Implementation of a Rapid Response Team with

Automated Event Detection and Early Warning

Lisbeth Votruba, RN, MSN, Clinical Nurse Specialist and Diane Wehby, RN, MSN, CCRN, Clinical Service Director Critical Care/Cardiovascular/Medicine · Saint Mary’s Health Care — A Member of Trinity Health, Grand Rapids, Michigan
Expect Something More

Rapid Response Team Implemented 2/05 Automating Event Detection and Early Warning 12/06
Background Trigger RRT implementation resulted in a 40% reduction Session : BIOSIGN0000-00003 NEXT  eal-time index (0-5) of patient normality
R
CHART BioSign™ Index
in CMI adjusted adult (non-psychiatric) mortality based on five vital signs

5.0
 sing the template of a CPR team, a
U 6%
 o implement a team who can be summoned
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rate. However results from a multi-center - H R
HR

Rapid Response Team (RRT) was created 6%

Primary Reasons for RRT Calls to the bedside of patient whose condition is
to respond immediately to medical
8% study 1, concluded that there was no clinical - M AP
48%
Airway/Breathing — 48%
- A lready deteriorating difference between hospitals that implemented
RR

- 0 2 Sat
emergencies throughout the hospital to: Circulation — 32%
BP

- A t high risk for deterioration

Sp02

a rapid response team and those that did not. - R R

Temp
Neurological — 8%
32%
- D
 ecrease the number of preventable cardiac Septic — 6%
Based on our outcomes data and those of other - Temp
Other — 6% - Has
 an acute change in one or more of
arrests and incidents of failure to rescue
situations at Saint Mary’s Health Care by 20%
the following: sites, could this be due to the event detection HR
b / min 142 SpO2 %
97  hreshold values
T
and triggering side of the Rapid Response
- Improve mortality and morbidity rates in RRT Activations
· C hange in vital signs
System. Therefore, we implemented BioSign™,
BP
mmHg 120 / 80
Resp
r / min 35 - 0 normal
- 3 alerting threshold
· D rop in blood oxygen saturation
( 90 ) 97.0
180
patients at risk for clinical deterioration 167 164
an Automated Patient Early Warning System, in T °F

6%
160 150
- 5 critical
RRT Implemented

outside of the intensive care unit 140

140
128
120
126 · A ltered mental status two intermediate care units to address this issue.
6%
120 112 New Patient Config 5/30/2006 4:50:42 PM 1
Introduction of the Medical Emergency Team (MET) System; A Cluster Randomized
Priority One (RRT) Activations

 he RRT consists of an experienced

T
100
99
· Perception that patient requires Controlled Trial. Lancet. 2005, 365; 2091-7.
80
intervention to prevent deterioration
69

Registered Respiratory Care Practitioner 60

40

(RCP) and an ICU Registered Nurse (RN). 20 13

25
· L ist of examples of common problems
8%
Pilot

The process is activated via a direct phone call

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was developed
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or overhead page
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 ring the resources to the patient, and

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do it quickly Case Study 1 Case Study 2

 he RRT works in conjunction with the
T Unplanned ICU Admissions
60
patient’s current medical and nursing team 12/25 71 yr female admitted to intermediate unit one month after total 3/30/07 64 yr male admitted to the intermediate unit 2 weeks after

48%
Educational Change Process
50 RRT Implemented
to implement care whenever possible. 40
knee arthroplasty with knee infection. IV antibiotics started, ID consult. lumbar laminectomy with hospital acquired pneumonia and infection
12/26 Experiences decreased UO, hypotension and fever. of laminectomy wound. ID consult, IV antibiotics started. 4/2 to OR for
The services of a medical intensivist are P hase 1: Failure to Rescue
Number of ICU Admissions

30 40% Reduction
I&D of laminectomy wound infection.
available as necessary 20
 hase 2: Rapid Response Team
P To MRI of Lumbar spine as
12/27 0:00–6:00 episodes of 17:55 found with Bipap off and 4:56 RN administers vicodin for
 he RRT quickly brings to the bedside
T
10

0
Hospital-wide Education BSI > 3.0. No nursing O2 Sat 79%. Improves when pain in response to inc. HR and
ordered by Infectious Disease,
clinical experts who assess and provide intervention noted. Bipap replaced. inc. BSI.
shows changes consistent with
 hase 3: Rapid Response Core
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laminectomy, no abscesses.
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the appropriate level of care

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Team Education
Number of Cardiac Arrests
Results 50 P hase 4: Medical staff education
42 8:35 Attending called for
9:45 RRT Call. Pulmonary edema. 6:05 RRT call for inc. HR and

RRT responded to over 1,300 calls for
40 38
P hase 5: Refining Triggers decreased UO and hypotension.
ABG, Bipap placed. Lasix given,
5:26 pt reports improvement
worsening crackles. Cardizem
30
Chest x-ray and Lasix ordered. in pain.
minimal UO. Bipap initiated.
assistance during the first year 27 ~ 50% Reduction
BUN/Cr 60/4.9
bolus followed by continuous
20 infusion, HR stabilizes, BSI <3.
 pproximately fifty percent of all RRT calls
A Cardiology consulted, patient
Cardiac Arrests

14
10 12
changed to po Amiodarone and
were for respiratory problems including 0 converts to normal sinus rhythm.
airway, oxygenation or ventilation management  Jan-Jun 04 Jul-Sep 04 Jan-Jun 05 Jul-Dec 05 Jan-Jun 06

4 0% reduction in CMI adjusted adult Adult Case Mix Index (CMI)

32% Unplanned ICU admissions have decreased

(non-psychiatric) mortality rate
4.00

3.50
Mortality Rate Excluding Psychiatric Patients
Raw Mortality Rate per 100 DC CMI Adj Mortality Linear (CMI Adj Mortality)

3.00
by 10-15 per month 2.50
12/28 To OR for removal and revision of infected total knee arthroplasty. Infectious disease and cardiology continue to follow the patient.
Mortality Rate per 100 DC

2.00

 he number of arrests occurring outside of

T 1.50
Unable to extubate postoperatively and pt was transferred to ICU with Although the patients recovery is slow, ICU admission is avoided.
acute renal failure due to sepsis and hypotension. Pt extubated 1/8 and 4/5 transfer to general medicine bed. 4/19 transfer to rehab facility.
the ICU has decreased by nearly 50% 1.00

0.50 finally discharged on 1/18. Could this patient’s outcome have been better
 ost avoidance dollars were approximately
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if we intervened earlier?
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1.5 million dollars over one year

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