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Rapid. Response Teams. Anna Ambrose, Respiratory Therapy John Barwise, Critical Care John Bingham, CCI Devin Carr, Nursing Bobbie Dietz, CCI Julie Foss, Nursing Drew Gaffney, Chief Quality Officer Leah Golden, Resuscitation Program Eric Grogran. Jeff Guy, Burn Unit Jeff Hill, CCI

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Rapid

Rapid

Response Teams


Rapid response team planning group serving vanderbilt since february 2005

Anna Ambrose, Respiratory Therapy

John Barwise, Critical Care

John Bingham, CCI

Devin Carr, Nursing

Bobbie Dietz, CCI

Julie Foss, Nursing

Drew Gaffney, Chief Quality Officer

Leah Golden, Resuscitation Program

Eric Grogran

Jeff Guy, Burn Unit

Jeff Hill, CCI

Brent Lemonds, Administrative Liaison

Diane Moat, Risk Management

Paul St. Jacques, Anesthesiology

Susan Thurman, Nursing

Les Wooldridge, Resuscitation Program

Jeanne Yeatman, LifeFlight

Rapid Response Team Planning GroupServing Vanderbilt Since February, 2005


Rapid

  • The CampaignIHI will join hands with other leading American health care organizations in launching an unprecedented 100,000 Lives Campaign, which will disseminate powerful improvement tools, with supporting expertise, throughout the American health care system.

  • This campaign aims to enlist thousands of hospitals across the country in a commitment to implement changes in care that have been proven to prevent avoidable deaths. We are starting with these six changes:

  • Deploy Rapid Response Teams…at the first sign of patient decline

  • Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart attack

  • Prevent Adverse Drug Events (ADEs)…by implementing medication reconciliation

  • Prevent Central Line Infections…by implementing a series of interdependent, scientifically grounded steps called the “Central Line Bundle”

  • Prevent Surgical Site Infections…by reliably delivering the correct perioperative antibiotics at the proper time

  • Prevent Ventilator-Associated Pneumonia…by implementing a series of interdependent, scientifically grounded steps called the “Ventilator Bundle”


Arrest prevention assessment response team

Arrest PreventionAssessment Response Team

Rapid Response

Team

  • Team members:

    • Critical care nurses

    • Respiratory Therapist

    • Physician Intensivist

      • When requested by team

  • Professional consult service for nurses and physicians seeking evaluation of a deteriorating patient


Rapid

SBAR

  • The SBAR (Situation-Background-Assessment-Recommendation) technique provides a framework for communication between members of the health care team. SBAR is an easy-to-remember, concrete mechanism useful for framing any conversation, especially critical ones, requiring a clinician’s immediate attention and action. It allows for an easy and focused way to set expectations for what will be communicated and how between members of the team, which is essential for developing teamwork and fostering a culture of patient safety.


Rrt call 1

10-7-05

10:45

8 North

51 yo Female

REASON FOR CALL:

Staff concerned

Labored breathing

SpO2 less than 90%

S: pt. desaturated when getting up to bedside commode; took 20 minutes to resaturate from 60’s to 95%

B: pulmonary HTN, SOB, anemia

A: RR=30, HR=90s, SpO2=70%

R: RRT called Pulmonary Fellow to bedside, who ordered EKG and 40 mg Lasix, transferred to MICU

RRT Call #1

Interpretation: Appropriate Call, patient stayed in MICU, made DNR by family and ultimately died. Debriefing was held, thought to be useful. SBAR tweaked.


Rrt call 2

10-10-05

18:05

8 North

60 yo Female

REASON FOR CALL:

Staff concerned

S: pt. desaturated to 94%

B: none given

A: BP=109/60, HR=105, RR=26, SpO2=94%, crackles heard on left

R: suctioned large mucus plug and placed pt. on 40% trach collar. Pt. remained on 8 North.

RRT Call #2

Interpretation: Appropriate call. New Nurses, Good learning tool. Floor suctioned patient while RRT enroute. RRT found problem resolved. Patient Discharged on 10/18.


Rrt call 3

10-15-05

16:20

9 North

59 yo Male

REASON FOR CALL:

Staff concerned

RR greater than 30

Labored breathing

HR greater than 120

Onset of agitation

S: 3 days post op; Primary team aware and monitoring pt.; symptoms progressing.

B: moved from 9 South at 11:00 for respiratory distress and more intensive monitoring

A: BP=104/57, HR=142, RR=38, SpO2=93%

R: spoke w/ wife, who required approx. 20 minutes of conference prior to allowing assessment to take place. Pt. continued w/ increasing RR, HR and confusion-

RRT Call #3

Interpretation: Appropriate call. Confusion about consistency of team. Floor expecting MD as first responder. Team needs to be identified to staff and family upon arrival. Resident had issues with team being called. Patient sent to SICU and intubated.


Rrt call 4

10-15-05

18:15

9 North

78 yo Female

REASON FOR CALL:

Staff concerned

RR less than 8

SpO2 less than 90%

Labored breathing

Decreased LOC

S: RRT arrived to find pt. being ventilated w/ bag-mask

B: ischemic bowel disease; staff noted that LOC had been decreasing for 4 days.

A: none given

R: pt. intubated and transferred to SICU

RRT Call #4

Interpretation: Appropriate call or would have been appropriate for STAT team. Notable that LOC had been decreasing for 4 days. Patient moved to SICU. Discussing withdrawing care.


Rrt call 5

10-29-05

00:05

8 North

53 yo Male

REASON FOR CALL:

Staff concerned

RR less than 8

Decreased LOC

Onset of agitation

SpO2 less than 90%

S: admitted from ED approx. 15 mins prior to RRT call; nurses noted increasing respiratory distress and eventual unresponsiveness and apnea

B: history of tongue CA s/p chemo and radiation. Of note, patient was confused upon admission to ED.

A: HR 126; SpO2 87%; BP 160/98

R: several unsuccessful attempts made at establishing definitive airway, including LMA and fiberoptic bronchoscopy; eventually transferred to OR for emergency tracheotomy and then on to MICU post-operatively

RRT Call #5


Rrt call 6

10-29-05

3:55

9 North

65 yo F

REASON FOR CALL:

Staff concerned

SpO2 less than 90%

HR greater than 120

S: pt. became bradycardic (39) and then tachycardic (170s) and desaturated to 38%. Bagged with 100% O2 in response to desaturation

B: history of esophageal CA; tracheomalacia requiring tracheostomy; of note, resident paged from 0400-0430 without response.

A: BP 153/68

R: scheduled metoprolol that was held at 2220 given and patient stayed in room.

RRT Call #6


Rrt call 7

10-30-05

5:35

8 South

55 yo F

REASON FOR CALL:

Labored breathing

S: “air hunger”; staff afraid her stoma will plug. Unable to pass 14 Fr. Suction catheter.

B: s/p laryngopharyn-gectomy undergoing radiation/chemo; s/p trach 10-28

A: RR 30; SpO2 98%; LOC intact; HR 80

R: saline lavaged and suctioned w/ 10 Fr. Catheter by RT; huge mucus plug obtained. Pt. reported immediate relief! Decision made to transfer pt. to 9 North—no beds; transferred to 6 South

RRT Call #7


Rrt call 8

10-30-05

20:45

9 North

54 yo M

REASON FOR CALL:

Staff concerned: “pt coughed incision open”

S: nurse holding pressure to incision; small amt. blood bubbling around open incision

B: hx of end stage lung dz s/p bilat. Lung transplant 9-30-05

A: RR 20; SpO2 95%; LOC intact; HR 87

R: vaseline gauze to bedside; CXR ordered; Rt. Lower lung sounds diminished; pt. stayed in room pending CXR result.

RRT Call #8


Other findings

Other Findings

  • 9N code 9/30 PEA arrest unsuccessful after 20 min

  • 8S code 10/1 Resp arrest – DNR – family desired everything except CPR and defib – extensive hx. Ovarian CA – Pt moved to MICU and expired

  • 8N 10/2 PEA arrest found on floor pulseless and apneic, possible PE, RUE DVT during admission despite anticoagulation, in and out of ICU several times including 2 intubations


Pilot unit data

Pilot Unit Data


Rapid

Vanderbilt: RRT Performance Measures

Vanderbilt RRT Performance Measures (n=24)


Rapid

Vanderbilt: Early Warning Signs

Vanderbilt Early Warning Signs(n=24 for 9 patients)


Highlighted results of collaborative 20 academic medical centers

Highlighted Results of Collaborative20 Academic Medical Centers

  • 462 calls in collaborative

  • 76% had early warning signs

  • 71% discharged alive

  • 8% went on to have cardiac arrest

  • 41% transferred to ICU

  • Concern about the patient was the most frequent early warning sign in 55% of the patients

  • 99.7% of the staff using the teams said they would use the RRT in the future

  • Resistance fades as RRT demonstrates value and benefit for patient care


Housewide rollout april 1 2006

Housewide Rollout April 1, 2006


Addition of cardiology rrt

Addition of Cardiology RRT

  • Responding to Cardiology Floors

  • November, 2008


Rapid

  • Family Initiated RRT

  • Initiated December, 2008 as a pilot


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