Role of Rapid Response Team in preventing deaths in hospitals by early detection & early intervention

1. Dr.Shailendra.V.L.
Director of Patient Safety
Al Bukeriya general hospital

2. CODE
PURPLE

3. Rapid Response team (RRT)Rapid Response team (RRT)
• Rapid Response Teams is a designated group of
healthcare clinicians who can be assembled
quickly to deliver critical care expertise in
response to grave clinical deterioration of a patient
located outside a critical care unit.
• RRTs provide early recognition & response to
signs of patient's deterioration

4. Why the need for RRTWhy the need for RRT
– Floor nurses and other hospital staff are
undertrained or are not trained to deal with
patients in crisis
– Teaches staff how to manage patients in crisis
prior to the actual code team’s arrival
– Part of a hospital quality Patient Safety
program
– Meets regulatory requirements - MOH &
CIBAHI

5. Scientific Evidence that RRTs helpScientific Evidence that RRTs help
• 50% reduction in the occurrence of cardiac arrest outside the ICU
– (Buist, M.D. et al. Effects of a medical emergency team on reduction of incidence
of and mortality from unexpected cardiac arrests in hospital: preliminary
study. BMJ 2002;324:1-6)
• 17% decrease in the incidence of cardiopulmonary arrests (6.5 vs
5.4 per 1000 admissions)
– (DeVita, M.A. et al. Use of medical emergency team responses to reduce hospital
cardiopulmonary arrests. Quality and Safety in Health Care 2004;13(4):251-254)
• Severe postoperative adverse events (i.e., respiratory failure,
stroke, severe sepsis, acute renal failure) were reduced by 58%,
emergency ICU admissions were reduced by 44%, postoperative
deaths were reduced by 37%, and mean duration of hospital stay
decreased from 23.8 to 19.8 days in surgical patients
– (Bellomo, R. et al. Prospective controlled trial of effect of medical emergency team
on postoperative morbidity and mortality rates. Critical Care
Medicine 2004;32:916-921)

6. Goals of RRTGoals of RRT
1. To save patient lives & eventually improve quality of
hospital care & improve patient safety
2. Increase early intervention & stabilization to prevent
clinical deterioration on any individual prior to the event
of cardiopulmonary arrest or other life threatening health
event
3. Decrease the number of cardiopulmonary arrests that
occur outside the ICU & ER department
4. Increase patient, family & staff satisfaction
5. Decrease hospital mortality rate
6. Reduce severe postoperative adverse events

7. TO ERR IS HUMAN…………..TO ERR IS HUMAN…………..
• According to the 1999 Institute of Medicine
Report ‘To Err Is Human’, approximately 100,000
Americans die each year from ‘preventable’
hospital errors.
• The annual toll exceeds the combined number of
deaths and injuries from motor vehicle accidents,
airline crashes, suicides, falls, poisonings and
drowning

8. Plans employed for Save 100,000 livesPlans employed for Save 100,000 lives
campaign in US started in 2004campaign in US started in 2004
• 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”

9. Plans employed for Save 100,000 livesPlans employed for Save 100,000 lives
campaign in UScampaign in US
• Prevent Surgical Site Infections…by reliably delivering the
correct peri-operative antibiotics at the proper time
• Prevent Ventilator-Associated Pneumonia…by
implementing a series of interdependent, scientifically
grounded steps called the “Ventilator Bundle”

10. Arrest PreventionArrest Prevention
Assessment Response TeamAssessment Response Team
Team members:
1.Primary nurse (who activated RRT)
2.Charge nurse of the unit
3.ICU airway nurse
4.Nursing supervisor on duty
5.Respiratory therapist
6.Unit resident doctor on duty
7.On call specialist
8.ICU resident on duty
9.ICU specialist on call

11. Key features of the RRT teamKey features of the RRT team
• There are three key features of the team members:
1.They must be available to respond immediately when called, and not
be constrained by competing responsibilities
2.They must be onsite and accessible
3.They must have the critical care skills necessary to assess and respond

12. RRT team actionsRRT team actions
– Teams of clinicians rush to a patient’s location
whenever a clinician feels the patient’s condition is
deteriorating or has deteriorated
– Teams are designed to rescue patients early in their
decline, before an adverse outcome occurs
• Hospitals using rapid response teams typically report
reductions in the number of cardiac arrests, unplanned
transfers to the ICU and overall mortality rates

13. The Joint Commission InternationalThe Joint Commission International
2008 National Patient Safety Goals2008 National Patient Safety Goals
Goal 16: Improve recognition and response to
changes in a patient’s condition.
Goal 16A: The organization selects a suitable method
that enables health care staff members to directly
request additional assistance from a specially
trained individual(s) when the patient’s condition
appears to be worsening

14. 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

15. SBARSBAR

16. 100

17. Adult criteria for calling RRTAdult criteria for calling RRT
1. Temperature:
< 35 or > than 38.9 degree Celsius orally
1. Acute change in respiratory rate:
1. < 8 breaths per minute or > 28 breaths per minute
2. Acute change in heart rate:
1. < 40 beats per minute or > 130 beats per minute
3. Acute changes in blood pressure:
1. < 90 or > 40 change from baseline
2. Drop of blood pressure 20% from the baseline
3. Systolic blood pressure > 190
4. Diastolic blood pressure > 110
4. Acute change in O2 saturation :
1. < 90% on 60% FIO2

18. Adult criteria for calling RRTAdult criteria for calling RRT
6. Acute change in level of consciousness
7. New onset of chest pain
8. New onset of seizures
9. Significant bleeding or decrease in hematocrit
10. Change in patient color (cyanosis)
11. Staff member worried or concerned

19. Pediatric criteria for calling RRTPediatric criteria for calling RRT
1. Airway threat:
1. Breathing:
1. Apnea
2. Hypoxemia:
1. SpO2 < 90%
2. SpO2 < 60% for children with cyanotic heart disease
3. Moderate to sever respiratory distress
4. Tachypnoea
1. 0 -3 months > 60
2. 3 – 12 months > 50
3. 1 – 4 years > 40
4. Over 5 years > 30
2. Circulation:
1. Heart rate:
1. < 1 year 100 – 180
2. 1- 4 years 90 – 160
3. 5 – 12 years 80 – 140
4. 12 years 60 – 130

20. Pediatric criteria for calling RRTPediatric criteria for calling RRT
2. Hypotension: (systolic BP)
< 3 months < 50
4 – 12 months < 60
1 – 4 years < 70
5 – 12 years < 80
> 12 years < 90
4. Neurological :
Acute change in mental status
Seizures

21. Calling RRT teamCalling RRT team
• The RRT may be called for physiologic changes in heart
rate, systolic blood pressure, respiratory rate, pulse
oximetry saturation, mental status or urinary output.
• Changes in laboratory values such as sodium, glucose and
potassium could also indicate a patient’s condition is
deteriorating.
• The nurse may also call the RRT because of a gut feeling
that all is not right.

22. How to call RRT ?????How to call RRT ?????
1. Attending nurse / doctor dials hotline 100.
2. Operator will announce CODE PURPLE followed by the ward
location three times
3. Operator will page the RRT team as a group
4. Five minutes is the response time for the group to arrive
5. 15 minutes is the maximum time for the team arrival

23. Role of First nurse in RRTRole of First nurse in RRT
1. Assesses patient, check vital signs
2. Identifies crisis, refer patient’s condition following SBAR guidelines
3. Call for help
4. Stays with the patient
5. Helps patient into comfortable position
6. Shares pertinent information with RRT members upon their arrival

24. Role of Charge nurse in RRTRole of Charge nurse in RRT
1. Bring crash cart to the site
2. Help the first nurse

25. Role of Nursing Supervisor in RRTRole of Nursing Supervisor in RRT
1. Responds immediately to Code PURPLE announcement on public
address system
2. Assess situation especially with regards to activities of nursing staff
& provides additional assistance if needed
3. Calls relevant consultants as requested by Code purple team leader
4. Coordinated transfer of patient to ICU if the need arises
5. Undertakes recording & documentation

26. Role of Intensive care unit nurse in RRTRole of Intensive care unit nurse in RRT
1. Responds to assist ICU resident on duty / ICU Specialist on duty to
access airway
2. Prepares ionotropes as needed to transfuse with infusion pump

27. Role of Respiratory therapist in RRTRole of Respiratory therapist in RRT
1. Assists the ICU resident / Specialist in managing airway
2. Provides portable ventilator from ICU if the need arises
3. Assists in transferring of the patient to ICU

28. Role of Unit resident on duty in RRTRole of Unit resident on duty in RRT
1. Comprehensively assess the patient & initiates appropriate
interventions
2. Controls drug therapy & overall procedure

29. Role of on call Physician in RRTRole of on call Physician in RRT
1. Assess the clinical condition of the patient
2. Stabilize the patient’s condition
3. Assist with the mobilization of resources required to further support
the patient
4. Decides about the transfer of patient to higher level of care
5. Educates & support nursing & medical staff
6. Conducts a debriefing session after the RRT for the team

30. Role of ICU resident on duty/ ICURole of ICU resident on duty/ ICU
specialist on callspecialist on call
1. Provides airway management, maintains oxygenation
2. Provides ventilation manually or by the use of portable ventilator
3. Assists in transfer to ICU if needed
4. Assists in inter-hospital transfer if needed

31. What Is the Role of the RRT?What Is the Role of the RRT?
• Assists the staff member in assessing and
stabilizing the patient condition.
• Assists the staff member in organizing information
to be communicated to the patient’s physician.
• Educates and supports the staff as they care for the
patient.
• If circumstances warrant, assists with patient
transfer to a higher level of care.

32. What Is the Role of the RRT?What Is the Role of the RRT?
• RRT is not intended to replace care provided by the
patient’s physician, since right after the consultation by the
RRT the appropriate physician is called.
• The person who calls the RRT should become a key
member of the team and assist the RRT.
• The team is usually trained to communicate and receive
communication using SBAR – Situation / Background /
Assessment / Recommendation).
• All team members should respond in a professional and
friendly manner, providing non-judgmental, non-punitive
feedback to the person that initiated the call.

33. RRT DocumentationRRT Documentation
• A structured documentation form should be used by the
RRT.
• The team can use a form to capture and organize
information about the patient’s condition prior to calling
them, as well as interventions that were required.
• This information can be used to analyze responses and plan
quality-improvement activities where needed. Aggregate
and quality data can also serve as a base for staff
education.
• It is important that feedback be provided to staff about the
successes of the RRT and lessons learned when responding
to patients in crisis.

34. RRT response careRRT response care
recordrecord

35. RRT team orderRRT team order
sets- Adultsets- Adult

36. RRT team order sets-RRT team order sets-
PediatricPediatric

37. Measurement of Effectiveness of the RRTMeasurement of Effectiveness of the RRT
• It has been suggested that several key measures be
used to evaluate the effectiveness of the RRT:
• Codes per 1000 discharges
• Codes outside the ICU
• Number of unplanned ICU admissions
• Utilization of the RRT
• Mortality

38. RRT Call #1RRT Call #1
• 10-7-2015
• 10:45 hours
• FMW – Room 5
• 51 years 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
re-saturate from 60 to 95%
• B: pulmonary HTN, SOB, anemia
• A: RR=30, HR=90s, SpO2=70%
• R: RRT called to bedside, Physician
ordered EKG and 40 mg Furosomide
(Lasix), transferred to ICU
Interpretation: Appropriate Call, patient stayed in ICU,. Debriefing was
held, thought to be useful.

39. RRT Call #2RRT Call #2
• 10-08-2015
• 18:05
• Male medical ward Room 9
• 60 years Male
• REASON FOR CALL:
– Staff concerned
• S: Patient desaturated to 85%
• B: None given
• A: BP=109/60, HR=105, RR=26,
SpO2=90%, crackles heard on left
• R: Suctioned large mucus plug
and placed patient on 40% tracheal
collar. Saturation improved to
95% with Oxygen. Patient
remained in ward
Interpretation: Appropriate call. New Nurses, Good learning tool.
Floor suctioned patient while RRT enroute. RRT found problem
resolved. Patient Discharged on 15/08/2015.

40. RRT Call #3RRT Call #3
• 10-01-2015
• 18:15
• Female medical ward room
7 - C
• 78 year Female
• REASON FOR CALL:
– Staff concerned
– RR less than 8
– SpO2 less than 90%
– Labored breathing
– Decreased LOC
• S: RRT arrived to find
patient being ventilated
with bag-mask
• B: Ischemic bowel
disease; staff noted that
LOC had been decreasing
for 4 days.
• A: None given
• R: Patient intubated &
transferred to ICU
Interpretation: Appropriate call for RRT. Notable that LOC had been
decreasing for 4 days. Patient moved to ICU.

41. Family Initiated RRT
•Initiated December,
2008 as a pilot