Dec 13, 2017 in Medicine

Rapid Response Teams

Abstract

 Rapid response teams (RRT) or Medical emergency teams (MET) were first studied in Liverpool Hospital, Sidney, Australia they found by responding early in patient deterioration, it was thought the it would provide better opportunities to intervene, administer appropriate treatment and prevent cardiac arrest, unexpected deaths and unplanned admissions to the ICU (Lee, 1195, p. 183). The research it will show how the instruction of staff on the medical-surgical floors will help with the early recognition and intervention of the patient that has deteriorated. I will interview staff to see if they have utilized the RRT over a 6-month period and obtain their opinions if the team is helpful to them. It will also show if rapid response teams (RRT) help decrease the number of Cardiopulmonary arrests in the hospital setting. The aim of this research is to investigate if RRT is beneficial to the patients and hospitals, and if they are important? This will also investigate if there are any set standards of practice for RRT through my article research. The research will be taken from the Crisis center, the staff, and the medical records of patients that have experienced an RRT at Cedars Sinai Medical Center in Los Angeles California. The nursing implications will show how through education, guidelines, and increased knowledge the nurse will gain better assessment skills and confidence in their knowledge about the deterioration of their patients.

Rapid Response Teams

Problem Statement

Problems in the professional setting are frequent deterioration of patients through their hospitalization. In most major hospitals there have been the implementation of Medical emergency Teams (MET) or Rapid response team (RRT) these are used interchangeably. These teams comprise of doctors and nurses that have special training in advanced life support skills. The role of the staff nurse is to be able to recognize and call the RRT when a patient’s condition starts to deteriorate and not to wait until the symptoms threaten their patients' lives. The RRT system has been found to be linked to the reduction of cardiac and respiratory arrest in the hospital setting. Rapid Response Teams (RRT) respond to a variety of patient condition changes, from respiratory to cardiac and everything else in between. Some research shows that “Implementation of a rapid response team was not associated with lower hospital –wide code rates. Similarly, rapid response intervention was not associated with improvements in the clinical meaningful outcome of hospital- wide mortality” (Chan, Khalid, & Longmore, 2008, p. 510). I will try to show that the code rates have decreased and that there is an improvement of the clinical meaningful outcome of hospital – wide mortality. I will evaluate if the RRT is helpful in the hospital and the staff as well as looking for documentation of clinical changes that may occur prior to documented RRT.

Research Design

The purpose of this study is to explore the differences of RRT in various hospitals from implementation to evaluation. In exploring these differences I will develop a conclusion about the standards that may be set for RRT, if cardiopulmonary arrests have declined since the implementation of RRT and the importance of these teams.                 

Research Procedure

For my research procedure I will obtain data from the hospital about all the RRTs called over a 6-month period. Then I will access the patient’s Electronic medical records. When I access the medical records I will collate the type of events that lead up to the RRT call. Then I will look at the medical records and see if there is any documentation prior to the event that could have been noticed by the staff to prevent the RRT call. If there is documentation in the chart that shows a pattern of precursors then this could be a teaching point for the staff to improve on their assessment skills. When the staff has good assessment skills the patients are cared for in a more though manner thereby decreasing the number of RRT called. This allows the staff; hospital and most of all the patients to benefit from the data collection. I will then collate data from the journals I have chosen, to find data on the importance of RRT and any standards of practice for that are set for RRT. When I have collated all of the data I will have answered my questions. Are Rapid response teams important? Are there standards of practice set for RRT? I will be able to form an assessment about the increase or decrease of Cardiopulmonary arrests since the inception of RRT. When I look at all the data I have collected it will help me see if both the hospital and the patients benefit from the RRT implementation.  

Role and Bias of Researcher

In the research I will develop questions and sub questions that will help determine the type of data that is useful. I will determine whom the data should be collected on and where to collect it. When the data is collected from the hospital RRT statistics and cross-referenced with the electronic medical records I will be able to accurately obtain an account of data about what precipitated an RRT. I will document, organize, and transcribe the data I collect. During my research I will remain ethical and confidential. As I collect data I will verify the accuracy of the information when cross-referenced with the RRT documentation and the medical records. Bias should not be present because data will be taken from directly from the patents medical records. The documentation will already be present so that the collation of data will make the potential for bias to be at a minimum.          

Target Audience

I will target adult patients that are hospitalized for surgeries and illness. I will gather data from adult patients that have had an RRT over a 6-month period in the hospital. This will allow for a broad range of patients with different illness and surgeries. I will not include DNR patients in my research. I will try to track the patients to discharge to see if their stay in the hospital was lengthened; age and gender are not an important factor in my research.

Instruments Used

The instruments I will be using are the data that are collected from all the RRT’s that have happened in the hospital for a 6-month period. I will also review the Electronic medical record to see if there is documentation that supports the theory that the patients exhibits signs and symptom at least 6- hours prior to the event. This data will be collated and reviewed to determine if the RRT implementation has been a benefit to the hospital and more importantly the patient.

Data to be Collected

I will obtain the data from RRT in the hospital over a 6- month period and the Electronic medical records that correlate with that data. I will look at what precipitated the staff to call an RRT. Were there any changes in the patients prior to the event that precipitated? I will follow the patients that I gathered data to see if there are any further events the patients experience while they are in the hospital. The collection of this data will help me in my research and help me answer the above questions I want to explore.

Techniques for Data Analysis

Data analysis is the process of reducing large amounts of collected data to make sense of them (LeCompte & Schensul, 1999). There are three things that occur during data analysis they are organization of data, reduction of data through summarization and categorization, identification of patterns and themes are identified and linked together (Patton, 1987). I have chosen to use a nonprobability sample specifically a convenience sample technique in my research. This type of sampling will allow the research to be taken from a local hospital. I will collect the data from the hospital about their RRT events, and then I will compare it to the Electronic medical record (EMR) to see if any precipitating factors were present prior to the event. This will allow data collection to be about real patients and real documented symptoms that precede an event that precipitates an RRT. I will gather data from the RRT records kept by the hospital and collate it with the electronic medical records to find out why the RRT occur, if there are any pre-documented signs of distress from the patients. This will allow me to determine if there are any ongoing areas of assessment that need to be addressed and reinforced to the staff, this could prevent future RRT. I will interview the some of the staff to see if over the last 6 months they have utilized the RRT and if they find the team helpful.     

Sampling Techniques

I have chosen to use a nonprobability sample specifically a convenience sample technique I will use in my research. This type of sampling will allow the research to be taken from a local hospital. This will allow data collection to be about real patients and real documented symptoms that precede an event the precipitates an RRT. I will gather data from the RRT records kept by the hospital and collate it with the electronic medical records to find out why RRT occur, if there are any pre documented signs of distress, and what the general outcomes of patients that have had RRT.  

Data Collection Method

The data collection method I will be using is the primary collection method. I will be pulling data from electric medical records and from the RRT records kept by the hospital. I will be evaluating the documented changes of the patients prior to their RRT if there were any. I will be gathering data on the increase or decrease of cardiopulmonary arrests after the implementation of RRT. I will also look at the secondary collection method to evaluate what data has been collected from other hospitals.                                                                                                                    

Literature Review

Importance of Rapid Response Teams

Why are rapid response teams important is an area I think needs to be defined. All 10 articles I listed talk about the importance in one-way or another. This is very important to know because without defining the importance you will not understand the need. Rapid response teams are important to decrease the number of declining patient conditions and the possible death of patients in the hospital. The articles from the above list that answered the question, Are there standards set for Rapid response teams? The articles from Hillman, Jamieson, Barbetti, Laurens, Garretson, and Numi all had standards in their articles similar to the above table. Some of the articles included more and some had less, but the general consensus was that Airway, circulation, neurology was the main reasons staff called the RRT. As the staff are instructed they should call whenever they are worried about their patient or have an issue that need immediate MET systems have evolved in part as a response to a sicker inpatient population in acute care hospitals with a shift toward outpatient care ever-shorter length of stay (Hillman et al., 2000). Rapid response teams have evolved to decrease the number of cardiac arrests, to provide quality of care and difficult managed-care directives demanding shorter lengths of stay of patients while they are in the hospital (Stolldorf, 2008).                                                     

Barriers of implementing RRT are cost. Due to the shrinking budgets and limited resources, initiating new programs and policies can be challenging in the health care environment (Johnson, 2009, p. 38-42). Merging it with the Code Blue team could also decrease the cost of implementing this new program. When these recourses are merged the Hospital will not have any additional expense of this team, this makes it very cost effective after the initial implementation. One of the barriers that hospitals face when implementing a RRT is the primary doctor doesn’t want to give up the care of his patient. Staff needs ongoing instruction on when and why to call for the RRT. At times the nurses are afraid to call for help in fear the team or coworkers will think they cannot take care of their patients. This is a big obstacle in staff training.

A best practice that hospitals implement is clinical parameters of RRT. When these are implemented for the staff to follow the team is called when their patients exhibit theses symptoms. In The hospital setting they have developed guidelines that nurses follow the call for the MET. They include but not limited to any problem that fits the table below (See Table 1.) This is just a guideline that we follow at Cedars Sinai Hospital, Los Angeles California (Appendix A).                                                                                   

Standards for Rapid Response Teams

The articles from the above list that answered the question, Are there standards set for Rapid response team are from Hillman, Jamieson, Barbetti, Laurens, Garretson, and Numi all had standards in their article similar to the above table (See Table 1). Some of the articles included more standards and some had less, but the general consensus was that Airway, circulation, neurology were the main reasons staff called the RRT. The article that was written by Stolldorf uses models by Donabedian. Donabedian’s conceptual framework to evaluate the quality of medical care (Donabedian, 1966). This model looks at Structure that evaluates conditions under which care is delivered. The Process that looks at activities that constitute healthcare. Lastly it looks at the outcome and the effectiveness of care. As the staff are instructed in this process they are reminded they should call whenever they are worried about their patient or have an issue that needs immediate attention by a Doctor and can’t reach the patient primary doctor in a safe and timely manner.                                                                                  

One of the Barriers of RRT standards of practice is education. When the RRT is implemented there is a lot of education required. The Doctors need to be informed of the new process and in most hospitals they need to agree. Doctors don’t like to give up control of their patients, but once they rely their patients receive faster medical assistance, they soon respond to the new practice favorably. Next the staff needs to be trained on the new process. This can sometimes be met with resistance, from the staff. Some of the reasons this happens is that the Nurses may feel they are being told how to do their job. They may also feel their assessment skills are being challenged. Either of these can make it difficult to implement a new process. Once everyone is educated and they see that the process saves lives, time and money the Doctors, and staff quickly accept the new process.                                                         

Best practices related to standards of practice set up for RRT are variable. The majority of hospital uses similar standards as defined in Table 1 above. There are variations that include decrease in urine output, loss of movement or other signs of stroke and chest pain.

Declining Cardiac and Respiratory Arrests

The article from the above list that mention information on cardiac and respiratory arrests are Johnson, Hillman, Jamieson, Garretson, Konrad, and Laurens. There is mixed information in these articles I have seen. Factors that influence the data collection of cardiac and respiratory arrests can be, if a hospital records the arrests of the patients, then the data can be collated. Some hospitals don’t keep statistical data so the author would have to get permission to go into all the medical records of the patients that had been admitted. The information on cardiac and respiratory arrest related to the implementation of RRT varies depending on the author. Some of the authors don’t differentiate between the data pre and post implementation. Some of the authors don’t explain their findings. Of the articles I researched most stated there was a significant decline in the number of cardiac and respiratory arrests after the implementation of RRT.                                                   

Barriers affecting data collection are the time and cost of collating data. When an arrest happens the hospital has to determine why it happened. They would need to eliminate age related, trauma, and end stage disease. Then they would have to look at other causes. All of this takes time and money that most hospitals don’t have to spend at the present time.   

Best practices for obtaining declining cardiac and respiratory arrests should include early intervention. When the staff is trained to recognize signs and symptoms of cardiac and respiratory compromise, then treatment can begin earlier rather than later. When the hospitals implement an RRT program the staff are taught how to recognize early signs of distress. Some of these symptoms may include subtle changes in respiratory status, cardiac rate and rhythm, and levels of mentation.                                                                                  

Who Benefits from Rapid Response Teams?

The articles from the above list that had information on who can benefit from rapid response teams include the article written by Hillman, Jamieson, Hoffman, Stolldorf all included how the Nurse benefits. The articles written by Jamieson and Garretson stated how the hospitals could benefit from the teams. The factors that influence how nurses can benefit are that they learn better assessment skills. They have more confidence in what they observe and hear from their patients. The Doctors and colleagues have more respect for them in regards to their nursing judgment. The factors that influence how hospitals can benefit are cost of extended care after an arrest. The cost of lawsuits if a family member or patient feels the staff neglected to recognize changes                

Barriers could again come from the lack of data collation on how the changes in the staff affect the effectiveness of the rapid response team. Without ongoing data collection it would be hard to know if any one benefits. As RRT evolves the most important factor is that Patients benefit the most. Best practice related to who benefits from rapid response teams is not talked about much in the articles I found. There is some information about ways nursing and hospital benefits but nothing that overtly states any best practice.

Result Interpretation

In my interpretation of data I should be able to address if RRT saves lives by responding early to the patient before cardiopulmonary arrest occur, then by showing that rapid response teams are important to the hospital and the patient. I will evaluate what standards the hospital uses in comparison to other hospitals I have researched to see if there are any standards of practice that is used for calling a rapid response. I will be able to show if the staff utilize the team and find it helpful. I will research the causes of RRT’s and look at the similarities among the patients to see if there was a decline in cardiopulmonary arrests after the implementation of RRT. When all of my data are collated and I look at the EMR I would like to be able to see who benefits from the rapid response team, the hospital or the patients. I believe I will see that both will benefit from these teams, the hospital will save recourses and money when the patient recovers faster, and the patients will benefit the most from the increased quality of life by not having to endue more procedures, and extended hospitalization and possibly death.  

Conclusion

With my next research proposal I would like to do it as on complete paper not separate papers, I think this would help me learn better how to develop a research proposal. The process we used in this paper was a little confusing to me when it was all done separately. The challenging parts of the paper for me were the instruments, sampling, and data collection methods sections. These areas were hard for me to ascertain which processes would be used and which sampling techniques. This was also confusing to me to find what matched my topic. With the primary collection method for my topic I was unable to use the data collection instrument as it’s intended to be used. I really enjoyed the research process; it was very intriguing to know how other authors investigated this topic. There were a vast number of articles that I read in order to find the information that I needed. It was enjoyable to read about various studies throughout the world. I would like to present this to the hospital staff to help them better understand why RRT is so important and why good nursing assessments are imperative.

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