going to call the team for a pt with hypoxia how about starting some o2 before they arrive?
if a known diabetic is "suddenly" unresponsive how about checking a glucose, etc

 

[chimichanga]

we have 1 at my facility. mostly what they do is common sense stuff:
hypoxia:give o2, suction secretions
hypotension: give fluids
aloc: check glucose, give narcan, etc
psvt: give adenosine

a lot of what they do could be done by the floor nurses if they were on top of things better. if you are going to call the team for a pt with hypoxia how about starting some o2 before they arrive?
if a known diabetic is "suddenly" unresponsive how about checking a glucose, etc

exactly

 

[Tigerz_Fan]

Then I would argue that you would not have diagnosed her aortic dissection. As mentioned previously, aortic dissections rarely present without chest pain, and you may have a case that is reportable. I would encourage you to write this up in the literature. I was unable to locate any literature where aortic dissection presented without chest pain.

Finally, I assume her aortic dissection ruptured. An aortic dissection without rupture is rarely fatal unless a clot dislodges and causes massive stroke, carotid artery dissection occurs, etc.

Good idea...

 

[bulgethetwine]

exactly

This is an easy one.

Rapid response teams are necessary because nurses no longer come furnished out of their programs with accomplished technical skill.

Oh sure, they have the lustre of a university degree, but ask a new nurse to start an iv, efficienctly suction a c-collar patient, think through altered mental status (glucose, narcan, O2, etc)....

it's just easier to make a phone call for the rapid response.

Time to emphasize the 2 year, technical nursing tract again. You can write as many flowery essays as you want, and send as many of your nurses to Ph.D programs to get some bulls*it doctorate in philospical nursing care.

But I'll take the war-hardened, common-sense furnished tech nursing grad anytime.

 

[chimichanga]

...Time to emphasize the 2 year, technical nursing tract again. You can write as many flowery essays as you want, and send as many of your nurses to Ph.D programs to get some bulls*it doctorate in philospical nursing care.

But I'll take the war-hardened, common-sense furnished tech nursing grad anytime.

It's not the program, it's the grad, as is true w/ most any profession...

And it's a lack of good extern opportunities, and most programs won't allow starting IVs on each other...

The amount of time a nursing student spends in the hospital setting (clinicals) is regulated by the BON...

So this (tired) argument of BSN nurses being less prepared is overstated, and hogwash...My BSN students had the same # of clinical hours as my CC grads...

Bring back the diploma program, which focused on academia and hands on (living in the hospital)

And besides, when you focus too much on technical skills (in school), then the (critical) thinking falls short...

 

[bulgethetwine]

It's not the program, it's the grad, as is true w/ most any profession...

And it's a lack of good extern opportunities, and most programs won't allow starting IVs on each other...

The amount of time a nursing student spends in the hospital setting (clinicals) is regulated by the BON...

So this (tired) argument of BSN nurses being less prepared is overstated, and hogwash...My BSN students had the same # of clinical hours as my CC grads...

Bring back the diploma program, which focused on academia and hands on (living in the hospital)

And besides, when you focus too much on technical skills (in school), then the (critical) thinking falls short...

I think maybe we're arguing the same thing? At least that's what I assume when you first state that my argument is tired and overstated but then you go on suggest they need to bring back the diploma program. Anyway, the broader point is that technical training and critical thinking skills are not mutually exclusive.

If it was, doctors wouldn't have to do a residency.

The pendumlum has swung too far in terms of didactic nursing education in this country. There is this ill-defined notion that everyone has to have a college degree as some sort of badge of self-worth. I have never once dichotomized nurses in my department as good/bad based on whether they have a college degree vs. a nursing diploma. It is the nursing boards themselves which has sought to create a class system. The aim to strive for higher education is admirable, but the methods are flawed and the results predictable.

With respect to a 4 year degree vs. a shorter diploma-type program, in my experience the extra years training, when it doesn't even furnish new nurses with any significant technical skill set, is a waste of economic resources (our dollars as well as the tuition of the individual). Does a nurse need to have an understanding of physiology, pathology, anatomy, etc? ABSOLUTELY! Does a nurse need to have the same depth of understanding that the 4 year BSN curriculum aspires to? Well, I suppose you could even argue that they do, but it's not efficient to feed it to them via a steady diet of text books and term papers.

Why not a have a paradigm shift in this country where to get a 4 year degree, you do 2 years of didactics, and 2 years in the hospital setting, as a sort of internship? Hospitals could bear part of the training costs, diminishing the burden to the nurse as well as the university/college system. In return, the hospital has a pipeline on recruitment.

Hey, I love it when I have a smart nurse who understands the nuances of medicine better than most junior residents. But those who are at that level got there because of experience, not because of their BSN 4 year curriculum. The benefits of all the "book smarts" the new grads come furnished with is far outweighed by the lack of phlebotomy skill, triage education, general patient assessments ability (how to know when your patient, previously not sick, is now sick) and prioritization abilities.

 

[chimichanga]

...The benefits of all the "book smarts" the new grads come furnished with is far outweighed by the lack of phlebotomy skill, triage education, general patient assessments ability (how to know when your patient, previously not sick, is now sick) and prioritization abilities.

Exactly why I advocate for students to become externs at least a year before graduation...

There aren't enough extern spots for all the students...And some hear that there is a shortage, and continue their old career until graduation, and then are completely unprepared...

And the things being taught in school need to change...I teach my students when to call a doc, and when not to. I teach them how to organize their call, and group them w/ the other nurses.

It's an uphill battle

 

[Observer]

I don't like them so far...

On paper, they are a great idea, but 9 times out of ten, the nurse overreacts and calls one...Then 15 people show up, and it's now chaos...

And if the nurse had been more on top of (what's usually) a progressive change in condition, the whole thing could have been avoided...I believe poor nursing judgement (or lack of basic nursing intervention) is at the root of the RR...

Unfortunately, in many hospitals the nurses have unreasonable patient loads and aren't able to monitor patients closely enough. The rapid response team mitigates this deficiency, and contributes to patient safety. It compensates for the fact that many nurses lack either the time or experience, and need a specialized teams to help them when they need back up.

You state that the nurse should have been on top of the deteriorating situation, but that statement fails to take in the logistical reality of today's healthcare system into consideration. The rapid response team does. It maximises staffing realities and efficiency. No nurse should be ashamed or hesitant to call the rapid response team, as it is an important component of patient safety.

 

[RTrain]

My hospital has an RRT, and I'm sure in a lot of cases it is helpful, but I think there are a lot of sticking points. The biggest of these is that our RRT does not have an NP, a PA, or an MD. It is run by a war-hardened ICU nurse who, yes, is very experienced but does not have the scope of practice to be the ranking provider in an urgent or emergent situation, IMHO.

About 50% of the time, the house officer on call is paged, and when s/he comes to the bedside the ICU nurse will not give up the reins on managing the situation, instead telling the resident what s/he must order and whom s/he must consult. When I was an intern, the RRT was called for a patient in afib with RVR when both I and my cointern were already at the bedside because the staff on the floor was absolutely convinced that they couldn't push diltiazem without the supervision of that ICU nurse. Needless to say, we were a little offended, but that's not really the point.

The other half of the RRT's, no MD is ever called, and that's worse. Best case scenario, it isn't that serious of a situation and an intern will wander onto the floor a few hours later and be surprised and slightly amused that the RRT had been there to manage his/her patient's migraine. Worst case scenario, an RRT patient will be wheeled down to the ICU (where a room is waiting for them, since the House Sup is on the RRT) in extremis with no warning for the ICU team. No contact between the ward team and the ICU team will have occurred, no transfer orders will be written (though some interventions and/or workup may have been done by an RRT on which there is no one with order-writing privileges) - the patient is sick and no one who knows him or her well is there. Not good.

Better communication, and a midlevel on the team, would go a long way to making at least our RRT a good thing for patients.

 

[chimichanga]

Unfortunately, in many hospitals the nurses have unreasonable patient loads and aren't able to monitor patients closely enough...

I have worked in places w/ crappy ratios...

You triage your patients, and give the most attention to the sickest...

Good nurses can do the math...Sure, we all miss subtle signs, but I think (perceived) poor staffing ratios, is a weak defense...

 

[Observer]

I have worked in places w/ crappy ratios...

You triage your patients, and give the most attention to the sickest...

Good nurses can do the math...Sure, we all miss subtle signs, but I think (perceived) poor staffing ratios, is a weak defense...

Unless you have worked in nursing, you speak ignorantly. It's up to healthcare to implement systems that enhance patient safety. The RRT is a response to that need, much the same way a SWAT team works. No, it's not a perfect system, none is, but it is often a needed one.

 

[a1qwerty55]

I have worked in places w/ crappy ratios...

You triage your patients, and give the most attention to the sickest...

Good nurses can do the math...Sure, we all miss subtle signs, but I think (perceived) poor staffing ratios, is a weak defense...

Unless you have 10 years as a doc, you haven't seen enough to really make any valid conclusions about appropriateness of RRT calls, nursing staffing or the causes of poor outcomes.

Having done more than that myself, I have seen the myriad of ways, physicians and nurses can kill patients, often by omission. They might not figure out that the mental status changes aren't sun downing but are actually a sign of an MI, sepsis, PE, whatever. It an RRT is called for AMS changes, at least there is the hope a second observer might figure it out and avert harm.

The whole goal of RRT's is to "take a second look". The intern, resident or staff thinks all is well but often are wrong. It is not uncommon that the nurse figures out what the docs just can't see, that the patient is doing poorly and no one has figured out why. The RRT is a forcing fuction which makes the team look again.

There are no inappropriate calls, so to imply that the nurses are making a mistake by calling misses the picture entirely.

Families, nurses, and even housekeepers can sense when a patient is doing poorly, even when the docs can't seem to figure it out.

As a basic concept, the primary team (doc) needs to be notified when the RRT is activated. To fail to do so marginalizes the team and those who know the patient best.

 

[a1qwerty55]

My hospital was one of the first to institute the RRTs. Our arrest rates on the general floors are so low now that nurses are having to do mock resuscitations because they are so out of practice.

We encourage our floor RNs to call whenever they are feeling uncomfortable with the patient status and unable to get the primary service to come assess the patient. When the call for RRT comes, an ICU charge RN and ICU resident respond.

We have tried hard to make the call for RRTs non-punitative. The floor RNs are often so busy already and they feel guilty for not catching a decompensating patient. So, whenever a RRT is called, the RN and MD always try to make it a point of thanking them for calling, even if it's something simple like a loose pulse ox probe or a nasal cannula that's blowing on the patient's forehead. If the RNs don't feel comfortable calling, then we'd be responding to calls for resuscitation rather than responding to prevent an arrest. Also, the floor RN does not need an MD order to call the RRT.

Amen, totally accurate description of a well executed program. Unfortunately as other posters have pointed out, many are poorly executed and thus less effective.

 

[a1qwerty55]

we have 1 at my facility. mostly what they do is common sense stuff:
hypoxia:give o2, suction secretions
hypotension: give fluids
aloc: check glucose, give narcan, etc
psvt: give adenosine

a lot of what they do could be done by the floor nurses if they were on top of things better. if you are going to call the team for a pt with hypoxia how about starting some o2 before they arrive?
if a known diabetic is "suddenly" unresponsive how about checking a glucose, etc

Common sense stuff saves lives.

Far too many nurses and physicians and PAs alike lack this. Do you expect your RN's to push adenosine, bolus fluids etc. unilaterally?

 

[a1qwerty55]

I'm not surprised RRT doesn't reduce in hospital mortality rates as the patients who code/ get RRT called are CTD anyway. With RRT, there is just less rushing around/ pandemonium.

Apparently, you missed the Bellomo study in CCM.
Mortality was reduced in that observational study.

 

[a1qwerty55]

I have experienced many of them, and they always seem to be an overreaction on the nurse's part, but this is just one hospital...Kind of a new concept seemingly...

Basically what I'm saying, is that, IMO, if the nurse triages her pts appropriately, gives the most attention to the "sickest" from moment one, she should (aside from a major acute change in condition) "see it coming" if you will, long before a rapid response is "needed"

And a good seasoned nurse, should call the charge nurse (for another opinion) and interact together, before the pt crashes...

Maybe it's not that black and white, but I've only ever seen one RR that was actually needed...

A good example (of + outcome w/ no RR): change of shift; day nurse notices new facial droop in pt x...she calls in night nurse (who had the pt the day before) and they both agree...we call PCP, get stat CT, pt has subacute subdural w/ 5mm shift...I (house sup) arrange admission to a hospital w/ neurosurg...Pt to ICU while transfer is arranged...

No drama, no fuss, no muss...we handled it well...If nurses would use available resources (charge, house sup, teach team, etc) RR 90% of the time, is not needed...

Many, as in like a couple of hundred? If not, your take probably isn't very valid. Also, realize that if 15 people show up this is not the typical model most hospitals employ.. are you at UPMMC by chance were they send the full code team with all RRT calls?

 

[deleted6669]

Common sense stuff saves lives.

Far too many nurses and physicians and PAs alike lack this. Do you expect your RN's to push adenosine, bolus fluids etc. unilaterally?

Our RRT is an icu nurse and a resp. therapist. when they arrive this is exactly what they do.they follow hospital based protocols and acls algorithms.
floor nurses everywhere should be empowered to institute acls protocols on unstable pts before the cavalry arrives. I would prefer that if someone is in vtach with a bp of 40 and aloc that they cardiovert before paging to ask for permission......wouldn't you?
certainly a call needs to be made but do the critical intervention 1st.....

 

[a1qwerty55]

Our RRT is an icu nurse and a resp. therapist. when they arrive this is exactly what they do.they follow hospital based protocols and acls algorithms.
floor nurses everywhere should be empowered to institute acls protocols on unstable pts before the cavalry arrives. I would prefer that if someone is in vtach with a bp of 40 and aloc that they cardiovert before paging to ask for permission......wouldn't you?
certainly a call needs to be made but do the critical intervention 1st.....

I agree with you, but ACLS measures are more of a code blue response rather than an RRT. Terminology is an issue here, as what in an RRT at one hospital is the code blue team at another.

 

[bulgethetwine]

what in an RRT at one hospital is the code blue team at another.

That's just a ridiculous statement.

A code blue is a call for hospital physicians to respond to a patient who is in extremis and, most probably, not breathing.

An RRT is something a hospital committee (that includes at least some non-physicians) dreams up as a passive aggressive way for nursing to get what they want, when they want it.

 

[Observer]

Unless you have 10 years as a doc, you haven't seen enough to really make any valid conclusions about appropriateness of RRT calls, nursing staffing or the causes of poor outcomes.

Having done more than that myself, I have seen the myriad of ways, physicians and nurses can kill patients, often by omission. They might not figure out that the mental status changes aren't sun downing but are actually a sign of an MI, sepsis, PE, whatever. It an RRT is called for AMS changes, at least there is the hope a second observer might figure it out and avert harm.

The whole goal of RRT's is to "take a second look". The intern, resident or staff thinks all is well but often are wrong. It is not uncommon that the nurse figures out what the docs just can't see, that the patient is doing poorly and no one has figured out why. The RRT is a forcing fuction which makes the team look again.

There are no inappropriate calls, so to imply that the nurses are making a mistake by calling misses the picture entirely.

Families, nurses, and even housekeepers can sense when a patient is doing poorly, even when the docs can't seem to figure it out.

As a basic concept, the primary team (doc) needs to be notified when the RRT is activated. To fail to do so marginalizes the team and those who know the patient best.

I wholeheartedly agree! RRTs are like insurance. You may not always need them, but they can be lifesavers! They are collaberative and supportive of less experienced staff, or staff that needs a second and third set of eyes. They are also an excellent learning experience for all!!!

 

[Bobblehead]

I wholeheartedly agree! RRTs are like insurance. You may not always need them, but they can be lifesavers! They are collaberative and supportive of less experienced staff, or staff that needs a second and third set of eyes. They are also an excellent learning experience for all!!!

I think it's always worth a second look at someone that just doesn't "look right" and if the RRT provides this, that's great. Most of the time when I've seen it in action it's very reasonable and depending on the institution (teaching vs. non-teaching) the ICU physician may tag along or be there shortly anyway.

I've only had one incident when a nurse was threatening a RRT call (and I do use that word deliberately) when she was unhappy with the way the primary team who happened to also be the surgical ICU team was managing the patient on the floor prior to transfer back to the ICU. That was more a function of personality pathology on the part of staff though vs. the actual function of a RRT.

 

[Observer]

I think it's always worth a second look at someone that just doesn't "look right" and if the RRT provides this, that's great. Most of the time when I've seen it in action it's very reasonable and depending on the institution (teaching vs. non-teaching) the ICU physician may tag along or be there shortly anyway.

I've only had one incident when a nurse was threatening a RRT call (and I do use that word deliberately) when she was unhappy with the way the primary team who happened to also be the surgical ICU team was managing the patient on the floor prior to transfer back to the ICU. That was more a function of personality pathology on the part of staff though vs. the actual function of a RRT.

You will always have some weirdos in every profession. If someone abuses the system, or makes threats such as you describe, good idea would be to document this and pass it along to their supervisor for review.

 

[shag]

At my facility, we have a new RRT program. I have yet to have the RRT called for one of my patients. The nurses love the program. Some like having backup, which is reasonable. Unfortunately, I have heard nurses state that they like the RRT because when they have a high ratio (1:4-5), they can call and have a sick patient "taken over".

Do your RRT's assume nursing care when they are called? Also, as a general surgery resident, I can see the potential for political turf wars when the RRT is called to assist in the care of a surgical patient. Has anyone experienced this?

 

[Observer]

At my facility, we have a new RRT program. I have yet to have the RRT called for one of my patients. The nurses love the program. Some like having backup, which is reasonable. Unfortunately, I have heard nurses state that they like the RRT because when they have a high ratio (1:4-5), they can call and have a sick patient "taken over".

Do your RRT's assume nursing care when they are called? Also, as a general surgery resident, I can see the potential for political turf wars when the RRT is called to assist in the care of a surgical patient. Has anyone experienced this?

Realistically, if a nurse has 4 other patients, of course a RRT is in the best interest of the ongoing needs of those patients. The average floor nurse needs that sort of support when she/he is responsible for monitoring a normal patient load. I don't understand what is surprising or mystifying about that. That's one of the reasons why there are RRTs.

 

[bulgethetwine]

Realistically, if a nurse has 4 other patients, of course a RRT is in the best interest of the ongoing needs of those patients. The average floor nurse needs that sort of support when she/he is responsible for monitoring a normal patient load. I don't understand what is surprising or mystifying about that. That's one of the reasons why there are RRTs.

Only 4 other patients?

Statements like this remind me why I like ER nurses!

 

[Observer]

Only 4 other patients?

Statements like this remind me why I like ER nurses!

That was merely an arbitrary number I came up with. (based on optimal staffing guidelines for a medical/surgical floor) I know many hospitals don't follow optimal ratios.