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Early warning system to be surveyed in January


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Changing staff mind-set may be toughest component to implementation

For those facilities watching the clock wind down on the implementation year given by The Joint Commission for National Patient Safety Goal (NPSG) 16.01.01, reflecting on the fundamental pieces of what staff members must know about your early warning system is vital.

Before the facility’s early warning system for patient deterioration goes live to the whole facility, make sure that all staff members are aware of the criteria for calling a rapid response team (RRT).

“Don’t have nebulous, loosely defined directions for staff,” says Glenn Krasker, president of Critical Management Solutions, a healthcare consulting firm based in Wilmington, DE. “Make sure that there are some clearly articulated criteria for when the response team will be called.”

Krasker says some organizations he has worked with tell their nursing staff to call an RRT when there is concern over a patient’s condition and the physician is not responding. Although those instructions are not necessarily bad, surveyors are going to ask to see in writing what the criteria are for calling an RRT and will use that as a starting point for tracing that process within the organization, he says.

Criteria that IHI—which started the push for RRTs in its 100 Thousand Lives Campaign and has continued in its 5 Million Lives Campaign—recommends include monitoring changes in:

  • Heart rate
  • Systolic blood pressure
  • Conscious state
  • Urine output
  • Respiratory rate
  • Perception of change by staff members (this should be defined by the other criteria listed to make sure the early warning system is being used most effectively, Krasker says)

The Joint Commission (formerly JCAHO) said in its 2009 NPSGs that facilities do not need to have an RRT or medical emergency team per se. This shows that the agency will be surveying on the coverage of all elements of performance (EP), not on the presence of a team, says Krasker.

“Just because you have a rapid response team doesn’t mean you have addressed all of these EPs,” he says. “I’d encourage organizations to look at where they are now and read the elements of performance for 2009 and make sure they have addressed all of those items as they go forward.”

Many facilities are already using the RRT model, and most who do find it works well for them. The trick is ensuring that the purpose of a team is to comply with NPSG.16.01.01 (formerly NPSG #16).

The team makeup

Melissa Lehman, RN, MSN, CPHQ, director of quality and risk management at East Texas Medical Center (ETMC) in Quitman, has been involved in the implementation of RRTs at the ETMC facilities in Athens in 2006 and Quitman in July.

For these small rural facilities, having staff members who were flexible in restructuring some of their responsibilities was helpful and necessary, Lehman says.

“One of the things we wanted to do was include the floor nurse who made the call in that team,” she says. “We had to work with our ER nurses and taught them to talk through their assessment ... so instead of just thinking and doing, talk about what you’re doing, because then you’re teaching.”

Krasker says it is most likely not necessary to hire additional staff members, but scheduling additional shifts for staff members involved in the rapid response process, especially at the start of implementation, might be necessary.

“Initially, I think organizations are seeing a relatively high use of the rapid response process,” Krasker says. “As staff get more comfortable with the criteria or making decisions for when a rapid response should be called, the number will come down and be more stabilized.”

Carma Schoemaker, RN, MSN, nursing director of Parkview Hospital in Fort Wayne, IN, helped lead Parkview’s RRT starting in 2005.

Schoemaker recommends the following staff members be included:

  • Stat nurse
  • Medical-surgical nurse
  • Respiratory therapist
  • Physician
  • Community hospital members, to help build their own teams

For the structure of her first team, which began at Parkview’s main, 600-bed campus in October 2005 and was rolled out to four community hospitals by February 2006, Schoemaker used the program to support housewide-monitored patients already in place at the facility as a guide in creating a rapid response system. She recommends other organizations do the same instead of starting from scratch.

“As the information started coming out [about RRTs], it seemed very logical that we would build off of something we already had in place,” says Schoemaker.

The importance of constant education

For staff members, getting used to the concept of an RRT takes many education sessions, says Lehman.

“When you make it formal, you bring in the brand-new nurse who might be uncertain,” she says, adding that some seasoned nurses at her facility were probably already engaging in early warning practices.

Key to a successfully functioning early warning system is to make sure every staff member has been trained. There should be general as well as specialized training for those who will be responding to a call. Schoemaker says she conducted education sessions at her facility every four to five months with the nursing units. She also created large posters that listed the criteria for calling an RRT.

Facilities should determine during the pilot testing phase how to improve staff education, says Krasker. For example, “How can they improve the education as they roll [rapid response systems] out hospitalwide and educate staff housewide so that the use of the response team or calls for response are more in line with the criteria?” he says.

The cultural effect

Implementing an early warning system can have a profound effect on a hospital’s culture and involves changing mind-sets, says Lehman.

Part of implementing an early warning system is letting patients and their families ask for assistance if they feel a patient’s condition is worsening.

Staff members often have difficulty accepting this part of the NPSG, says Schoemaker, because it might make staff members feel they are doing their jobs incorrectly. It also involves giving up some control in caring for the patient.

However, “the more you’re transparent with pa-tients and families in what your goal is—that your goal is to [ensure] safe quality care—it makes it more evident that that really is what you’re striving for,” says Schoemaker.

“It’s a paradigm shift in thinking, ‘When do I call?’ ” says Lehman. “Don’t wait for the bad thing to happen. If you see that small drop in blood pressure or heart rate, or their level of consciousness is changing, that’s when you act. You don’t wait until arrest occurs, because all those symptoms happen six to eight hours before the arrest. It’s just teaching the nurses not to miss that time frame.”

Often, it is a hospital’s failure to educate appropriately that makes staff members incapable of recognizing the symptoms of a patient in distress, Lehman says.

“It’s responding to a spark before it becomes a fire,” she adds.