hospital quality

1. D R / Z E I N A B E L N A G A R
L E C T U R E R O F P S Y C H I A T R Y
A I N S H A M S U N I V E R S I T Y
RAPID RESPONSE
SYSTEMS/
TEAM

2. ∎
WHAT IS THE RAPID RESPONSE
TEAM?
A RRT – known by some as the Medical
Emergency Team – is a team of clinicians who bring
critical care expertise to the patient’s bedside or
wherever it is needed

3. WHY SHOULD YOU CARE?
∎ People die unnecessarily every day in our hospitals
∎ It is likely that each of you can provide an example
of a patient who, in retrospect, should not have died
during his or her hospitalization
∎ There are often clear early warning signs of
deterioration

4. DOES IT WORK? BEFORE …..AFTER
No. of cardiac arrests 63 …..22
Deaths from cardiac arrest 37….. 16
No. of days in ICU post arrest 163 ….33
No. of days in hospital after arrest 1363…. 159
Inpatient deaths 302…. 222

5. NATIONAL PATIENT SAFETY GOAL
∎ Goal 16:
Improve recognition and response to changes in a
patient’s condition
∎ 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

6. IMPLEMENTATION
∎ the Institute for Healthcare Improvement (IHI)
recommends:
• Engaging senior leadership
• Identifying key staff for RRTs
• Establishing alert criteria and a mechanism for calling
the RRT
• Educating staff about alert criteria and protocol
• Using a structured documentation tool
• Establishing feedback mechanisms
• Measuring effectiveness
• can be customized to meet your institutions’ needs
and resources

7. IMPLEMENTATION TEAM MEMBERS
Multidisciplinary Team
• Nursing
• Quality Management
• Respiratory
• Communications
• Physicians
• Pharmacy

8. RRS STRUCTURE
Activator(s) can be:
∎ Floor staff
∎ A technician
∎ The patient
∎ A family member
∎ Specialists
∎ Anyone sensing the acute deterioration

9. RRS STRUCTURE
∎ Activator(s) are responsible for calling the
Responder(s) if a patient meets the calling criteria
∎ Responders must reinforce the Activator(s) for
calling:
“Why did you call?” vs.
“Thank you for calling. What is the situation?”
Remember: There are no “bad calls”!

10. RRS STRUCTURE
Responders
1. come to the bedside:
2. assess the patient’s situation
3. determine patient disposition, which could include:
• Transferring the patient to another critical care unit
(e.g., ICU or CCU)
4. A handoff back to the primary nurse/primary
physician
5. Revising the treatment plan
Activators may become Responders and assist in
stabilizing the patient

11. CRITERIA FOR CALLING RRT
• Acute change in heart rate < 40 or > 130 bpm.
• Acute change in systolic BP < 90 or > 180mmHg.
• Acute change in RR < 8 or > 28 per minutes.
• Acute change in SaO2 < 90% despite oxygen.
• Acute change in consciousness or cognition, or
seizures.
• Acute change in urine output < 50ml in 4 hours.

12. TEAMWORK & RRS
∎ The RRS has all these barriers to effective care:
1. Conflict
2. Distractions
3. Fatigue, Workload
4. Misinterpretation of cues
5. Lack of role clarity
6. Inconsistency in team membership
7. Lack of time
8. Lack of information sharing

13. ACTIVATORS MUST KNOW THE
ROLES AND RESPONSIBILITIES OF
RESPONDERS AND VICE VERSA
Activator needs...
Responders need... ICU requires...
ICU requires... Administration requires... Patient
needs...

14. TRANSITION SUPPORT (“BOUNDARY
SPANNING”)
1. Manage data
2. Monitor transitions
3. Educate staff on situation and roles
4. Ensure data recording
5. Assist in role orientation

15. EXAMPLE OF ONE RRS
∎ Activators call Responders using a pager
Who are the Responders?
∎ ICU Physician
∎ICU Charge Nurse
∎ Nurse Practitioner (if available)
∎ RRS coordinator
∎Transportation service
∎ For Pediatric Unit, chaplain’s office,
security, and respiratory therapist are also included

16. EXAMPLE OF ONE RRS
Training
∎ using Situation-Background-Assessment-
Recommendation (SBAR)
∎ Single-discipline training sessions
∎ Data Collection includes reporting:
Who called the response team and what criteria
were used? (Task-oriented checklist by roles)
∎ Who responded and in what timeframe?
∎ What was done for the patient?
∎ What are the top 5 diagnoses seen in the RRS?

17. EXERCISE I: LET’S IDENTIFY YOUR RRS
STRUCTURE
Think about the four components of the
RRS:
Activators, Responders, Improve Quality
QI and Administrative
∎ Who are the Activators?
∎ What are the alert criteria?
∎ How are Responders called?
∎ What do Activators do once Responders arrive?
∎ Who are the Responders?
∎ How many Responders arrive to a call? ∎ What is each
person’s role?

18. EXERCISE I: LET’S IDENTIFY YOUR RRS
STRUCTURE
What are the common challenges facing your RRS?
∎ Patient deterioration?
∎ System activation?
∎ Patient handoffs?
∎ Patient treatment?
∎ Evaluation of the response team?

19. RRS EXECUTION
∎ Using the scenario provided, identify the five phases
of the RRS and what tools and/or strategies were used
during each phase
∎ Detection
∎ Activation
∎ Response, Assessment, and Stabilization
∎ Disposition
∎ Evaluation

20. RRS ACTIVATION: SBAR
ACTIVATOR ROLE
∎ SBAR provides a framework for team members to
effectively communicate information to one another
,following information:
∎ Situation―What is going on with the patient?
∎ Background―What is the clinical background
or context?
∎ Assessment―What do I think the problem is?
∎ Recommendation/Request―What would I
recommend/request?
Remember to introduce yourself...

21. SYSTEM EVALUATION:
Integrated Sense making Approach
∎ What can go wrong?
∎ What are the consequences?
∎ How do things go wrong?
∎ How likely are they?
∎ What went wrong?
∎ Why did it go wrong?

22. SYSTEM EVALUATION:
SENSE MAKING TOOLS
∎ Proactive approaches
∎ Failure Modes and
Effects Analysis (FMEA)
∎ Probabilistic Risk
Assessment (PRA)
∎ Reactive approaches
∎ Root Cause Analysis (RCA)

23. Sign Score Remarks
Systolic BP (mmHg) ≤70 mmHg+3
71-80 mmHg+2
81-100 mmHg+1
101-199 mmHg0
≥200 mmHg+2
Heart rate (beats per minute) <40 bpm+2
41-50 bpm+1
51-100 bpm0
101-110 bpm+1
111-129 bpm+2
≥130 bpm+3
Respiratory rate (breaths per minute) <9 bpm+2
9-14 bpm0
15-20 bpm+1
21-29 bpm+2
≥30 bpm+3
Temperature in °C (°F) <35°C / 95°F+2
35–38.4°C / 95–101.1°F0
≥38.5°C / 101.3°F+2
AVPU Score
(Alert, Voice, Pain Unresponsive
Alert 0
Reacts to voice+1
Reacts to pain+2
Unresponsive+3
Modified Early Warning Score (MEWS) for Clinical Deterioration
The MEWS can be used on all hospitalized patients to allow for the
early detection of clinical deterioration and potential need for
higher level of care.

24. Interpretation
• A score ≥5 is statistically linked to increased
likelihood of death or admission to an intensive care
unit.
• For any single physiological parameter scored +3,
consider higher level of care for patient.
MANAGEMENT
• Once the MEWS identifies a patient at risk of
deterioration, the medical team will need to identify
the cause and address it accordingly.

25. CRITICAL ACTIONS
• This score can be used by any healthcare worker
with proper training in how to use it and interpret
the results.
N. B.: It is meant to be used on a regular basis rather
than once on admission.

26. • The Modified Early Warning System (MEWS) is a tool
designed to identify patients with declining
conditions.
• It was originally designed for nurses.
• MEWS is based on the principle that clinical
deterioration can be seen through subtle changes.

27. THANK YOU