Robert Herkes discusses how the RPA in Sydney resources it's RRT. Recorded at the ANZICS S&Q 2014: Rapid Response Teams.

1. How we resource our RRT -
Robert Herkes
Director, Intensive Care Service, Royal Prince Alfred Hospital
Medical Director, NSW Organ and Tissue Donation Service.
on behalf of the RPA Clinical Emergency Steering Committee
Royal Prince Alfred Hospital in Sydney

2. RESOURCING
the major problem with high dose RRT

3. RRT Design – the key to
resourcing.
•One design will not suit everywhere
•Need to consider –
• Governance
• Existing structures
• Size and staffing of hospital
• Hospital philosophy
• Evidence of current problems with deteriorating patients
• How much reform is needed?
Are there EXTRA Resources available?
Who is available to carry the RRT load?

4. Royal Prince Alfred Hospital
• 800 beds incl 48 ICU beds
• ~45000 adult separations per year
• Well staffed with doctors and nurses
• Issues with deteriorating patients
• Switch board – Calls undifferentiated
• Observation Charts – No Respiratory Rate recorded, No track and
trigger
• Junior staff sometimes unable to identify who to call
• Junior staff feeling unsupported
• IIMS showing some doctors not acting on known deterioration
• Well functioning multi-disciplinary cardiac arrest team
• Wards still wanted to ‘OWN’ their patients

5. Royal Prince Alfred Hospital
•General agreement that hospital needs a RRT
•Committee formed
• Direct report to CEO
• Given governance to re-arrange Hospital as needed
• Clinical Emergency Response System Nurse appointed
• Decisions taken to re-engineer care at multiple levels
• Re-teach vital signs to all ward clinical staff
• Re-educate nurses, allied health and doctors about deterioration
• New escalation plans for all wards 24 / 7
• New switch board processes to handle clinical emergencies
• New Observation chart with single triggers
• Re-educate medical and surgical registrars in clinical emergencies
• Audit of calls instituted
Local Champion

6. Royal Prince Alfred Hospital
•Resourcing
•One extra nurse to support system re-engineering
•One extra night medical registrar
BUT
•No other extra resources
•Use all hospital employees
• Cleaners, orderlies, clerks, allied health, nurses, doctors,
administrative staff… i.e. several thousand staff
• Even use ICU if needed!
•Change hospital any way committee thought
sensible.

7. RRT Design – Our Clinical
Emergency Response System
• Three level response system
• Clinical Emergency (Clinical review)
• Where home team registrar reviews their patients deterioration
• ICU Assist
• Where ICU helps with Ward
patient’s problem
• Cardiac arrest
• Mandatory trigger at
deterioration
• Discretionary level of call
• Careful audit of all calls
• Committee has governance of all levels of staff and
processes….

8. Clinical Emergency (Review)
Team Registrar looking after their patients
• Undertaken by team registrar
• Must respond within 30 minutes of call
• If patient continues to deteriorate or no
response from registrar – call ICU assist
• Switch Board reorganised and empowered to
escalate call
• CERS nurse sent all
deteriorations daily to
review appropriateness
• CERS nurse able to
escalate calls

9. ICU Assist
ICU staff helping ward with ward’s patient
• Undertaken by ICU nurse and
ICU trainee registrar
• Respond within 10 minutes
• If patient continues to
deteriorate call Cardiac Arrest

10. Cardiac Arrest
• Undertaken by ED nurse,
Anaesthetic, Cardiology and
ICU registrars
• Must respond immediately

11. Continued audit and education

12. Design has allowed an
enormous number of calls to
be accommodated AND
avoided overloading the ICU
Gattas, Stirling on behalf of RPA Clinical Emergency Steering Committee

13. This is a HIGH DOSE
rapid response
system
Gattas, Stirling on behalf of RPA Clinical Emergency Steering Committee

14. 0
20
40
60
80
100
120
140
160
Quarterly
averagecall
rate
(/
1000hospital
separations)
Average call rate for Primary Ward-Based andICU-Based Response Teams
Clinical Review
Rapid Response
CALL RATES: This system is delivering a HIGH DOSE
Gattas, Stirling on behalf of RPA Clinical Emergency Steering Committee

15. Gattas, Stirling on behalf of RPA Clinical Emergency Steering Committee
CALL DEMOGRAPHICS
Clinical Review vs Rapid Response
Table. Basic demographics of Clinical Review and Rapid Response Calls J
ul 2009 - J
un2012
Clinical Review
(Primary Care
Team)
Rapid Response
Team (ICU)
Clinical
Review/RRT
split (%/%)
TOTAL
Total Number of Calls (% total) 11237 (87) 1633 (13) 88%/12% 12870
Time of Call
Day (0700h-1859h) 5636 905 86%/14% 6541
Night (1900h-0659h) 5601 728 89%/11% 6329
Ratio Day:Night 1.0 : 1 1.2 : 1 1.0 : 1
Day of Call
Weekday (Mon-Fri) 8442 1240 88%/12% 9682
Weekend (Sat-Sun) 2795 393 88%/12% 3188
Ratio Weekday:Weekend (for call type) 6.0 : 2 6.3 : 2 6.1 : 2

16. Gattas, Stirling on behalf of RPA Clinical Emergency Steering Committee
TRIGGER DEMOGRAPHICS
When ramp up call type is discretionary
Table. Frequency of single, multiple, and specific calling criteria, J
ul 2009 - J
un 2012
Clinical Review
(Primary Care Team)
Rapid Response
Team (ICU)
TOTAL
Number of concurrent calling criteria [no. calls (% of call type)]
No criterion listed 3 (0.0) 0 3 (0.0)
Single criterion 8751 (77.9) 851 (52.1) 9602 (74.6)
Two concurrent criteria 2075 (18.5) 568 (34.8) 2643 (20.5)
Three or more concurrent criteria 408 (3.6) 214 (13.1) 622 (4.8)
Specific criteria [no. calls (% of call type)]
Systolic blood pressure <90mmHg 3061 (27.2) 191 (11.7) 3252 (25.3)
Respiratory rate >24/min 2376 (21.1) 123 (7.5) 2499 (19.4)
Respiratory rate >24/min AND pulse
oxygen saturation <90%
573 (5.1) 165 (10.1) 738 (5.7)
Systolic blood pressure >200mmHg 654 (5.1) 15 (0.9) 669 (5.2)
Decreased level of consciousness* 284 (2.5) 241 (14.8) 525 (4.1)
New seizure * 34 (0.3) 51 (3.1) 85 (0.7)
Other criteria 1848 (16.4) 552 (33.8) 2400 (18.6)
* Prominent among RRT callscompared to CRcalls

17. Gattas, Stirling on behalf of RPA Clinical Emergency Steering Committee
SHORT TERM CALL OUTCOMES
When ramp up call type is discretionary
Table. Immediate outcomes following CR and RRT calls, J
ul 2009 - J
un 2012*
Clinical Review
(Primary Care Team)
Rapid Response
Team (ICU)
TOTAL
Outcome [no. of outcomes/no. of calls (% of call type)]
Stabilised on ward 8506/11237 (75.7) 679/1633 (41.6) 9185/12870 (71.4)
Transferred to
Intensive Care Unit
242/11237 (2.2) 592/1633 (36.3) 834/12870 (6.5)
Escalated to Rapid
Response Team
532/11237 (4.7) n/a 532/12870 (4.1)
Escalated to Cardiac
Arrest Team
50/11237 (0.4) 90/1633 (5.5) 140/12870 (1.1)
* Calls may have more than 1 outcome. n/a=not applicable

18. Calls by Hospital Service
0
50
100
150
200
250
300
350
Number
of
Calls
Specialty
Clinical Emergency ICU Assist Pre-Arrest Cardiac Arrest

19. 0
0.5
1
1.5
2
2.5
3
3.5
4
Quarterly
average
non-DNR
non-ICU
cardiac
arrest
rate
(/
1000
hospital
separations)
Quarterly average non-DNRnon-ICU cardiacarrest rate onward
YES IT WORKS: Increasing system call rate is
associated with decreasing cardiac arrest rate
Gattas, Stirling on behalf of RPA Clinical Emergency Steering Committee
ROL
L
OUT
BEFORE AFTER

20. ORGANISATIONAL CULTURE
Sydney LHD Staff Survey Sept 2013
“Patients receive effective emergency
assistance through the [rapid response
system]”
96% strongly/agree
“Overall the [program] has benefited
patient safety in our hospital”
94% strongly/agree
Yates Sydney LHD Survey Report N=478, September 2013

21. RRT Design – Engineering the
hospital
• Mandatory triggering but discretionary level
works well for staff
•First responders are ward registrars who cannot
initiate ICU-level care in the ward
•This is a physician
driven ramp up
rapid response
system
•Along the way the
whole hospital has
improved

23. Common Triggers
Jan-March 2014
552
478
193
223
122 106
10 20 20
1
634
0
100
200
300
400
500
600
700
Number
of
Calls
Trigger

24. Response Times
37%
1%
0%
62%
CE - Responder Times
<30 mins
30-60 mins
>60 mins
Unknown 91%
5% 4%
ICU A - Responder Times
<10 mins
>10 Mins
Unknown