JUNE 2005 • Volume 29 • No. 6

A Rapid Response Team for Stanford

by: LAWRENCE M. SHUER

Many of us can relate to the near terror of trying to decide whether to summon urgent assistance when a patient is deteriorating rapidly but yet does not fit the protocol for calling a code. This dilemma is especially acute for our young residents, but it is based on a fear and anxiety that never entirely goes away no matter how long we practice. In this twilight zone, we may fear that if we call a code, we might be accused of summoning resources that colleagues might later consider wasteful, premature and unnecessary. But yet if we continue to struggle. . .

Fortunately, at SHC we are now beginning to address this dilemma and similar care issues in a rigorous, innovative manner by joining the Institute for Healthcare Improvement's 100,000 Lives Campaign. Overall, this initiative is an effort to introduce best practices across the country based on the hypothesis that a few highly effective interventions implemented widely enough can prevent 100,000 deaths nationally over the next 18 months. IHI, a nonprofit organization founded in 1991 and based in Cambridge, Mass., wishes to enlist up to 2,000 hospitals for the study, and SHC has heartily joined this noble effort.

So far IHI has proposed six categories of best practices that they believe will go far towards reducing mortality and morbidity. These are:

1) Prevent adverse drug events
2) Prevent central line infections
3) Prevent surgical site infections
4) Prevent ventilator-associated pneumonia
5) Deliver reliable, evidence-based care for acute myocardial infarction
And. . .
6) Deploy rapid response teams

Up until May 4 we were well on our way to full participation in the IHI campaign. We had implemented its suggestions for making changes on the first five items, but we had no rapid response team (RRT). In fact, many of us did not know even what such a team would do Ñ or even what the term really meant.

I'll back up: an RRT is a team of expert critical care clinicians who provide rapid, urgent and emergent care to non-ICU patients anywhere in a hospital setting with the intent of preventing hospital complications.

The underlying principle of the RRT is early detection, recognition and rapid resuscitation to prevent hospital complications and improve clinical outcomes. The closest we have had to an RRT is our "Code Blue" team, which is usually called only for patients who are unresponsive without a detectable pulse, apneic, or with agonal respirations, and usually, are requiring cardiopulmonary resuscitation (CPR).

Yes, the "Code Blue" team has been called occasionally for patients who do not meet all these criteria, but there is widespread reluctance to calling out the team for fear of "crying wolf". Of course other informal mechanisms do exist to help patients with urgent or emergent conditions not requiring CPR. We can consult with an ICU fellow about how to manage an unstable patient. Also available are crisis nurses, who are ACLS-certified critical care registered nurses who can support their nursing colleagues with urgent or emergent problems arising on non-ICU units. And nurses can and do call respiratory therapists to provide urgent or emergent assistance with airway, oxygenation and/or ventilation needs for patients showing signs of respiratory compromise.

Our Quality Improvement and Patient Safety Department did a retrospective safety review of potential or actual harm caused to patients when early signs weren't appropriately recognized and responded to. During a two-year period we found a significant number of episodes on a variety of services throughout SHC where it looked as if an RRT team might have made a difference.

The overwhelming recommendation from that study was to redesign our existing informal system into an effective rapid response team that would be available on call 24-7 to check patients and recommend how to keep them from harm. The Medical Staff's Quality Improvement and Patient Safety Committee accepted that recommendation, and the Medical Board passed a resolution to set up and deploy a rapid response team without delay.

The RRT's explicit goals are to decrease cardiac arrests, improve ICU utilization, decrease rates of hospital complications and decrease hospital mortality. Published articles bear out the success of this approach. Initial research examining the effect of an RRT on the outcomes of patients admitted for surgery at an Australian academic medical center documented significant relative risk reductions (RRR) in acute respiratory failure, 79 percent; severe sepsis, 74 percent; stroke, 78 percent; and acute renal failure requiring continuous renal replacement therapy, 89 percent (CCM 2004, 32:916). Relative reductions of 26 percent and 37 percent in hospital mortality were found following the implementation of an RRT, as well as a 17 percent relative reduction in hospital length of stay and a 65 percent relative reduction in the number of cardiac arrests (Critical Care Medicine/ CCM 2004, 32:916; Medical Journal of Australia/ MJA 2003,179:283).

Our strategy for introducing an RRT envisions a concurrent call to the primary service whenever an RRT call goes out. We will be educating and training nurses, residents and staff about when and why to trigger a call. We hope that deploying an RRT at Stanford will decrease incidents that otherwise would require the "Code Blue" team.

Please understand that an RRT call on one of your patients does not reflect poorly on your care, but is instead a protocol to ensure that patient safety and care is paramount - an integral part of our culture of safety. There should not be any embarrassment or blame for those involved in calling for an RRT consult on a patient. If you have any comments or suggestions about the Rapid Response Team or the 100,000 Lives Campaign, please e-mail Kelly DeMaria, director of the Quality Improvement and Patient Safety Department, kdemaria@stanfordmed.org; Joe Hopkins, associate chief of staff and chair of the Quality Improvement and Patient Safety Committee, joeh@stanford.edu; or contact me, lshuer@stanford.edu.

By establishing an RRT we will become full participants in the 100,000 Lives Campaign. More importantly, if the experience of others applies to Stanford, as I'm convinced it does, we will certainly save lives and reduce morbidity for our patient.