Redesign Paper

BEAR Running head: EARLY ASSIST

Brenner Early Assist Response Team Christy Holshouser University of Alabama School of Nursing

NFH 602 Julie Cash October 21, 2009

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Brenner Early Assessment Response Abstract The goal of the rapid response team (RRT) is to improve recognition and response to changes in patient conditions. The team is composed of clinicians who bring critical care expertise to the patient bedside or wherever it is needed. The implementation of rapid response teams is one of six initiatives started in 2004 by the Institute for Healthcare Improvement, known as the 100,000 Lives Campaign. This campaign was developed to “decrease the number of inpatient preventable deaths in the United States by 100,000 during the period between December 2004 and June 2006” (Berwick et al., 2006). Brenner Early Assessment Response Team was developed in response to this initiative and the 2008 Joint Commission National Patient Safety Goals.

Redesign/Reengineering in the Workplace The redesign project was one of taking statistical information from adult rapid response teams obtained from clinical trials and applying concepts of that information to the pediatric population to develop a pediatric rapid response team. As of November 2007 only two institutions (Royal Children’s Hospital in Melbourne, Australia and Cincinnati Children’s Hospital in Cincinnati, Ohio) had implemented such response teams. The goal was to decrease the mortality rate of in-patient, out-of-ICU, cardiopulmonary arrests. Research revealed that all patients, adult and pediatric, present with evidence of changes in physiologic status sometimes hours before an actual cardiopulmonary arrest. Research also revealed that the survival rate of these patients is poor. “Survival data focusing on codes outside of the pediatric intensive care unit (ICU) setting are similar, with just 33% surviving to discharge” (JAMA, 2007, p. 2268).

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Review of the Literature Rapid response teams were initiated to be in compliance with the 2008 National Patient Safety Goals: Goal 16 - “Improve recognition and response to changes in a patient’s condition” (Joint Commission, 2008, p. 24). The goal dictates seven elements of performance. The RRT provides a way for staff members to directly access individuals with specialized training to give needed assistance for a patient who presents in a worsening medical condition. The rationale for this goal is as follows, “A significant number of critical inpatient events are preceded by warning signs prior to the event. A majority of patients who have cardiopulmonary or respiratory arrest demonstrate clinical deterioration in advance. Early response to changes in a patient’s condition by a specially trained individual(s) may reduce cardiopulmonary arrests and patient mortality” (Joint Commission, 2008, p. 24).

Prior to 2007, there were only two published studies that had looked at the effects noted after the implementation of a rapid response team. The two studies were at Royal Children’s Hospital in Melbourne, Australia and Cincinnati Children’s Hospital in Cincinnati, Ohio. The findings from the study in Australia did not support the benefit of the medical emergency team (MET).

In a cluster-randomized control trial of 23 hospitals in Australia, MERIT study investigators (2005) noted that medical emergency teams “did not substantially affect the incidence of cardiac arrest, unplanned ICU admissions, or unexpected death” (MERIT, 2005, p. 2091). The calling incidence in the hospitals using the MET increased (p=0.0001), but it was noted that greater than 80% was not associated with an adverse event such as cardiac arrest or unexpected death (p<0.0001). “A reduction in the rate of cardiac arrests (p=0.003) and unexpected deaths (p=0.01) was seen from the baseline to the study period for both groups combined” (MERIT, 2005, p.

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2091). The investigators listed several possible reasons for their findings including inadequate education during the study period, incorrect use of the MET, non-representative of hospitals with high adverse event rates, and intensive care staff may have been utilized as support staff prior to the MET being called. The study from Cincinnati Children’s Hospital showed a significant decrease in the code rate, but not in the mortality noted hospital wide.

Sharek et al. (2007) conducted a cohort study at Lucille Packard Children’s Hospital (LCPH). The study’s goal was to examine the implementation of an MET and the effect that it would have on mortality and code rates outside of the intensive care (ICU) setting. The team consisted of a “pediatric ICU-trained fellow or attending physician, ICU nurse, ICU respiratory therapist, and nursing supervisor” (Sharek et al., 2007, p. 2267). A team response could be initiated if a patient met the standard criteria. The team was available around the clock for treatment and triage needs. Results showed a decrease in hospital-wide mortality rates and code rate for patients outside of the ICU setting (P=.007). The study listed two possible explanations for the changes noted after implementation of the MET. The first explanation was that LCPH serves a large high-risk population and the second was that LCPH had a longer post-intervention time than that of Melbourne at 12 months and Cincinnati at 8 months. “Sharek et al. have provided the most persuasive finding to date regarding the efficacy of pediatric RRTs – a mortality benefit” (Nowak & Brilli, 2007, p. 2312).

Redesign/Reengineering Process Since the mid nineties, a pediatric code blue team has been in use at Brenner Children’s Hospital (BCH) that was maintained by existing staff. Between July 1, 2004 and June 30, 2005 BCH had 54 code blues. Thirty seven of those patients survived the initial code, but only seventeen of those patients were able to be discharged from the hospital. Those numbers

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represented only a 31.48% survival rate.

Over the past years, the acuity on the pediatric units had increased as evidenced by Quadramed classification of acuity. That increase made it difficult for a nurse to provide the care needed when the patient to nurse ratio was at least 4:1. In February 2006 it was recommended that a pediatric early intervention team be organized.

Education of the pediatric staff consisted of introduction of the RRT concept, physiologic instability criteria for activating the team, and education in the use of SBAR (situation, background, assessment, recommendation) communication. The RRT was implemented on June 15, 2008. The team consisted of a pediatric intensive care (PICU) physician, charge nurse and respiratory therapist and could be activated by calling the PICU. After a two month observation of the team use and function there were two concerns noted: low call volume and that patient deterioration was noted but the call was not made to the team until the deterioration had worsened. In response, changes were made that consisted of a second number to use to activate the team in the event that the PICU number could not be answered immediately, re-education of staff through classroom instruction, algorithms, and use of bulletin board information, conferencing with pediatric residents regarding their role, and conferencing with hospital faculty regarding concerns. Continued evaluation of the team noted that the primary activator of the call to the team was a physician, that nurses reported not wanting to “bother” the PICU, and that some nurses only viewed the team as a “code” team and was not utilizing it as an early intervention team. To address these concerns, the concept of the team was presented as an early intervention team and re-introduced as the Brenner Early Assist Response (BEAR) team. The changes in the team were as follows: 1) specially trained, critical care nurse to respond to the call, evaluate the situation, and provide coaching and support for the bedside staff, 2) the PICU

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physician would remain in the PICU and available to PICU patients unless needed, 3) the critical care nurse would call the primary physician or the PICU physician as warranted by the event and assist in transport of the patient to a higher level of care as needed. The team is currently very young and will require further research, but these changes helped to correct the misconceptions of the team and decreased the overall rate of cardiopulmonary arrest and admission to the intensive care unit. The call volume has increased from one call in August 2008 to 13 calls in August 2009.

The integration of the rapid response team to the current system of the hospital has proven successful in many ways. Systems theory encompasses components working together due to of a driving force (McNamara, 1997-2008). In the case of rapid response teams, that driving force is the detrimental condition that can occur from an adverse patient condition such as cardiopulmonary arrest. The education of the nursing staff has increased competence and confidence in patient care, and has empowered the nurses to seek out further education opportunities to provide excellent patient care (Krimsky, 2009). The function of the team with the nursing staff has brought benefit to patient safety, and improved outcome was reflected in the decrease of out-of ICU codes and increase in call volume.

Recommendations Education of staff is crucial for any change to occur. In the future it would be beneficial to enhance the learning process by using role play or simulation of deteriorating patient conditions (Chen & Stroup, 1993). The team can be involved in instruction of the bedside nurse regarding the physiologic instability criteria and with the use of a simulation manikin be able to coach the bedside nurse in the proper care of and appropriate initiation of the RRT.

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Implication for Masterâ&#x20AC;&#x2122;s prepared nurses The level of expertise possessed by the APN would dictate the benefits to a RRT that may range from an administrative role in the implementation of the team to the actual bedside practice that could lead the team. By utilizing the core competencies inherent in the APN role, the APN can help to prevent a failure to rescue that is described by the Institute of Healthcare Improvement as a failure in planning, a failure to communicate, and a failure to recognize deteriorating patient conditions (Institute of Healthcare Improvement, 2007). The primary competency of direct patient care is the APNâ&#x20AC;&#x2122;s strongest feature in regard to patient assessment and intervention.

Through collaboration the APN can expedite the response process by initiating laboratory, radiological and medication orders that are beyond the scope of practice of a registered nurse. To foster growth and competence, the APN brings educational skill to coach and guide not only hospital staff, but also families and other care providers to care for a patient that is presenting with signs of a worsening condition. From an ethics perspective, the APN can assist in debriefing of the parties involved in the patient encounter including nursing personnel, medical staff, and families. The leadership potential possessed by an APN can vary and will help to differentiate the best placement on the team for the practitioner. The role of the APN is growing, but research and continued documentation of their efficacy and efficiency is needed.

Summary Great strides have been made in the methods to prevent adverse patient conditions and rapid response teams are helping to make that possible. There is still much to be learned and hospitals that are participating in this endeavor need to continue to monitor and provide data to support or suppress the need for these teams. As a result of dedication, the 100,000 Lives Campaign had a

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success of 130,000 lives saved in the endeavor (Institute for Health Care Improvement, 2006).

References Berwick, D. M., Calkins, D. R., McCannon, J. C., & Hackbarth, A. D. (2006). The 100,000 lives campaign setting a goal and a deadline for improving health care quality [Electronic version]. JAMA, 295(3), 324-327. Retrieved October 2, 2009 from PubMed. Chen, D., & Stroup, W. (1993). General systems theory: Toward a conceptual framework for science and technology education for all [Electronic version]. Journal of Science Education and Technology, 2(3), 447-459. Retrieved October 2, 2009 from PubMed. Institute for Health Care Improvement. (2006). 100,000 lives campaign: How-to-guide: Getting Started Kit: Rapid response teams. Retrieved October 2, 2009, from IHI: http://www.ihi.org/IHI/Programs/Campaign/.

Institute for Health Care Improvement. (2007). The 5 million lives campaign: Rapid response teams. Retrieved October 20, 2009, from www.obsmedical.com/downloads/files/IHI%20RRT%20Slides.ppt.

Joint Commission. (2008). National Patient Safety Goals (24). Retrieved from http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/08_npsgs.htm Krimsky, W. S. M. (2009). Web M&M morbidity and mortality rounds on the web. Rapid response teams: lessons from early experience. Retrieved October 18, 2009, from http://www.webmm.ahrq.gov/perspective.aspx?perspectiveID=12.

McNamara, C. (1997-2008). Systems thinking. Retrieved October 20, 2009, from Authenticity Consulting, LLC: http://managementhelp.org/systems/systems.htm#anchor5802.

MERIT study investigators. (2005). Introduction of the medical emergency team (MET) system: A cluster-randomised controlled trial [Electronic version]. The Lancet, 365, 2091-2097.

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Retrieved October 2, 2009 from PubMed. National Patient Safety Goals. Joint Commission Web page. Available at: http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/08_npsgs.htm Accessed October 2, 2009.

Nowak, J. E. & Brilli, R. J. (2007). Pediatric rapid response teams is it time? [Electronic version]. JAMA, 298(19), 2311-2313. Retrieved October 2, 2009 from PubMed. Sharek, P. J., Parast, L. M., Leong, K., Coombs, J., Earnest, K., Sullivan, J. et al. (2007). Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a children's hospital [Electronic version]. JAMA, 298(19), 2267-2275. Retrieved October 2, 2009 from PubMed. .