Rapid Response System Rollout Underway
BWH has rolled out Rapid Response System (RRS) programs on several non-ICU inpatient units in October, November and December, and plans are in place to extend RRS coverage to all non-ICU inpatient units in coming months.
Rapid response systems (RRSs) provide multidisciplinary clinical responders 24-hours-a-day to deliver immediate bedside care for deteriorating non-ICU patients and to initiate interventions to prevent further deterioration. RRS at BWH calls for any bedside clinical staff to page a first-responding physician (the primary or covering intern, physician assistant or surgeon) and to notify the RRS critical care nurse and respiratory therapist when a patient exhibits signs of deterioration. The pages to these RRS clinicians will take priority and trigger an urgent response.
“Delayed or suboptimal intervention for inpatients with unexpected clinical deterioration is an important and not uncommon clinical problem associated with increased morbidity and mortality,” said Jeffrey M. Rothschild, MD, of the Department of Medicine and physician co-chair in the roll out of RRS at BWH. “Data from our first few months suggest that the RRS is improving patient care, and, as we expand the program, we hope to reduce cardiac arrests.”
RRS pilots have been rolled out on Tower 14 and 15 and Shapiro 8E and 8W. On Dec. 15, the RRS coverage will be extended to CWN 8, 9 and 10 for adult patients and the nurseries. The RRS will extend to the remaining non-ICU inpatient units early in 2009.
Since its initiation in October, the RRS has been activated 45 times. The Center for Clinical Excellence will analyze data relative to RRS, including incidence rates of cardiac arrests, non-DNR deaths and unplanned ICU transfers, and that data will be reported to the Emergency Response Committee.
In one instance, Donna Cook, RN, a clinical staff nurse, noticed her elderly patient was developing respiratory distress. She called in the RRS team, and in minutes, the physician evaluated the patient, prescribed a diuretic and had the patient put on CPAP for breathing assistance for a short time.
“In about an hour, the patient was breathing easier on her own and much more comfortable in her room, not an ICU,” Jan McGrath, MHA, BSN, RN, nurse manager, Tower 15 AB, said. “With one call to telecommunications, we can page phycisians and PAs who respond with a respiratory therapist and critical care nurse.”
McGrath added, “The most important aspect of RRS is the immediate response of additional resources at the bedside to care for our patients before a code and/or ICU transfer.”
Diane Lancaster, PhD, RN, director of Quality Measurement & Improvement in the Department of Nursing and co-chair of the RRS implementation team, has been working Nursing leadership to roll out the RRS. “The system provides clinical nurses with the infrastructure necessary to obtain a quick response to signs of clinical deterioration much earlier in the patient’s course,” she added.
RRS includes the use of early warning criteria and improved clinician communication tools. Early warning criteria are a set of standardized physiologic instability criteria utilized by the bedside nurse or other clinicians to trigger activation of the RRS team members. Data has shown that patients often exhibit one or more of these criteria hours in advance of an arrest. In addition to numerical thresholds, pattern recognition of unstable patients may also be used to activate the RRS.
In addition to recognition of failing patients, members of the clinical team must communicate their findings to one another. One communication tool supported within the RRS is SBAR: Situation: what is going on with the patient; Background: what is the clinical context; Assessment: what does the clinician think the problem is; and Recommendation: what would the nurse/ bedside clinician suggest to correct it and, in the setting of a RRS event, includes a request for urgent physician evaluation.
When an RRS event is activated, the bedside nurse or his/her surrogate will page the primary or covering intern, resident or PA, all of whom are considered to be “First Responder A” and expected to call and /or see the patient within five to 10 minutes. If Responder A is an intern or PA, prior to seeing the patient, he or she must contact a more senior physician, such as resident, fellow or attending (first responder B), to concurrently see the patient. Each service will communicate who is the first responder B for their patients.
If the patient does not improve within 30 minutes, first responders will contact the senior physician responder, attending, fellow or chief resident, to assist. All RRS events must be communicated to the attending physician in a timely fashion, usually via a text page, with or without a subsequent phone call. Only RRS events that quickly resolve and without change in the patient’s unit location may be communicated by e-mail. Following the RRS event, the physician or PA must complete their section of the RRS form, and this may replace documentation in the progress notes.
All RRS events are to be documented, with all clinicians completing their sections of the RRS form, which becomes a part of the patient’s medical record. As a part of improving the quality of this program, participants in the RRS event are encouraged to provide feedback such as concerns or recommendations and encouraged to conduct a quick debriefing following each event. The CCE will monitor RRS utilization and look for missed opportunities by reviewing records of non-ICU patients with cardiac arrests and unexpected deaths (non-DNR patients) to look for evidence of deterioration in advance of the arrest or death.
The BWH Early Warning Criteria for RRS activation are:
Respiratory
RR less than 8 or more than 35 breaths per minute
O2 saturation less than 85 percent for more than 5 minutes or need to increase O2 to 100 percent
threatened airway or new severe dyspnea
Cardiovascular
Heart rate less than 40, more than 140 with symptoms or any rate more than 160
Systolic Blood Pressure less than 85 or more than 200 for more than 30 minutes
Diastolic Blood Pressure more than 110 with symptoms
Neurologic
acute change level of consciousness or mental status
new focal weakness
prolonged seizures
Other
uncontrolled bleeding
staff member worried