Rapid Response

Team

M. Chadi Alraies
Chief Medical Resident
St. Vincent Charity Hospital/Case Western Reserve
University
Sunday, February 10, 2008
 Acknowledgment
 Critical Care Committee
 Dr. J. Sopko
 Krystyna Strozewski
 Karen Komondor R.N.
 Dr. Abdul Alraiyes

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 100,000 Lives Campaign
Objectives
(December 2004 – June 2006)
 Save 100,000 lives
 Enroll more than 2,000 hospitals in
the initiative
 Build a reusable national
infrastructure for change

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 The 100,000 Lives Campaign
Scorecard
 An estimated 122,300 lives saved by
participating hospitals

 Participation in Campaign interventions:

 Rapid Response Teams: 60%

 AMI Care Reliability: 77%

 Medication Reconciliation: 73%

 Surgical Site Infection Bundles: 72%

 Ventilator Bundles: 67%

 Central Venous Line Bundles: 65%

 All six: 42%

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 Campaign Objectives
(Summer and Fall
2006)
 Save 100,000 lives.
 Enroll more than 2,000 hospitals in the
initiative.
 Build a reusable national infrastructure
for change.
 Raise the profile of the problem - and our
proactive response.
 Complete implementation of all six
Campaign interventions in
participating hospitals by January
2007. M Chadi Alraies 7
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 Prevent Pressure Ulcers
 Reduce Methicillin-Resistant Staphylococcus
aureus (MRSA) Infection.
 Prevent Harm from High-Alert Medications...
starting with a focus on anticoagulants, sedatives,
narcotics, and insulin
 Reduce Surgical Complications... by reliably
implementing all of the changes in care
recommended by the Surgical Care Improvement
Project (SCIP)
 Deliver Reliable, Evidence-Based Care for
Congestive Heart Failure…to reduce
readmissions
 Get Boards on Board….Defining and spreading
the best-known leveraged processes for hospital 9
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Boards of Directors, so that they can become far
 What is Rapid Response
Team?
 RRT is a team of clinicians who bring
critical care expertise to the patient
bedside (or wherever it is needed)
 Based on three problems which can lead
to failure to rescue:
 Failures in planning (assessments, treatments,
and
 goals)
 Failure to communicate (patient to staff, staff
to staff and staff to physician, etc.)
 Failure to recognize deteriorating patient
condition M Chadi Alraies 10
 What difference can the
RRT make?
 50% reduction in non ICU arrests.
 Buist MD et al. in BMJ. 2002; 324: 387-390.
 Reduced post operative emergency
ICU transfers (58%) and deaths
(37%).
 Bellomo R et al. in Crit Care Med. 2004; 32: 916-921
 Reduction in arrest prior to ICU
transfer (4% vs. 30%).
 Goldhill DR et al. Anesthesia. 1999;54(9): 853-860.

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 Why we are
initiating RRT?
 Why we are initiating
RRT?
 Between 48,000 –96,000 lives are lost due
to medical error each year.
 Fortunately, only a small fraction of errors
and accidents actually result in harm.
 Patient Harm May Occur For A Variety Of
Reasons.
 Medication Errors
 Procedure Errors
 Infection Harm
 Accidents
 Equipment Failures
 Communication breakdowns are causally
implicated in a majority of errors and
accidents. M Chadi Alraies 13
 Why we are initiating
RRT?
 Often when you review the chart of
several patients that suffered cardiac
or respiratory arrest in our hospital
you will find alterations in:
 Subjective complaints,
 Vital signs,
 Telemetry changes,
 Nursing documentation that precede the
event from hours to days in advance. 
 Right?
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In establishing a
rapid response
team, the goal is
To respond to
a “spark”
before it
becomes a
“forest fire”
 background
 Known by some as the Medical
Emergency Team.
 The purpose of the RRT is to bring
critical care expertise to the patient
bedside (or wherever it’s needed).
 Team is not intended to take the
place of immediate consultation with
the physician if needed.

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 background
 After consultation with the Rapid
Response Team, a call is placed to
the appropriate physician.
 The intention is to help patients in
the time window of clinical instability
and not to replace physician
involvement in that process.

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 To Err Is Human:
Building a Safer Health System

 Report published in 1999 by the

Institute of Medicine (IOM).
 44,000 to 98,000 Americans die each
year as the result of medical errors.

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 Crossing the Quality Chasm: A
New Health System for the 21st
Century

 Published in In 2001 by the Institute

of Medicine (IOM).
 Fundamental changes that must be
made to the American health care
system in order to produce badly
needed improvements in care.

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 Crossing the Quality Chasm: A
New Health System for the 21st
Century
 Six primary aims:
 Safer,
 More effective,

 Efficient,

 Patient-centered,

 Timely, and

 Equitable.

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 failure to rescue
 Three main systemic issues
contribute to the problem: 
– Failures in planning (includes
assessments, treatments, goals)
– Failure to communicate (patient to
staff, staff to staff, staff to physician,
and sign outs, etc.)
– Failure to recognize deteriorating
patient condition

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 Rapid Response Team
Results
Measure Before After RRR
No. cardiac 63 22 65%
arrests
(p=.001)
Deaths from 37 16 56%
cardiac
arrest        (p=.005)
No. days in 163 33 80%
ICU post
arrest (p=.001)
No. days in 1363 159 88%
hospital post
arrest  (p=.001)
Inpatient 302 222 25%
Deaths
(p=.004)
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.
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In our hospital
RRT Trigger
Criteria
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 Respiratory
 New Respiratory rate less than 8 or
greater than 28
 New Acute change in oxygen
saturation less than 90%
 New Threatened airway

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 Cardiovascular
 New Acute change in systolic BP to less
than 90mmHg
 New Acute sustained increase in diastolic
BP greater than 110mmHg
 New Acute change in HR less than 50 or
greater than 120
 New onset chest pain or chest pain
different than admission assessment
 New Acutely cold, pulseless or cyanotic
extremity
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 Neurologic
 New Confusion, agitation, or delirium
 New Unexplained lethargy/difficult to
arouse
 New Difficulty speaking or difficulty
swallowing
 New Acute change in pupillary
response
 New seizure
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 Other
 New Temperature greater than 39.0
Celsius
 New Uncontrolled pain (if different
than admission pain assessment)
 New Acute change in urine output
less than 50ml/4 hours
 New Acute bleeding (i.e., bleeding
with a change in vital signs, urine
output or mental status)
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 When to activate the
RRT call
1. When on of the above criteria
deteriorate significantly (very fast).
2. Two or more of the above criteria
fulfilled.

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Three key features of the team
members

 The team members must be

available to respond immediately
when called. 
 They must be onsite and accessible.
 They must have the critical care
skills necessary to assess and
respond.

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 RRT team member
 ICU on-call resident/floor on-call
resident
 Nurse supervisor
 ???Respiratory Therapist

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How to activate RRT

Overhead page

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 Primary physician
notification
 After patient assessment by RRT
 ICU oncall resident/nurse supervisor has
to notify the PCP about the RRT plan
 Taking actions before notifying the
PCP is acceptable if the patient
fulfilled the criteria.
 If PCP didn’t response…

Please notify Dr. Sopko
8195908 M Chadi Alraies 35
Teaching/non-teaching
patients

ALL M Chadi Alraies 36

RRT work/audit
sheet
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 Utilization of the Rapid
Response Team
 Definition:
 Track the number of calls to the
Rapid Response Team each week to assess
that the team is being utilized and to measure
its effectiveness.
 Goal:
 Increase the use of the Rapid Response Team
over time. 
 Data Collection Plan:
 Determine the total number of calls to the
Rapid Response Team each week.
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Rapid Response
Team Record
 Rapid Response Team
Record
 SBAR
 Situation,
 Background,
 Assessment,
 Recommendation
 Structure enhances communication among
team members.
 Organizations are encouraged to
customize this tool to meet their local
requirements and standards.

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 Rapid Response Team
Record
 This tool was developed to:
 Document,

 Analyze, and
 Share …
 Why the Rapid Response Team
was called?
 What interventions took place?

 What patient outcome was

achieved?
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 Directions
 Designate a team member to
complete a RRT Record for each
call. 
 Use the “work Sheet” to document.
 The Record should be filled out as
soon after the call as possible.

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Rapid Response
Team Education
Checklist
 Rapid Response Team Education
Checklist
 Medical Staff Education
 General information
 Benefits
 RRT Education
 ACLS or advanced critical care training
 Communication skills
 Appropriate expectations
 Importance of responding in a timely manner
 Importance of providing non-judgmental, non-
punitive feedback to call initiator.

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 Rapid Response Team Education
Checklist
 Nursing Staff Education
 Criteria for calling
 Notification process
 Communication and teamwork skills
 SBAR, Assertiveness / Critical Language
 Appropriate expectations
 Importance of calling even when unsure
 Non-judgmental, non-punitive nature of the
Rapid Response Team
 Have information available for Rapid
Response Team (chart, medication
administration record, etc.)
 Role as a member
M Chadiof the team
Alraies 47
Questions?
 References
 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.
 Move Your Dot™: Measuring, Evaluating, and Reducing
Hospital Mortality Rates (Part 1). IHI Innovation Series
white paper. Boston: Institute for Healthcare
Improvement; 2003.
 Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR,
Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH.
Incidence of adverse events and negligence in
hospitalized patients. Results of the Harvard Medical
Practice Study I. N Engl J Med. 1991;324(6):370-376.
 Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR,
Barnes BA, Hebert L, Newhouse JP, Weiler PC, Hiatt H.
The nature of adverse events in hospitalized patients:
Results of the Harvard Medical Practice Study II. N Engl J
Med. 1991;324(6):377-384.
 Buist MD et al. in BMJ. 2002; 324: 387-390.
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 Bellomo R et al. in Crit Care Med. 2004; 32: 916-921