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Acute Myocardial Infarction	Medication Reconciliation (ADE)
Boards on Board	Pressure Ulcers
Catheter-Associated UTI	Rapid Response Teams
Central Line Infections	Surgical Complications
Congestive Heart Failure	Surgical Safety Checklist
High-Alert Medications	Surgical Site Infections
MRSA	Ventilator-Associated Pneumonia

Use this table to quickly find a mentor for deploying Rapid Response Teams with demographics similar to your own, or use 'ctrl+f' in your web browser to search for specific key words on this page.

Advocate Good Shepherd Hospital – Barrington, IL
Availability Status: Available to answer requests
Licensed Beds: 181
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: October 2005
Mentor Contact Name: Linda Lau, RN, MSN, Manager MSICU & RRT
Mentor Contact Email: Linda.Lau@advocatehealth.com
Mentor Contact Phone: 847-842-4896

Additional Information:

Advocate Good Shepherd is a community hospital in Barrington, Illinois.  Our Rapid Response Team contains dedicated critical care nurses that work collaboratively with other team members to provide a strong clinical force and care delivery system.  Full time equivalent (FTE) positions are designated to assure availability for a true rapid response.  All of the Rapid Response Team RNs are required to have a minimum of two years of ICU experience, Advanced Cardiac Life Support, Pediatric Advanced Life Support and Trauma certifications and the American Stroke Association NIHSS training.  It has been said by one of the RRT RN’s that, “We can bring ICU care anywhere.”  The result is critical care for all patients in need and mentoring to nurses who are at the bedside.

We felt it was vital to the success of our Rapid Response Team program to have RNs who do not have other duties such as being an ICU charge nurse or having a patient assignment.  The challenge came in making this program budget neutral.  The new Rapid Response Team RN role was created by combining a remote telemetry RN position with the rapid response role.  We made the conscious decision that the new role would be staffed by existing ICU trained staff members with no new employee hired into the position.  These decisions helped to maintain the roles budget neutral status along with providing positive patient outcomes.  The combination of the roles of RRT RN and the existing dysrhythmia role allows the Rapid Response Team RN to be proactive in response to abnormal cardiac rhythms identified in centrally monitored patients while being available for Rapid Response calls.  The remotely monitored patients are continually observed by trained monitor technicians and Rapid Response Team RNs.  Along with observing the cardiac and oxygen saturation status, the RN “rounds” on each patient at least once every shift to establish a base line assessment.

The primary Rapid Response Team responders include the Rapid Response Team RN, a Respiratory Therapist, the assigned bedside RN, and the primary physician (who is just a telephone call away).  The primary team provides rapid assessment and interventions initiated per protocol.  As needed, we can expand team members to include secondary responders, which include pharmacy, laboratory, and supervisors.  If more than one rapid response occurs simultaneously, the ICU charge nurse is utilized as a back-up.  The patient’s nurse and the Rapid Response Team use SBAR as a communication tool to facilitate interactions among the team and with physicians.  The documentation and legal implications have been explored to meet the needs of all areas including outpatient and visitors.

Specific policies and protocols allow the Rapid Response RN to perform basic interventions without additional orders, including obtaining EKGs, ABGs, chest x-rays, laboratory diagnostics, and administering emergency medications.  Obtaining these results, interventions and re-assessments, allow a higher level of communication regarding patient status to be provided to the physician.  The availability of the Rapid Response Team prevents “disengagement” of patients requiring transfer to a critical care unit, including stat radiology studies, since all patients are accompanied by a critical care RN.  The Rapid Response RN is also an integral part of the Code Blue team.

Since the implementation of the Rapid Response Team, we have expanded the program to include inpatient, outpatient, visitors and families.  Units such as OB, Mother/Baby, Pediatrics, and Behavioral Health required additional education for the Rapid Response Nurses.  Our next steps for 2007-2008 include expanding the availability to have family members activate the RRT, expanding the team as “helping hands” for in hospital pediatric monitoring and emergencies and becoming part of the Stroke Alert team.

Data collected from January 1 through December 31, 2006:

• 394 Rapid Response calls were documented for 2006.
• 61.4 % were stabilized and not transferred to a higher level of care.
• 20.60 % (13) of the Code Blues were located out of the ICU settings as compared to 53.06% (26) in 2005.  This demonstrates a 32.46% reduction of codes outside the ICUs.
• In 2006, there were 1,260 Rapid Response interventions (as described above) implemented by the Rapid Response nurses from the RRT protocols.  There were 205 documented Nurse to Nurse consults initiated 2,275 patients were remotely monitored/admitted by the Central Tele/Rapid Response Team.
• 99.5 % of nurses surveyed stated that the Rapid Response Team met the patient and the nurses' immediate needs.  Of physicians surveyed, 100% agree that the Rapid Response Team communicated effectively the assessment and recommendations for the patient and that the patients’ needs were met by the team.

[9/7/07]

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Alexian Brothers Medical Center – Elk Grove Village, IL
Availability Status: Available to answer requests
Licensed Beds: 387
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: October 2004
Mentor Contact Name: Patty Gessner
Mentor Contact Email: gessnerp@alexian.net
Mentor Contact Phone: 847-437-5500 ext. 5073

Additional Information:

Thanks to a dedciated nursing/respiratory staff and a supportive intensivist team, we have celebrated much Rapid Response Team success.  We attribute our "no questions asked" policy and dependability as another key contributing factor.  Also, our RN responder does not have a patient assignment which has allowed us to broaden the scope to include transfer rounds, and sepsis rounds.

Our program was quickly embraced by the entire hospital.  Nursing reports less frustration and more confidence with regards to the care of their patients.  Physicians have reported their satisfaction and believe that their patients are now in a safer environment.  The responders enjoy the opportunity to educate while on the call.

Calls have led to root cause analysis and system improvements.  Our program was featured in the Joint Commission Journal on Quality and Patient Safety for reducing code blues.

Disciplines represented on Rapid Response Team: RN, RT, intensivist as needed.

We did not initially add FTEs for our team, but we started with a responder only 12 hours/day, 5 days/week.  As we expanded to 24/7, we needed more nursing coverage (ultimately 3 FTE's).

Patient/Family activation: Our protocol is simple in that the patients and families are instructed upon admission that they have access to the Rapid Response Team if they feel they are having a medical emergency.  We utilize 911 on an in-house line and the emergency operator activates the team.  We began in December 2008 and, to date, no one has used the 911 mechanism.  What has happened, however, is that families talk to the nurses more often and then the RN calls the Rapid Response Team if they are concerned.

February 2006 codes per 1,000 discharges = 3.15
Current codes per 1,000 discharges = 2.99
Avoided 34 code blues in 9 months
Reduction in overall code blue from 7/month to 5/month

70% of the calls are stabilized, avoiding a critical care admission and complications.

Mentor designation - 2/14/06
Information updated - 11/04/09

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Berkshire Medical Center – Pittsfield, MA
Availability Status: Available to answer requests
Licensed Beds: 309
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: October 2001
Mentor Contact Name: Casey Joseph, MPH
Mentor Contact Email: cjoseph@bhs1.org
Mentor Contact Phone: 413-447-2964

Additional Information:

• Implemented in 2001 by a multidisciplinary team.
• Team consists of senior medical resident, charge nurse from ICU/CCU, respiratory therapist and primary nurse.
• Nurse driven process, using RRT criteria for activation.
• Critical Care Committee has ongoing oversight and responsibility for the team.
• Maydays on the inpatient nursing units have decreased 52%.
• Maydays in the ICU have decreased 27%.
• Reduction in the number of maydays per 1000 discharges from 4.58/1000 in 2000 (prior to the team) to 2.84/1000 in 2005.
• Over the last 3 years total Team calls have increased 27%.

[2/14/06]

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Blessing Hospital – Quincy, IL
Availability Status: Available to answer requests
Licensed Beds: 435
Teaching / Non-Teaching Status: Teaching
Setting: Rural
Start Date of Intervention Work: June 2005
Mentor Contact Name: Jolene Beaber, Director of Respiratory Therapy
Mentor Contact Email: jolene.beaber@blessinghospital.com
Mentor Contact Phone: 217-223-8400 ext. 6284

Additional Information:

• Blessing Hospital successfully implemented the Rapid Response Team initiative rapidly and met with immediate positive results.
• The initiative was phased in over nine weeks and Family activation added February, 2006.
• Response from physicians, nursing staff and patients has been overwhelmingly positive.
• Comments from nursing staff demonstrate the Rapid Response Team as a patient centered and nurse supportive initiative.
• Taking critical care skills to the patient regardless of their location has made a positive impact on patient outcomes.
• There has been a total of 72 activations of the Rapid Response Team June 2005-December 2005.
• 10% increase in code survival to discharge.
• A 22% decrease in codes outside of the ICU.

[2/14/06]

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Brookwood Medical Center – Birmingham, AL
Availability Status: Available to answer requests
Licensed Beds: 550
Teaching / Non-Teaching Status: Non-teaching
Setting: Urban
Start Date of Intervention Work: January 2003
Mentor Contact Name: Tonya Roddam
Mentor Contact Email: tonya.roddam@tenethealth.com
Mentor Contact Phone: 205-877-2516

Additional Information:

Our rapid response system is a team of multidisciplinary clinicians who bring critical care expertise to the bedside.  At Brookwood Medical Center, our team includes a critical care RN and Respiratory Therapist with back up from a critical care director and house supervisor.  The clinician who initiates the call is also a part of the team as the goal of the Rapid Response Team is not to take over the care of the patient but to provide support to the nurse.  The physician involved in the care of the patient receives immediate communication and drives the interventions to stabilize the patient.  The Rapid Response Team also facilitates appropriate interventions as specified in the Rapid Response policies and protocols that allow the team to perform basic interventions without additional orders.  Obtaining these results, interventions and reassessments allows a higher level of communication regarding the patient status to be provided to the physician.  The Rapid Response Team nurse is also an integral part of the Code Blue Team.

The Rapid Response System has expanded to include patient and family initiated calls.  It is a low volume service but can have an impact on the reduction in non-ICU codes.  Since its initiation October 2008, the patient family service here at Brookwood has been quite successful.  Any patient or family member can access the RRS by dialing HELP (#4357) from any bedside telephone.  The call is directed to an operator who screens the call for non-medical issues.  The operator then activates the Rapid Response Team and the team responds as they would for any call made by a clinician.  The patients and families are educated on admission as to the appropriate use of the service.  They utilize the HELP line for situations similar to those for which they would call 9-1-1 from home.  The RRS receives on average two calls per month from patients and families.

Feedback on satisfaction is obtained through reports collected from team members, requestors of the Rapid Response Team, physicians, patients and families.  Physicians have reported their satisfaction and believe that their patients are now in a safer environment.  The responders also enjoy the opportunity to educate while on the call.  This information is reported to appropriate directors and staff to provide both positive and constructive feedback of the service as well as to drive change within a department, process or system.  One process improvement came from feedback by responders needing direct communication with the physician.  A designated cell phone was purchased for use by the Rapid Response Team when responding to a call so that the physician can directly contact the team members.

The Rapid Response Team conducts a 12-hour patient follow-up visit, and provides a debriefing after the Rapid Response call.  Debriefings are used to provide a thank-you for the call, provide feedback on the patient status, identify any teachable moments using a real event, and encourage future calls.

In an effort to track outcomes and support quality improvement, data is currently being collected on “failure to rescue” patients.  These patients are defined by their requirement for CPR or intubation at initiation of or during the Rapid Response consultation.  This information will help identify teachable moments using real events.  To further patient safety, an added role was designed to complement the Rapid Response Team through the provision of a “Rapid Response Resource nurse” for each area in the hospital.  This role is an additional responsibility to qualified critical care nurses that serve on the Rapid Response Team.  These nurses support the team through rounding every two weeks to a designated area and providing Rapid Response Team information, in-services on the system, handouts, labels and flyers to the staff, patient and families.  The other part of the role is asking the charge nurse about who are the most acute patients on their unit.  Once identified, and if warranted, the Rapid Response Team resource nurse can make a call to the responding Rapid Response Team members to provide early assessment and intervention.  We have found that patient acuity communication has encouraged critical thinking among nurses outside of critical care.

Currently, we are exploring the development of new documentation forms that will meet the needs of the team and medical record legalities.

To gauge the impact of the Rapid Response Team, we collect, analyze, and report data to the appropriate PI committees.  The Critical Care Physician PI chair reviews all Rapid Response Team documented visits for appropriateness of the interventions, patient outcomes, and process or system delays.  Rapid Response Team visits are reviewed as an episode and in aggregate to determine the need for performance improvement.  We use data to drive change within a department, process or system.  Metrics are developed by the PI committee to monitor the impact of the change. 

The most common reasons for a Rapid Response Team call are changes in respiratory status, and level of consciousness.  From initiation until now, we continue to realize a sustained 54% reduction in non-ICU codes.  We have also found a 10% overall reduction in code events and a reduction of 0.6 codes per 1,000 discharges from 2008-2009.  Over a 10-month period, we experienced an 88% increase in Rapid Response Team consultations with a subsequent decrease in non-ICU codes.  We also found a reduction in the number of emergent transfers to the critical care units.

Mentor designation - 12/7/07
Information updated - 2/24/10

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Carondelet St. Joseph’s Hospital – Tucson, AZ
Availability Status: Unavailable to answer requests
Licensed Beds: 425
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: March 2005
Mentor Contact Name:
Mentor Contact Email:
Mentor Contact Phone:

Additional Information:

Our Rapid Response Team (Advanced Clinical Assessment Team) is comprised of an ICU charge nurse and a respiratory therapist and was initiated within six weeks using a rapid cycle implementation process.  The team was fully functional on 3/1/05, with 24/7 coverage. In the first 12 months, we have averaged 18 calls per month (11.3/1000 admissions) with respiratory change in status (36%) the most frequent reason for call.  Transfer to ICU occurred 48% of the time.  High degree of satisfaction by bedside nurses and by attending physicians.  Because of the heightened awareness of early intervention, an early recognition of clinical deterioration program was initiated in January 06 and will train all nurses over the next six months.

Code Blue Calls:
CY-04 = 177                                   CY-05 = 137
CY-04  14.8 codes/month                 CY-05  11.4 codes/month
CY-04  9.5 codes/1000 admissions    CY-05  7.0 codes/1000 admissions

[3/30/06]

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Carteret General Hospital – Morehead City, NC
Availability Status: Available to answer requests
Licensed Beds: 117
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: May 2005
Mentor Contact Name: Tonya Fluellen, RN, MSN
Mentor Contact Email: tfluellen@ccgh.org
Mentor Contact Phone: 252-808-6470

Additional Information:

Our hospital has increased awareness of the importance of early intervention to avoid cardiac/resp. events or otherwise deterioration in patient status.

Our floorstaff is now seeking help and assistance sooner which has enhanced collaboration, among nursing units as well as the respitory department

Our Rapid Response Team consists of a CCU RN and a Respiratory staff member.  We initially started out with a PCU RN as a part of this team, but found it worked best with just the two members.

We did not add any FTE’s, but instead utilized the same members from the CCU staff and RT staff that would respond if there were a code blue.  These staff members were initially anxious that they would be called for everything and not be able to care for their patients.  After the staff came to understand that a Rapid Response Team call was better than an actual code, this anxiety began to dissipate.

During the early stages of implementation, we developed a multidisciplinary team that consisted of a staff member from every nursing unit as well as the respiratory department.  This team presented inservices and education on each nursing unit to explain what was going to be implemented.  We also developed story boards and fliers that were posted throughout the hospital to educate hospital employees, doctors and the public about what we were implementing and why.  During the education on the units, the staff was made aware of the number to call for the rapid response team and the fliers and storyboards all over the building also displayed this number.  A CCU staff member and RT staff member are assigned a rapid response cell phone each shift, 7 days a week.

The Director of Medical Services and VP of Nursing met with the doctors to let them know what we were starting and to get their buy in.  They were initially skeptical, but after the first few success stories, their buy in began to show.

Codes outside the CCU decreased by 50% between May 2005 and May 2006.  Our number of RRT’s is more than 50% greater than number of codes outside of CCU.  During months with a higher number of RRT calls, the number of codes were down.

[8/19/06]

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Catholic Medical Center – Manchester, NH
Availability Status: Available to answer requests
Licensed Beds: 330
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: June 2005
Mentor Contact Name: Peggy Lambert
Mentor Contact Email: plambert@cmc-nh.org
Mentor Contact Phone: 603-663-6408

Additional Information:

In a community hospital setting, within 6 months we were able to plan and implement a Rapid Response Team.  This included working with medical staff leaders providing education to the medical staff, introducing SBAR to the nursing staff, developing tools and the processes we would follow.  We adapted a documentation tool from the IHI website and have been tracking elements to help evaluate our success with this program.  We also worked with Kathy Duncan, KathyDDuncan@comcast.net, from IHI to develop a dashboard.

This information is from our Rapid Response Team dashboard first quarter results:
Number of Codes Outside ICU:  Down 10%.  Although the number of codes has gone up, the number of codes outside the ICU has dropped 10%.  Very sick patients are getting to the ICU BEFORE they code.

Average before RRT 2.42
Average after RRT 2.17
Percent Decrease -10.34%

Mortality rate for the entire hospital is down 10% since implementation of Rapid Response Team.

Average before RRT 2.83% (278 deaths/9821 discharges)
Average after RRT 2.54% (124deaths/4877 discharges)
Percent Decrease -10.18%

[3/14/06]

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Centra Health – Lynchburg, VA
Availability Status: Available to answer requests
Licensed Beds: 403
Teaching / Non-Teaching Status: Non-teaching
Setting: Urban
Start Date of Intervention Work: May 2005
Mentor Contact Name: Connie Schieck, RN, MSN, CNAA, Director of Acute Care Nursing
Mentor Contact Email: connie.schieck@centrahealth.com
Mentor Contact Phone: 434-200-2232

Additional Information:

Keys to Rapid Response Team Success:

• Early education of critical care staff and med-surg nurses of need for RRT and benefits of RRT.
• Dedicated Critical Care nurses who had experience and were trained in FCCS course.
• Open communication between nurses in critical care and nurses on other units
• Calls made every shift to remind staff that the RRT is available.
• Piloted it 11p-7a on 4 floors, then 7p-7a, then 24-7, and then all over the hospital.  After piloting it 11p-7a at one hospital, we began a trial 11p-7a at the second hospital.
• We have a physician and nurse champion.
• Conducted breakfast meetings with all charge nurses and discussed RRT and what we were trying to accomplish.
• We have succeeded because nurses want to care for patients and do the best they can for them.  Nurses see this as using all possible skills to help the patients.

Also: Evaluations from the floors have been excellent.  We did not add FTES.

Codes on the floors outside of the ICUs have decreased by 35%.

[4/27/06]

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The Chester County Hospital – West Chester, PA
Availability Status: Available to answer requests
Licensed Beds: 220
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: May 2005
Mentor Contact Name: Dianne Lanham, RN, MSN, CPHQ
Mentor Contact Email: dlanham@cchosp.com
Mentor Contact Phone: 610-431-5588

Additional Information:

We started our Rapid Response Team hospital-wide on May 5, 2005.

Keys to the success of our team:

Our Rapid Response Team has been a huge success with our nurses.  Our critical care nurse practitioners can order treatments and medications in our state and, therefore, our patients have immediate evaluation and intervention.

Our attending physicians ask the nurses to call the Rapid Response Team when they have been contacted by phone by the nurse and they themselves become concerned about the patient's condition.

Our Rapid Response Team call rate is quite high for a 220-bed hospital because the nurses feel respected and supported for any call they make.

Our nurses have given feedback to staff development that they need more frequent mock code blue training due to the low volume of code blue calls.

We have incorporated our "Code PCI" and "Code Gray" (stroke alert), and Sepsis Alert into the Rapid Response Team process.  Staff call the Rapid Response Team when they suspect an inpatient has suffered an AMI or stroke.  The process mimics the ED processes for both and expedites the care of these patients to meet the recommended treatment times.

Our nurses and physicians love our Rapid Response Team!

We instruct patients and families to ask their nurse to call if they have any concerns and need further evaluation.  This is in our patient handbook and on our in-house TV.  We are in the process of making it clear that the patient or family member can make the call themselves. We are planning our process at this time.

No FTEs were added to staff our Rapid Response Team.  We use our critical care nurse practitioners from 6 am to 8 pm to respond to Rapid Response Team calls and from 8 pm to 6 am, our house physicians.  This arrangement is financially neutral.  We have not quantified any other financial benefits.

We are in the process of completing a satisfaction survey related to Rapid Response Team performance.  Physicians, nurses, PA's, and NP's have completed the survey so far (N=27). The results so far indicate that 98% of the respondents scored each question with strongly agreed or agreed positive response.  The survey addressed communications, appropriate care, assistance with care, the value of the Rapid Response Team as a resource and their desire to have the Rapid Response Team continue.

Nurses ask if we have a Rapid Response Team when interviewing for a staff position.

We have averaged 71 Rapid Response Team calls per month over the last 6 months-FY 09 Q1 (66), Q2 (77), Q3 (70), Q4 (71)

We have averaged 0.8 codes per 1,000 discharges over the last 6 months FY 09 Q1 (1.7), Q2 (3.7), Q3 (0.9), Q4 (0.7)

Data on non-ICU code blues:
FY 09 Q1 (0), Q2 (9), Q3 (2), Q4 (2)

Mentor designation - 3/30/06
Information updated - 3/3/10

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Children's Healthcare of Atlanta at Egleston – Atlanta, GA
[Pediatric Mentor]

Availability Status: Available to answer requests
Licensed Beds: 216
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: December 2006
Mentor Contact Name: Christiane Levine RN, Senior Process Improvement Consultant 
Mentor Contact Email: Christiane.Levine@choa.org
Mentor Contact Phone: 404-785-6992

Additional Information:

In 2006, Children's Healthcare of Atlanta (CHOA) began working on a comprehensive approach to the deteriorating patient.  Using the root cause analysis process, we identified similar factors contributing to past codes.  These factors led us to four major opportunities for improvement:

1. Increase timely recognition of the deteriorating patient: Computer-based education programs about shock and deterioration for staff and physicians.  Purchased patient simulators that mimic the patient in compensated and uncompensated shock.  Created awareness around recognition of shock through other means, e.g., education blitz.
2. Develop effective communication skills under pressure: Adopted SBAR as communication tool and educated all staff and physicians on its use. 
3. Educate about escalation of care: All staff were made aware of the escalation policy and tree. It was posted more prominently on our intranet.  The "Speak Up!" Campaign was designed to empower staff at all levels (e.g., PCTs, RNs, RCPs) to speak up for the benefit of the patient, with administration supporting them.  Many staff are afraid to speak up because they care concerned about making a working relationship tense in the future or of a less than optimal response to their concerns.  We wanted to create an environment of psychological safety for the patient's caregiver.  Staff was educated through articles in our newsletter, posters, the intranet, staff meetings, and campaign tables.  We tied the campaign together using the color orange.  
4. Implement Rapid Response Teams: We have two campuses - one teaching model and one community model.  This posed a challenge to standardize the process and team makeup, but we were able to create a model that would serve the needs of both.  We launched our team in December 2006, after only 90 days of preparation.  Our RRT consists of a Pediatric ICU nurse and Respiratory Therapist.  We do not have an MD in our model and no FTEs were added.  The RRT has strengthened the relationship between PICU staff and the floor staff and we put no parameters on calling the RRT. ("Any call is the right call!")

1. Our unexpected mortality rate had decreased by 50% from 2006.

2. Since implementation of our Rapid Response program in December 2006, we have had over 140 calls.

3. Our codes outside the ICU have increased (baseline = 0.15 per thousand patient days in 2006, 0.3 thus far in 2007).  We believe that this is because we now are capturing more than before.  These codes were called to intervene prior to the patient experiencing full cardiac or respiratory arrest; we have not seen that level of prevention in the past, nor have we had the ability to track those patients as we were only monitoring those that had a code blue evaluation filled out by the code blue team.  It is to this that we are attributing the increase.

CHOA has realized that the RRT is a tool for continued improvement.  It has shed light on barriers that we were not aware of before implementation and we are learning in which areas staff need more education.  We are further investigating the codes outside the ICU and expect these to decrease as we continue RRT education and the Speak Up Campaign.

[7/7/07]

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Children's Healthcare of Atlanta at Scottish Rite – Atlanta, GA
[Pediatric Mentor]

Availability Status: Available to answer requests
Licensed Beds: 234
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: December 2006
Mentor Contact Name: Christiane Levine RN, Senior Process Improvement Consultant
Mentor Contact Email: Christiane.Levine@choa.org
Mentor Contact Phone: 404-785-6992

Additional Information:

In 2006, Children's Healthcare of Atlanta (CHOA) began working on a comprehensive approach to the deteriorating patient.  Using the root cause analysis process, we identified similar factors contributing to past codes.  These factors led us to four major opportunities for improvement:

1. Increase timely recognition of the deteriorating patient: Computer-based education programs about shock and deterioration for staff and physicians.  Purchased patient simulators that mimic the patient in compensated and uncompensated shock.  Created awareness around recognition of shock through other means, e.g., education blitz.
2. Develop effective communication skills under pressure: Adopted SBAR as communication tool and educated all staff and physicians on its use. 
3. Educate about escalation of care: All staff were made aware of the escalation policy and tree. It was posted more prominently on our intranet.  The "Speak Up!" Campaign was designed to empower staff at all levels (e.g., PCTs, RNs, RCPs) to speak up for the benefit of the patient, with administration supporting them.  Many staff are afraid to speak up because they care concerned about making a working relationship tense in the future or of a less than optimal response to their concerns.  We wanted to create an environment of psychological safety for the patient's caregiver.  Staff was educated through articles in our newsletter, posters, the intranet, staff meetings, and campaign tables.  We tied the campaign together using the color orange.  
4. Implement Rapid Response Teams: We have two campuses - one teaching model and one community model.  This posed a challenge to standardize the process and team makeup, but we were able to create a model that would serve the needs of both.  We launched our team in December 2006, after only 90 days of preparation.  Our RRT consists of a Pediatric ICU nurse and Respiratory Therapist.  We do not have an MD in our model and no FTEs were added.  The RRT has strengthened the relationship between PICU staff and the floor staff and we put no parameters on calling the RRT. ("Any call is the right call!")

1. Our unexpected mortality rate had decreased by 50% from 2006.

2. Since implementation of our Rapid Response program in December 2006, we have had over 140 calls.

3. Our codes outside the ICU have increased (baseline = 0.15 per thousand patient days in 2006, 0.3 thus far in 2007).  We believe that this is because we now are capturing more than before.  These codes were called to intervene prior to the patient experiencing full cardiac or respiratory arrest; we have not seen that level of prevention in the past, nor have we had the ability to track those patients as we were only monitoring those that had a code blue evaluation filled out by the code blue team.  It is to this that we are attributing the increase.

CHOA has realized that the RRT is a tool for continued improvement.  It has shed light on barriers that we were not aware of before implementation and we are learning in which areas staff need more education.  We are further investigating the codes outside the ICU and expect these to decrease as we continue RRT education and the Speak Up Campaign.

[7/7/07]

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Cincinnati Children's Hospital Medical Center – Cincinnati, OH
[Pediatric Mentor]

Availability Status: Available to answer requests
Licensed Beds: 511
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: June 2004
Mentor Contact Name: Uma Kotagal, MD, Sr. Vice President for Quality and Transformation
Mentor Contact Email: uma.kotagal@cchmc.org
Mentor Contact Phone: 513-636-0178

Additional Information:

Team developed which includes PICU Fellow, Senior Pediatrics Resident, PICU Staff Nurse, Respiratory Therapist and Manager of Patient Services (Nursing Supervisor).

Team is called using one phone number 24 hours/7days per week.  This activates all pagers for team members.  Promised response is within 15 minutes.  Medical Response Team can be called by any member of the care team including the patient's family members/guardians.

Triggers for calling the response team include patient "not acting right," "getting worse," increased work of breathing or "you are concerned."  Specific criteria include changes in vital signs, Pediatric Early Warning Score (PEWS).

During implementation, all MRT participants and all unit staff involved in the call completed surveys related to how well the process worked.  Evaluations were very positive from both groups.  Team activations continue to occur on a regular basis across the organization and each activation is reviewed.

No FTEs were added to staff our Rapid Response Team.

Patients or families can activate our team.  We have had only approximately 15 parent/guardian-triggered MRTs since initiation.  Preliminary experience has been positive.

Codes outside the ICU per 1000 patient days is being used as the measure since preventing them was the object of implementing the team.  Rate went from 0.27 per 1,000 patient days pre-implementation to 0.11 per 1,000 patient days post implementation through February 2006. 

Current Medical Response Team (MRT) Preventable Codes:  Current rate is 0.  Have not had a MRT preventable code since 6/08.

Mentor designation - 5/12/06
Information updated - 3/15/10

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Columbus Regional Hospital – Columbus, IN
Availability Status: Available to answer requests
Licensed Beds: 325
Teaching / Non-Teaching Status: Non-teaching
Setting: Rural
Start Date of Intervention Work: September 2005
Mentor Contact Name: Jennifer Dunscomb
Mentor Contact Email: jdunscomb@crh.org
Mentor Contact Phone: 812-376-5575

Additional Information:

• Developed the Critical Advisory Network (CAN), which is the same team as rapid response, comprised of a critical care nurse and a respiratory therapist.
• Approved by medical staff, CAN members are able to obtain diagnostics as needed and implement protocols such as respiratory, chest pain, ACLS, hypotension, etc.
• CAN members are consultants to the primary med-surg nurse and mentor the floor nursing staff in better communication with the physicians using the SBAR tool (Situation, Background, Assessment, Recommendations).
• Developed CAN competencies and training program prior to implementation.

1.8 FTE added for Critical Night Nurse Advisor position.  This is a hourly position that does not provide direct care.  The role is focused on identifying patients who may fail and providing mentoring to the bedside nurses for a plan of action.  An Early Warning System, which is a hand-held device that detects patients failing, helps the nurses to identify patients to target.

• Average med-surg code rate per month 0.67
• Percentage of med-surg codes decreased from 59% in 2005 to 27% in 2009 with only 1 failure to rescue event
• Codes per 1,000 discharges 4.6
• Average > 40 CAN calls per month
• High satisfaction from medical and nursing staff.  Night shift nurses especially satisfied.  This was reflected multiple times in comments on the employee satisfaction survey.

Mentor designation - 1/31/06
Information updated - 2/10/10

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Community Hospital East – Indianapolis, IN
Availability Status: Available to answer requests
Licensed Beds: 400
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: July 1996
Mentor Contact Name: Cleo Ann Burgard
Mentor Contact Email: cburgard@ecommunity.com
Mentor Contact Phone: 317-621-5329

Additional Information:

• Tremendously enhanced confidence in the medical surgical staff nurse in their care and critical thinking skills
• Enhanced relationships with ICU and medical surgical staff nurses
• Enhanced relationships between the ICU physicians and the medical surgical staff
• Tremendous MD satisfier
• Recruitment and retention strategy for nursing
• Reduction in total hospital codes
• Reduction in codes in medical surgical to near zero for months at a time
• Reduction in percent of patients who need to be transferred to a higher level of care

[2/14/06]

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Contra Costa Regional Medical Center – Martinez, CA
Availability Status: Available to answer requests
Licensed Beds: 166
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: August 2005
Mentor Contact Name: Steven Tremain, MD
Mentor Contact Email: stremain@hsd.cccounty.us
Mentor Contact Phone: 925-370-5122

Additional Information:

Success occurred because the Rapid Response Team is composed principally of a critical care nurse and a respiratory therapist.  Physicians become involved when the RRT determines involvement is necessary.  Staff was trained on SBAR and SBAR is used as the communication method for nurses to report to the RRT.  All nurses who summoned the RRT are unconditionally supported. RRT was piloted on one medical unit, and was determined by the staff to be so helpful that it was rapidly spread (pulled) to the entire hospital.  We are now beginning to implement patient and family activation of the RRT.

RRT calls in 2006 = 62. Of these, 31 were transferred to a higher level of care.  Before RRT implementation, 2005 had 9 floor codes with 7 deaths.  In 2006, there were only 3 floor codes.  All 3 patients were discharged alive.  There were no deaths due to floor codes in 2006.  Note: A consultant was touring the hospital when a Code Blue was called.  A staff nurse said, "That's unusual.  We don't have them anymore."  He asked, "Why not?" She answered, "The RRT is called before a patient gets that sick."  At that point, the operator announced that the Code Blue was cancelled; it had been called in error.

[3/13/07]

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Exempla Saint Joseph Hospital – Denver, CO
Availability Status: Available to answer requests
Licensed Beds: 563
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: November 2002
Mentor Contact Name: Maria Kinsella
Mentor Contact Email: Kinsellam@exempla.org
Mentor Contact Phone: 303-866-8514

Additional Information:

Exempla Saint Joseph Hospital began its Rapid Assessment Team or RAT team in November 2002 based on articles from Australia documenting the benefits of these outreach teams.  In the 3+ years since then, we have seen a significant reduction in the number of unmonitored codes.  An aggressive marketing campaign directed to the floor nurses have them fully on board with this initiative.  The data from this team has also supported other initiatives such as medication reconciliation.  We have been a leader in this field, presenting a poster of our work at this year's Society of Critical Care Medicine conference in January and VHA has used our team as speakers for their regional 100K Lives start-up conferences.

From its inception, we have seen a significant reduction in the number of unmonitored codes and we have had 6 months of ZERO floor codes!

In the last 12 months we are averaging 0.325 unmonitored codes per 1000 patient days without a corresponding increase in patient mortality.  Our team usage is up from 106 calls in 2003 to 163 calls in 2005.

[2/14/06]

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Fairview Ridges Hospital – Burnsville, MN
Availability Status: Available to answer requests
Licensed Beds: 150
Teaching / Non-Teaching Status: Non-teaching
Setting: Urban
Start Date of Intervention Work: September 2005
Mentor Contact Name: Helen Strike, VP Patient Care Services
Mentor Contact Email: hstrike1@fairview.org
Mentor Contact Phone: 952-892-2104

Additional Information:

The team has met with tremendous success and has proven to be one of the most profound changes we have made at our facility to deal with real and perceived communication and care issues.

The positive reception has been unanimous from physicians, staff, and patients.  We have had calls at our front door, in our gift shop, and for staff members who have collapsed or become acutely ill.  On November 22, 2005, we expanded our team to include all children age 1 month and above.  We are also creating special OB and neonatal Rapid Response Teams.  Our Pain Nurse Practitioner is creating pain protocols for the RRT to use to assist those patients with acute and/or intractable pain.

Since implementation:
• 45 calls
• 1 cardiac arrest outside ICU
• 24 patients stayed in their rooms
• 15 transferred to the ED
• 6 treated in outpatient area or transferred to the ED for further treatment
• Ratings of 5 (very successful) from all staff who have called the RRT and from all staff who respond as members of the RRT

[1/31/06]

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Harborview Medical Center – Seattle, WA
Availability Status: Available to answer requests
Licensed Beds: 367
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: October 2005
Mentor Contact Name: Laura Nelson
Mentor Contact Email: lauran@u.washington.edu
Mentor Contact Phone: 206-731-3755

Additional Information:

We've had an existing very successful ‘STAT Nurse’ program in place for about 10 years.  We built on that program by adding a respiratory therapist. By creating an SBAR tool with clinical triggers for calling the RRT, all levels of acute care staff (including residents) felt they were given permission to call for support prior to a or pre-code situation.

We are up to an average of 83 RRT calls per month.  We were a high performer on the University Hospital Consortium's RRT initiative with 0% of our patients during the reporting period going on to arrest anytime after the RRT intervention.  We also were pleased that 24% of calls were due to "concerns about the patient" which indicates a high level of staff acceptance to this type of support.  We are currently developing metrics to assess our impact on cardiac/respiratory codes although we are certain that these are reduced.

[1/31/06]

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Henry Ford Hospital – Detroit, MI
Availability Status: Available to answer requests
Licensed Beds: 806
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: December 2004
Mentor Contact Name: Jack Jordan
Mentor Contact Email: jjordan1@hfhs.org
Mentor Contact Phone: 313-874-3925

Additional Information:

Two rapid response nurses are in the hospital 24/7.  All nurses on general practice units have been trained on how, when and why to alert the rapid response team.  The rapid response team has been a huge success and has been equally well-received by residents and nurses.  Residents have found that having extra resources available to watch over the highest acuity patients allows them to take more aggressive action without over burdening the responsible nurse.

Henry Ford Hospital uses a single nurse responder combined with a concurrent page to the resident assigned to the patient.  If the care needs to be escalated, the ICU fellow will be contacted.

Started on two units.  Spread when residents rotated and started telling RNs to call.

Patients/families can activate the Rapid Response Team.

Almost 10,000 Rapid Response Team calls (as of 7/31/09).

Reduced the percent blue alerts outside ICU rate by 30%.

Mentor designation - 1/31/06
Information updated - 10/19/09

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Jewish Hospital – Louisville, KY
Availability Status: Available to answer requests
Licensed Beds: 442
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: June 2003
Mentor Contact Name: Paula Heinz
Mentor Contact Email: paula.heinz@jhsmh.org
Mentor Contact Phone: 502-587-4935

Additional Information:

Implemented Rapid Response Team successfully and continued operational success for over 2 years.  Team protocols and monitoring forms have been developed and outcome measures tracked monthly.

Initial reduction in codes outside the ICU from 2.0/1000 pt days to 1.4/1000 pt days and codes reduced overall from 3.2/1000 pt days to 2.8/1000 pt days.

[1/31/06]

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Johns Hopkins Children's Center of the Johns Hopkins University – Baltimore, MD
[Pediatric Mentor]

Availability Status: Available to answer requests
Licensed Beds: 170 pediatric beds
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: October 2004
Mentor Contact Name: Elizabeth Hunt
Mentor Contact Email: ehunt@jhmi.edu
Mentor Contact Phone: 410-955-2393

Additional Information:

• Our Pediatric Rapid Response Team is comprised of a PICU fellow, PICU nurse, PICU respiratory therapist, senior pediatric resident, junior pediatric resident, pediatric intern, pharmacist, nursing shift coordinator, chaplain and security. 

• "Family concern" is on the formal list of reasons to trigger a Rapid Response Team call and we have educated our nursing and resident house staff that if a family member is scared or worried they should call us. We have had a number of calls where family concern was listed as either a primary or secondary reason for calling. 

• We monthly review all calls and arrests and have set up a computerized tracking system to identify trends and progress. 

• Since our transformation into a Rapid Response Team, we have seen an increase in calls to the team and a decrease in the number of children experiencing an actual cardiopulmonary arrest.

• Deployment of our Pediatric Rapid Response Team has led to a 50% increase in calls to the team and a 30% decrease in the combined rate of respiratory and cardiopulmonary arrests on the wards.

[4/17/06]

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Kent Hospital - Warwick, RI
Availability Status: Available to answer requests
Licensed Beds: 359
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: August 2005 - Implemented "sepsis team" concept in January 2009
Mentor Contact Name: Virginia Wilcox, RN, CCRN (Nurse Manager - Intensive Care Unit)
Mentor Contact Email: vwilcox@kentri.org
Mentor Contact Phone: 401-737-7010 ext. 5180

Additional Information:

Utilization of the Rapid Response Team has increased dramatically since January 09 due to the focus on the sepsis patient in our hospital.  We have increased our calls from 30 calls per month to an average of 73 calls per month.

Cardiac arrests decreased from 7.6 per 1,000 discharges to 3.0 per 1,000 discharges in the subsequent 13 months post-implementation of the Rapid Response Team.  Overall, we have seen a 60% decline in the number of patients who had cardiac arrests. Codes outside ICU have decreased over time.

The Rapid Response Team has become a valuable asset to Kent Hospital.  It has empowered staff to activate this team when they feel there has been an acute change in their patient's condition.  During our "Grand Rounds" on the Rapid Response program, staffs from many nursing units as well as from the Emergency Department and Interventional Radiology voiced satisfaction with the program.  It is viewed as taking critical care expertise to the bedside.

Kent started the program with one nursing unit as a pilot for a period of one month.  Both team members and nursing unit staffs were surveyed during this initial phase to help determine if there were problems to solve before expanding the program to other units.  There was very positive reaction to the team.  The program was then expanded hospital-wide.

Over time, we have found expanded roles for this team.  For example, we have completed extensive education for the emergency department relating to early identification of the sepsis patient.  As we rolled out the sepsis bundle to our hospital, it quickly became evident we needed an organized approach to this patient population.  Since we already had the rapid response team in place, we decided to expand that team's expertise to encompass the sepsis bundle elements.

Our "sepsis team concept" became a great way to collaborate with the emergency department to ensure we that were identifying sepsis patients early and to implement the elements of the sepsis bundle as indicated.  We educated all rapid response team members as well as the emergency department staff (physicians and nurses) on the sepsis bundle.  Next, we empowered the emergency room nurses to activate the team so extra help could quickly respond to assist with bundle implementation.  This was especially helpful during peak times in the emergency department.  With the rapid response team on board early, transfers to ICU occurred much more quickly.

The team is now highly regarded at our hospital.  The critical care nurses have a sense of pride in the assistance they provide to the patients and nurses on the individual nursing units.  The team composition works well for us.  Each represented discipline responds promptly.  They consistently work toward either stabilizing the patient or assisting with transfer to a higher level of care if required.
 
Our team is comprised of an ACLS certified Critical Care nurses who have at least 2.5 years of Critical Care experience, a Respiratory Therapist, and a Physician's Assistant. 

Initially, no FTE's were added to the Critical Care budget.  Since our start in August 2005, the number of calls has steadily increased.  When we added the concept of the "Sepsis Team" to the role of the RRT in January 2009, we recognized the need for additional resources.  We now dedicate one nurse on each shift to this role.

We hope to implement family activation within 6 months.

Mentor designation - 1/18/08
Information updated - 10/2/09

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LSU Health Science Center - Shreveport – Shreveport, LA
Availability Status: Available to answer requests
Licensed Beds: 448
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: March 2006
Mentor Contact Name: Sheree Jordan
Mentor Contact Email: mjorda@lsuhsc.edu
Mentor Contact Phone: 318-675-7610

Additional Information:

As a teaching institution, we had to be creative in involving the residents by not excluding them or their education.  Our team uses a collaborative approach for plan of care using a critical care RN and Respiratory therapist.  Using the collaborative approach, the bedside nurse contacts the patient's resident.  The resident, RN, and RT then meet at the patient's bedside along with the bedside nurse to develop a rapid plan of care for the patient.  If there is a difference of opinion at the patient's bedside, the ICU physician is consulted.

Our team was developed and initiated without any additional FTE's.

We piloted our team on our telemetry unit then added one general care floor at a time until it was implemented institution wide. 

We recently added the family aspect to our detection of deteriorating patients.  Patients and families are educated to call the primary nurse and if no response, to go to the charge nurse and unit manager.

At LSU Health Science Center, our rapid response team has definitely had some "growing pains."  We have leveled off in our utilization for the past 6 months.  Our typical month yields about 15 calls.  Our transfer to the ICU holds between 40-50%.  This is in part due to the fact we have no step down beds. 

Our overal hospital mortality has not changed, but our DNR status deaths remain in this number.  Since the initiation of our rapid response team, we have seen numerous patients converted to DNR status rather than all measures being done and the family later having to make the decision to withdraw care. 

We have dropped our codes per 1000 patient average from last year from 11.8 to 7.42.

We are currently seeing a decrease in our non ICU codes from 62 in 2007 to 52 in 2008.

Mentor designation  - 2/6/07
Information updated - 10/1/09

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McLeod Regional Medical Center – Florence, SC
Availability Status: Unavailable to answer requests
Licensed Beds: 371
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: June 2004
Mentor Contact Name:
Mentor Contact Email:
Mentor Contact Phone:

Additional Information:

The Rapid Response Team had a successful four month pilot.  The Rapid Response Team successfully expanded out to cover the adult population using the four adult ICU's and Respiratory Therapy as the responding team.  The Rapid Response team has received overwhelming support from the physicians.  McLeod was featured in the Best Hospitals Issue of US News and World Report and in USA Today for its Rapid Response Team.

Since beginning the Rapid Response Team, there have been 489 calls. Since October 2005 the Rapid Response Team has responded to 130 calls, with 82% of those patients able to remain on the nursing unit after intervention.  McLeod has seen a 34% decrease in the number of Cardiac Arrest outside the ICU when comparing the periods of February 2004 through December 2004 and the period of  February 2005 through December 2005.

[2/14/06]

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Miller Children's Hospital – Long Beach, CA
[Pediatric Mentor]

Availability Status: Available to answer requests
Licensed Beds: 281
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: November 2005
Mentor Contact Name: Mihai Marinescu
Mentor Contact Email: mmarinescu@memorialcare.org
Mentor Contact Phone: 562-933-1908

Additional Information:

• We have strong support from our Pediatric Intensive Care physicians who are in house 24 hours a day, 7 days a week. 
• The hospital administration has made the AHA Pediatric Advanced Life Support required for all RNs in Pediatrics.  This education has increased the confidence of the staff on Rapid Cardiopulmonary Assessment and when to call for early intervention. 
• We developed a pocket-size card for all staff on when to call for the Rapid Response which includes signs and symptoms of Respiratory distress, shock, acute changes as well as abnormal vital signs. 
• We also developed signage at each phone on how to activate the team and the exact location of the patient in need.

During November '05 and April '06 there were 89 cases that required transfer to PICU as a result of RRT activation – 2 patients expired.  There were 3,324 discharges during that same period with a total of 13,982 bed days. 

Measures:
# of codes outside ICU between November 2005 and April 2006 = 0
RRT Activation per 1000 inpatient discharges = 26.8
RRT Activation per 1000 patient days = 6.4
Survival of RRT patients to discharge = 97.8%

[6/2/06]

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Mission Hospitals – Asheville, NC
Availability Status: Available to answer requests
Licensed Beds: 800
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: December 2005
Mentor Contact Name: Stuart Scott, RN, Coordinator of Rapid Response Team
Mentor Contact Email: stuart.scott@msj.org
Mentor Contact Phone: 828-213-4307; 828-207-2229

Additional Information:

Mission Hospitals Rapid Response Team is participating in the NC Rapid Response Team Collaborative project.  The Rapid Response Team was implemented on the St. Joseph Campus November 2005.  A second team for the Memorial Campus began in May 2006.  During this time, St. Joseph had 703 calls and performed 5,804 follow-up visits.  Memorial Campus answered 418 calls and performed 3,606 visits.

Nursing, physicians and respiratory staff have embraced the program.  In the near future, plans are to prepare the teams to integrate referral calls from families as well as patients.

Overall, code blue calls outside the ICUs have decreased by 32.5%.

The Rapid Response Team has received 50% of its calls from day shift and 50% from night shift.  Utilization of RRT each day is similar as well.  The statistics are as follows: 14% of total calls occurred on Sunday, Monday, Wednesday, Friday and Saturday.  Thirteen percent of total calls occurred on Thursday and 17% on Tuesday. 

The Team’s majority of evaluations in response to calls lasted between 16-30 minutes at approximately 29% of the time.  Twenty two percent of the calls had evaluations by the team lasting from 1 - 2 hours. 

The greatest accomplish of the RRT is the patient disposition with 75% of patients being able to remain on the unit without having to transfer to ICU.  Seventeen percent of patients did transfer to ICU and 6% of patients transferred to a progressive care unit. 

Of the staff that has been randomly surveyed each month since May 2006, 100% would call again and felt that the Rapid Response Team treated them with respect.  Of these respondents, 99% agreed the experience with the RRT was a great learning opportunity and felt that the communication with the RRT was professional. 

Follow-up visits are defined as patients who are followed by the Rapid Response Team that leave the ICUs and transfer to step-down or regular nursing units.  These are initiated not by a call from the staff but rather as a transfer notice of a patient out of ICU. 

One particular unit has excelled in the utilization of the Rapid Response Team and their resulting numbers reflect the positive interaction.  The unit is 9 Step Down - a medical/cardiac unit - on the St. Joseph Campus.  This incredible unit has the next to highest RRT utilization rate in the hospital, rendered 128 calls to the RRT in 7 months and have seen a 75% decrease in code blue calls when measured at the same time frame as last year.  The Mortality Rate for the entire hospital has decreased from 2.4% to 2.0% in the last seven months.

[3/13/07]

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Monongalia General Hospital – Morgantown, WV
Availability Status: Available to answer requests
Licensed Beds: 207
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: March 2006
Mentor Contact Name: Camille Western, RN, Patient Safety Coordinator
Mentor Contact Email: westernc@monhealthsys.org
Mentor Contact Phone: 304-598-1388

Additional Information:

The Monongalia General Hospital Rapid Response Team chose criteria based on actual symptoms identified in chart reviews of patients with cardiac and respiratory arrests.  One criteria used is the family is concerned about the patient.  Patients and families are educated on this through the patient handbook, posters, and education by staff.  When families verbalize concerns to a nurse, the nurse calls the Rapid Response Team.  We feel this involves our families in actively promoting patient safety.

Thorough education is done to encourage calls to the team for any one symptom of a deteriorating patient.  Separate education plan was developed for the team members who respond to the Rapid Response calls.

No additional FTE's are used to staff the Rapid Response Team.  Rapid Response Team members include ICU nurse, CCU nurse, respiratory therapist, house supervisor, and the primary nurse for the patient.  The average time spent per call is 30 minutes.

The physicians in our hospital embrace the team and will initiate calls for a deteriorating patient.

During the first year, we had 48 calls to the Rapid Response Team.  Most frequent reason for calls has been respiratory symptoms and the second most common reason has been a change in level of consciousness.

51% of the calls resulted in the patient being moved to a higher level of care. 

Survival rate to discharge for patients was 92%.

We have noted a decrease in Code Blues outside the ICU  by 15% and have noted increased survival rate of the Code Blue from <40% prior to RRT and now >50% survival to discharge. 

Without intervention, all team members felt 100% of the RRT calls would have resulted in Code Blues.

[6/26/07]

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Mountain View Hospital District – Madras, OR
Availability Status: Available to answer requests
Licensed Beds: 25
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: July 2006
Mentor Contact Name: Suzi Bean, RN, BSN, Director of Quality Management
Mentor Contact Email: sbean@mvhd.org
Mentor Contact Phone: 541-460-4051

Additional Information:

The Mountain View Hospital District Rapid Response Team is made up of the House Supervisor, ED physician and Respiratory Therapist.  No FTEs were added.

Top five factors contributing to our success: 

1)  We educated the Rapid Response Team members extensively on a kind, gentle teaching approach.  We knew if staff felt criticized, word would travel fast in our small facility and it would not work.
2)  We don't page the team overhead; we only notify those we need by phone or pager.  On several occasions when we couldn't find team members, we paged overhead and everyone who would respond to a code did.  This intimidated the nurses and they have asked that we do not page overhead because they just want the Rapid Response Team. 
3)  Physician support from the most vocal and most critical.
4)  A willingness and a method to get feedback about the team and to change things that weren't working well.
5)  Proven results and celebrations for the initial few activations to make it a positive rewarding experience for all.

Because we are a small hospital, we put our teams in place hospital-wide and this was successful.

In 2007, we added the ability of the family to activate the team.  This is somewhat informal.  The nurse educates the family of the option and there is also printed information in the patient handbook.  Our staff and physicians were somewhat reluctant to adopt this because they were concerned that this resource might be used inappropriately. 

We have had two families activate the team and all parties were satisfied with the result.  In both instances, the family had voiced concerns to the nurse, but were not satisfied with the result of measures taken.  The nurse reminded them of the option to activate the Rapid Response Team and they chose to do so.  In both cases, there were issues that needed further attention, in one case a transfer to higher level of care. 

SBAR communication tool initially adopted for Rapid Response Team is now being used as the primary communication tool between physician and nursing staff in the family birthing suites and for communicating with receiving physicians for inter-hospital transfers.

Utilization of the Rapid Response Teams was 3 in the first 6 months of the program.  Our activation rate is now an average of 15 activations per year.

Codes per 1000 discharges in 2005 prior to the program was 5.1.  This dropped to 0.7/1000 the first year we instituted our Rapid Response Teams and codes per 1000 discharges in 2009 were 1.6.  In the past 6 months we have had 0 codes. (We average about 100 discharges per month.)

Mountain View hospital was able to roll out Rapid Response Teams very quickly, with great physician and staff support and with phenomenal results.

The Rapid Response Team initiative has brought additional positive outcomes important for nursing staff recruitment and retention: Nurses feel empowered, there is a heightened awareness for early intervention and an enhanced emphasis on shared learning.

Our new staff especially appreciate the ability to activate the team and get help.  We get feedback from the nursing staff about the security and support they feel they have.  Our family practice physicians, who sometimes can't get to the hospital right away, are also very appreciative of the Rapid Response Team, and it's not uncommon for them to suggest its use when they get a concerned call from a nurse and they are not in the immediate area.

Mentor designation - 8/16/07
Information updated - 3/4/10

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The Nebraska Medical Center – Omaha, NE
[Adult & Pediatric Mentor]

Availability Status: Available to answer requests
Licensed Beds: 548
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: August 2004
Mentor Contact Name: Angela Anderson, Critical Care Clinical Quality Coordinator
Mentor Contact Email: ananderson@nebraskamed.com
Mentor Contact Phone: 402-559-4768

Additional Information:

Initially implemented a Medical Emergency Team (MET) in August 2004.  Observed low utilization and lack of knowledge about program benefits as it relates to patient safety.  In early summer of 2005, participated in UHC Commit to ACTion for RRT and, as a result, changed policies and procedures for the Rapid Response Team, changed name of MET to RRT and created mandatory education program for nursing.  Rapid Response Team utilization has incrementally increased since August 2005 and remains consistent.  Nursing staff express increased satisfaction with the availability of this resource. 

The organization is now preparing to implement a Pediatric Rapid Response Team in February 2006.  In January 2010, we added a metric to each inpatient nursing unit's Balanced Score Card to set a specific Rapid Response Team goal each month.  This led to an increase in Rapid Response Team utilization.

Disciplines represented on your Rapid Response Team: ICU Nurse, Respiratory Therapist, Physician, Phlebotomist

No FTEs were added to staff our Rapid Response Team.

Nebraska Medical Center has a separate pediatric team consisting of the PICU lead nurse, the pediatric supervisor and a respiratory therapist.

The team can be initiated for the following:  new or prolonged seizure, symptomatic change in HR, SBP, RR, or SpO2 less than 88%, acute respiratory distress or family or caregiver request.  These reasons are the same as the adult team.  (The adult team, however, has parameters in place around their vital signs and urine output.)  Families cannot independently activate the team; they can, however, request activation through a staff member. 

We collect data on when and on what unit the pediatric Rapid Response Team was called, whether it was called early enough, what the precipitating factors were that led to the call and how long these factors existed, and whether a code blue was called after the Rapid Response Team.

Codes per 1000 discharges remain variable, ranging from 7.0 to 16.4 but with an average of 9.3 codes per 1000 discharges.

Rapid Response Team usage before August 2005: Average of 2 calls per month.
Current Rapid Response Team usage: 50+ calls per month.

Mentor designation - 1/31/06
Information updated - 2/24/10

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North Carolina Children’s Hospital – Chapel Hill, NC
[Pediatric Mentor]

Availability Status: Available to answer requests
Licensed Beds: 136
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: August 2005
Mentor Contact Name: Tina Schade Willis, MD
Mentor Contact Email: twillis@unch.unc.edu
Mentor Contact Phone: 919-966-7495

Additional Information:

Mean calls/1000 discharges increased from 16 to 23/1000 discharges after implementing direct family education and activation in 2007 although only 2 calls per year are activated directly by a family member.

The median days between non-ICU/Emergency Department pediatric cardiac arrests increased from 33 to 95 after implementing the Rapid Response Team in 2005.  This significant decrease in cardiac arrest rate has been sustained since initial implementation in 2005.

The cost of implementing our Pediatric Rapid Response System was minimal.  No FTEs were required for this staffing model.  The cost involves training and education of new personnel, supplies such as posters and flyers for family and staff education, and administrative costs for performance improvement and data collection and monthly reports to staff. 

The success of our Rapid Response System has led to numerous other performance improvement initiatives such as the development of our adult patient rapid response system, team training, pediatric sedation improvement initiatives and family activation of the rapid response system. 

The keys to success include multidisciplinary design and oversight of the rapid response system.  Including physician champions, patient/families and frontline staff input are necessary for success.  Support from hospital leadership must be transparent throughout the institution for this system to reach the highest level of success.

Team composition:  Pediatric Intensive Care Unit (PICU) MD Team Leader, PICU Charge Nurse, Pediatric Respiratory Therapist, Senior Pediatric Resident, and the patient's primary team and family if they are available.  The team is available in-house 24 hours per day, seven days per week.

We launched our Pediatric Rapid Response System (PRRS) after several months of designing calling criteria, activation protocols, and education.  We did not limit the location of the team in a pilot model, but to make continuous improvements over time, we have piloted changes in one unit prior to changing the system hospital-wide.  One example of this was piloting family activation in one unit in Spring of 2007 prior to spreading family activation throughout the other units the following month.

In 2007, we conducted a study implementating formal family education and empowerment in direct activation of the pediatric rapid response team in the same manner that hospital staff activate the team.  This was completed with multidisciplinary oversight including family members of patients in our institution and patient safety advocates.  The family activation system has existed throughout all pediatric acute care units since 2007 and is provided for all English and non-English speaking families through in-person verbal and written materials at the time of admission.  We complete monthly in-person interviews with families throughout the acute care units to measure and track understanding of the pediatric rapid response system and improvement needs in our family education system. 

Since implementation of family activation, our rapid response activations have increased  from 16 to 23 calls/1000 discharges although direct family activation accounts for only approximately 2 total calls per year.  This increase in calls by staff members may be due to increased comfort in calling and culture of safety now that family members and patients are empowered to activate the team.  Overall, 5% of all calls include "family concern" listed as an indication for activation.  Since initial implementation of the system in 2005, the significant decrease in cardiac arrest rate has been sustained.

Read the North Carolina Children's Hospital profile in the 2008 IHI Annual Progress Report.

Mentor designation - 3/30/06
Information updated - 10/1/09

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North Country Regional Hospital – Bemidji, MN
Availability Status: Available to answer requests
Licensed Beds: 117
Teaching / Non-Teaching Status: Non-teaching
Setting: Rural
Start Date of Intervention Work: April 2005
Mentor Contact Name: Nancy Mickelberg, RN, Director of ICU
Mentor Contact Email: nmickelberg@nchs.com
Mentor Contact Phone: 218-333-5693

Additional Information:

North Country Regional Hospital successfully rolled this intervention out with tremendous buy in from both staff and physicians.

It has been a win-win initiative for staff, physicians and most important our patients.

Besides rescuing patients in a timely manner, before they are able to deteriorate and code, we are looking at trends in where and when the rapid responses are called and for what diagnoses and using the information in our ongoing nursing education and core competencies.

We have had 46 rapid responses since the formal inception of the rapid response team.

In that same amount of time we've only had two codes on non ICU, non outpatients.

[1/31/06]

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Onslow Memorial Hospital – Jacksonville, NC
Availability Status: Available to answer requests
Staffed Beds: 162
Teaching / Non-Teaching Status: Non-teaching
Setting: Rural
Start Date of Intervention Work: December 2005
Mentor Contact Name: Jo Malfitano MSN, MBA, RN, CPHQ, NE-BC, Performance Improvement & Accreditation Manager
Mentor Contact Email: jo.malfitano@onslow.org
Mentor Contact Phone: 910-577-2549

Additional Information:

The Onslow Memorial Rapid Response Team is initiated by the primary care nurse for any acute changes in patient condition and consists of an ICU nurse and Respiratory therapist (when needed).

Patients and families do not formally access the Rapid Response Team staff.  They are, however, empowered to contact any hospital employee to address needs.

We have not added additional FTEs for our Rapid Response Team.  We now have an ASCOM phone/pager system that has improved communications.  We have included the MICU staff as a back up for the Rapid Response Team.

Lessons learned:

Adapting to change in processes can be difficult for some and, if concerns are not addressed early and sufficiently, the new process may not be effective or lead to the desired results.

Make the implementation of the Rapid Response Team as simple as possible.  The more steps a nurse has to go through to initiate the Rapid Response Team, the less likely s/he is to use this resource.

Compiling data from the primary care nurse’s point of view enables the Rapid Response Team to identify areas of the process for improvement.

Using common terminology such as the word “rapid” may at times lead to miscommunications and misunderstandings of the team and its purpose.  This word becomes a trigger and can be mistaken for the Rapid Response Team.

The responsiveness of the process and timely intervention provided demonstrated effectiveness in patient outcomes such that, during the month of December 2009, 69% of rapid response patients were able to remain in there current room and not require transfer to higher level of care (IMCU or ICU).

The Onslow Memorial Hospital Rapid Response Team has effectively reduced the number of Code Alerts outside of our Emergency Department and ICU by 54% since December 2005.  As a result of increased calls per month, Onslow Memorial Hospital experienced only eight codes outside of the ED and ICU during 2007.  On average in 2007, 50% of the patients were able to remain in their room following a Rapid Response intervention. Patient outcomes have also improved, avoiding prolonged hospital stays and associated increased costs.

The data for 2009 remains consistent with the prior year with a reduction in codes outside the ED and ICU at or above 50% from the initiation of the program.  We have been able to sustain the successes and have an embedded process that has demonstrated effective patient care quality outcomes.

Staff satisfaction:  Staff who utilize the Rapid Response Team feel more comfortable  knowing that, if they have the slightest feeling of uncertainty regarding a patient's condition they, can call the team without hesitation.  The Rapid Response Team feel empowered to be a part of the team and to exercise their resourcefulness and their expertise.

Mentor designation - 8/15/08
Information updated - 3/15/10

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Oregon Health and Science University – Portland, OR
Availability Status: Available to answer requests
Licensed Beds: 509
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: June 2005
Mentor Contact Name: Kitling Lum, RN
Mentor Contact Email: lumk@ohsu.edu
Mentor Contact Phone: 503-494-8579

Additional Information:

Our champions for this initiative are the two Division Directors from the ED/Neuro ICU and Respiratory Therapy Department and our physician champion is a CSICU intensivist.  With their guidance, skill, and vision, this program was introduced and embraced by senior leadership.

Our Rapid Response Team was implemented in June of 2005.  The team consists of one CSICU RN, one Respiratory Therapist, and the primary service; the MICU fellow is called when physician back-up is needed.  Initially, a core team of ICU staff nurses agreed to respond to the RRT calls, be the code 99 responder and take a patient assignment.  However, it was soon realized that the calls were increasing as was the time allocated to the calls and the decision was made that the RRT nurse would not take a patient assignment.

We have just implemented a process for follow-up on each patient discharged from the ICU and the RRT nurse is conducting those follow-ups.  The staff also does follow-up within 12 hours of each RRT call.

Staff interested in applying for an RRT position on the team must submit a request to the nurse manager and meet certain criteria, such as excellent communication skills, a desire to be on the team and good clinical decision-making.
 
Education of hospital staff consisted of a pre-implementation survey, posters throughout the hospital, and education to leadership and management about the goals of RRT and the IHI initiatives.  Prior to implementation, members of the team visited staff in clinics, nursing units and other hospital areas to introduce themselves, inform staff about the team and its purpose and how to access them.  Telephone stickers were made with the access number and provided to all areas of the hospital.  We have also developed cards for ID badges that outline the criteria for when to call the RRT, with our motto being "if you are concerned, so are we."  Since implementation, the team has been invited to many nursing staff meetings, and physician teams meetings.

A one-year follow-up survey will be sent to all staff and responses will be compared to our first survey.  If changes or improvements are needed, we will implement those knowing we are working as a team with all members of the hospital.

The team has responded to 340 calls since implementation of RRT in June 2005.
As of June 2006, codes per 1000 patient discharge days are 1.2 compared to 1.6 one year ago.  When comparing Jan-June 2005 to the same period this year, codes outside of the ICU have decreased from 27 to 20 respectively.  48% of calls result in transfer a higher level of care and 35% of patients remain in room.

The monthly number of RRT calls has increased steadily over time.  Last year, the average number of calls per month was 24 compared to 32 calls calls per month this year.

[10/28/06]

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Our Lady of Lourdes Memorial Hospital – Binghamton, NY
Availability Status: Available to answer requests
Licensed Beds: 267
Teaching / Non-Teaching Status: Non-teaching
Setting: Rural
Start Date of Intervention Work: October 2004
Mentor Contact Name: Susan Fuchs, RN Director of ICU
Mentor Contact Email: sfuchs@lourdes.com
Mentor Contact Phone: 607-798-5420

Additional Information:

We call our RRT the Medical Emergency Team (MET).  We began testing MET and the SBAR communication technique on the night shift for approximately 4 weeks.  Other shifts began to request MET, therefore we spread to all 3 shifts.  We are a community hospital, we do not have house staff or intensivists.  Our team consists of an ICU RN and RT.  The program has been very successful. Staff education is ongoing and does occur with each call.  The MET mentors the primary RN during the call. We have seen an increase in the number of MET calls.  The feedback from staff and patients/families has been very positive.

Over the past calendar year, January through December 2005:

We had an average of 13 MET calls per month.  We continue to see an increase in the number of MET calls each month.

Our average response time is 3.4 minutes.  Our goal is 10 minutes.

Our average time spent on a MET call is 20 minutes.  Our goal is 30 minutes.

[1/31/06]

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Parkview Hospital – Fort Wayne, IN
Availability Status: Available to answer requests
Licensed Beds: 694
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: October 2005
Mentor Contact Name: Katie Reader
Mentor Contact Email: katie.reader@parkview.com
Mentor Contact Phone: 260-373-3270

Additional Information:

Parkview Hospital initiated its Rapid Response Team in October 2005.  Blending a successful "Stat Nurse" program with the technology of eICU, the RRT brings a critical care experienced nurse (stat nurse), the intensivist, by way of a robot, and respiratory therapy to the patient's bedside.  The bedside nurse is in immediate communication with the intensivist with the first call.  This process allows immediate action in way of physician orders, treatments, transfer if neccassary.  The attending physician is paged at the same time the RRT call is made.  The attending physician then works with the intensivist or assumes care of the patient situation.

Since October of 2005, RRT as expanded to all hospitals in the Parkview Health System.  There is support by eICU intensivist and a robot at all but one location at this time.  The ability to have a physician as a member of the RRT most definitely has made an impact on patient outcomes.

187 RRT calls system wide 10/05 - 7/06
Codes outside the ICU: Decreased from 42% prior to RRT to less than 25% 7/06
Codes per 1000 discharges; Decreased from 10.2 to 7.3 in 7/06

Evaluation of process and RRT by bedside nurses is outstanding.  The staff views this process as effective to improve patient outcomes, supportive to all nurses, especially new nurses.

[10/28/06]

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Ridgeview Medical Center – Waconia, MN
Availability Status: Available to answer requests
Licensed Beds: 129
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: March 2005
Mentor Contact Name: Melissa Pitts
Mentor Contact Email: melissa.pitts@ridgeviewmedical.org
Mentor Contact Phone: 952-442-2191 ext. 5142

Additional Information:

Ridgeview had an informal resource team prior to the launch of the 100K campaign.  A formal, structured process for a rapid response team was implemented in May of 2005.  The team consists of a critical care nurse and a respiratory care practioner.  There has been steady growth in the utilization of the team from the medical and surgical nursing units.  The rapid response team has overwhelming support from its customers and a high level of satisfaction among the team members.

Overall Ridgeview mortality has decreased.  Since July 2005, only one code has occurred outside of the critical care unit.

[2/14/06]

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River's Edge Hospital & Clinic – St. Peter, MN
Availability Status: Available to answer requests
Licensed Beds: 22
Teaching / Non-Teaching Status: Non-teaching
Setting: Rural
Start Date of Intervention Work: March 2005
Mentor Contact Name: Benjamin W. Chaska, M.D., MBA, CPE, FACPE, Chief Medical Officer and Patient Safety Officer
Mentor Contact Email: bchaska@riversedgehealth.org
Mentor Contact Phone: 507-934-8416

Additional Information:

Adaptation: Recognize, Respond and Treat- Prompt recognition of a decline in patient condition to decrease patient transfers to a higher level of care.

Actions Taken:
• Changes in patient status are rapidly identified and reported to physician.
• Form developed to aid in information gathering prior to calling physician.

Results: Reduced transfers, increased revenues and reduced inpatient mortality rate.

Disciplines represented on our Rapid Response Team: Physicians, nurses, managers, pharmacy, information systems, CFO, CEO, CMO, patient safety officer, and the director of nursing

No FTEs were added to staff our Rapid Response Team.

We used rapid cycle introduction and put the process in place over a few months.

Average savings per transfer was $6210.

Reduced rolling six month inpatient med-surg mortality rate from 26/1000 admissions to 4 to 8/1000 admissions.  This was a reduction in mortality by 70% to 85%.

There have been no codes on the med surg unit or unanticipated deaths since 2006.

Mentor designation - 1/31/06
Information updated - 2/22/10

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Sacred Heart Medical Center – Spokane, WA
Availability Status: Available to answer requests
Licensed Beds: 623
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: January 2006
Mentor Contact Name: Denise Dominik
Mentor Contact Email: dominid@shmc.org
Mentor Contact Phone: 509-474-3733

Additional Information:

SHMC has rolled out our adult rapid response team with great results.  Within the first 30 days of go live we have 86 activations (we have approximately 500 adult beds) and 28 of those patients were transferred to a higher level of care.  Our rate of codes has dropped outside the ICUs and staff satisfaction with the team is very high.  The team rounds on ICU transfer patients and post activation patients as well as attends codes to identify if a patient should have had an activation eariler.

There were 16 lives saved within that first month.  We reduced rate of codes from 11.3 to 6 per 1000 discharges.  Improved nursing satisfaction is noted by follow-up surveys with 80% return rate.

In March 2006, we saw 108 RRT activations with 31 transfers to higher level of care and our codes outside the ICU went from 7.3 codes per 1000 discharges in February 2005 to 2.5 codes per 1000 discharges in February 2006.  We saved an additional 31 lives in the month of March.  Our staff evaluations on the team continue to be overwhelmingly positive. 

[4/27/06]

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St. Catherine of Siena Medical Center – Smithtown, NY
Availability Status: Available to answer requests
Licensed Beds: 311
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: December 2005
Mentor Contact Name: Patricia Butera, Clinical Nurse Educator
Mentor Contact Email: Patricia.Butera@chsli.org
Mentor Contact Phone: 631-862-3699

Additional Information:

We have created a Rapid Response team consisting of an ICU or CCU nurse, Respiratory Therapist, Hospitalist or Nurse Practitioner and Nursing Supervisor.  The team may be called any time a nurse requires immediate attention for his/her patient.  The patient is assessed and because there is a hospitalist or NP on the team, immediate treatment begun.  The patient may remain in their room or moved to the critical care unit following the team call.  There has been an overwhelmingly positive response in our non-teaching hospital from the attending physicians, experienced nursing staff as well as the new graduate nurses and has proven to be a significant retention strategy for our nursing staff.

We have had 32 RRT calls throughout the facility in the first quarter of 2006 with the following outcomes:

• 63% reduction in cardiopulmonary emergencies (CE) outside the critical care units
• 48% reduction in emergency intubations outside the critical care units
• 88% of patients discharged home or to skilled nursing facility 
• Tremendous increase in nursing and physician satisfaction related to the ability to expedite care to their patients by calling an RRT
• Improved communication to attending physician regarding patient's status

[3/30/06]

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St. Joseph Hospital – Cheektowaga, NY
Availability Status: Available to answer requests
Licensed Beds: 207
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: November 2004
Mentor Contact Name: Denise Bartosz
Mentor Contact Email: db4071@chsbuffalo.org
Mentor Contact Phone: 716-891-2683

Additional Information:

This is probably the first initiative that the medical staff, nursing staff and ancillary staff have all given very positive feedback.  Our implementation team took a lot of time developing the program and did a number of small tests of change.  It was important to us that the first few times the RRT was called that all went well.  We had planned a one month trial on 2 floors for the evening shift.  The first two calls went so well that full nursing floor roll-out took place just one week after the first call.  Within one month, all nursing floors and ancillary departments (radiology, cardiology, physical therapy, interventional radiology, GI lab, sleep lab) were educated and able to call the RRT.

RRT Call per 1000 Discharges:
Nov - Mar the rate of calls per 1000 discharges is 17.

Codes per 1000 discharges:
Jan - Oct 2005  rate was 8.81
Nov 2005 - Mar 2006 rate is 7.81

[5/12/06]

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St. Joseph Hospital – Orange, CA
Availability Status: Available to answer requests
Licensed Beds: 522
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: May 2004
Mentor Contact Name: Carmen Ferrell & Soudi Bogert
Mentor Contact Email: carmen.ferrell@stjoe.org or soudi.bogert@stjoe.org
Mentor Contact Phone: 714-771-8000 ext. 28382 or 28389

Additional Information:

Utilizing principles of reliability which include rapid cycle testing, staff engagement and fostering a culture of safety, we were able to contribute to the benefit and welfare of patients and attain a return on investment for the hospital.

The Rapid Response process where expert consultation by a Critical Care Nurse and Respiratory Therapist occurs when the call is placed by the medical/surgical nurse, assisted in improving collaboration and communication amongst caregivers with a patient who is clinically deteriorating on the medical surgical unit.  These interactions have increased staff satisfaction with MET responders.

We evolved the concept of MET team into other services like the Behavioral Emergency Response Team (BERT), the Post-partum, Antepartum Response Team (PART), and the Emergency Response Team (ERT).  All of these teams function within the same principles as the MET and respond to specific emergencies which serve both the patients and the staff with resources needed immediately.

In May 2007, we evolved the MET team into a family-activated team "Condition H."  We trialed it on a Med/Surg floor to develop the education to staff and patients effectively.  To date, we have had 37 family-activated calls.  Patients and their families report that this team is one of the best aspects of care offered at this hospital and they not only come back to this hospital, but will refer others because of their experience with this team.

We have evolved the team to a proactive Rapid Response team (August 2008) where a dedicated RN is available 24/7.  The proactive team assesses all patients within the hospital for potential deterioration and proactively intervenes when appropriate.  This team now responds to Code STEMI, Code Stroke, Code Sepsis as leads of these processes and to treat and place the patient appropriately.

Disciplines represented on our Rapid Response Team:
MET RN and Respiratory Therapist.  Intensivist gets called in when needed.

FTEs added to staff your Rapid Response Team: 4.2 FTEs in Critical Care budgets

Piloted the team in Medical Surgical unit for 3 months and, before the pilot was over, other units were calling for the team.  We had good physician champions and staff champions assisting us with this process.

• Added family advisors to our team
• Implementing Early Warning Systems (EWS) trigger tools (January 2007)
• Pilot of Patient/Family-activated MET team calls (March 2007)

Next Steps:
• Determine how to continue to decrease codes outside of the ICU through 1:1 staff education by MET RNs.
• Increase knowledge of health care practitioners (MDs, staff) about having courageous conversations on end-of-life wishes with patients and families and actively documenting these.  Have active family conferences with every single patient/family in critical care within 48 hours of arrival to critical care.

Data on utilization of the Rapid Response Team as of September 2009 (FY = July to June):
(Calls/1000 discharges)  FY 08 = 14.8; FY 09 = 19.17; YTD FY 10 = 62.9

Data on code blues per 1,000 discharges: FY 08 = 6.1; FY 09 = 5.69; YTD FY 10 = 5.49
Over two-year period, decreased codes in the medical/surgical units by 60%

Data on non-ICU code blues:
 FY 08 = 74; FY 09 = 48; FY 10 = 17

• In 2004, approximately, 100% of patients evaluated by the MET team were transferred to the ICU
• In 2005, approximately 75% were transferred to ICU
• In 2006, only 25% of patients who were evaluated by the MET team were transferred to ICU.
• In 2009, only 10% of patients who are evaluated by the MET team are transferred to ICU.

Current data on the financial implications of deploying our Rapid Response Team:
We have a cost savings to the hospital of $2,740,500 since inception.

We have published data describing the increase in staff satisfaction by having a Rapid Response Team on board.  Increase in retention with turnover rates in nursing at 7%; national benchmark = 10%. 

We have spread this concept to 13 additional hospitals within our health system, and 7 community hospitals in Southern California.  We have assisted hospitals throughout the nation that have inquired about our team from the state of Washington, Georgia, and Texas as well as Canada.

Reduction of mortality from 19% (1st QTR 04) to 11% (2nd QTR 06).
Raw mortality non-risk adjusted FY 08 = 1.55%; FY 09 = 1.43%; YTD FY 10 = 1.34%
Mortality Ratio  FY 08 = 0.83 ; FY 09 = 0.72 ; YTD FY 10 = 0.64
Code Blues Outside ICU / MET calls / Condition H 
FY 08 = 74 / 404 / 9; FY 09 = 48 / 368 / 23; YTD FY 10 = 17 / 584 / 5

Mentor designation - 3/30/07
Information updated - 3/3/10

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St. Joseph's Mercy Health Center – Hot Springs, AR
Availability Status: Available to answer requests
Licensed Beds: 296
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: August 2006
Mentor Contact Name: Lynn Pellegrino, RN, MSN, APRN-BC
Mentor Contact Email: lpellegrino@htsp.mercy.net
Mentor Contact Phone: 501-622-1840

Additional Information:

The Rapid Response Team was piloted on one unit that has a high volume of medical surgical patients in July 06 and was implemented house-wide in August 06.  The team consists of an ICU nurse, respiratory therapist, and the nursing house supervisor.  Initially, we had to work out the process for contacting the team.  We now use the overhead paging system and this works well.  The team has been well received by the medical and clinical staff.

No FTEs were added.  St. Joseph's utilizes our ICU nurses, respiratory staff and hospitalists for our Rapid Response Team.

We are currently developing a pilot to implement a protocol for families to activate the Rapid Response Team.

Our patient satisfaction data has demonstrated that families are very pleased with the Rapid Response Team.

Since the initiation of the Rapid Response Team, the number of calls to the team has ranged from 4 - 18 per month. For calender year 2009, the average number of calls per month was 9.  The team continues to be well received by staff, physicians and families.

Overall the number of codes had decreased 50% from a total of 8 per month to an average of 3 per month since implementation of the Rapid Response Team within and outside the ICU.  Rapid Response Team calls are made primarily from the surgical, cardiac step down and specialized medical units.  Primary reasons for calling the Rapid Response Team continue to be 02 saturation less than 90%, staff concerns regarding patients symptoms and a change in mental status. Roughly 60% of the patients remain on the medical units after interventions.  ABGs, EKGs, O2 and blood/sugar draws are performed by the team.

Staff satisfaction has increased with the implementation of the Rapid Response Team because they have immediate access to assistance when they are concerned about a change in status of their patients.  As an organization that places a strong emphasis on safety practices, this team has been instrumental in stabilizing, assessing patients and providing immediate feedback to the physician before a crisis develops.

Mentor designation - 3/13/07
Information updated - 3/3/10

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St. Luke’s Hospital – Cedar Rapids, IA
Availability Status: Available to answer requests
Licensed Beds: 560
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: February 2005
Mentor Contact Name: Peg Bradke
Mentor Contact Email: BradkeMM@crstlukes.com
Mentor Contact Phone: 319-369-7269

Additional Information:

Keys to the success of our team:

• Commited staff that practice through simulation training.  Important part of success is building relationship among the team members.  
• Rapid Response Team metrics and cases are reviewed each month by Code Blue/Rapid Response Team oversight team for improvement opportunities.  
• Educational cases are presented at peer review shared governance meetings.
• Phased in quickly with excellent results and cases to share for educational purposes. 
• Shared patient/family experience to improve process.  Family involvement is encouraged. 
• Unit nurses and families report greater confidence regarding care of the patient with changing conditions and with transfers.
• Rapid Response Team enjoys the opportunity to educate/mentor while on the call.

No FTEs were added to staff our Rapid Response Team.

Piloted for 6 months on three units then proceeded to hospital wide.

Family activation:  We describe our team in a letter in admission packets, signs posted in patient rooms and information given during admission process.  Families are encouraged to be part of the team and the informational letter encourages them to use a number to access the team.  We have not had a family call the number directly, but have had them ask the nurse to call the MET team. 

After long term complex patient transfer out of critical care, the Rapid Response Team makes a visit 2 times during the next 2 days to check in on patient and family and assure transition/handoff is perceived as positive.

2009 Data:
• St. Luke’s non-Critical Care codes went down from 24% in 05 to 13% in 09
• 129 calls in first year, current year calls 239
• 26% treated and remain on the unit
• 74% transferred to higher level of care
• Average time team spends on the call is 22 minutes
• Transfer times to critical care, if needed, have been reduced 35%
• Code blue rate per 1,000 discharges was only 0.69, which is significantly lower than that reported nationally
• Average only 50 codes per year for entire hospital
• 26% of unplanned transfer to Critical Care are Rapid Response Team calls, this is a metric that is measured every month and shared with each individual unit to encourage their own evaluation of the Rapid Response Team to improve their processes

Mentor designation - 8/31/06
Information upated - 3/10/10

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St. Mary Medical Center – Apple Valley, CA
[Adult & Pediatric Mentor]

Availability Status: Available to answer requests
Licensed Beds: 186
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: October 2005
Mentor Contact Name: John Brady & Donna Grant
Mentor Contact Email: john.brady@stjoe.org; donna.grant@stjoe.org
Mentor Contact Phone: 760-242-2311 ext. 5146 & 5525

Additional Information:

2005  6 calls per month average
2006  8 calls per month
2007  9 calls per month
2008  19 calls per month
2009  16 calls per month
2010  69 calls in January 2010 year to date (trialing a proactive RRT nurse)

2005  10.4 codes per 1,000 discharge
2006  6.4 codes per 1,000 discharge
2007  4.25 codes per 1,000 discharge
2008  3.9  codes per 1,000 discharge
2009  4.6 codes per 1,000 discharge
 
Data on non-ICU code blues:
(raw number of out of unit codes)
2005  49 codes
2006  33 codes
2007  18 codes
2008  27 codes
2009  21 codes

Our raw mortality has dropped 34% in 3 years
2005 1.8 Baseline raw mortality
2006 1.5
2007 1.3
2008 1.2
2009 1.2

Our observed to expected mortality ratio (O/E) is .63 currently. (Anything under 1.00 is lower than expected, above 1.00 is higher than expected.)
 
Our Hospital Standardized Mortality Ratio (HSMR) is 50.4 for first half 2008.  The average US hospital is 70.5.  The lower the score the lower the mortality.

Keys to success:

Our key to success is the recognition of call triggers by the frontline staff and was the chief process change.

The team developed emergency RRT orders (standardized procedures) enabling them to be able to address emergent needs.  These orders also are used when visitors or employees fall ill on campus (CMS 250 yard rule). 

Another important element is call data analysis & continuous process improvement (key driver).   

The adult team is composed of an ICU Team Leader/ or Staff Nurse, Administrative Coordinators serve as back-up, and a Respiratory Therapist.

The pediatric team: There is a dedicated Pals Certified ED RN and a Respiratory Therapist. Security and Spiritual Care Services along with Primary RN & Team Leader of the patients unit are also members of team.  An Emergency Department Physician Champion is the team's medical advisor.

No additional FTEs were allocated.  One of our sister ministries, Mission Hospital won the Codman Award in 2008 for their work in proactive rounding and focusing on sepsis patients.  The St. Joseph Health System may decide to spread this to other ministries as a system wide initiative.  

We initially piloted the RRT on one unit which was a medical surgical floor.  We piloted for three months then spread unit by unit untill global.

St. Mary Medical Center (SMMC) has analyzed our Rapid Response Team data and identified many process improvement activities including:

Discovered an increase in RRT calls with opiate naive patients requiring the use of reversal agents following a new pain program. (Provided both medical and nursing re-education & implemented PI tracking.)

Temporary staff not aware of Rapid Response Team program. (Provided re-education for temp staff and worked with their agency.)

Hypoxic late call trends and failure to rescue. (Enforced need to call entire Rapid Response Team when oxygen sats fall below 90%.)

Review all out-of-unit calls for potential missed triggers. (Provided re-education.)

Backsliding staff calling for a casual consult rather then call entire Rapid Response Team. (Provided re-education.)

Identify potential failures to communicate. (Examples reported to nursing and medicine committees).

Identify failures to rescue. (Staff documented triggers but failed to act, share the stories, use Just Culture ask What and Why)

Identify failures to plan. (Report all calls to Rapid Response Team within 24 hours of admission that require transfer to ICU; report to Critical Care Committee.)

Perform annual mortality review using IHI tools for 2X2 matrix.

ICU nurses/RRT members are using sepsis screening tools for early detection of sepsis.  We started a formalized sepsis team in 2008 and are using the IHI sepsis bundles.

Condition H or patients and families may call for (HELP) began January 1, 2009.

Our pro-active RRT rounding program is enhancing our patient and family perceptions of care.

Mentor designation - 2/23/09
Information updated - 2/10/10

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Santa Clara Valley Medical Center – San Jose, CA
Availability Status: Available to answer requests
Licensed Beds: 574
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: January 2006
Mentor Contact Name: Carolyn Brown
Mentor Contact Email: Carolyn.brown@hhs.sccgov.org
Mentor Contact Phone: 408-885-2093

Additional Information:

• RRT is now an accepted and valued component in the management of care when a patient's condition is not stable and a nurse feels that additional support is needed.  A team has been identified and expert responders are available at all hours of the day, 7 days a week.
• Staff and physician education have contributed to our success to date and we have seen that even physicians who do not have a designated role on the team often respond and volunteer their assistance whenever an RRT is paged.
• The interdisciplinary campaign team, led by a physician, responsible for development and implementation of the plan addressed concerns about availability of resources in collaboration with our executive steering committee and continue to be leading the evaluation and ongoing management of the intervention.  Feedback on effectiveness of the strategy has been extremely positive and the number of RRT calls is steadily increasing while codes outside the ICUs are decreasing.  Active participation of physicians, nurses, respiratory therapists, and shift supervisors in creating the plan has built a solid foundation for accountability and ongoing success.
• At our organization-wide Patient Safety Fair, the RRT booth was one of the most popular and interesting and featured a professionally produced, team-created video reenacting an RRT response, a colorful and informative storyboard, giveaways promoting the Rapid Response Team, and opportunities to speak with team members.

• The percentage of Code Blues outside the ICUs has decreased from an average of 48% (range 35% to 60% in the 6 months prior to implementation) to 25% in the first 10 weeks of implementation.
• Total of 82 RRT calls during the first 10 weeks.
• 52% of patients who were seen by the RRT remained in in Med/Surg and did not require transfer to a higher level of care.
• RN satisfaction with RRT in all 10 categories ranged from 4.7 to 5 (on a 5 point scale, 5 being the highest level of satisfaction).
• Physician satisfaction in all 8 categories ranged from 4.7 to 5.

[4/28/06]

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Self Regional Healthcare – Greenwood, SC
Availability Status: Available to answer requests
Licensed Beds: 420
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: September 2005
Mentor Contact Name: John Paguntalan
Mentor Contact Email: jpaguntalan@selfregional.org
Mentor Contact Phone: 864-725-4926

Additional Information:

• Implemented RRT on 40 bed Telemetry Unit in September 2005
• Using IHI and NRCPR tracked results
• Moved pilot to Medical Floor in February 2006
• Presented implementation and results at SC Node Meeting in Feb 2006 to participants
• Asked by two small rural hospitals in our area to mentor in RR  based on preentation at SC Node meeting
• Teleconference presentation to listeners on NRCPR call in April 2006
• Selected as posterboard presenter for MET at national NRCPR conference in June 2006

% of Codes outside CC before RRT implementation 11%
After RRT implementation 5%
Decrease in codes outside CC 54%

[6/2/06]

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Sequoia Hospital – Redwood City, CA
Availability Status: Available to answer requests
Licensed Beds: 421
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: May 2004
Mentor Contact Name: Joanne Jeffords, VP, Mission and Quality
Mentor Contact Email: joanne.jeffords@chw.edu
Mentor Contact Phone: 650-367-5855

Additional Information:

lmplementation came from sharing the Australian MET results with our medical staff and educating nursing staff through 1:1 by the Rapid Response Team leads.  The concept was welcomed based on our prior year's success with the ICU collaborative.  During initial implementation, team leads actively rounded on units to help nursing staff identify potential Rapid Response Team patients.  Early on, we addressed physician and staff concerns about implementation.

Our continued success has come from:
• Daily contacts between staff and Rapid Response Team members.
• Providing timely follow up to staff who utilize Rapid Response Team.
• All calls are handled as important.  We never allow criticism, only learning and support.
• Post our ongoing measures on the units.
• Interdisciplinary team reviews all calls to identify possible areas for improvement.  For example, we identified and implemented a standardized approach to unit placement of patients requiring BI PAP.

For the first 130 cases (5/2004 - 12/2005) the results are as follows:

• 50% of cases stabilized on the unit and did not require transfer to higher level of care.
• 52% of calls required less than 15 minutes of the Rapid Response Team presence and support.
• Of 130 cases, only 2 cases reviewed were believed to be "inappropriate" – staff was encouraged in both cases to use the Rapid Response Team again.

Goal:  Decrease codes in lowest level care units; approximately 30% drop in codes on the medical-surgical unit.

56% of cases have come from day shift (0700 - 1900)

Average 7 - 9 calls month; target is 15

Overall non risk adjusted mortality has shown a positive decline from 2.06% (1st Q CY 2004) to 1.50% (4th Q CY 2005).

[2/28/06]

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Southwestern Vermont Medical Center – Bennington, VT
Availability Status: Available to answer requests
Licensed Beds: 99
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: September 2005
Mentor Contact Name: Alexandra Heintz, Director of Quality and Safety
Mentor Contact Email: AH@phin.org
Mentor Contact Phone: 802-447-5071

Additional Information:

We feel we have had the "function" of rapid response teams built into our hospitalist program since April 2002 when nursing and medical staff agreed that hospitalists could be called for any problem on any inpatient at any time.  We formalized the "rapid response" format in 2005.  Hospitalists were eager to be members of the team.  They worked with the Safety Department and nursing to develop criteria for a Rapid Response call.  Education was done for Med/Surg nurses, Respiratory Therapists and Hospitalists.  Also occuring simulataneously was a mandatory program for all nurses: hand-off communication (SNAP).  A piece of that program is using SNAP in a Rapid Response situation. 

We have a "Condition H" (patient/family-activated) team.  This has been in place for one year at SVMC.  The composition of that team is slightly different than the regular Rapid Response Team.  Our "Condition H" team consists of a hospitalist and the RN designee of the unit where the patient is located.

From 11/08 we had a 6.02 calls/1000 discharges which increased to 21.2 by 5/09.

No codes from 11/08 through 5/09 on Medical/Surgical Units.

Disciplines represented on your Rapid Response Team: Hospitalist and Respiratory Therapists - No FTEs were added.

With each Rapid Response call, staff using the team are given a survey to complete on its effectiveness.  The survey results always indicate positive feedback.

Mentor designation - 2/14/06
Information updated - 10/1/09

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Swedish Medical Center – Seattle, WA
Availability Status: Available to answer requests
Licensed Beds: 697
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: January 2005
Mentor Contact Name: Theresa Bervell
Mentor Contact Email: theresa.bervell@swedish.org
Mentor Contact Phone: 206-386-6724

Additional Information:

The Rapid Response Team (RRT) has been strongly embraced at Swedish Medical Center, with high levels of satisfaction expressed by RRT members, staff contacting RRT, attending physicians, and even patients.

With three campuses (hospitals) comprising Swedish Medical Center, we have learned how to implement RRT in a variety of settings, large and small.

Swedish created a unique educational module for RRT geared toward RRT members which included differentiating between RRT and a "code" team, employing supportive communication techniques, and use of SBAR communication.

Inpatient Mortality at Swedish Medical Center decreased 6% in 2005.

At Swedish Medical Center's largest campus, where the team was implemented in January, codes decreased by more than 25% for the first nine months of 2005 when compared with the same time period in 2004.

[1/31/06]

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Tacoma General/Allenmore Hospital – Tacoma, WA
Availability Status: Available to answer requests
Licensed Beds: 521
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: October 2005
Mentor Contact Name: Tammi Lead
Mentor Contact Email: tammi.lead@multicare.org
Mentor Contact Phone: 253-403-2889

Additional Information:

The Rapid Response improvement team developed order sets, documentation tools, and evaluation forms, which allowed staff to implement selected interventions while physician notification occurred along with recording staff perceptions of process.  Initial months of activity resulted in minor changes to the order set based on newly developed protocols and additions to the team based on staff input. Communication process was also changed with a focus on consistency across the system to increase timely notification of the Rapid Response Team (RRT).

Education was expanded across the system to include support departments such as Social Work and Imaging.  Clinical staff collaborated with the Marketing Department to create a fact sheet for patients and families that has been placed in the waiting rooms of the clinical departments.  Future work will include developing a process for family activation of RRT along with placing educational information in all patient rooms.

Thirty-six Rapid Response Team calls were initiated between October and December 2005.  Sixteen patients transferred to a higher level of care, nineteen stabilized, and one deteriorated into a Code 4 (the occurred within the first two weeks of implementation).
 
The Code 4 occurrence rate has declined from 3.72 per 1000 discharges in 2004 to 2.46 per 1000 discharges in 2005 or improvement of nearly 34%.  In addition, a survey of the staff indicates high satisfaction with the Rapid Response Team process.

[3/30/06]

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Transylvania Community Hospital – Brevard, NC
Availability Status: Available to answer requests
Licensed Beds: 25
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: July 2005
Mentor Contact Name: Scotta L. Orr, RN, BSN, MPH, Director of Quality/Accreditation Services
Mentor Contact Email: sorr@tchospital.org
Mentor Contact Phone: 828-862-6383

Additional Information:

The Transylvania Community Hospital Rapid Response Team is comprised of a respiratory therapist and a critical care nurse on call 24 hours/7 days a week.  The hospitalist and clinical nurse specialist also respond when they are in house. ED staff responds when a CCU nurse cannot leave the unit.  Staff notification of a code occurs using both the overhead paging system and personal pagers.

Initial development and implementation of the Rapid Response Team occurred quickly.  The team is in an ongoing process of development and education to maintain a high level of timely response, standards of care and positive outcomes. Standard protocols for intervention and documentation were developed and approved by the medical staff.

Transylvania Community Hospital’s team was initiated house-wide vs. using a test unit method due to our small size and number of beds.

Education was initially provided and is continually updated for staff in all areas of the hospital so the entire hospital can utilize the program, not just bedside nursing units.  Special attention and education is provided to non-nursing personnel (i.e., radiology, MRI, registration) to call the Rapid Response Team in their specialty areas instead of waiting to send the patient back to their room.

• 100% of response time is less than 5 minutes

• Duration of calls range from 16 -30 minutes

• 78% reduction in code blue calls from 2004 to 2007

• 32% reduction in crude inpatient mortality rate since 2004

Patient Disposition:
• 22% transferred to tertiary referral hospital
• 11% no change in level of care
• 4% patients declined in status to full code
• 67% transferred to ICU

[2/8/08]

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UF & Shands Jacksonville – Jacksonville, FL
Availability Status: Available to answer requests
Licensed Beds: 696
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: January 2006
Mentor Contact Name: Cynthia Gerdik, RN, Division Director Critical Care/Rapid Response
Mentor Contact Email: cynthia.gerdik@jax.ufl.edu
Mentor Contact Phone: 904-244-8460

Additional Information:

Keys to success:

1. SJMC RRT team does not wait for a phone call, as we initially designed ourselves as a critical care outreach program, proactively assessing identified high-risk patient populations.  The dedicated ICU RN rounds at least twice a shift on all nursing units, proactively asking staff if they are worried or concerned about any of their patients.  Units with more non-ICU codes are rounded on at least twice in 12 hours.  The relationship that the staff have built with our Rapid Response Team RNs has also been critical to our success.

2. SJMC RRT team also proactively rounds on new staff and GNs to develop relationships and encourage them to call whenever needed.

3. SLMC RRT team evolved into the first responder team for visitor and employees, responding to approximately 6-8 per month.

4. In October of 2007, patients and families were given the ability to activate the Rapid Response Team.  Since inception, we have averaged less than one call per month. 

5. We encourage all staff to call us.  Surprisingly, clerks calling us to alert the team that the physician is writing STAT orders on a patient.  Many times the clerk is the "air traffic controler" of med-surg units and often know about stat orders before the bedside nurse.

We piloted the Rapid Response Team in the smaller hospital on our campus in January 2006 in the smaller 125-bed campus hospital and expanded to our larger 500-bed campus hospital in July 2007.

In October of 2007, we phased in allowing family members to call for a rapid response and have found this to be a valuable adjunct to helping identify patients at risk for deterioration.

Protocol for a family activating your team:

We educate our patients and families that calling the Rapid Response Team is like calling 911 from home.  We dedicated a single phone extension and have advertised it as 4-CARE 4-2273 or Partners in Care.  All patient room and telephones have the 4-CARE phone extension posted for easy dialing/access.

Family utilization data:

We have had 24 calls in the last 25 months with all but two calls valid.  We have transferred four of the patients to a high level of care and two visitors to the ED.

Research indicated that hospitals that have adopted patient- and family- activated Rapid Response Teams have approximately one or two calls per month.  (See link to references here.)  As a proactive Rapid Response Team, we are seeing fewer.

Data on utilization of the Rapid Response Team demonstrating increase over time (Calls/1000 discharges):

We have a proactive or critical care outreach team so we round on patients and employees resulting in more calls than national average of 50 per month.

2009  .22 or 22%  average 230 calls per month
2008  .17 or 17%  averaged 176 calls per month
2007  .16 or 16%  averaged 106 calls per month
2006  .7 or 7%      averaged 35-50 calls per month

With about 200+ Rapid Response Team calls a month on our campus, about 59% of them are the result of dedicated ICU RN rounding on nursing units at least once in each 12 hour shift.  Fewer than 30% of our calls are overhead pages as we allow the staff to call our cell phones or beepers directly.

Data on code blues per 1,000 discharges:

2009  trending to be less than 9 per month (91 thru Oct 2009)
2008  141 med-surg codes  11 per month
2007  182 med-surg codes  15 oper month
2006  295 med-surg codes  25 per month

In the past three years, with a progressive phased implementation, the mortality rate has decreased from 32.8/1000 discharges to 18.6/1000 discharges (VHA benchmark is 22.2/1000).
2009 18.6 thru 10-09
2008 24.3
2007 28.1
2006 32.8

The team proactively rounds on approximately 40-50 patients each shift and eight to ten employees each shift.

As this is a campus with two hospitals there are two Rapid Response Teams responsible for the 125-bed hospital called Pavilion and the 500-bed hospital called Clinical Center.  Each hospital has an experienced RRT ICU RN and RT available 24/7. 

No FTEs were added, each ICU provided FTEs from their individual budgets for implementation of this patient safety initiative.  The Rapid Response Team ICU RN does not have another assignment.  He/she proactively rounds on identified high risk patient populations; our team does not wait for a phone call from staff.

On both sides of the campus, all med-surg trach, halo, and chest tube patients are proactively rounded on as are all Med-surg patients on high-risk medications such as Heparin drips.  In the Clinical Center, all transfers out of the six adult ICUs are proactively rounded on for a minimum of 48 hours, and in the Pavilion all admitted patients are proactively rounded on for stability.  Transferring patients between our campus hopsitals requires ambulance transports as there is no underground tunnel.

Mentor designation - 5/1/08
Information updated - 2/24/10

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United Health Services Hospitals - Binghamton General Hospital/Wilson Regional Medical Center – Johnson City, NY
Availability Status: Available to answer requests
Licensed Beds: 493
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: July 2005
Mentor Contact Name: Rosemary Ciotoli
Mentor Contact Email: rosemary_ciotoli@uhs.org
Mentor Contact Phone: 607-763-6726

Additional Information:

Team members include Senior Resident, Critical Care Nurse, Respiratory Therapist and Nurse Leader (Nurse manager or Supervisor).  No additional FTEs were required.

Documentation tools used:
SBAR (for nurse to team report and nurse to MD report)
RRT Progress record
RRT Physician order form (preprinted orders of key interventions)
Debriefing Form (to be used after every event)

We also use posters and a power point presentation for education.  We are developing educational brochures to educate families on the RRT, but have not yet rolled out.

First 6 months of implementation: decrease in inpatient CPR calls outside the ICU setting by 40%.
2x2 IHI matrix of mortality chart reviews: lower right quadrant (non comfort care, no ICU adm) moved from 36% pre RRT to 14.3% post implementation.

[6/2/06]

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University of Iowa Healthcare – Iowa City, IA
Availability Status: Available to answer requests
Licensed Beds: 762
Teaching / Non-Teaching Status: Teaching
Setting: Rural
Start Date of Intervention Work: July 2005
Mentor Contact Name: Vicki Ibarra, Quality Management Coordinator
Mentor Contact Email: vicki-ibarra@uiowa.edu
Mentor Contact Phone: 319-356-1002

Additional Information:

Key effectiveness measures include the number of Rapid Response Team calls, number of codes, % of patients transferred to ICU after event, % of patients intubated after event, in-hospital deaths/discharge and codes outside the ICU.

The team consists of a senior medicine (or surgery) resident, an intensive and specialty services nursing supervisor and the respiratory care supervisor.  To provide critical patient care support, they assess, stabilize, assist with communication, educate and assist with transfer, if necessary. 

Since July 1, 2005, any care provider can call the Rapid Response Team when concerned about a clincially unstable adult patient.  Staff have been educated regarding the criteria for calling the Rapid Response Team (Dial 199).  Posters and pocket cards keep this criteria in sight.  In the last fiscal year, we expanded the Rapid Response Team call option to ambulatory care units.  In February 2009, a Pediatric Rapid Response Team was established. 

No FTEs were added to staff our Rapid Response Team.

We did not pilot our Rapid Response Team.  We started it in 2005 on the adult non-ICU units.

There were 386 RRT deployments from July 1, 2008 through June 30, 2009. 
60% of the patients were transferred to ICU
15% had subsequent cardiopulmonary arrest
82% of the patients were discharged alive

In the first year of implementation, which was 2005, we saw a 39% reduction in code events outside of the ICU.  We have sustained this over time. 

Data on code blues per 1,000 discharges: We continue to see a reduction or stabilization of codes. 

There were 80 true codes in FY 08 and 90 true codes in FY 09.  A "true code" is one in which CPR was done or the patient was intubated.  Some calls are for syncope, etc. and we do not count them in our true code count.  If all calls were counted, there were 148 code calls in FY 09 with 90 being true codes. 

Mentor designation - 3/30/06
Information updated - 11/04/09

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University of Kansas Hospital – Kansas City, KS
Availability Status: Available to answer requests
Staffed Beds: 650
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: February 2005
Mentor Contact Name: Carol Cleek
Mentor Contact Email: ccleek@kumc.edu
Mentor Contact Phone: 913-588-5696

Additional Information:

Activations continue to rise from 37 per month during FY06, to 55 in FY07, 72 in FY08 and 92 in FY09.  All services and all units have activated rapid response teams since their inception.  In addition, Rapid Response Teams have been activated in parking structures, restrooms and numerous outpatient clinics.  As the organization has become more savvy about the use of Rapid Response, most freqent triggers focus on physiological changes causing concern to the caregiver.  Currently, about 57% of activations result in the patient being transferred to a higher level of care.

Since the inception of the Rapid Response Team, total Codes/1000 discharges has declined by 49%, from 10.17 in 2005 to 5.17 for FY09.  Similarly, the number of codes outside the ICU/1000 discharges has declined from 6.11 prior to the initiative to 1.92 for the most recent fiscal year, a 68.5% decrease.

We have now gone 25 consecutive months with a mortality index well below 1.0 (expected) and rank in the top decile of teaching hospitals nationally.  Rapid Response Teams have significantly contributed to this performance. 

Implementing Rapid Response Teams has proven to be difficult for many teaching hospitals.  Fortunately, this has not been the case for University of Kansas Hospital.  Led by a cross-functional team (physicians, nurses and ancillary staff) and supported by a strong leadership team, Rapid Response Teams were implemented two months after the 100,000 Lives Campaign was introduced.  The Rapid Response Team has been utilized for patients in all medical services and by every unit in the hospital.  In addition, even with the arrival of new residents in the fall, the utilization rate of Rapid Response Teams has remained consistent, indicating an acceptance of this important resource by the physician community.

The success of the initiative was facilitated through strong planning, effective, multi-dimensional communication and continuous measurement and improvement.

Rapid Response Teams have been implemented with no additional FTE's.  The team consists of a seasoned Critical Care Nurse and a seasoned Respiratory Therapist.  Critical Care Physician is available to the team should the need arise. 

Another success factor has been the ongoing data collection and analysis by the cross-functional Rapid Response Team steering team (which has merged with the Code Blue Team).  This group has continued deeper and deeper dives into the data.  They are looking to determine if there is a statistically signficant impact of Rapid Response Teams on code survival rates.  They are also looking at Rapid Response Teams activated within 12 hours of patient admission to determine if signs/symptoms were missed upon admission which would have indicated the patient be cared for in a higher acuity setting. 

The team has built in a follow-up visit with the patients within two hours of the Rapid Response Team activation to ensure the patient's condition remains stable and no further interventions are needed.

Initially the plan was to pilot the teams on two units.  However, the first call for an Rapid Response Team came from a unit which had heard about the pilot.  The response was unanimous to fully implement the process and that decision has proven to be the correct one.

Our family activation protocol has been in place for approximately one year.  The staff were not sure how frequently patients/families would choose to activate the Rapid Response Team, but have found its use to be minimal.  The awareness of staff and the quick, effective response of the team usually results in an activation by staff long before a patient/family has identified the need.

Mentor designation - 3/20/08
Information updated - 11/04/09

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University Medical Center – Tucson, AZ
[Adult & Pediatric Mentor]

Availability Status: Available to answer requests
Licensed Beds: 365
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: November 2005
Mentor Contact Name: Deborah Pesicka, Quality Specialist
Mentor Contact Email: dpesicka@umcaz.edu
Mentor Contact Phone: 520-694-4062

Additional Information:

UMC has taken a unique approach to the Rapid Response Team (RRT) concept.  Some services expressed a reluctance to have RRT members from other services responding to their patients at risk.  Out of necessity, we developed four (4) RRTs: Medical, Surgical, Cardiothoracic, and Pediatric.  Each ICU is partnered with floors to which their patients are most likely transferred.  Each team consists of the ICU Charge RN and the Charge Respiratory Care Practitioner, with MD back-up.  The requesting unit calls a designated RRT number to connect to the teleoperators who in turn page the appropriate RRT.  The requesting unit also pages the attending team including a Rapid Response Team code in the message.  The patient's RN initiates an RRT report form which includes a SBAR section, s/he then stays at the bedside and assists the RRT.  The RRT responders then stabilize the patient and complete the RRT report form.  If a transfer of location is necessary, the RRT responders facilitate the transfer.  Although the multi-tiered RRT unavoidably increases complexity, our unique system has been very successful thus far and has allowed a specialized RRT to aid patients in urgent need.  As an added benefit, harmony between services is maintained in our busy academic medical center and the primary goal of providing optimal patient care is achieved.

We average 10-15 RRT activations monthly.  Greater than 50% of the time the RRT arrives within 5 minutes of the activation.  Although we've not seen an on-going change in Codes-outside-the-ICU, attempting to capture this number has made us aware of inconsistencies for reporting Codes within the hospital.  Once we improve that process, we anticipate that there will be a fall in codes-outside-the-ICU.

[5/12/06]

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The University of Texas M. D. Anderson Cancer Center – Houston, TX
Availability Status: Available to answer requests
Licensed Beds: 465
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: January 2005
Mentor Contact Name: Doris Quinn, PhD, MSN, Director, Process Improvement and Quality Education
Mentor Contact Email: DCQuinn@MDAnderson.org
Mentor Contact Phone: 713-745-2579

Additional Information:

In its first 10 months of operation, M. D. Anderson’s Medical Emergency Rapid Intervention Team – called MERIT – responded to more than 600 calls to inpatient units and medical emergencies in the hospital.  Preventable inpatient cardiac arrests outside the Intensive Care Unit (ICU) dropped by 67 percent – far exceeding the team’s goal of a 20 percent reduction.

MERIT, which began operating in the Main Building on Jan. 3, 2005, comprises 20 senior critical care nurses from the ICU who are assigned to the rapid response team on a rotating basis as their primary nursing assignment for the shift.  In addition to critical care experience, MERIT nurses obtain additional training in advanced life support and critical care transportation.  The MERIT medical director, in conjunction with a patient’s primary physicians, provides physician oversight.

MERIT members are scheduled to respond to calls for support from inpatient floor staff when a patient demonstrates signs of deterioration.

During its first 10 months of operation, MERIT responded to the majority of calls based on nurse judgment, and respiratory or heart rate changes.  Team members also visit every patient who has left the ICU within 12 hours to ensure there are no changes in that person’s condition.

• More that 600 Rapid Response Team calls in 10 months
• 67% Reduction in arrests outside the ICU
• Reduction in the percentage of patients who need to be transferred to a higher level of care

[5/12/06]

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Virginia Mason Medical Center – Seattle, WA
Availability Status: Available to answer requests
Licensed Beds: 270
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: July 2004
Mentor Contact Name: Michael Westley, MD
Mentor Contact Email: michael.westley@vmmc.org
Mentor Contact Phone: 206-625-7373 ext. 62525

Additional Information:

Our RRT is called MET (medical emergency team) and includes a hospitalist, Critical Care nurse and respiratory therapy, triggered by acute status changes or a worried clinician.

No additional FTEs.

Pilots began in July 2004 on one unit with rapid spread both through RN “word of mouth” and fairly rapid house-wide deployment.

We implemented a F.A.S.T (Family Activated Safety Team) in August 2008 with approximately 30 calls to date. 

Our MET and FAST demonstrate our commitment to patient safety by providing clear processes through which any concerned VMMC staff or family can reach out directly and summon immediate help, day or night.

65 calls/1000 discharges

4.5/1000 discharges

.8/1000 discharges reduced from 1.5/1000 discharges in 2005

2006 Data:
VMMC averaged about 70 calls monthly.

2009 Data:
VMMC averages about 90 calls monthly and have virtually eliminated potentially preventable CPR codes outside the CCU.

Mentor designation - 02/14/06
Information updated - 02/10/10

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White County Medical Center – Searcy, AR
Availability Status: Available to answer requests
Staffed Beds: 186
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: January 2006
Mentor Contact Name: Peggy Turner or Cyanne Hamill
Mentor Contact Email: pturner@wcmc.org or chamill@wcmc.org
Mentor Contact Phone: 501-380-3480 or 501-380-2281

Additional Information:

The White County Medical Center Rapid Response team consists of the House Nursing Supervisor, Critical Care Nurse and a Respiratory Therapist.  No additional FTE's were added.

Reasons for success:

Embraced by the nursing staff.  New staff had the reassurance that they could have help and teaching from peers.  Great for recruitment of staff.  Overwhelmed staff had a resource to call for help.  Cooperativeness between nursing and Respiratory Therapy was enhanced.

Our persuasive champions were the House Nursing Supervisors.  They initiated many of the calls and prompted other nurses to do so.

Staff physicians were fully behind this practice being initiated.  They felt like they were being given good solid information when they were called and that we were really on top of patients' condition changes.

Immediate positive results were seen with this initiative.  The number of codes went down. CCU transfers decreased.  Staff embraced the practice. Patients were well cared for.

Continual teaching about the Rapid Response Team keeps it in the forefront of staff's minds.  About every three months, we repeat some form of education to keep the practice fresh in everyone's minds.

We share our success stories monthly at the leadership meetings and information is then communicated to the staff level.  Information is shared at medical staff meetings as well.  We collect data and share this on a monthly basis with our other patient safety indicators.

We started this housewide right away.  We had very few skeptics.  We planned well.  Involved all the right people.  Educated, listened to feed back and rapidly implemented.  This was by far one of our most successful projects and easiest to implement.  We had various pilot versions of the documentation tool until we finalized it.

25% reduction in codes outside of CCU & ER since inception January 2005. 

Reduction in codes from 0.6/1000 patient days in 2005 to 0.45/1000 patient days in 2007.

Rapid Response Team calls increased 32% from 2006 to 2007.

Hospital-wide mortality rate has decreased 11.5% since Rapid Response Team began.   

Overall decrease in patients needing to be transferred to a higher level of care.

[4/03/08]

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Winter Haven Hospital – Winter Haven, FL
Availability Status: Available to answer requests
Staffed Beds: 527
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: January 2006
Mentor Contact Name: Cynthia Ritter, Administrative Supervisor
Mentor Contact Email: cynthia.ritter@mfms.com
Mentor Contact Phone: 863-293-1121 ext. 4292 or Pager #1235

Additional Information:

Data on utilization of the Rapid Response Team (Calls/1000 discharges)
CY06: 0.63%
CY07: 1.31%      
CY08: 1.27%

Data on non-ICU code blues

Non-ICU   Code Rate      % Reduction
CY-06:      0.48%     
CY-07:      0.44%            9.45%
CY-08:      0.38%            13.61%

Winter Haven Hospital in Florida qualified this year as a Magnet hospital.  Our strength in the application was our implementation of patient safety practices such as Rapid Response Teams, Patient Safety briefings and Executive Patient Safety Walk-rounds.  We could not have achieved Magnet status without all three of these initiatives.

We began our Rapid Response Team in January 2006.  We have seen a steady decline in non-ICU code blues in spite of a rapidly increasing acuity of patients.  Our utilization of Rapid Response increased dramatically in the first year.  It has leveled off since then.  In 2008, we extended Rapid Response Team to patients and families believing that it was “the right thing to do.”

We developed a team and a structured pilot.  Our first pilot was restricted to one nursing unit.  The restriction did not give us the data we needed to continue.  We then decided to pilot the team on all units but for just one month.  By the end of the month, we had sufficient data to show us that it was feasible without adding FTE's.  Responders spend 15 minutes or less responding to the call.

Nursing from ICU's, PACU, and the Emergency Department respond to Rapid Response Team calls on a rotating assignment.  Respiratory Therapy and House supervisors respond.  Our hospital based intensivist is sometimes called on for assistance.  No FTE's were added.

Rapid response teams are a part of our culture now for both staff and families.  We couldn't give safe care without them.  We have implemented an order protocol to be used by the team that includes many of the emergency treatments we have found useful in our 2 years of experience.

We have added families and patients to the Rapid Reponse.  We advertise it as "Condition H" (for "Help").  Patients and families receive information in their admission packets.  Brochures are placed in family lounges throughout the organization.  We repond to these calls with the same personnel who respond to Rapid Response.  The different name allows us to separate the data.  Calls for Condition H are a very small percentage of overall calls.  It is important to treat these calls with the same urgency as Rapid Response Team or Code.  These calls often present opportunities for better communication with patients and families.  Our House Supervisors have been very helpful in facilitating the communications.

Mentor designation - 10/24/08
Information updated - 10/19/09

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Yale-New Haven Hospital – New Haven, CT
[Pediatric Mentor]

Availability Status: Available to answer requests
Licensed Beds: 144 pediatric beds
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: January 2005
Mentor Contact Name: Andrea Benin
Mentor Contact Email: andrea.benin@ynhh.org
Mentor Contact Phone: 203-688-8692

Additional Information:

Yale-New Haven Hospital has been successful in implementing rapid response teams for Pediatrics by instituting a team based out of the ICU that is available 24 hours per day, 7 days per week.  This team has been very favorably received by the medical and nursing staff.  As of January 2006, we are implementing an equivalent program for the adult-care services.

Thus far, we have analyzed pilot data comparing the first 6 months of implementation of the pediatric rapid response team (RRT) to the same 6 months of the year prior.  We have found that there was a notable decline of 39% in the number of hours between the time patients first demonstrated a possible indication for transfer to the pediatric intensive care unit (PICU) and their time of transfer to the PICU.  We are currently implementing monthly evaluation of a set of metrics that includes the time between patients' first indication that they might need care in the PICU and transfer, time elapsed between call for and arrival of the RRT, proportion of patients progressing to full-codes before transfer, the number of codes per 1000 discharges, the proportion of in-hospital codes that occur outside the PICU, and the number of calls to the RRT per month.

[8/4/06]