Rapid Response Teams Decreasing Intubation and Code Blue Rates Outside the Intensive Care Unit

As part of its "100 000 Lives Campaign," the Institute for Healthcare Improvement introduced rapid response teams (RRTs) in 2004 to bring critical interventions to the bedside at the first sign of deterioration. They quickly caught on, and by 2008, the Joint Commission had made RRTs part of hospital accreditation.1Most in-hospital arrest states are caused by respiratory compromise and hypotension.2–4 RRTs were based on the finding that caregivers outside of intensive care units (ICUs) often were unable to recognize these and other early signs and symptoms of patients' deteriorating condition or waited too long to call for assistance to prevent a cardiac arrest, which can occur up to 6 hours before a code blue situation.1,4–6 At the first sign of deterioration, RRT activation brings critical interventions to the bedside, including a team of multidisciplinary critical care providers and resources4,7 (Table 1). The frequent monitoring that occurs in the hospital facilitates fast interventions to avoid code blue situations, which occur when patients reach a state of cardiac arrest. Ideally, RRTs mean that hospitals have fewer activations of the code blue team.When our academic medical center first created an RRT in 2006, the team included ICU registered nurses who were assigned either to patient care or as charge nurses. The RRT structure became a burden for the ICU nursing staff because ICU nurses sometimes had to respond to activations while assigned to patient care. An RRT event took the nurse away from the ICU for 45 minutes, on average, during which time the ICU was short staffed. In addition, each RRT event produced a stressful situation because no formalized or centralized management of patient flow existed. The ICU nurse was often stranded with the critically ill patient waiting for a bed at a higher level of care to become available or waiting for interventions to be performed that would allow the patient to stay on the unit.Over time, the nursing department realized that the existing RRT design was inefficient. So in 2011, our academic medical center sought to redesign the RRT while maintaining the emphasis on the role of the ICU nurse. The redesign, which was led by nurses, eliminated the need to remove nurses from the units by creating a dedicated team of ICU nurses to function on the RRT. The responsibilities of this non–unit-based RRT nurse position are listed in Table 2.Dedicating a team of ICU nurses to function as designated RRT nurses streamlined the RRT process and improved patient care by supporting early recognition and intervention for non-ICU patients in deteriorating condition.Debate still exists about whether use of RRTs improves patients' outcomes and mortality,8 but at least some studies have shown that it does. Karpman and colleagues9 concluded that RRTs did not improve the "severity-of-illness-adjusted outcome of patients transferred to the ICU from the non-ICU patient care areas" after studying the direct relationship between the number of RRT activations and increased ICU admissions from non-ICU patient care areas.Meanwhile, Al-Qatani and colleagues10 examined the effect of implementing an intensivist-led multidisciplinary RRT on cardiopulmonary arrests and hospital mortality and found that after the RRT was implemented, non-ICU cardiopulmonary arrests decreased from 1.4 to 0.9 per 100 hospital admissions.In a similar study,11 researchers concluded that in-hospital mortality rates decreased after RRT implementation in 6 of 10 tertiary care hospitals. Furthermore, a retrospective chart review indicated that before implementation of the RRT, the percentage of cardiopulmonary arrests was 83% or 1.84 per 1000 discharges and mortality was 1.42 per 1000 discharges whereas after RRT implementation, cardiopulmonary arrests decreased to 12.7% or 1.7 per 1000 discharges and hospital mortality decreased to 1.25 per 1000 discharges.3Certainly the success of the RRT relies on staff awareness and willingness to activate it. Our initial difficulties with RRT activation are reflected in the review of the literature. Studies have shown that nurses are aware of the RRT, but many still hesitate to activate it when patients show signs of distress. Two independent studies reported that the relationship between nurses and physicians can be a barrier, because many nurses believe that the physician should be contacted before an RRT.6,12 Some nurses may view the RRT as punitive and personal or as a reflection of poorly delivered care. In a survey of nurses who work in hospitals with RRTs, nurses have reported that negative implications of RRTs include strained relationships between nurses and physicians, tension between the ICU nurse and bedside nurse, negative reflection of poor care delivery, increased workload on hospitalists, and reduced autonomy for the primary provider and the bedside nurse.12When our academic medical center first decided to implement the RRT in 2006, it formed a multidisciplinary subcommittee of the existing code blue committee to design the RRT team. The subcommittee developed 2 documents to record each general RRT activation and each obstetrical RRT activation.In its first iteration, before redesigning the RRT design and implementing a designated RRT nurse, RRT documentation was the responsibility of the ICU nurse. The form to document an RRT was basic, with 3 areas to record vital signs; a large, free text area for noting events; and check boxes for outcomes. The information collected on this part of the form included patient information, trigger for activation, activator, responding team members, date and time of activation, activation location, interventions, disposition, and outcomes. This information was entered into a computer database that stored information on every RRT activation and tracked outcomes for performance improvement. Documentation was often incomplete. Contributing to the poor documentation was the fact that the form itself lacked any consistent mechanism for recording vital signs, patient assessment, and interventions.Furthermore, although the ICU nurse was responsible for bringing the actual RRT form to the RRT event, the person responsible for completing the form varied. Employees from different disciplines completed it, including the ICU nurse, nursing supervisor, bedside nurse, respiratory therapists, and nursing students. In addition, the process for entering the information into the database was not clearly established. The data entered were often incomplete and lacked quality control.In 2011, the Department of Nursing redesigned the RRT team to include 4 full-time-equivalent nurses dedicated to the RRT. Responsibility for documenting the RRT and data entry became the responsibility of the RRT nurse. This change resulted in complete and accurate data collection and entry. However, as the RRT nurses became acclimated to their role, it became clear that the RRT documentation form was inefficient. So they redesigned the RRT form as a flow sheet capturing vital signs, fetal heart tones, and interventions. In addition, the form was redesigned to accommodate obstetrical activations so that a separate form was no longer needed.Over time, the RRT nurses also realized that the database was not capturing metrics, such as events that occurred within 24 hours of an emergency department stay, within 24 hours of an ICU stay, or within 24 hours of direct admission. So the RRT subcommittee met to redesign the database. The subcommittee worked with staff from the information systems department to adjust the existing database to capture the revised metrics. In particular, this provided a new mechanism to track patient progress and milestones throughout hospitalization. A comment section was added to enable daily data entry, and indicators were added to include obstetrical causes. Other changes included the addition of primary team notification, palliative care consultations, and pastoral care. Documentation of "who called the RRT" was eliminated and instead the activating discipline is now entered.The database generates reports on a quarterly basis. For each quarter, the number of RRTs is divided by the number of patient days for that quarter, and multiplied by 1000 to produce the rate of RRTs per 1000 patient-days. This rate eliminated the fluctuations that resulted from changes in hospital census during each time period. This calculation was also done to determine the non-ICU code blue rate per 1000 patient-days.Between 2012 and 2014, RRT activations increased throughout the hospital while non-ICU code blues and emergent intubations decreased (see Figure). During this time period, a significant increase occurred in RRT activations along with a significant decrease in non-ICU code blues. Results also suggested a decrease in intubations; however, this trend was not significant.Since the RRT redesign, a culture change has occurred at our hospital. The RRT is no longer viewed as negative or punitive, but rather it is accepted and encouraged. RRT nurses provide an open channel of communication between the patient care nurse, physician, and family. The RRT is activated earlier and more frequently. As RRT activations have increased, non-ICU code blues have decreased, as have emergent intubations.As the RRT process has evolved, the database is periodically updated to focus on specific metrics. The data are used to continually improve quality and outcomes. The RRT database is periodically adjusted to capture targeted quality and outcomes information. For instance, the existing database uses heart rate as a trigger for RRT activation, but a newer version of the database will differentiate between bradycardia and tachycardia as triggers.The RRT database is also periodically adjusted to capture targeted quality and outcomes information. In addition, data will capture information occurring 12 hours before activation. This information will be used in case review and for teaching. Postactivation data to be collected will include change in level of care up to 4 hours after the RRT and effectiveness of treatment techniques.Our RRT is used only in inpatient units at this time. For example, if a patient received a diagnostic procedure and experienced a change in status, the RRT system was not activated. In 2014, the RRT expanded to radiology so that patients who decompensate while undergoing a radiologic procedure may benefit from RRT resources and intervention. Because critical care patients receive numerous radiologic procedures, this change has provided support to the ICU nurse. In addition, the radiology technicians have reported that the RRT has given them greater "peace of mind" compared with the past, when they reported feeling alone when patients experienced a change in status, for example, chest pain or shortness of breath.Future plans for RRT include expansion beyond inpatient areas to other areas throughout the hospital. For instance, RRTs will soon be available to the clinical decision unit, an observation unit of the emergency department with a capacity of 30 beds. Additionally, the RRT program is considering expansion to the outpatient cardiac catheterization laboratory, ultrasound, and nuclear medicine.The success of the RRT redesign can be attributed to its multidisciplinary approach and support from nursing administration. To continue its success, the institution needs to analyze the current RRT and code blue policies, procedures, and use along with current performance improvement methods. Administratively, the hospital needs to continue dedicating full-time–equivalent positions to the RRT nurse. Ongoing education is also needed so that all disciplines are informed about the role of this newly developed RRT nurse position. As part of this effort, the RRT nurses in our institution provide education sessions to newly hired nurses, interns, residents, respiratory therapists, chaplains, and pharmacy residents.RRTs were designed to bring critical care interventions to patients in deteriorating condition who are outside of the ICU. After initial implementation, our institution redesigned the nursing structure of the team to include dedicated critical care nurses, and this redesign has improved patient care.Although debate still exists about whether RRTs improve patients' outcomes and mortality, the declining rates of non-ICU code blues and emergent intubation at our hospital since the implementation of the RRT suggest that RRTs do, at least as long they are designed to fit within the needs of the institution. The perception of RRTs has improved, and channels of multidisciplinary communication and collaboration have improved, as well. Thanks to these positive indicators, expansion of RRT coverage to additional areas in our hospital is planned for the future.CCNWe thank the members of the rapid response team at Thomas Jefferson University Hospital for their expertise and diligence. Eleanor Gates, rn, msn, vice-president of surgery/trauma and service excellence, provided guidance and support. We also thank biostatistician Kristen Carlin, mph, for her expertise, patience, support, and commitment to this project. Jennifer Fisher Wilson, ms, from the Writing Center at Scott Memorial Library, Thomas Jefferson University, also provided her expertise and guidance.