Rapid Response Team Planning GroupRapid Response Team Planning GroupServing Vanderbilt Since February, 2005Serving 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

• 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 PreventionArrest Prevention Assessment Response TeamAssessment 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

SBARSBAR

• 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 #1RRT 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

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 #2RRT 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.

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 #3RRT 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-

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 #4RRT 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

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 #5RRT 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 #6RRT 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 #7RRT 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 #8RRT 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.

Other FindingsOther 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 DataPilot Unit Data

Commit to ACTion Rapid Response Teams 2005© 2005 University HealthSystem Consortium

Vanderbilt: RRT Performance MeasuresVanderbilt: RRT Performance Measures

Vanderbilt RRT Performance Measures (n=24)Vanderbilt RRT Performance Measures (n=24)

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SBARDocumentation

ICU Transfer Cardiac/RespArrest

Discharged Non-pilot Calls

Performance Measures

Commit to ACTion Rapid Response Teams 2005© 2005 University HealthSystem Consortium

Vanderbilt: Early Warning SignsVanderbilt: Early Warning Signs

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

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Commit to ACTion Rapid Response Teams 2005© 2005 University HealthSystem Consortium

Highlighted Results of CollaborativeHighlighted Results of Collaborative20 Academic Medical Centers20 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, 2006Housewide Rollout April 1, 2006

Responding Unit

SICU MICU

Covered Units 9N, 9S, L&D, 5,6 RW, 6S, 4E, Interventional Radiology, Endoscopy

11N, 8N, 8S, 7N, 3RW, CRC, Subacute, 10S,

TVC Medicine Obs

Addition of Cardiology RRTAddition of Cardiology RRT

•Responding to Cardiology Floors

•November, 2008

Family Initiated RRT

•Initiated December, 2008 as a pilot