Evidence-Based Practice at Delnor-Community Hospital, Geneva, IL

Rapid response teams (RRT) are becoming prevalent in healthcare organizations across the country due to a large campaign by the Institute for Healthcare Improvement.  Numerous hospitals are working with critical care nurses to quickly implement a RRT to improve patient safety and clinical outcomes.  RRT positions intensive care unit (ICU) nurses to be the clinical experts that are called to the patient’s bedsides to collaborate and confirm a patient’s deteriorating condition.  Floor nurses are encouraged to utilize the expertise of ICU nurses without threat of disrespect or embarrassment.  This type of collaboration may bring a positive culture change between floor and ICU nursing.  Attitudes, staffing issues and financial constraints within the ICU may impact start-up implementation of a RRT.  After 16 months of activation and 267 patient RRT reports, data collection revealed that the RRT reduced the monthly rate of floor Code Blues by 56% and unnecessary transfers to ICU decreased by 10%.  The conservative organizational financial savings of $171,480 per year was calculated using the labor and cost accounting methodology.  This report describes the challenges, solutions and benefits discovered by the critical care nurses after implementation of a RRT in a small community hospital.

It is critical for nurses to be aware of clinical signs and symptoms that may lead to a cardiopulmonary arrest situation or Code Blue.  The pre-arrest condition can be recognized by staff and early interventions initiated to prevent Code Blues.  If nurses are provided with a 24/7 RRT and an ongoing awareness to anticipate unexpected patient scenarios, patient deaths may be prevented.  Preventing a Code Blue should be a top priority for floor nurses because statistics show that the survival rate to discharge after a full cardio-pulmonary arrest is only 15%.  Anticipation of Code Blue situations involves early recognition of pre-arrest vital signs, patient trends, activation of RRT and nurse-to-nurse collaboration before it’s too late to prevent a death.

Three fundamental problems are identified that lead to failure to rescue within hospitals: breakdown of effective communication patterns such as between patients and to staff, staff and to staff, staff and to physician, physician to and physician; failure to recognize early signs of patient’s hemodynamic deterioration; and incomplete assessments, care planning, treatments and goals for quality patient care.

After 16 months of activation and 267 patient RRT reports, data collection revealed that the RRT reduced the monthly rate of floor Code Blues by 56%.   The average 2006 monthly Code Blue outside the ICU/ER/OR per 1000 discharges was 0.63, decreased from 1.22 the previous year of 2005. Unanticipated transfers from the medical/surgical floors to the intensive care unit were decreased by 10%.  Because of early interventions, 63% of all RRT patients remained on the medical/surgical floors and did not require a change in the level of care.  Overall, only 2% of the total RRT patients resulted in Code Blue activation during the hospital stay.  Although RRT patients average a length of stay of 10 days that implies a high clinical acuity level, the total survival rate at discharge rate was 86%.    

      The RRT Steering Team has ongoing data collection and monthly reports that are sent out within the organization.  Data collected on location, shift, day of the week and triggers to activation assist in evaluating staffing levels for RRT and floor acuity activity.   Over the last 16 months, of a RRT, we have had a total of 267 calls with a monthly average of 18.   The activation call times were distributed throughout the three shifts with the greatest occurrence on 3-11pm shift (41%).   Surprisingly, Wednesday was the most common day for RRT calls (18%) but they were rather evenly distributed across the week.  The average RRT call time at the bedside was 30 minutes with a maximum time of 1 hour and 57 minutes to minimum of 9 minutes in consultation.  Many times staff reported more than one reason for activating RRT:  staff concerned about patient (50%); change in respiratory status (45%); change in mental status (24%); change in heart rate/rhythm (14%) and change in blood pressure (12%).   The RRT nurse’s interventions started at the bedside during the call were:  Oxygen Protocol (63%), ECG (29%), ABG (23%), AccuCheck (16%), Chest x-ray (21%), Lasix (8%), Respiratory nebulizer treatments (7%) and Hypo/Hyperglycemic Protocol (3%).

      These results show that reducing episodes of failure to rescue was a positive outcome from an effective new RRT. Data collection continues to be ongoing for monthly analysis to provide feedback for performance improvement of the RRT team with organization of educational sessions for staff growth and development. It is difficult to measure the lives that were saved because of RRT.   The hospital-wide operational and financial benefits of implementation of a RRT greatly outweigh the challenges of start-up. A summary of the benefits include:   improved patient safety, decreased length of stay, decreased Code Blue, decreased transfers to the intensive care unit, increased nurse awareness and identification of signs and symptoms leading to patient deterioration, decreased mortality and morbidity, increased physician satisfaction with nurses, increased patient satisfaction, and increased nurse job satisfaction.  Developing a structured RRT for patient safety empowers all staff to operate at a higher competence level.  Most nurses have an intrinsic desire to function at a higher level.  RRT are nurse driven, self-directed and self-managed working teams that promote patient safety and efficiency within the hospital.