TM for Rapid Response Systems

TM for Rapid Response Systems

RRS Overview What is the Rapid Response System? The Rapid Response System (RRS) is the overarching structure that coordinates all teams involved in a rapid response call What is TeamSTEPPS? Mod 1205.2 Page 2 Page The Agency for Healthcare Research and Quality’s curriculum and materials for teaching teamwork tools and strategies to healthcare professionals This module of TeamSTEPPS is for RRS TEAMSTEPPS 05.2

RRS Overview What is the Rapid Response Team? Mod 1305.2 Page 3 Page RRS has several parts, one of them being the Rapid Response Team (RRT) A RRT – known by some as the Medical Emergency Team – is a team of clinicians who bring critical care expertise to the patient’s bedside or wherever it is needed (IHI, 2007) TEAMSTEPPS 05.2

RRS Why Should You Care? People die unnecessarily every day in our hospitals It is likely that each of you can provide an example of a patient who, in retrospect, should not have died during his or her hospitalization There are often clear early warning signs of deterioration Establishing a RRS is one of the Joint Commission’s 2008 National Patient Safety Goals Teamwork is critical to successful rapid response The evidence suggests that RRS work! Mod 1405.2 Page 4 Page TEAMSTEPPS 05.2

RRS Does it Work? Before After No. of cardiac arrests 63 22 Deaths from cardiac arrest 37 16 No. of days in ICU post arrest 163 33 No. of days in hospital after arrest 1363 159 Inpatient deaths 302 222 Bellomo R, Goldsmith D, Uchino S, et al. A prospective before-and-after trial of a medical emergency team. Medical Journal of Australia. 2003;179(6):283-287. Mod 1505.2 Page 5 Page TEAMSTEPPS 05.2

RRS Does the RRS Work? 50% reduction in non-ICU arrests Buist MD, Moore GE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study. BMJ. 2002;324:387-390. Reduced post-operative emergency ICU transfers (58%) and deaths (37%) Bellomo R, Goldsmith D, Uchino S, et al. Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med. 2004;32:916-921. Reduction in arrest prior to ICU transfer (4% vs. 30%) Goldhill DR, Worthington L, Mulcahy A, Tarling M, Sumner A. The patient-at-risk team: identifying and managing seriously ill ward patients. Anesthesia. 1999;54(9):853-860. 17% decrease in the incidence of cardiopulmonary arrests (6.5 vs. 5.4 per 1000 admissions) DeVita MA, Braithwaite RS, Mahidhara R, Stuart S, Foraida M, Simmons RL. Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Qual Saf Health Care. 2004;13(4):251-254. Mod 1605.2 Page 6 Page TEAMSTEPPS 05.2

RRS NQF Safe Practices In 2003, the National Quality Forum (NQF) identified the RRS as a chief example of a team intervention serving the safe practice element of Team Training and Team Interventions RRSs are viewed as an ideal example of safe practices in teamwork meeting the objective of establishing a proactive systemic approach to team-based care In 2006, the NQF updated their Safe Practices recommendations Mod 1705.2 Page 7 Page NQF continues to endorse RRSs and concludes that annually organizations should formally evaluate the opportunity for using rapid response systems to address the issues of deteriorating patients (NQF, 2006) TEAMSTEPPS 05.2

RRS Joint Commission 2008 National Patient Safety Goal Goal 16: Improve recognition and response to changes in a patient’s condition Mod 1805.2 Page 8 Page 16A. The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening TEAMSTEPPS 05.2

RRS Implementation When implementing RRS, the Institute for Healthcare Improvement (IHI) recommends: Engaging senior leadership Identifying key staff for RRTs Establishing alert criteria and a mechanism for calling the RRT Educating staff about alert criteria and protocol Using a structured documentation tool Establishing feedback mechanisms Measuring effectiveness RRS can be customized to meet your institutions’ needs and resources Mod 1905.2 Page 9 Page TEAMSTEPPS 05.2

RRS RRS Structure Mod 110 05.2 Page 10 Page TEAMSTEPPS 05.2

RRS Activator(s) Activators can be: Mod 111 05.2 Page 11 Page Floor staff A technician The patient A family member Specialists Anyone sensing the acute deterioration TEAMSTEPPS 05.2

RRS Responder(s) Responders come to the bedside and assess the patient’s situation Responders determine patient disposition, which could include: Transferring the patient to another critical care unit (e.g., ICU or CCU) A handoff back to the primary nurse/primary physician Revising the treatment plan Activators may become Responders and assist in stabilizing the patient Mod 112 05.2 Page 12 Page TEAMSTEPPS 05.2

RRS Activators & Responders Activator(s) are responsible for calling the Responder(s) if a patient meets the calling criteria Responders must reinforce the Activator(s) for calling: “Why did you call?” vs. “Thank you for calling. What is the situation?” Remember: There are no “bad calls”! Mod 113 05.2 Page 13 Page TEAMSTEPPS 05.2

RRS Support: Quality Improvement & Administration The Quality Improvement (QI) Team supports Activators and Responders by reviewing RRS events and evaluating data for the purpose of improving RRS processes The Administration Team of the RRS brings organizational resources, support, and leadership to the entire RRS and ensures that changes in processes are implemented if necessary Mod 114 05.2 Page 14 Page TEAMSTEPPS 05.2

RRS Let’s Watch the RRS in Action Mod 115 05.2 Page 15 Page TEAMSTEPPS 05.2

RRS Teamwork & RRS The RRS has all these barriers to effective care: Conflict Lack of coordination Distractions Fatigue Workload Misinterpretation of cues Lack of role clarity Inconsistency in team membership Lack of time Lack of information sharing Mod 116 05.2 Page 16 Page TEAMSTEPPS 05.2

RRS Necessary Teamwork Skills Mod 117 05.2 Page 17 Page TEAMSTEPPS 05.2

RRS Inter-Team Knowledge Supports effective transitions in care between units Is a prerequisite for transition support (or “boundary spanning”) Consists of understanding the roles and responsibilities of each team within the RRS Mod 118 05.2 Page 18 Page TEAMSTEPPS 05.2

RRS Inter-Team Knowledge Activator needs ICU requires Administration requires Patient needs Responders need ICU requires In the RRS, inter-team Teamwork Activators must know TEAMSTEPPS 05.2 t lity en ua m Q ove pr Mod 119 05.2 Page 19 Page Im the roles and responsibilities of Responders and vice versa s tiv c A s or t a er nd po es R knowledge means all RRS members possess a shared understanding of the roles and responsibilities of all other members n io t tra s i in m d A

RRS Transition Support (“Boundary Spanning”) Requires inter-team knowledge Combines monitoring transitions in care and providing backup behavior when needed Provides role support Mod 120 05.2 Page 20 Page Example: Activator becoming Responder TEAMSTEPPS 05.2

RRS Transition Support (“Boundary Spanning”) Manage data rs de on t lity en ua m Q ove pr Im Mod 121 05.2 Page 21 Page Monitor transitions p es R s or t iva t Ac n io t tr a s i in m d A TEAMSTEPPS 05.2 Educate staff on situation and roles Ensure data recording Assist in role orientation

RRS Example of One RRS Activators call Responders using a pager Who are the Responders? Mod 122 05.2 Page 22 Page ICU Physician ICU Charge Nurse Nurse Practitioner (if available) RRS coordinator Transportation service For Pediatric Unit, chaplain’s office, security, and respiratory therapist are also included TEAMSTEPPS 05.2

RRS Example of One RRS (continued) Training Includes direct teaching modules on rapid response and practice using Situation-Background-AssessmentRecommendation (SBAR) Online training modules Single-discipline training sessions Data Collection includes reporting: Mod 123 05.2 Page 23 Page Who called the response team and what criteria were used? Who responded and in what timeframe? What was done for the patient? What are the top 5 diagnoses seen in the RRS? TEAMSTEPPS 05.2

RRS Example of Another RRS Activators call Responders using an overhead page and a pager Family members are considered Activators Responders include: Mod 124 05.2 Page 24 Page Nursing staff Respiratory care staff ICU staff TEAMSTEPPS 05.2

RRS Example of Another RRS (continued) Training In-class sessions Simulation center Interdisciplinary training in same location Data collection Mod 125 05.2 Page 25 Page Event debriefing Task-oriented checklist by roles TEAMSTEPPS 05.2

RRS Example of Another RRS (continued) Nursing Tasks Completed? 1. Check the patient’s pulse. 2. Obtain vital signs. 3. Place the pulse oximeter. 4. Assess patient’s IVs. Respiratory Therapist Tasks Mod 126 05.2 Page 26 Page Completed? 1. Assess the airway. 2. Count the respiratory rate. 3. Assist ventilation. 4. Check the patient’s pupils. TEAMSTEPPS 05.2

RRS Exercise I: Let’s Identify Your RRS Structure Think about the four components of the RRS: Activators, Responders, QI and Administrative Who are the Activators? What are the alert criteria? How are Responders called? What do Activators do once Responders arrive? Mod 127 05.2 Page 27 Page Who are the Responders? How many Responders arrive to a call? What is each person’s role? TEAMSTEPPS 05.2

RRS Exercise I (continued): Let’s Identify Your RRS Structure What are the common challenges facing your RRS? Are there challenges during: Mod 128 05.2 Page 28 Page Patient deterioration? System activation? Patient handoffs? Patient treatment? Evaluation of the response team? TEAMSTEPPS 05.2

RRS RRS Execution Mod 129 05.2 Page 29 Page TEAMSTEPPS 05.2

RRS Detection Tools/Strategies HUDDLE STEP Activator sees signs of acute deterioration before actual deterioration Situation Monitoring DETECTION DETECTION Mod 130 05.2 Page 30 Page TEAMSTEPPS 05.2

RRS Detection: STEP Assessment Use your institution’s detection criteria for RRS activation Is it time to activate the RRS? Mod 131 05.2 Page 31 Page TEAMSTEPPS 05.2

RRS Where can Detection occur? Detection can occur from a variety of sources or concerns Mod 132 05.2 Page 32 Page TEAMSTEPPS 05.2

RRS RRS Activation Communication Tools/Strategies SBAR Mod 133 05.2 Page 33 Page TEAMSTEPPS 05.2

RRS RRS Activation: SBAR SBAR provides a framework for team members to effectively communicate information to one another Communicate the following information: Situation―What is going on with the patient? Background―What is the clinical background or context? Assessment―What do I think the problem is? Recommendation/Request―What would I recommend/request? Remember to introduce yourself Mod 134 05.2 Page 34 Page TEAMSTEPPS 05.2

RRS Response, Assessment & Stabilization Tools/Strategies: Leadership Brief Huddle Responders analyze patient condition; attempt to stabilize RESPONSE, ASSESSMENT & STABILIZATION Mod 135 05.2 Page 35 Page Leadership, Situation Monitoring, Mutual Support, Communication, & Inter-Team Knowledge RESPONSE, ASSESSMENT & STABILIZATION TEAMSTEPPS 05.2 Tools/Strategies: Communication Check-back Call Out Tools/Strategies: Mutual Support Task Assistance CUS

RRS Response, Assessment & Stabilization Huddle Devise contingencies for sending the patient to the ICU or other ancillary units. Devise contingencies for a handoff back to the general care area (i.e., keeping the patient in current location). Mod 136 05.2 Page 36 Page TEAMSTEPPS 05.2

RRS Response, Assessment & Stabilization CUS Words Mod 137 05.2 Page 37 Page TEAMSTEPPS 05.2

RRS Patient Disposition Communication Tools/Strategies Handoffs SBAR I PASS the BATON Mod 138 05.2 Page 38 Page TEAMSTEPPS 05.2

RRS Patient Disposition Disposition can refer to a number of decisions, including: Mod 139 05.2 Page 39 Page Transferring the patient to another unit A handoff back to the primary nurse/primary physician (i.e., patient stays in same location) A handoff to a specialized team (cardiac team, code team, stroke team, etc) A revised plan of care TEAMSTEPPS 05.2

RRS RRS Transition: I PASS the BATON Mod 140 05.2 Page 40 Page TEAMSTEPPS 05.2

RRS RRS Evaluation Tools/Strategies Activators, Responders, Admin & QI Components evaluate performance and assess data for process improvement Leadership, Sensemaking & Communication EVALUATION EVALUATION Mod 141 05.2 Page 41 Page TEAMSTEPPS 05.2 Debriefs Sensemaking Checklist

RRS Evaluation: Debriefs Debriefs occur right after the event and are conducted by the Responders Debriefs should address: Mod 142 05.2 Page 42 Page Roles Responsibilities Tasks Emphasis on transitions in care Achievement of patient stabilization TEAMSTEPPS 05.2

RRS System Evaluation: Sensemaking Sensemaking Review Sheet 1. How did the Activators and Responders react to this situation? 2. When looking at the “big picture,” are there any patterns or trends? Mod 143 05.2 Page 43 Page TEAMSTEPPS 05.2

RRS System Evaluation: Sensemaking Tools Proactive approaches Failure Modes and Effects Analysis (FMEA) Probabilistic Risk Assessment (PRA) Reactive approaches Root Cause Analysis (RCA) Integrated Sensemaking Approach What can go wrong? What are the consequences? How do things go wrong? How likely are they? What went wrong? Why did it go wrong? Mod 144 05.2 Page 44 Page TEAMSTEPPS 05.2

RRS Let’s look back at our example Mod 145 05.2 Page 45 Page TEAMSTEPPS 05.2

RRS Exercise II: RRS Execution Using the scenario provided, identify the five phases of the RRS and what tools and/or strategies were used during each phase Mod 146 05.2 Page 46 Page Detection Activation Response, Assessment, and Stabilization Disposition Evaluation TEAMSTEPPS 05.2

RRS Exercise III Let’s see if we can identify the tools needed or used in each example Scenario 1 Scenario 2 Mod 147 05.2 Page 47 Page Scenario 3 Scenario 4 Scenario 5 TEAMSTEPPS 05.2

RRS Scenario 1 The nurse called the RRT to a patient who exhibited a reduced respiratory rate. The team was paged via overhead page. Within several minutes, team members arrived at the patient’s room; however, the respiratory therapist did not arrive. After a second overhead page and other calls, the respiratory therapist arrived, stating that he could not arrive sooner due to duties in the ICU. This critical team member did not ascribe importance to the rapid response call and failed to provide a critical skill during a rapid response event. As a result, there was a delay in the assessment of the patient’s airway and intervention pending arrival of the response respiratory therapist. Mod 148 05.2 Page 48 Page TEAMSTEPPS 05.2

RRS Scenario 2 The RRT was called for a patient who had a risk of respiratory failure. The patient was intubated and transferred to a higher level of care. Response team members and the nurse who called the team completed a Call Evaluation Form. The response team members noted that some supplies, such as nonrebreather masks and an intubation kit, were not readily available on the floor, which resulted in a delay. This delay could have impacted the patient, and it also affected the team members’ ability to return to their patient assignments. The patient’s nurse noted on the form that the response team seemed agitated by the lack of supplies and the delay. The evaluation forms were sent via interdepartmental mail to the quality department as indicated on the form. The forms were not collated or reviewed for several weeks. The analyst responsible felt that most of the reports prepared in the past were not used by or of interest to management. Several times the agenda item for RRS updates had been removed from the Quality Council’s meeting agenda due to an expectation that the “Rapid Response System is running fine.” Mod 149 05.2 Page 49 Page TEAMSTEPPS 05.2

RRS Scenario 3 A family member noticed the patient seemed lethargic and confused. The family member alerted the nurse about these concerns. The nurse assured the family member that she would check on the patient. An hour later, the family member reminded the nurse, who then assessed the patient. The nurse checked the patient’s vital signs. She did not note any specific change in clinical status, though she agreed that the patient seemed lethargic. At the family member’s urging, the nurse contacted the physician, but the conversation focused on the family member’s insistence that the nurse call the physician rather than conveying a specific description of the patient’s condition. Based on the unclear assessment, the physician did not have specific instructions. The physician recommended additional monitoring. Another nurse on the floor suggested calling the RRT, which she heard had helped with this type of situation on another floor. The first nurse missed the training about the new RRS, which was not discussed in staff meetings. Based on her colleague’s recommendation, the nurse called the RRT via the operator. The overhead page stated the unit where assistance was needed but not the patient’s room number. The operator forgot to take down all of the usual information because he missed lunch and was distracted. The team arrived on the floor but had to wait to be directed to the appropriate room. Once there, the RRT received a brief overview from the nurse, who left the room shortly afterward. The responders conducted an assessment of the patient and identified that the patient was overmedicated. Mod 150 05.2 Page 50 Page TEAMSTEPPS 05.2

RRS Scenario 4 The RRT was called to the outpatient (OP) area for a report of a patient with a seizure. The usual or expected set of supplies was not available for the team in the OP area. The RRT arrived and assessed the patient. As part of the assessment, the team ordered a stat lab. The lab technician working with the OP area had not heard of the RRS and refused to facilitate a stat lab because he was unfamiliar with having this need in an OP area. The RRT members were frustrated but did not challenge the lab technician. The patient was taken to the Emergency Department. Mod 151 05.2 Page 51 Page TEAMSTEPPS 05.2

RRS Scenario 5 A night nurse noted that a patient who had been on the unit for 2 days seemed more tired than usual. Although the patient was usually responsive and animated, she did not seem as responsive during the evening shift. After checking on her twice, the nurse noted that the patient seemed weak and confused. The nurse called the physician at 3 a.m. and described the patient’s general status change as being “not quite right” but did not provide a detailed report or recommendation. The physician, frustrated, did not ask probing questions about the patient. The physician noted that it was 3 a.m., mentioned that perhaps the patient was tired, and instructed the nurse to monitor the patient. The next morning, the physician came in to do rounds and could not find a complete update from the previous evening. Upon assessing the patient, the physician ordered a stat MRI to rule out stroke. The nurse experienced anxiety due to deterioration of patient status and inability to communicate with the physician. The physician was frustrated by not clearly receiving all of the relevant patient information during the first physician-nurse communication. The patient’s stroke remained unidentified during evening shift. Mod 152 05.2 Page 52 Page TEAMSTEPPS 05.2