Rapid

1. Rapid Response Teams

2. 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

3. 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”

4. 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

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. 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

12. 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

13. 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

14. 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

15. 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

16. Pilot Unit Data

17. Vanderbilt: RRT Performance Measures Vanderbilt RRT Performance Measures (n=24)

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

19. 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

20. Housewide Rollout April 1, 2006

21. Addition of Cardiology RRT • Responding to Cardiology Floors • November, 2008

22. Family Initiated RRT • Initiated December, 2008 as a pilot