36 Nursing2006, Volume 36, Number 1 www.nursing2006.com

About the IHI: Founded in 1991 and based inCambridge, Mass., the Institute for HealthcareImprovement (IHI) is a not-for-profit organizationcultivating innovative concepts for improving

patient care and implementing programs forputting these ideas into action. The 100,000 LivesCampaign is a nationwide initiative of the IHI toradically reduce morbidity and mortality in

Institute for Healthcare Improvement’s 100,000 Lives Campaign

BEST-PRACTICE I NTERVENTIONS:

How a rapid responseteam saves livesHow a rapid responseteam saves lives

www.nursing2006.com Nursing2006, January 37

ENTERING A PATIENT’S ROOM,you say, “Hi, Mr. Gaines. How areyou this afternoon?”

He says, “I feel a little dizzy.”You see he’s diaphoretic and

pale. On further assessment, youfind that his pulse is rapid andirregular at 135. His blood pres-sure is 78/50, down from a base-line of 118/70, but he’s alert andoriented. What do you do? Callthe attending physician or medicalresident? Or perform a more thor-ough assessment and monitor himclosely?

When you know that somethingis just “not right” with a patient,but he doesn’t meet code criteria,you may have to make a tough callbased on your judgment and expe-rience. You may hesitate to call forhelp if you have little to go onbesides a gut feeling. But a wait-and-see approach could be risky ifthe patient suddenly takes a turnfor the worse. And even if you calla physician immediately, interven-tions could be delayed for hourswhile you play phone tag and waitfor new orders.

At our hospital, a nurse hasanother option. If she even sus-pects her patient is headed fortrouble, she calls a “Condition C.”

(The “C” stands for crisis.) Withinminutes, a rapid response teamarrives at the bedside to assess thepatient and provide emergencycare if needed. Typically within ahalf hour, either the crisis isresolved in the unit or the patientis transferred to an intensive careunit (ICU) or monitored bed.

Deploying a rapid response teamis one of six strategies promoted bythe Institute for HealthcareImprovement (IHI) to preventavoidable deaths (see About thisseries). In contrast to a code blueteam, a rapid response team isdesigned to intervene when a

patient’s condition starts to deterio-rate, before he experiences cardiacarrest. In most hospitals, ICU nurs-es and respiratory therapists (RTs)anchor the team.

At our facility, we call the rapidresponse team a medical emer-gency team (MET). In this article,we’ll describe how the systemworks in our hospital, why bed-side nurses have embraced it, andwhat you can learn from ourexperience to improve care andsave lives in your facility. Formore about rapid response teamsin other facilities, see Rapidresponse teams in action.

About this seriesThis article kicks off a series of articles that examine the Institute for Health-care Improvement’s (IHI’s) suggested 100,000 Lives Campaign interventionsfrom a staff nurse’s perspective. Each article in the series focuses on one ofsix key strategies that have been proven to prevent avoidable deaths: • deploying rapid response teams• preventing ventilator-associated pneumonia• delivering evidence-based care to treat acute myocardial infarction• preventing adverse drug events• preventing central line infections• preventing surgical site infections.

We’ll discuss how to prevent ventilator-associated pneumonia next monthand explore the remaining strategies in future issues of Nursing2006. For anexamination of the IHI’s 100,000 Lives Campaign from a managerial perspec-tive, see the “Best-practice protocols” series in Nursing Management, June toDecember 2005.

American health care. Building on the successfulwork of health care providers all over the world, theInstitute introduced proven best practices across thecountry to extend or save as many as 100,000 lives.

The IHI and its partners in this work believe thatachieving this goal by June 2006 is possible. To learnmore, contact the IHI at 1-866-787-0831 orhttp://www.ihi.org.

Learn why bedside nurses are embracing this lifesaving innovation.BY CAROL C. SCHOLLE, RN, MSN, AND NICOLETTE C. MININNI, RN, CCRN, MED

38 Nursing2006, Volume 36, Number 1 www.nursing2006.com

Calling for helpBedside nurses are encouraged tocall a Condition C at the first signthat a patient’s condition is deterio-rating. The IHI has identified thesesubtle signs and symptoms ofinstability that may appear hoursbefore cardiac arrest: • mean arterial pressure less than70 or more than 130 mm Hg• heart rate less than 45 or morethan 125 • respiratory rate less than 10 ormore than 30• complaints of chest pain• change in mental status.

We’ve also developed specificguidelines to help nurses recognizeCondition C situations. Besides thebasic criteria listed above, theseguidelines list other changes thatshould raise a red flag; for exam-ple, chest pain unrelieved by nitro-glycerin; sudden loss of movementor weakness of face, arm, or leg;change in color of central orperipheral skin (pale, dusky, gray,or blue); unexplained agitationlasting more than 10 minutes; andbleeding into the airway. These cri-teria are posted in every nursingunit and distributed to all new staffmembers.

Although all nurses know theclinical criteria, they’re alsoencouraged and empowered totrust their instincts and call aCondition C whenever they feelthat something just “isn’t right”with a patient.

As part of our program, nursesare also taught what to do whilewaiting for the MET to arrive (seeWhile you wait…preparing for theteam’s arrival). These simple butextremely important tasks includecalling a colleague for help, gettingthe crash cart to the bedside, set-ting up oxygen and suction, andpositioning the patient on thebackboard in case he needs car-diopulmonary resuscitation.

The MET responders are amultidisciplinary team. When theyarrive at the scene of a crisis, theytake on eight specific roles and

assume associated responsibilities.If fewer than eight people respondto the call, team members assumeadditional roles as needed.• Airway manager (MD or CRNA)ventilates the patient and performsintubation if indicated.• Airway assistant (RN or RT)assists with ventilation and handlesoxygen and suction setup.• Bedside assessor (ICU RN or bed-side RN) assesses for patent intra-venous (I.V.) access, administersmedications, and applies defibrilla-tor pads. • Crash cart manager (ICU RN)prepares medications and recordscode events.• Treatment leader (MD) directsmedical treatment, assesses teamperformance, and makes patienttriage decisions.• Circulation manager (RN, MD, orRT) checks pulse and performschest compressions if indicated.• Procedure clinician (MD orCRNP) performs medical proce-

dures, such as chest tube or centralI.V. line insertion. • Data manager (RN) obtainspatient chart, records interven-tions, and reviews test results.

The secret to our success withthis program is the bedside nurse,who has the power and authorityto put it in motion and get imme-diate help for a patient who’s head-ed for trouble. This perspective hasrequired nurses and other care-givers to rethink some of their tra-ditional roles within the nursingand hospital culture.

Cultural evolutionDuring the past two decades, nurs-ing culture has evolved to recog-nize a nurse’s critical thinkingskills and to promote independentfunctioning. No longer guided pri-marily by physician orders, best-practice nursing care now alsodepends on established practiceprotocols and standards, and onevidence-based patient-care guide-

Rapid response teams in actionPioneered in Australia, rapid response teams have been introduced in about950 U.S. hospitals participating in the 100,000 Lives Campaign, according tothe Institute for Healthcare Improvement (IHI). These teams are designed torescue patients early in their decline, before cardiac arrest occurs. Hospitalsusing rapid response teams typically report reductions in the number of car-diac arrests, unplanned transfers to the ICU, and, in some cases, overall mor-tality rate.

At some hospitals, including the University of Pittsburgh (Pa.) MedicalCenter Presbyterian Shadyside Hospitals, the rapid response (Condition C)team and code blue (Condition A) team are composed of the same eightpeople: the bedside nurse, two ICU nurses, two respiratory therapists, anothernurse or junior resident, a critical care intensivist, and a critical care fellow.With this system, the bedside nurse needn’t spend time deciding which teamto call. In most hospitals, however, rapid response teams are smaller and dis-tinct from code teams.

Although many rapid response teams include a critical care intensivist anda physician assistant, most are anchored by an ICU nurse and a respiratorytherapist. Bedside nurses call the team into action by phone, beeper, or over-head page; team members may be alerted simultaneously or sequentially. Insome hospitals, nurses have the option of calling in the team at their discre-tion; in others, calling the team is mandatory if the patient exhibits certainsigns and symptoms. These variations, which reflect differences in hospitalculture and resources, illustrate the flexibility of the rapid response concept.

Hospitals that have fully implemented a rapid response program reportthat teams are called 10 to 15 times per month for every 100 occupied beds,according to the IHI. Source: Rapid response teams: The case for early intervention, Institute for Healthcare Improvement,http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/.

www.nursing2006.com Nursing2006, January 39

lines. Our list of Condition C crite-ria is an example of a guidelinenurses use independently to enlistemergency assistance.

The biggest challenge to thesuccess of our program was per-suading bedside nurses to acceptand act on the empowerment thatCondition C activation offered.Calling the intern or resident onduty at the first sign of trouble wasthe established norm. At first,nurses were reluctant to “jumpover their heads” by calling theMET for help.

They were also sensitive to criti-cism about calling for help basedon nursing intuition. But the archi-tects of the MET program knewthat nursing intuition is no myth.Instead, they recognized it as aform of critical thinking, definedas the blending of knowledge,skills, and attitude. Because thenurse is in a position to make fre-quent patient observations, she’sthe first to see subtle changes thatindicate a patient is improving orgetting worse. With the power toact on this information at the righttime, she can get immediate helpfor a patient headed for trouble,possibly preventing a cardiac arrestand death.

Getting it togetherIf you’re developing a rapidresponse program at your facility,incorporate these points into theplanning.• Engage the support of the facili-ty’s senior leadership.• Determine the best structure forthe team in your environment. Nomatter what structure you adopt,team members should have criticalcare expertise, receive team train-ing, and be able to respond imme-diately to a call without constraintfrom competing responsibilities. • Provide appropriate educationand training to team members andto those who will utilize the team.• Establish structured criteria andmechanisms for activating theresponse.

While you wait...preparing for the team’s arrival

This algorithm shows unit nurses’ responsibilities from the time the bedside nurse(RN 1) recognizes a crisis and calls a Condition C until the team’s arrival.

RN 1Assesses patientIdentifies crisisCalls for help

Stays with patient

CPR indicatedRN 1

Flattens bed Begins CPR

CPR not indicatedRN 1

Helps patient into comfortableposition

Assesses vital signs

RN 2Responds with crash cart

Hands bag-valve–mask (BVM)device to RN 1

Attaches patient to monitor/automated external defibrillator

(AED)Analyzes rhythm

Removes backboard from crash cartand places under patient

Obtains I.V. access

RN 2Responds with crash cart

Hands BVM device to RN 1Attaches patient to monitor/AED

Obtains I.V. access

RN 3/nursing assistantArrives with patient chart

Sets up suctionProvides additional assistance as

needed (for example, obtains sup-plies, gets lab work documentation,

supports family)

RN 3/nursing assistantArrives with patient chart

Sets up suctionTests blood glucose

RN 1Shares pertinent patient informa-

tion with rapid response teammembers upon their arrival in unit

40 Nursing2006, Volume 36, Number 1 www.nursing2006.com

• Adopt a detailed standard docu-mentation tool.• Develop an immediate follow-upmechanism, such as a phone callfrom the MET coordinator, to letthe bedside nurse know that shemade the right call.

Five E’s for successThese five E’s are the basis for ourprogram’s success:

Education. All staff members areeducated about the program.Everyone knows what a ConditionC is, when it’s appropriate, andhow to call one. Staff nurses alsolearn what to do while waiting forthe MET response.

The ICU nurses, bedside nurses,RTs, and other designated respon-ders are trained for their roles in asimulation lab. Crisis team trainingis a 4-hour program based on theconcept that practice makes per-fect. Videotaping of simulatedcrises and analysis of performanceare part of the program.

Empowerment. All staff nursesare authorized and expected to usetheir assessment and critical think-ing skills to decide when a patientneeds help. They’re also empow-ered to act according to establishedcriteria and are supported in doingthis by nursing and medicaladministration.

Efficiency. Standardizing teammembership, clearly defining par-ticipants’ roles and duties, andestablishing a policy and procedurefor initiating the call for help havecreated an efficient system.

Equipment. Over the years,we’ve standardized the equipmentused for emergency treatment.Crash carts and defibrillators in allof our 50-plus nursing units at twohospitals are set up exactly thesame. Emergency bags carried byMET responders are stocked withstandard airway intubation equip-ment and medications, and arearranged in exactly the same way.Standardizing equipment hasadded to the efficiency of theresponse, boosted confidence in

the responders’ ability to function,and promoted self-confidenceamong MET members.

Evaluation. Continuous evalua-tion of the response process hashelped us improve the emergencyresponse process and its outcomes.Almost every Condition C called islater reviewed by a team of nursesand physicians. The situation isdeconstructed and opportunitiesfor process improvements areinvestigated. Several qualityimprovement initiatives and proto-cols have been developed as aresult of the Condition C reviews;for example, a protocol for treatinghypoglycemia, the creation of ablood administration team, andchanges in practice related topatient-controlled analgesia and tothe transport of critically illpatients.

Success storiesAs our MET system has evolved,we’ve seen a dramatic increase inthe number of Condition C’scalled. At first glance, you mightthink that this is bad news—toomany patients in crisis. But lookingmore closely, we found that thishas been accompanied by a pro-portional decrease in the numberof “Condition A’s”—our code des-ignation for cardiac arrest. Byproactively responding to threaten-ing situations, the MET programhas reduced the number of patientswho progress to cardiac arrest by30% and reduced the rate of unex-pected mortality by 27%.

What do nurses think?Nurses want to do what’s best fortheir patients by delivering thehighest possible quality of care.They also enjoy working in anenvironment where their work isvalued and their voices are heard.Nurses at our facility believe theMET program supports those val-ues.

In an informal survey of 300nurses in our organization, mostrespondents felt that the MET pro-

gram improved patient care and thenursing workplace. Nearly all(98%, or 210 of 214 respondents)rated the MET program as impor-tant, very important, or essential totheir practice. Two out of threenurses said they’d consider theavailability of a rapid response pro-gram when making future deci-sions about where they mightwork.

How Mr. Gaines faresWhat happened to Mr. Gaines, thepatient who was feeling dizzy at thestart of this article? Within minutesof the MET responders’ arrival, he’sassessed and found to be in rapidatrial fibrillation with a heart rate of160. The treatment leader orders 5mg of metoprolol (Lopressor) I.V.push. After a few minutes, Mr.Gaines’ heart rate slows to 70, thearrhythmia converts to normalsinus rhythm, and his blood pres-sure returns to baseline. The crisisover, Mr. Gaines is transferred to amonitored bed.

As it happened, Mr. Gaines didn’t need the services of all thehealth care professionals whoresponded—but if his conditionhad deteriorated to cardiac arrest,he would have. Calling for helpbefore the situation deterioratedfurther may have made the differ-ence between a calm transfer to amonitored bed and a hasty trip tothe ICU—or worse.‹›SELECTED REFERENCESDeVita MA, et al. Improving medical crisisteam performance. Critical Care Medicine.32(2, Suppl.):S61-S65, February 2004.

DeVita MA, et al. Use of emergency team re-sponses to reduce cardiopulmonary arrests.Quality and Safety in Health Care. 13(4):251-254, August 2004.

Foraida MI, et al. Improving the utilization ofmedical crisis teams (MET) in an urban tertiarycare hospital. Journal of Critical Care. 18(2):87-94, June 2003.

Carol C. Scholle is director of critical care and trans-plant services at the University of Pittsburgh (Pa.)Medical Center (UPMC) Presbyterian Hospital.Nicolette C. Mininni is an advanced practice nurse atUPMC Shadyside, also in Pittsburgh.

SELECTED WEB SITE

Institute for Healthcare Improvement, 100,000Lives Campaignhttp://www.ihi.org/IHI/Programs/Campaign/Last accessed on December 1, 2005.