Textbook of Rapid Response Systems (eBook)

Michael A. DeVita, MD Professor, Critical Care Medicine University of Pittsburgh School of Medicine Department of Critical Medicine Pittsburgh, PA, USA Ken Hillman, MBBS, MD, FRCA (Eng), FCICM Professor of Intensive Care Director of the Simpson Centre for Health Systems Research The University of New South Wales The Australian Institute of Health Innovation The University of New South Wales Liverpool, Australia Rinaldo Bellomo, MD Chair, Australian and New Zealand Intensive Care Research Centre Professor, Faculty of Medicine, University of Melbourne Honorary Professor, Faculty of Medicine, Monash University Honorary Professor, Faculty of Medicine, The University of Sydney Honorary Principal Research Fellow, Howard Florey Institute, University of Melbourne Director of Intensive Care Research Staff Specialist in Intensive Care Department of Intensive Care Austin Hospital Melbourne, Australia

Preface 8
Contents 10
Contributors 14
Part I:RRSs and Patient Safety 20
Chapter 1: Rapid Response Systems History and Terminology 21
Principles 21
Terminology 24
Summary 26
References 26
Chapter 2: RRS’s General Principles 31
Introduction 31
Overview 32
Summary 35
References 35
Chapter 3: Measuring and Improving Safety 37
Introduction 37
Approach for the Organizational Evaluation of Patient Safety 38
Measuring Defects 41
How Might We Improve Safety? 44
A Framework to Improve Reliability 44
Why RRSs Can Improve Safety 51
Summary 51
References 51
Chapter 4: Integrating a Rapid Response System into a Patient Safety Program 54
Overview 54
Creating and Sustaining Safety 55
Definition and Relevance of Human Factors Engineering 55
The MET as a Driving Force for a Patient Safety Program 56
Root Cause Analysis 56
Failure Mode and Effect Analysis 58
Safety Culture and High-Reliability Organizations 59
Patient Safety Overall 60
Summary 61
References 61
Chapter 5: Acute Hospitalist Medicine and the Rapid Response System 63
History of the Hospitalist Movement 63
Models of Hospitalist Care 64
Benefits of Hospitalist Systems 65
Hospitalists as Acute Providers 66
Thoughts for the Future 67
References 68
Chapter 6: Medical Trainees and Patient Safety 70
Healthcare, Healthcare Facilities and Medical Trainees 70
The Healthcare Environment 71
Medical Trainees: The Undergraduate Years 71
Medical Trainees and Patient Safety: The First Few Years 72
Provision of Care for Identified Illnesses 72
Provision of Care for Medical Incidences 72
Improving Patient Safety in Institutions with Medical Trainees 73
Postgraduate Training and Specialization 74
Summary 75
References 75
Chapter 7: Rapid Response Systems: A Review of the Evidence 79
Introduction 79
Evaluating the Evidence 80
Identifying the Deteriorating Patient, the RRS Afferent Limb 81
The Efferent Limb: The Responding Team 82
The Rapid Response System: Is It Effective? 83
Summary 87
References 88
Chapter 8: Healthcare Systems and Their (Lack of.) Integration 93
Identification of the Seriously Ill At-Risk Patient 97
Response to the Seriously Ill Patient 97
Education 97
Evaluation 98
Support 98
References 99
Chapter 9: Creating Process and Policy Change in Healthcare 101
Introduction 101
Changing Healthcare Policy 101
References 106
Chapter 10: The Challenge of Predicting In-Hospital Cardiac Arrests and Deaths 107
Introduction 107
Organizational Crisis Theory: Hazards, Defenses and Latent Conditions 107
Iatrogenic Patient Death: Individual or Organizational Accident? 108
Can We Predict Hospital Iatrogenic Death? 111
Prevention of Futile Clinical Cycles with Hard Defenses 115
Communication Technology as a Hard Defense 117
References 118
Chapter 11: The Meaning of Vital Signs 122
Introduction 122
Pulse Rate 123
Blood Pressure 124
The Shock Index 125
Temperature 126
Respiratory Rate 128
Oximetry 128
Age and Vital Signs 129
Combining Vital Signs 132
Summary 132
References 133
Chapter 12: Matching Illness Severity with Level of Care 137
Evidence of Incorrect Placement of Patients 138
Definitions of Levels of Care 139
Identifying a Patient’s Level of Illness 140
Response to Acute Illness 141
Knowledge and Experience of Ward Staff 141
Potential Impact of Staffing Levels and Patient Flow on Outcomes 142
New Approaches to Matching Care with Patient Severity of Illness 142
New Patient Admission Processes 143
Early Treatment of Patients in the Emergency Department 143
New General Medicine Specialists 143
Rapid Response and Medical Emergency Teams 144
Better Decisions About Limitation of Care and Resuscitation 145
Summary 145
References 145
Chapter 13: Causes of Failure to Rescue 153
Introduction 153
Causes of FTR: Patient-Level Factors 155
Causes of FTR: Hospital- or System-Level Factors 158
Summary 160
References 160
Part II:Creating an RRS 163
Chapter 14: Impact of Hospital Size and Location on Feasibility of RRS 164
Introduction 164
Antecedents to Serious Adverse Events and Cardiac Arrests, and Criteria for RRS Activation 165
Models, Location and Size 165
Teaching Hospitals and Academic Medical Centers 166
Secondary Referral Centers 168
District General Hospitals 169
Small City Hospitals with an Intensive Care Unit 170
Summary 170
References 171
Chapter 15: Barriers to the Implementation of RRS 173
Introduction 173
Sources of Obstacles and Inertia 173
Foundations for System Change 176
Impediments Within the Hospital 177
Strategies to Overcome Hurdles 180
Summary 183
References 183
Chapter 16: An Overview of the Afferent Limb 186
Introduction 186
Improving the Function of the Afferent Limb 187
Improving Regular Monitoring and Assessment 187
Ensuring Vital Signs Measurements Are Accurate 188
Ensuring Vital Signs Measurements Are Accurately Recorded 188
Systems for Identifying the Sick or Deteriorating Patient 188
Aggregate Weighted Track-and-Trigger Systems 189
Single Parameter Track-and-Trigger Systems 190
Efficiency of Aggregate Weighted and Single Parameter Track-and-Trigger Systems 191
Other Clinical Observations that May Be Used to Trigger Rapid Response Systems 191
The Value of Monitoring Systems for Improving Detection of Critical Events in Low-Risk Populations 192
Calling for Assistance 193
The Role of Technology 193
Summary 194
References 194
Chapter 17: The Impact of Delayed RRS Activation 198
Background: Principles of the Rapid Response System 198
How Often Is RRS Activation Delayed? 199
What Are the Consequences of Delayed MET Activation? 200
How Should Delayed MET/RRT Activation Be Classified? 200
What Are the Causes of Delayed Response Activation? 201
How Can Delayed RRS Activation Be Avoided? 202
References 202
Chapter 18: The Case for Family Activation of the RRS 205
Introduction 205
The Origins of Patient- and Family-Activated Rapid Response: Condition H 206
Patient- and Family-Activated Rapid Response in Legislation, Accreditation, and Safety Organizations 207
Features of Patient- and Family-Activated Rapid Response Systems 208
Administration and Design 208
Patient Education 209
Triggering Criteria 209
Screening 209
Team Composition 210
Follow-Up and Data Collection 210
Gauging Success 210
Summary 211
References 212
Chapter 19: RRT: Nurse-Led RRSs 215
Identification of Hospital Resources 217
Nursing Leadership of RRTs 217
Support for the Nurse-Led Rapid Response Team 218
Communication Tools 218
Specific Protocols 219
Chain of Command Process 220
Benefits of a Nurse-Led RRT 222
Nursing Leadership and Mentoring After the RRT Call 224
Data Collection 224
Efficacy 227
Summary 227
References 228
Chapter 20: MET: Physician-Led RRSs 229
Introduction 229
Principles Underlying the Physician-Led MET 229
What is a Physician-Led MET? 230
What Does the Physician-Led MET Do? 232
Why Do Patients Need MET Calls? 234
What Are the Advantages and Disadvantages of Physician-Led METs? 235
References 236
Chapter 21: Pediatric RRSs 239
Introduction 239
Development and Operation of Pediatric Rapid Response Systems 240
Operational Team Responses: One-Tier Vs. Two-Tier 240
Recognition of Children with Critical Illness 241
Activation Triggers or Calling Criteria 241
Early Warning Scores 244
Outcomes of Some Pediatric Rapid Response Systems 246
Barriers to Implementation and Use of Rapid Response Systems 249
References 250
Chapter 22: Sepsis Response Team 252
Introduction 252
Early Goal-Directed Therapy 253
Implementing EGDT 255
Barriers to Implementation of EGDT 256
Summary 257
References 257
Chapter 23: Other Efferent Limb Teams: (BAT, DAT, M, H, and Trauma) 260
Basic Condition Response 261
Stroke Team 261
Trauma Team 262
Blood Administration Team 263
Chest Pain Team 263
Condition L (Lost Patient) 264
Difficult Airway Team 265
Pediatric Response Team 265
Condition M 266
Summary 267
Chapter 24: Other Efferent Limb Teams: Crisis Response for Obstetric Patients 269
Background and Justification 270
Design and Introduction 270
Staff Education 273
Response Team Training 274
Data Collection, Review, and Process Improvement 274
Usage of Condition O at Magee-Womens Hospital and Discussion 275
Summary 278
References 279
Chapter 25: Personnel Resources for Responding Teams 280
Introduction 280
Shortcomings of the Current System 281
How Organization Can Help in Crisis Response 282
Rethinking the Thinking 284
Structure 285
Human Resources 285
Activation of the RRS 286
The Ad Hoc Team 287
Changing the Existing Culture 288
Operating Room Crisis Teams 291
Summary 293
References 294
Chapter 26: Equipment, Medications, and Supplies for an RRS 295
Introduction 295
Institutional Oversight of Equipment 295
Personnel Response 297
Nursing Responder Equipment 304
Airway Equipment 304
Emergency Cart Standardization 305
Selecting an Emergency Cart 305
Need for Specialty Carts 306
House-Wide Crash Cart 308
Medication Selection 308
Pharmacy Emergency Cart Exchange Process 311
Restocking Medications in the Emergency Cart 311
Additional Methods for Supplying Emergency Medications 311
Obstacles to Implementation 312
Supply Standardization in the Emergency Carts 313
Summary 315
References 315
Chapter 27: The Administrative Limb 316
Why Is an Administrative Arm Needed? 316
What Should the Aims and Objectives of the Administrative Arm Be? 317
What Are the Components of the Administrative Limb? 318
The Intensive Care MET Administrative Group 319
Coordinating the Efferent Limb 321
Monitoring of Outcomes 321
Directing Future Research 321
Linking with the Clinical Governance Unit 322
The Role of Hospital Administration 322
References 323
Chapter 28: The Second Victim 324
Identifying Emotional Vulnerability and Recognizing Second Victims 325
Immediate Support During the Crisis 326
Support Long After the investigation 329
Emotional First Aid When Entire Teams Are Suffering 330
How to Formalize a Support Network 331
Putting It All Together 332
References 332
Part III:Monitoring of Efficacyand New Challenges 334
Chapter 29: RRSs in Teaching Hospitals 335
Introduction 335
Implementing RRSs in Teaching Hospitals 337
The Afferent Limb 337
The Efferent Limb 338
Hospital Culture and Management 338
Experiences with the RRS 339
Summary 340
References 340
Chapter 30: The Nurse’s View of RRS 342
Introduction 342
The Nurse’s Point of View 343
Steps to Ensuring a Successful Rapid Response System 344
Summary 345
References 345
Chapter 31: Resident Training and RRSs 347
Introduction 347
Origins of Rapid Response Systems: A Solution to a Real Problem 348
Concerns Over Implementing Medical Emergency Teams and Rapid Response Systems 349
Opportunities for Resident Involvement in METs/RRSs 350
A Win–Win Situation 351
What a Rapid Response System Can Teach Residents About Patient Safety 352
Summary 353
References 354
Chapter 32: Optimizing RRSs Through Simulation 356
Introduction 356
Unique Aspects of Hospital Crisis Teams 357
The Ad Hoc Nature of Crisis Teams 357
Simulation of Crises as Diagnostic Tool 357
What to Teach 358
Goals of Crisis Response Teams 359
Designated Roles: Assignment and Definition 359
Communication 364
Leadership 365
Debriefing 366
What to Measure 367
Summary 368
References 368
Chapter 33: Evaluating Effectiveness of Complex System Interventions 370
Characteristics of Complex System Interventions 370
Defining the Components of Complex System Evaluation 371
Choosing the Appropriate Research Methodology 373
Sub-system Interactions After a Complex System Intervention 375
Cost and Cost-Effectiveness 375
Interpreting Study Results of Complex System Interventions 376
Summary 377
References 377
Chapter 34: RRS Education for Ward Staff 380
Introduction 380
The Challenge for Ward Staff 381
The Evidence for Improving Education of Ward Staff in Acute Care 382
What General Ward Staff Need to Know 383
Challenges in Training Ward Staff in the Immediate Management of Acute Illness 385
Education Essential to the Implementation of an RRS 388
Current Initiatives in Acute Care Education 388
Short Courses in Acute Care 389
The Role of the Response Team in Educating Ward Staff 389
Evidence for Benefit in Acute Care Educational Interventions 390
Summary 390
References 391
Chapter 35: Standardized Process and Outcome Assessment Tool 395
Introduction 395
Standardization of the RRS Process 396
Initiating RRS 396
Data Collection 397
Evaluation 398
Outcome 399
Summary 400
References 400
Chapter 36: The Impact of RRSs on Choosing “Not-for-Resuscitation” Status 402
Background 402
Not-for-Resuscitation Decision Making 403
Rapid Response Teams and Not-for-Resuscitation Orders 404
Evidence for the Impact of Rapid Response Teams on Not-for-Resuscitation Orders 405
Summary 408
References 409
Chapter 37: The Costs and the Savings 412
The Cost of Adverse Events 412
Evolution of the Rapid Response System 413
Costs Associated with a Rapid Response System 414
Efferent Arm Costs 415
Afferent Arm Costs 416
Quality Improvement Arm Costs 417
Administrative Arm Costs 418
Societal Costs 419
Potential Hidden Costs 419
Savings 420
Hospital Savings 420
“Societal” Savings 422
Summary 423
References 423
Index 426