Resus Room Service - Sarah Webb
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Rapid response systems (RRSs) have become a routine part of the way patients are managed in general wards of acute care hospitals. They have been adopted by national health and safety organisations in North America, Canada, the United Kingdom and Australia and are increasingly being used in other parts of the world. Studies have almost universally shown significant reductions in outcome indicators such as mortality (up to one third) and cardiac arrest rates (up to 50%). However the validity of these outcomes is questionable as most of these studies are single-centre, before-and-after studies conducted by one or two clinical champions in Rapid Response. This presentation reveals that the implementation of an Intensivist led Rapid Response Team in an Australian quaternary hospital did not demonstrate such dramatic results. In fact, after one year of service the standardised mortality ratio and the in-hospital cardiac arrest rate remained similar. The presentation explores some of the operational impacts of a RRS including the replacement of critical thinking with reliance on protocols and the progressive super-specialisation of medical teams. Despite these impacts and relatively static patient outcome data, the service has rapidly become an integral part of the hospital. Barriers between Intensive Care and ward staff have broken down and quality outcome results have consistently shown ward nurses and doctors feel better prepared, educated and supported in managing clinical deterioration. These surprising results raise the question; should we place more value in quality outcomes?
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Resus Room Service - Sarah Webb
- 1. Room Service Resuscitation Sarah Webb @sarahbebewebb Nurse Practitioner, Intensive Care Unit Royal North Shore Hospital, Sydney, Australia MN (Nurse Practitioner), MN (ICU), Gdip (Midwifery), Gcert (ICU), Bach Nurs
- 5. CERS CNC David Wastell RRT Clinical Lead Prof Carole Foot Resuscitation CNC Sarah Webb RRT Director Dr Liz Hickson 11th February 2013
- 8. Low systolic blood pressure High systolic blood pressure High heart rate Low 02 saturations Low respiratory rate ALOC (Pain or Voice) Low heart rate
- 10. What we thought about RRT
- 11. What our ward colleagues thought of RRT
- 12. Your Logo Staff deskilling • 95% strongly disagreed that the RRT caused deskilling • 91% disagree RRT calls are required because nursing staff have mismanaged their patients Patient Safety • 87% agreed RRT help teaches how to manage sick patients • 96% agreed the system allowed them to seek help when worried Effective Teamwork • 96% agreed RRT encourage effective teamwork • 89% disagreed that they would be reluctant to call the RRT for fear of being criticised
- 13. Intranet Paging EMR RR Form CPA Form Key Performance Indicators Track and Trigger audits Surveys Resus Trolley Transition REACH Medical ALS 11 Met with Merits State Innovation Award Team of the Year Award Quality 14 Chapter Movie Weekly RRT Teaching Weekly mock events 93% education saturation Education
- 14. 2012-2013 2013-2014 Unexpected Cardiopulmonary Arrests (per 1000 separations) 0.8 1.1 Unplanned ICU Admissions (per 1000 separations) 0.6 0.8 Hospital Standardised Mortality Ratio 1.25 .95
- 16. Summary
- 18. References 1 Jones DA, DeVita MA, Bellomo R. Rapid response teams. N Engl J Med 2011; 365: 139-146. 2 Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients — results from the Harvard Medical Practice Study I. N Engl J Med 1991; 324: 370-376. 3 Wilson RM, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. Med J Aust 1995; 163: 458-471. 4 Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington, DC: National Academy Press, 2000. 5 Hillman K. The changing role of acute care hospitals. Med J Aust 1999; 170: 325- 328. 6 Adhikari NKJ, Fowler RA, Bhagwanjee S, Rubenfeld GD. Critical care and the global burden of critical illness in adults. Lancet 2010; 375: 1339-1346. 7 Donni-Lenhoff FG, Hedrick HL. Growth of specialization in graduate medical education. JAMA 2000; 284: 1284-1289. 8 Schein RM, Hazday N, Pena M, et al. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest 1990; 98: 1388-1392. 9 Hillman KM, Bristow PJ, Chey T, et al. Antecedents to hospital deaths. Intern Med J 2001; 31: 343-348. 10 Hillman KM, Bristow PJ, Chey T, et al. Duration of life-threatening antecedents prior to intensive care admission. Intensive Care Med 2002; 28: 1629-1634. 11 Donaldson LJ, Panesar SS, Darzi A. Patient-safety-related hospital deaths in England: thematic analysis of incidents reported to a national database, 2010–2012. PLoS Med 2014; 11: e1001667. 12 Hillman K, Chen J, Cretikos M, et al; MERIT Study Investigators. Introduction of the medical emergency team (MET) 359.el-369.el. 15 Chen J, Ou L, Hollis SJ. How accurate are the diff erent predictive models in identifying deteriorating patients? The ViEWS may not be as clear as we fi rst thought. Crit Care Med 2014; 42: 986-987. 16 Gerdik C, Vallish RO, Miles K, et al. Successful implementation of a family and patient activated rapid response team in an adult level 1 trauma center. Resuscitation 2010; 81: 1676-1681. 17 Loekito E, Bailey J, Bellomo R, et al. Common laboratory tests predict imminent death in ward patients. Resuscitation 2013; 84: 280-285. 18 Esmonde L, McDonnell, Ball C, et al. Investigating the eff ectiveness of critical care outreach services: a systematic review. Intensive Care Med 2006; 32: 1713- 1721. 19 Clinical Excellence Commission. Between the Flags project: the way forward. Sydney: CEC, 2008. http://www.cec.health.nsw.gov. au/__documents/programs/between-the-fl ags/2013/btf-the- wayforward-2008.pdf (accessed Jul 2014). 20 Chan PS, Jain R, Nallmothu BK, et al. Rapid response teams. A systematic review and meta-analysis. Arch Intern Med 2010; 170: 18-26. 21 Hillman KM. Run, don’t walk. Crit Care Med 2012; 40: 2712-2713. 22 Hillman K, Alexandrou E, Flabouris M, et al. Clinical outcome indicators in acute hospital medicine. Clin Intensive Care 2000; 11: 89-94. 23 Chen J, Bellomo R, Flabouris A, et al; MERIT Study Investigators for the Simpson Centre and the ANZICS Clinical Trials Group. The relationship between early emergency team calls and serious adverse events. Crit Care Med 2009; 37: 148-153. 24 Buist M, Bernard S, Nguyen TV, et al. Association between clinically abnormal observations and subsequent in-hospital mortality: a prospective study. Resuscitation 2004; 62: 137-141. 25 Bellomo R, Goldsmith D, Uchino S, et al. A prospective before-and-after trial of
Editor's Notes
- Hello everyone. This presentation is about Room Service resuscitation but before I start I’d like to wet your appetite. Take a look at this…
- So I’d like to do is shine some light on one of these systems…the rapid response system. But before you all fall asleep don’t worry I’m not going tell you all about yet another single centre, before and after study that showed reduced cardiac arrests and hospital mortality…. Because we weren’t able to show this…
- In fact, what I think Rapid Response is all about is comfort and cost. What sort of a hotel do you prefer to stay in? Would you rather stay in a 5 star height of luxury hotel that costs about $400 a night or would you rather stay in a more simple establishment for $100 a night. Both have the essentials; a bed, toilet facilities and adequate food. But the five star hotel is much more expensive and much more enjoyable to stay in, even staff love working there because it’s such a nice enviornment, and not only is the food restaurant quality there’s even a service that delivers it to your own room.
- 2 years ago I was part of a team that implemented the first rapid response service in our organisation. This picture was taken on the very first day that our rapid response service began. All of us only had began in these positions just a few months before. There are three main reasons are hospital decided to implement our roles and the RRT… We had 16 serious clinical incidents in one year…that were all related to clinical deterioration. Our hospital was being accredited under new national standards which we were going to fail because we didn’t have a rapid response system. And finally our hospital was also being rebuilt so in terms of change management this was an ideal time to overhaul the resuscitation processes. This was a really interesting time for us because we go to see first hand the impact of a rapid response system.
- What we really noticed was a before and after effect, a shift from a reliance on critical thinking to a reliance on protocols. Before we had the RRT our ward nursing and medical colleagues had to be independent in assessing and trouble shooting clinical deterioration appropriately, critical care expertise was only activated when ward staff had exhausted their own clinical skills. These days it often seems like critical thinking has been replaced by protocols such as mandatory escalation, where ward nurses and doctors activate a critical care team based on a track and trigger observation chart.
- The reason track and trigger systems have been implemented in national health and safety standards around world is because there is a well established link between abnormal physiological parameters and adverse patient events such as unexpected death, cardiac arrest or admission to ICU. The theory is that the ward nurses track the observations, and when they fall out of normal parameters they are triggered to call the critical care team. A second set of eyes who review the patient and treat the cause of deterioration before it cascades into a sentinel event.
- But the sensitivity of these systems is a serious concern for us. This chart represents the percentages of RRT activation in our first year. We had 3740 calls and 37% of our calls were for low blood pressure. The criteria for this is a systolic blood pressure of less than 90mmHg. Now of course, this might be seriously concerning in a small cohort of patients but the majority of these calls are treated with simple medicine not critical care. In fact of all those 3740 calls only 9% resulted in transfer to a higher level of care. Facts like this make us think is this really the work of critical care teams?
- Who are the right people to provide this service? A secondary effect that we noticed was that the RRT compounded the progressive specialisation of medical and surgical teams. What I mean by this is that specialist doctors are becoming more focused on their particular specialty. And the problem with this is, that the more focused specialties become, the bigger the clinical gap between them becomes. We are the best to equipped to treat these patients and prevent adverse events but shouldn’t home teams be more holistic than a surgical site or single organ dysfunction? And if we’re having to review all the patients in the hospital who have deranged observations then who is ultimately responsible for them and where does that responsibility end? On the other hand when I have my hip replacement I’d rather have a surgeon who does nothing but hips all day everyday… and when I become hypotensive a week later I’d rather be reviewed by people who know the most about systemic inflammatory response.
- The third effect that we really noticed was the impact that the RRT had on the clinicians. From our perspective after the first month this is how I think most of us felt once we had seen our 40th call for a SBP 88. This isn’t what critical care is about. Where are the cardiac arrests and emergency intubations. For the RRT nurses it was still kind of fun… most of us had only ever worked in ICU so we were quite excited to check out the rest of the hospital. But for our doctors who’d already spent years working on the wards there really was sense of sense of deflation. It was incredibly frustrating for them to follow these very rigid protocols when simple medicine would have sufficed and we wondered if all we were doing was deskilling the ward staff.
- Now the ward staff were barely represented in the movie at the beginning of this talk and prior to the RRT we had a very different view of our ward colleagues as I’m sure they did of us… but what we hadn’t appreciated was that as the wards were getting busier and busier, the patients were aging and becoming more complex and the home teams were becoming more focused on their specialty… the ones left holding the pieces were the ward staff. RR Service might have replaced critical thinking with protocols but those protocols actually empower these guys to call for help they need it, it also creates unique teaching opportunities with critical care team which is espcecially valuable for the junior ward doctors.
- In fact when we ran a survey for are ward colleagues in the first year of the RRT and the results were really surpising. In terms of deskilling they didn’t see the RRT made them deskill at all. In terms of patients of patient safety they felt the system actually improved their ability to manage sick patients and they now felt they had someone they could call if they were worried. In terms of team work almost all of them felt that the rrt encouraged effective teamwork… Now this data isn’t the stuff that usually influences hospital administrators to continue funding services but I think this demonstrate an important cultural shift, a breaking down of the barriers between ICU and the wards and a new alliance between ICU and the ward stuff which makes our working environment and especially the wards environment much more enjoyable.
- Implementing this system was an enormous effort and it certainly wasn’t just our team, there were numerous key stakeholders in the executive committee as well as nursing and medical clinicians both in the ICU and throughout the hospital who contributed to this project. The education alone was huge. We made a 14 part movie that could be played to the mass audiences, we ran weekly teaching RRT teaching sessions, weekly mock events on the wards and at the end of the year we showed 93% education saturation throughout the hospital. We rigorously followed our KPIs… we worked with the electronic medical record team to implement an intranet paging system, we built electronic forms for rapid response and cardiac arrest calls to make sure that our data was as clean and robust as possible. We ran numerous Quality Initiatives; Observation audits, staff satisfaction surveys, we standardised and simplified the resuscitation equipment in the entire hospital, we dramatically increased the advanced life support accreditaion of our junior medical staff from 2% to 55% in the first year, we smashed hospital accrediation, we won a state innovation award and we even implemented a process were patients and relatives could call the rrt directly. There was nothing held back... Nothing left in the tank.
- When it comes to evaluating Rapid Response Teams, the holy grails are improved cardiac arrests, Icu admissions and hospital mortality. and you can see our results don’t actually look that promising. But having lived and breathed this data, counting arrest forms, analysing excel spreadsheets, pivot tables and data dictionaries, I actually take these KPIs with a grain of salt because there’s a surprising amount of variability in the way this information can caulcuated and the factors that influence them are vast. I can bore anyone who ineterested in this over lunch but for the purporse of this talk… Rapid Response Teams may not dramatically change our patient outcomes the way we had hoped.
- So if our patient outcomes haven’t really changed what have we achieved then? Have we just upgraded from our 2 star hotel? Have we just implemented a form of room service?
- In summary, RRTs shift a reliance on critical thinking to a reliance on protocols, they compound the progressive specialisation of our home medical teams, they may not involve the most exciting resuscitation medicine, they may not dramatically improve our patient outcomes but they do supbstantially improve working environment for our ward colleagues and break down barriers between ICU and the wards.. Which I think can only be beneficial for the patients.
- So I’d like to leave you with one last image I mean message. The next time your booking your hotel remember to book the five star one with the room service, your outcomes are probably going to be same but the journey will be much more enjoyable.