This document is a research proposal submitted by James Nichols to examine the impact of implementing a Rapid Response Team (RRT) at St. Vincent Hospital. The proposal aims to compare patient outcomes between St. Vincent, which does not have an RRT, and the University of Arkansas Medical Center, which has had an RRT for 5 years. The proposal outlines the significance of RRTs to nursing practice, the research question, theoretical framework, ethical considerations, literature review on RRT effectiveness, and proposed methodology for comparing patient data from general medical/surgery units at the two hospitals.

1. RUNNINGHEADER: RAPIDRESPONSETEAMS
Rapid Response Teams: Improving Patient Outcomes on General Surgery & Medical Units
A RESEARCH PROPOSAL
SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR
NUR6403 NON-THESIS PROJECT
FOR THE MASTER OF SCIENCE IN NURSING ADMINISTRATION
AND EMERGENCY MANGAGEMENT AT
ARKANSAS TECH UNIVERSITY
GRADUATE DEPARTMENT OF NURSING
BY
JAMES NICHOLS, B.S.N., R.N., B.B.A, M.S.T, C.PA.
SPRING 2016

2. Rapid Response Teams
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Table OF CONTENTS
Introduction……………………………………………………. 4
Significance of Problem to Nursing Profession………………….5
Statement of Purpose……………………………………………..5
Theoretical Framework/Model……………………………………6
Ethical Issues……………………………………………………..7
Review of Literature……………………………………………... 8
Methodology……………………………………………………...11
Conclusion……………………………………………………….. 12
References…………………………………………………………13
Appendix A (Rapid Response Team Form) ……………………..17
Appendix B (Rapid Response Team Feedback Form)……………18

3. Rapid Response Teams
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Abstract
Healthcare organizations around the country share the problem of increasing patient
acuity on medical and surgical units with continuing staffing constraints. One initiative used to
increase patient safety and patient outcomes under these dangerous conditions is the Rapid
Response Team (RRT) a team of nurses usually an Advanced Practice Nurse, a Critical Care
Nurse with trauma experience and a respiratory therapist on call by both staff and the patient’s
family to respond to a downturn in patient condition (Kapu, Lee, & Wheeler, 2014). The overall
effectiveness of the Rapid Response Teams remains in question after several years of intensive
studies. While Rapid Response Teams have been credited with reduction in fatalities from
Cardiac events at the same time admissions to Intensive Care Units have increased due to Rapid
Response Team interventions. Also, cost of hospital operations after implementation of Rapid
Response Teams have increased while overall mortality rates in hospitals served by Rapid
Response Teams have remained steady (Berg, Chan, Comilla, Nallmothu, Renuka & Sasson,
2010). Leading to more questions regarding the effectiveness of RRTs.

4. Rapid Response Teams 4
Introduction
The Registered Nurse’s (RN) primary focus in patient safety is to become “an around the
clock surveillance system in hospitals for early detection and prompt intervention when
patient’s conditions deteriorate” (Aiken, 2002). The second most important responsibility of the
RN is to identify and intervene in a timely manner if the patient deteriorates physically or is in
danger of death (Parker, 2014). The Institute for Healthcare Improvements as part of its
100,000 Lives Campaign in 2004 recommended Rapid Response Teams to provide floor nurses
the resource needed to respond to patient downturns (Berrois, Caple, Elmer, Jensen, Kashyap,
O’Horo and Velagapudi, 2014). Rapid Response Teams are based on the concept that by
having specialized teams of nurses providing interventions at the first indication of a physical
downturn negative patient event can be prevented (Berg, Chan, Comilla, Nallmothu, Renuka &
Sasson, 2010). Subsequent research has shown only a reduction in cardiac arrest after
implementation of the rapid response system with only limited improvements in other
categories (Byrden & McNeill, 2013). Rapid Response teams have been shown to reduce the
average length of stay and increase discharges while increasing Intensive Care Unit admissions
(Evans, 2013). Despite predictions of cost savings the actual cost per hospital day per patient of
implementing a rapid response team has been estimated to be $23.00 per patient but an increase
in the number of intensive care unit admissions may reduce this cost to the hospital overall
(Adang, Schoonhoven, Simmes, Vander Hoven, 2014)(Evans, 2013). Despite the fact that the
United States health care system is the most costly in the world the United States still has
between 50 and 100 thousand patient deaths each year (Evans, 2013).

5. Rapid Response Teams 5
Significance of the Problem to Nursing Practice
Between 44,000 and 98,000 hospital patients die each year because of medical errors or
oversights. Rapid Response Teams are one tool used to try to lower these numbers (Evans,
2013). While the United States health care system is the costliest in the world it has one of the
highest rates of inpatient deaths (Evans, 2013). The increasing acuity of patients on surgical and
medical floors combined with the continuing staffing limits make the safeguarding of patients a
more challenging issue as time goes by. The use of Rapid Response Teams and other innovative
techniques will be necessary in the future to compensate for the lack of man power and
increasing workload.
The staffing of the Rapid Response Team primarily with RNs and respiratory technicians
continues to broaden and expand the opportunities and scope of practice of nursing personnel.
Also, the use of RN’s in the consulting role allows for more open and free communication
between peers and facilitates the problem solving process (Kapu, Lee & Wheeler, 2014).
Statement of Purpose
The purpose of this study is to determine if implementing a Rapid Response Team at St.
Vincent will improve patient outcomes in at risk patients by implementing a study comparing
levels of patient safety and levels of patient outcomes at University of Arkansas Medical Center
at Little Rock where a rapid response system has been implemented for the past five years and
with St. Vincent Hospital the states only Magnet designated hospital where no rapid response
system exists in order to determine the cost effectiveness, safety and patient outcome changes
resulting in the different environments.

6. Rapid Response Teams 6
Research Question
Will the implementation of a Rapid Response Team on medical surgical units at St.
Vincent improve patient outcomes for at risk patients in comparison with patients receiving the
code white intervention?
Theoretical Framework/Model
This study will use the Iowa Model of Evidence Based Practice to Promote Health Care
combined with Abdallah’s Theory of Nursing as a framework and to develop practice guidelines
incorporating a decision algorithm for when it will be appropriate for the RN to activate the
Rapid Response Team.
The Iowa model of evidence based practice looks at the big picture, each stage of health care
delivery from the overall infrastructure to the provider to the patient (Dontje, 2007). The problem
noted in this case is the lack of options by the primary care giver in the event of a patient
downturn. The population is a group of patients who have access to a Rapid Response Team
such as the patient at UAMS. The Intervention of interest in this case is the use of the Rapid
Response Team, a group of highly trained nurses who come to the bed side at the first sign of the
patient’s condition taking a downturn. The comparison group would be a patient population
where a Rapid Response Team is not available. (St. Vincent. Infirmary). The outcome or hoped
for outcome would be that patients would avoid an escalation in level of care due to worsening
health conditions due to early interventions by the Rapid Response Team.
The theory that is most applicable to this problem is Abdallah’s Theory of Nursing focusing on
21 nursing problems.

7. Rapid Response Teams 7
The issue being addressed is the immediate health of the patient and as Abdallah’s theory is both
the most comprehensive, similar to the Iowa Model, and yet the most basic theory focusing on
the most detailed definition of the responsibilities of a care giver Abdallah’s theory is the most
appropriate.
The following problems in Abdallah’s list are specific to this situation.
Problem 3. To insure safety through the prevention of accident, injury and other trauma and
through prevention of the spread of infection.
Problem 5. Maintain supply of oxygen to the body cells. Provide respiratory therapy by the
Rapid Response Team if needed.
Problem 8. Maintain electrolyte and fluid balance. Initiation of fluid bolus or blood
administration if needed by the Rapid Response Team.
Problem 9. To recognize the physiological responses of the body to diseases condition. To watch
for changes in skin color, mental status and other signs of change by both the primary care RN
and later the Rapid Response Team.
Problem 10. To facilitate and maintain the regulatory mechanism and functions. Monitoring both
the vital signs and the patient’s mental status by both the primary care RN and later by the Rapid
Response Team.
The theory relates to this project because by investigating whether a rapid response team could
improve the results of patients on the general surgery floors who are taking a downturn
preventing increases in the level of care, preventing patient from falling into increased levels of

8. Rapid Response Teams 8
danger and improving their outcomes goals 3, 5, 8, 9 and 10 of Adm. Abdallah’s 21 nursing
problems can be accomplished.
Another interesting theory that falls loosely into the area which is the theory of servant
leadership by Liden, Panaccio, Hu and Meuser. Which states that a leader focuses on the needs
of the individual and has the foresight to understand the needs of the individual and provide for
them.
Ethical Issues
A conflict exists when the Rapid Response Team activates sometimes continuity of care is
interrupted the primary care team according to an article by Berrios et. al. should remain actively
engaged in the continued care of the patient working in conjunction with the Rapid Response
Team (RRT) after the RRT is activated, this ensures that the patient’s and familie’s wishes are
given the proper weight in any treatment (Berrois, Caple, Elmer, Jensen, Kashyap, O’Horo and
Velagapudi (2014). The hospital Institutional Review Board (IRB) of both UAMS and St.
Vincent will approve this project before implementation as data will be collected to measure the
outcomes. Patient confidentiality and privacy will be protected by removing all identifiable
information from any data used in this study.
Review of Literature
The purpose of the review of literature is to present current research on the effectiveness of
Rapid Response Teams in relation to improved patient outcomes and lower patient mortality
rates. Between 50 and 98 thousand patients die from avoidable cause while hospitalized each
year Rapid Response Teams may be one method of lowering those numbers (Evans, 2014). A
literature review was performed in Feb. of 2016 using PubMed, CINAHL, Cochrane, Google

9. Rapid Response Teams 9
Scholar, Ovid, and Ebsco using the key terms Rapid Response Team & Implementation. The
following articles were retrieved.
Clinical Outcomes
In a 2013 study by Evans using a 300 bed non-urban hospital as a setting the researcher
reviewed five years of data to determine the effects of implementation of a Rapid Response
Team on patient mortality, patient cardiac arrest, and length of patient stay and per patient cost
(Evans, 2014). Evans found that the increased cost per patient of implementation of the Rapid
Response Team was $23.00 per patient per day, this was largely because of the need for
dedicated nurses who because they were not based in one unit could not increase the census and
thus billable hours. Evans also found that the length of stay increased by an average of .40 days,
a statistically lower number of deaths occurred after the implementation of the Rapid Response
Team and total discharges increased while admissions to the Intensive Care Units increased
(Evans, 2014). Adang, Schoonhoven, Simmes and Van der Hoven found similar cost increases in
a 2014 study in the Netherlands (Adang, Schoonhoven, Simmes & Van der Hoven, 2014).
Bryden and McNeill in a systematic review of 43 studies found by using the Ovid Medline,
EMBASE, CINHAL, Web of Science, Cochrane Library and NHS database in Sept 2012 found
that many of the studies were of poor quality but that a correlation existed between the skill level
of the members of the Rapid Response Team and positive patient outcomes (Bryden and McNeil,
2013). Berg, Chan, Jain, Nallmouthu and Sasson in a 2010 systematic review and meta-analysis
of 18 studies covering 1.3 million hospital admissions also found evidence lacking only finding a
reduction in cardiac arrest outside the Intensive Care Units with no corresponding increase in
survival of these same patients (Berg, Chan, Jain, Nallmouthu and Sasson, 2010). Pham, Pfoh,
Sydney Weavers and Winters in a 2013 systematic review of 44 studies of Rapid Response

10. Rapid Response Teams 10
Systems found that while rates of cardiac arrest were lowered overall hospital mortality was not
improved by the implementation of a Rapid Response System (Pham, Pfoh, Sydney Weavers and
Winters, 2013).
Fikkers, Mintjes, Schoonhoven, Simmes & Van der Hoven found in a study of 1376 patients
before Rapid Response Team implementation and 2410 patients after Rapid Response Team
implementation in a university medical center in the Netherlands found a fifty percent reduction
in cardiac arrest and unexpected deaths (Fikkers, Mintjes, Schoonhoven, Simmes & Van der
Hoven, 2012).
Avis, Foy, Grant and Foy reported a decrease in patient codes after implementation of the Rapid
Response Team two years earlier there was a corresponding increase in calls for the Rapid
Response Team at Thomas Jefferson University Hospital (Avis, Foy, Grant and Foy, 2016).
Mackintosh, Rainey and Sandall in a study in a UK teaching hospital over 12 months found that
the use of Rapid Response Teams reduced variability in recording and recognizing a patients
downturn, increased RN’s initiating procedures to escalate the level of care of patients and in the
process increased patient safety and outcomes (Mackintosh, Rainey and Sandall, 2012).
Bonafeide, Keren, Locailio, Viany and Weinrich in a 2014 study of 1810 patients found that a
Rapid Response Team intervention was 62% effective in preventing escalation in level of care
(Bonafeide, Keren, Locailio, Viany and Weinrich, 2014).
Implementation of Rapid Response Team
Avis et.al. detailed the criteria for activation of the Rapid Response Team which included heart
rate greater than 125 or less than 45, oxygen saturation less than 90%, Systolic blood pressure
greater than 180, seizure, chest pain, change in mental status, postpartum hemorrhage, unplanned

11. Rapid Response Teams 11
spontaneous delivery, vaginal bleeding before delivery, patient non responsive to treatment and
concern of staff (Avis et. al., 2016). In educating staff about the Rapid Response Team Johnson
used video to review the purpose, activation procedure and hoped for outcomes of the RRT with
staff (Johnson, 2009). Kapu et.al determined that the addition of the Acute Care Nurse Practioner
to the RRT increased efficiency by allowing facilitation of transfers and more treatment option
(Kapu, Lee & Wheeler, 2014). Bonafide el. Al found that three barriers to quick activation of the
RRT were lack of self-efficacy by the RN, perception of hierarchy and negative expectation of
outcomes (Bonafide, et. al. 2014). Elliot & Scott detailed documentation forms and feedback
forms to be used by Rapid Response Teams and activating staff ( Elliott and Scott, 2014) (See
Appendix A & B). Johansen, Lennes, Howell, Hsu and Stevens found a correlation between a
primary team focused implementation and care providers willingness to activate the RRT
(Johansen, Lennes, Howell, Hsu and Stevens 2014). Parker in a 2014 study found that nurses
who utilize analytical decision making versus intuitive decision making were twice as likely to
activate the RRT (Parker, 2014).
Methodology
The purpose of this project is to determine the desirability of implementing a Rapid Response
Team at St. Vincent Infirmary in Little Rock. The proposed rapid response team will be
composed of an Advanced Practice Nurse, A Critical Care – Trauma Certified Nurse and a
Respiratory Therapist combined these individuals will function as a mobile dedicated Rapid
Response Team.
In order to determine the desirability of the implementation of a RRT a comparison of a
hospital which currently has a functioning Rapid Response Team composed of RNs and RTs

12. Rapid Response Teams 12
needs to be made with the St. Vincent system to determine which option provides the best patient
outcomes and patient safety profiles. Because UAMS is located less than one mile from St.
Vincent, is of comparable size, serves a comparable client base and has been using the Rapid
Response Team for over five years this study will review patient records for the last two years
for a comparable med-surg unit at UAMS with two years of patient records of a similar med-surg
unit at St. Vincent in order to determine which response to patient downturns leads to the optimal
patient outcomes and protects the patients in the best manner.
The optimal comparison would involve general surgery or general medical floors.
Specialty patients that are only treated at one facility would have to be removed from the
comparison. A program that matched patients of equal acuity and with similar diagnosis / health
history for the comparison would be optimal if it could be done in a manner that did not skew the
results. Matching of individual patients would also eliminate any volume differences that might
exist. Comparison of staffing levels would also have to be factored in as well as any other factors
that might have more of an effect on patient outcome than the independent variables in this case
which would be rapid response team or no rapid response team.
The major obstacle to this proposal would be being allowed access to the patient records
at both facilities and having access to the level of data analysis expertise necessary to modify the
data in order to transform the two data sets into truly comparable formats.
Conclusion
With increased patient acuity, lower staffing ratios, an aging population and limited
reimbursement for patient complications preventing patient injury and status downturns is
essential to the viability of St. Vincent and the long term health of the community at large. Due
to the lack of conclusive evidence and the individual differences in the hospitals, rapid response

13. Rapid Response Teams 13
team make ups, activation protocols and other factors a comparison of two local hospitals with
the two different ways of dealing with patient complications would be beneficial in determining
whether a Rapid Response Team is the correct way to maximize the patient safety and patient
outcomes at St. Vincent Hospital in Little Rock.

14. Rapid Response Teams 14
References
Adan. E., Schoonhoven, L., Simms, F. & Van Der Hoven, J. (2014). Financial Consequences of
the Implementation of a Rapid Response System on a Surgical Ward. Journal of
Evaluation in Clinical Practice. 20 (2014) 342-347. New York. N.Y. John Wiley and
Sons. Retrieved From:
http://libcatalog.atu.edu:2059/ehost/pdfviewer/pdfviewer?sid=126d5357-0782-41cb-
a0f3-f7340b14c469%40sessionmgr4002&vid=0&hid=4212
Aiken, L., Clarke, S., Sloane, D., Slochalski, J. & Silber, J. (2002). Hospital Nurse Staffing and
Patient Mortality, Nurse Burnout, and Job Dissatisfaction. The Journal of American
Medical Association. 288, 16. New York. N.Y.: American Medical Association.
Retrieved From:
Avis, E., Foy, M., Grant, L. & Foy, M. (2016). Rapid Response Teams Decreasing Intubation
and Code Blue Rates Outside the Intensive Care Unit. Critical Care Nurse. 36, 1. New
York. N.Y.: Elsevier. Retrieved From:
http://libcatalog.atu.edu:2059/ehost/pdfviewer/pdfviewer?sid=b9794d46-c6aa-4b0b-
8051-af71f02984b3%40sessionmgr4002&vid=0&hid=4212
Berg, R., Chan, P., Nallmothu, B., Jain, R., & Sasson, C. (2010). Rapid Response Teams A
Systematic Review and Meta-Analysis. Journal of American Medical Association
Internal Medicine. 170, 1. New York, N.Y.: American Medical Association. Retrieved
From: http://archinte.jamanetwork.com/article.aspx?articleid=481530

15. Rapid Response Teams 15
Berrois, R., Caple, S., Elmer, J., Jensen, J., Kashyap, R., O’Horo, J. and Velagapudi, V. (2014).
the Role of the Primary Care Team in the Rapid Response System. Journal of Critical
Care. 30, 2015, 353-357. New York. N.Y.: Elsevier. Retrieved From:
http://libcatalog.atu.edu:2081/nursing/docview/1655761125/fulltextPDF/6B50747691424032P
Q/17?accountid=8364
Bonafeide, C., Keren, R., Locailio, R.,Vian, M. & Weinrich C. (2014). Impact of Rapid
Response System Implementation on Critical Deterioration Events in Children. Journal
of American Medical Association Internal Medicine. 168, 1. New York, N.Y.: American
Medical Association. Retrieved From: http://www.ncbi.nlm.nih.gov/pubmed/24217295
Byrden, D. & McNeill, G. (2013). Do Either Early Warnings System or Emergency Response
Teams Improve Hospital Patient Survival? A Systemic Review. Resuscitation. 84 (2013)
1652-1667. Dublin, IR.: Elsevier. Retrieved From:
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88bd-c321c22161d7%40sessionmgr113&vid=0&hid=128
Dontje, K. (2007). Iowa Model. Medscape. Retrieved From:
http://www.medscape.com/viewarticle/567786_4
Elliot, S. & Scott. S. (2009). Implementation of a Rapid Response Team. Critical Care Nurse.
29, 3. Retrieved from:
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023e957f4cd8%40sessionmgr115&vid=0&hid=128

16. Rapid Response Teams 16
Evans, M. (2013). The Effects of a Rapid Response Team on Clinical Outcomes. Journal of
Nursing. 3, 3. Philadelphia, PA. Retrieved from:
http://libcatalog.atu.edu:2081/nursing/docview/1319285590/fulltextPDF/6B50747691424
032PQ/2?accountid=8364
Fikkers, M., Mintjes, J., Schoonhoven, L., Simmes, G., & Van der Hoven, J. (2012). Incidence
of Cardiac Arrest and Unexpected Deaths in Surgical Patients Before and After
Implementation of a Rapid Response System. Annals of Intensive Care. 2, 20. London.
U.K.: Springer. Retrieved From:
http://libcatalog.atu.edu:2081/nursing/docview/1652684521/6B50747691424032PQ/7?ac
countid=8364
George, J. (2012). Nursing Theories the Base for Professional Nursing Practice. Prentice Hall.
Upper Saddle River, N.J.
Liden, R., Panaccio, A., Hu, J. & Meuser J. (2014). Servant Leadership: Antecedents,
Consequences, and Contextual moderators. The Oxford Handbook of Leadership and
Organizations. Oxford University Press. Oxford. U.
Johnson, A. (2009). Creative Education for Rapid Response Team Implementation. The Journal
of Continuing Education in Nursing. 40,1. New York. N.Y. Retrieved From:
http://libcatalog.atu.edu:2095/ehost/pdfviewer/pdfviewer?vid=10&sid=90e4c36a-4684-
43dd-aa0a-7cefcbd4c472%40sessionmgr110&hid=128
Johansen, A., Lennes, I., Howell, M., Hsu, D. & Stevens, J. (2014). Long Term Culture Change
Related to Rapid Response System Implementation. Medical Education, 48, 1211-1219.
John Wiley and Sons. New York. N.Y. Retrieved From:

17. Rapid Response Teams 17
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Kapu, A., Lee, B. & Wheeler, A. (2014). Addition of Acute Care Nurse Practitioners to Medical
Surgical Rapid Response Teams. Critical Care Nurse. 34, 1. New York, N.Y. Retrieved
From: http://libcatalog.atu.edu:2059/ehost/pdfviewer/pdfviewer?sid=78792d18-6cad-402a-
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Mackintosh, N., Rainey, H., & Sandall, J. (2012) Understanding How Rapid Response Systems
May Improve Safety for the Acutely Ill Patient: Learning From the Frontline. British
Medical Journal. 2012. 21. 135-144. London. U.K. Retrieved From:
http://connection.ebscohost.com/c/articles/74697267/republished-original-research-
understanding-how-rapid-response-systems-may-improve-safety-acutely-ill-patient-
learning-from-frontline
Parker, C. (2014). Decision Making Models Used by Medical Surgical Nurses to Activate Rapid
Response Teams. Med-Surg Nursing. 23, 3. Pitman, N.J. Retrieved From:
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Pham, J., Pfoh, E., Sydney, D., Weavers, S. and Winters, B. (2013). Rapid Response Systems as
a Patient Safety Strategy. A Systematic Review. Annals of Internal Medicine. 158, 5.
New York. N.Y. Retrieved From: http://annals.org/article.aspx?articleid=1657886

18. Rapid Response Teams 18
Documentation of Rapid Response Team (Appendix A)
(Elliot and Scott, 2014)

19. Rapid Response Teams 19
Feed back to Rapid Response Team (Appendix B)
Thank you for calling the Rapid Response Team
The Rapid Response Team is here for you. If there is anything we can do to improve our
response, we need and welcome your input
Please take a few minutes to answer our questions below
Did the team arrive promptly?
Yes No
Was the RN/RT efficient and respectful?
Yes No
Did you feel the patients’ needs were addressed appropriately?
Yes No
Did you feel supported by the RRT?
Yes NO
Would you call the RRT?
Yes No
(Elliot & Scott, 2014)