What Do We know?
Laura was a novice RN working the Orthopedic unit. She was confident with her assessment skills up to a point. She had been lucky to land this job, and her preceptor had been exceptionally supportive. She knew when a patient was having difficulty postoperatively, plus she was able to differentiate between the odd case of surgical atelectasis versus a more serious case of respiratory compromise. But Mrs. Simpson (name changed to protect privacy) was completely different.
Mrs. Simpson was acting odd. Her vital signs were stable, but her affect was flat. Her upper extremities appeared flaccid, a change from her immediate postoperative assessment. Worse, she seemed somnolent, barely able to speak or open her eyes. Was this a stroke, Laura wondered, or something else? Concerned, and not sure what her next steps should be, she called an RRT, to alert her facility’s Rapid Response Team. Within moments, the patient room was crammed with an ICU nurse, an Intensivist, her Charge nurse, the day shift Supervisor, a rounding Pharmacist, and the hospital’s Chaplain. The team began assessing Mrs. Simpson immediately, quizzing Laura for details and background information.
RRT’s (rapid response teams, or rapid response systems) were initiated in 2005, with an initial goal of decreasing in-hospital mortality. A secondary purpose was to recognize and intervene when patients might need rescuing in-house to avoid potential cardiopulmonary arrest (CODE) situations. It was determined that the deterioration of clinical vital signs could be missed, as well as significant assessment “signals”, such as increased work of breathing, decreased urine output, pallor, and change in level of consciousness. These signals might indicate those patients who warranted increased surveillance or placement in an upgraded level of care before a cardiac or respiratory arrest occurred.
Although RRT set-up and composition has evolved many times since initiation in 2005, the basic process has two arms: the afferent arm (activation of the team) and the efferent arm (the functioning of the team itself). Small community hospitals may have a response team of only an ICU nurse and a house Supervisor. Large teaching facilities that perform transplants may have Residents as well as several Pharmacists and Anesthesiologists. Facilities that specialize in cancer treatment might provide a Chaplain as well as experts in Hospice or Palliative care. It depends on the type of facility and what the goals of the institution might be. Respiratory therapists are typically involved at almost every RRT because oxygenation of the patient is vital, with many requiring intubations as well as mechanical ventilation.1
In 2008, RRT’s picked up steam nationwide as part of JCAHO’s National Patient Safety Goals. The goal stated that a form of rapid response team must be present in hospitals across the United States. The goal specifically required hospitals to implement systems to enable “healthcare staff members to directly request additional assistance from specially trained individual(s) when the patient’s condition appears to be worsening.”2 At this time, most hospitals invested heavily in Committees and teams to develop charts, graphs, and parameters with specific clinical vital signs, including heart rate, respiratory rate, blood pressure, oxygen saturation, etc., in the hopes of pinpointing exactly which patients met criteria for activation of an RRT.
However, as Laura found with Mrs. Smith, patients rarely fit into a pre-arranged category. They just don’t cooperate that way. As a result, Laura had acted on her gut instinct when activating the RRT, which was a bold move. Initially, nurses had been a bit hesitant to activate the team, fearing repercussions, which has been found to be more common in facilities where physicians respond as part of the team.3 And although RRT’s were initially met with glowing reviews, statistically they failed to make a dramatic difference to in-hospital mortality. But why?
The reasons examined were two-fold. First, let’s go back to the two arms of the RRT, the afferent (activation) arm, and then the response (efferent) arm itself. The answers are complicated. One is that nurses simply don’t activate RRT’s early enough. It doesn’t matter how many graphs, charts, or tweaking systems are built into the EHR (electronic health record) to pick up minute changes in patients. Signs of patient clinical deterioration can be quite subtle until suddenly the patient is compromised, and then everything proceeds rapidly downhill. Sepsis works that way, as does ARDS. Both invade the body quietly and overwhelm systems, tissues until the process is difficult to contain and reverse. Evaluating vital signs and laboratory data can still be later signs of distress.
The second reason RRT’s may not change statistics is that the efferent arm (the process) is complex. People may not do the right things at the right time once they arrive, OR they may do everything perfectly, depending upon the goals of care. Placing the patient into Hospice or Palliative care or having EOL (end of life) discussions at the bedside post RRT will not improve in-house mortality statistics, but it could mean you have performed exactly the right decision for that patient.
Meanwhile, Laura was on tenterhooks worrying if Mrs. Simpson could possibly be an EOL discussion. She was worried she might have missed a slight stroke in the immediate postoperative assessment. She didn’t believe she had missed a facial droop or slurred speech earlier that day. Thankfully, Laura had recognized the change in her patient quickly. Although the facility she worked in now allowed family members to call RRT’s, none had done so, which reflected current statistics throughout the country.
When hospitals and facilities began to consider allowing family members to initiate RRT’s, most assumed they would be flooded with inappropriate calls for missed cafeteria items or calls to assist a patient to the bathroom, instead of calls to rescue patients who needed clinical help. The opposite proved to be true. Family members refrained from accessing RRT’s, preferring to speak with a healthcare team member about their concerns first.
Not surprisingly, “interdepartmental relationships often improve with the use of an RRT”, although the patient’s primary nurse remains the pivotal part of the entire process.3 The primary nurse remains at the bedside throughout the assessment, answering questions for the team, and helping decipher the puzzle of what has occurred, as well as what needs to transpire next. The team may decide the patient needs to be transferred to the Intensive Care Unit, or a Pharmacist may give advice that antibiotics or diuretics need to be initiated ASAP. As the team deciphers what has transpired, a plan of care begins to emerge.
As the RRT team and Intensivist questioned Laura, several differential diagnoses were discussed and eliminated regarding Mrs. Smith. It was determined that Mrs. Smith was post spinal surgery. She had received a dose of epidural analgesia in the holding area preoperatively. Although Laura believed her patient’s symptoms to be those of a stroke patient, CVA was quickly ruled out. Mrs. Smith had pallor and was somnolent. It was determined by the Pharmacist that Hydrocodone had been given to the patient in the early afternoon hours. Naloxone was suggested and quickly administered. Within moments, Mrs. Smith was awake and agitated, asking repetitive questions. Due to the short half-life of Naloxone, plus the need for further surveillance, Mrs. Smith was moved to ICU for overnight monitoring.
Post RRT, review of the process demonstrated the team on the Orthopedic unit required further education related to narcotic dosing for patients who have been given preoperative epidural pain management. Communication between the PACU (pre-anesthesia) and the Orthopedic unit also needed to be improved. But, overall, the RRT process worked well, and Mrs. Smith was transferred to an appropriate level of care. The remainder of her hospital stay proved uneventful.
As Laura demonstrated, “nurses serve vital roles on these teams in acute care institutions around the globe”.1 While the role and the composition of each RRT team is still evolving, what has yet to be determined is how we are impacting patients for the long term: both quality of life and patient functionality. Are we saving patients that survive up to one-year post hospital stay? What are their recidivism rates? How long do they stay out of the hospital and remain in a functional capacity? These questions remain to be answered by nurses and teams of the future.
But as Laura might tell anyone who would ask, she feels safer knowing her patients have backup that is merely a phone call, and an entire team, away. She knows the next patient like Mrs. Smith could occur with any assignment, on any given day.
- “Rapid Response Teams: What’s the Latest?”, Jackson, S. December 2017-Volume 47-Issue 12- p 34-41, Nursing.
- “Rapid Response Systems”, Patient Safety Primer, AHRQ, last updated August 2018.
- “Tweaking Rapid response Teams”, Colwell, J., September 2015, acphospitalist.org.