Follow these 10 tips for responding to patients’ deteriorating conditions
Small hospitals struggling to implement a rapid response system may want to take a cue from East Texas Medical Center in Athens, a 28-bed facility that saw its calls for code blues—as well as its mortality rates—drop after it instituted an emergency team.
The medical center’s effort began in 2006, when leadership formed a team to address the issues by looking at baseline data, Melissa Lehman, RN, MSN, CPHQ, said during HCPro’s May 14 audioconference, “Rapid Response Systems for Small Hospitals: Tips and Tools to Overcome a Lack of Resources.”
The team included leaders from the floor, the ED, and the ICU.
“We initially looked at what resources were available and not available for nursing,” Lehman said. The hospital discovered it had no formal education in place, and staff members didn’t know who or when to call for additional help.
Staff members adopted a motto of “call early, call often” to encourage nurses to call if they felt at all worried, Lehman said. Through posters, badge buddies (a small paper with the details for a required call), and continual education, staff members learned more about when to make a call to the rapid response team.
Badge buddies listed the criteria for calling. The criteria included an acute change in heart rate, an acute change in blood pressure, or failure to respond to treatment. (See "Get the help needed for your patient" below for all changes in conditions.)
Even if the patient didn’t exhibit any of the conditions listed in the criteria, nurses were encouraged to call if they felt something was awry.
Reinforcing to staff members that no call is a bad call was critical to the hospital’s success.
“We wrote, revised, and revised again the actual policy for the rapid response team,” said Lehman. The hospital used situation-background-assessment-recommendation (SBAR) as a documentation tool, and the policy was distributed for the staff to view.
Once staff members knew when to call, they could do so over a beeper system, overhead page, or via Nextel phone.
“Education played a big role,” Lehman said. “With the implementation of the rapid response program, calls went up and our mortality and codes outside the ICU went down.”
However, as the program continued, Lehman said she saw a decrease in calls and implemented a staff-made video to revamp the rapid response system.
“We knew there were missed opportunities, and we saw there needed to be more education,” she said.
After the policy was in place and being followed, the hospital monitored the number of rapid response team calls made. “We investigated all the code blue calls in the facility to see if there was a missed opportunity to use the rapid response team process,” said Lehman. “We reported the number of calls and possible missed opportunities to staff members and encouraged using the process.”
Monthly data were distributed to staff members so they could see how many rapid response calls were made and the relationship to mortality rate. “We made graphs to show staff. It’s always surprising to see the rates about your hospital, even if you’re doing well,” Lehman said. Managers commended staff members on their efforts and guided them about what they could be doing better through positive reinforcement and celebrations, such as ice cream socials.
“When we started this, we wanted to be sure to foster positive relationships through the program,” Lehman said. “It only takes one ‘My goodness, why did you call that in for?’ to throw a wrench into the program.”
The hospital encouraged staff members to teach each other and ask each other advice on patients’ care.
Kathy Duncan, RN, faculty member at the Institute for Healthcare Improvement and a leader in the implementation of rapid response teams, offered 10 tips for creating successful rapid response teams during the audioconfererence.
Learn from each other. “I’ve seen med-surg nurses learn from ICU nurses and vice versa,” Duncan said. “Following your gut feeling is often correct. Sometimes, ICU nurses get distracted with bells and whistles, and med-surg nurses can remind them of the instinct that’s inside them. Just the act of calling someone for help and then having two or three people assessing the patient together is a huge learning opportunity. You can have a colleague there to bounce ideas off of. Maybe a respiratory therapist hears some fluid in the lungs and the nurse says he has a history of this. It’s the discussion of assessing a patient that helps everyone learn.”
Utilize communication tools. Standard communication tools such as SBAR are good for new nurses, who are often afraid to call. Using this across the hospital often provides ease when it comes to patient communication.
“It’s a great tool to have in place. Nurses often get anxious about calling a physician, and a standardized communication tool helps with delivering and receiving the message,” said Duncan, adding that having open communication hospitalwide about rapid response is a necessity. “Constantly reminding staff that calling is okay and encouraging more dialogue is important,” she says.
Have a script. Telling staff members that there is no ”bad call” will encourage participation. Duncan suggests using every call as a learning opportunity. Using a script such as, “Thank you for calling. How can I help you?” prompts positive reinforcement when the call is made. “You’re thanking them for making the call, and the direct language includes the caregiver who made the call and sets the stage,” said Duncan.
Get the staff excited about numbers. Everyone can get excited about saving lives, and using specific examples allows for people to relate.
“The staff gets excited about code numbers going down,” said Duncan. “Simpler is better when communicating data. It’s important that the staff has a of sense how many calls are being made per week, month, and year. It encourages them that the process is still going on, even if they haven’t made any calls.”
Communicate with families. “Families know the patient better than staff, and staff should listen when they raise a red flag,” said Duncan.
Admission can be the first step when informing families about the facility’s rapid response team. “Tell the family that you have this program, and if they feel as though they need some clinical assistance, they may activate the rapid response team,” she said.
Also, by responding to patients earlier, family members appreciate the hospital staff for “calling in the troops on a loved one,” said Duncan. “Make sure you have a solid program with your staff first, and then pilot the family activation in one unit. See how it works, and then spread it hospitalwide.”
Educate all hospital employees. Because patients may spend a lot of their day off the nursing unit, nonnursing staff members often know something may be wrong but don’t know what to do. “Involve nonclinical staff in the education process,” said Duncan.
If a patient goes to radiology and the radiologist doesn’t feel comfortable or senses something is wrong, he or she can call the rapid response team. “Most people who work in hospitals care about helping people, and this gives them resources to do that,” said Duncan.
Follow-up is vital. “Have event follow-up 12–24 hours after the call to ensure interventions were appropriate,” said Duncan. This allows for the proper level of care, validation that staff members did the right thing, and staff encouragement.
Learning is essential for sustaining change. “Following up with staff members a few days after the event will enhance the culture,” said Duncan. “Learning never goes away. Use each call as an opportunity for education.”
Foster relationships. “By emphasizing each person’s contribution, it allows for people to get together, tell the stories,” said Duncan. “Everyone can relate to someone’s story, both staff and administration have ‘aha’ moments when they recognized someone was deteriorating and didn’t know what to do or needed additional help. Stories have a way of really sinking in.”
Make elimination of system failures a priority. This process breaks down into three buckets, said Duncan. “Failure to recognize, failure to communicate, and failure to plan. And each of these buckets has a different strategy,” she said.
Failure to recognize can stem from the need to reeducate staff members.
“Make sure the staff knows how to check for things and when to call for help,” said Duncan.
Failure to communicate may be a system problem. Nurses and physicians need to know how they talk and listen to each other. “It’s the constant positive reinforcement regarding rapid response calls that are made, and then listening and learning from each other,” said Duncan.
Failure to plan is a systemwide problem. Occasionally, hospitals must hold patients in the ED for long periods of time, and these patients may deteriorate before going to the floor.
Editor’s note: To order HCPro’s audioconference “Rapid Response Systems for Small Hospitals: Tips and Tools to Overcome a Lack of Resources,” go to www.hcmarketplace.com.
Get the help needed for your patient
Sample badge buddy:
Initiate rapid response
__ Staff concerned/worried:
__ HR < 40
__ HR > 130
__ RR < 8
__ RR > 28
__ SpO2 < 90%
__ Uncontrolled bleeding
__ New onset seizures
__ Failure to respond to treatment
__ Acute change LOC
__ FiO2 > 50%
Source: East Texas Medical Center, Athens.