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Beyond Code Blue: Rapid Response Teams Decrease Mortality

Nationally, statistics indicate fewer than 5% of hospital inpatients survive to discharge following a code blue. At The University of Kansas Health System, multiple rapid response teams are in place to intervene long before a code. About 90% of patients who receive care from these special teams survive to discharge.

Early intervention saves lives

Jennifer Johnson* was recovering well from her cardiac bypass at The University of Kansas Health System. She had moved to a regular floor and was getting ready to go home. On a walk around the halls, she told a nurse she wasn’t feeling right. Her breathing had become rapid, and her behavior was altered. If this had happened in 2004, Jennifer would have been taken back to her room, and the nurse would have contacted the physician. Depending on the physician’s availability, Jennifer could easily have coded before her condition was diagnosed and treated. Her chances of survival to discharge, based on national data, would have been less than 5%.

But Jennifer benefited from changes at the hospital since 2005. In addition to calling Jennifer’s physician, the nurse called a rapid response team (RRT), which identified cardiac tamponade and began treatment immediately. The cardiac surgery team sprang to action and took her back into surgery. Jennifer survived.

Significant results achieved

The University of Kansas Health System established its first RRT in 2005 as part of its participation in the Institute for Healthcare Improvement’s 100,000 Lives campaign. The hospital was among the earliest adopters and has become an IHI mentor hospital, exemplifying the best in RRT implementation. One of the 100,000 Lives campaign goals was to establish rapid response teams that could be called to quickly assess and treat patients at the first signs of decline, rather than waiting for a full code event. Key to the concept was the requirement that any staff member be allowed to call the RRT, regardless of position.

Our hospital is among a small number of hospitals that have taken the freedom to call the team further – encouraging patients and family members to use it as well. Through welcome packet information, posters in patient rooms and education from the staff, we encourage patients and visitors to look for signs of decline and feel comfortable calling the RRT if needed.

Another unique aspect of our RRT process is that we don’t limit teams to caring for hospital inpatients. We are willing to send an RRT to any location on campus – outpatient clinics, lobbies and even parking structures. The teams have often been able to intervene in critical situations when the patient might otherwise have to wait for a 911 call response.

Since 2005, our hospital has managed more than 7,800 RRT activations, with average monthly calls growing from 20 in 2005 to 200 today. Fewer than half of these patients go on to the ICU. And, while the program is just one of many designed to increase survival, we have seen a dramatic decrease in mortality over the last seven years.

  • About 90% of The University of Kansas Health System patients for whom an RRT is called now survive to discharge, up from 80% in 2005.
  • Code blue calls here have also decreased. In 2005, they averaged 10.18 per 1,000 discharges, and they were down to 7.0 per 1,000 in 2011.

Nationally, according to the IHI, more than 1,500 hospitals are now actively using or implementing RRTs. Cardiac arrest rates, mortality rates and ICU lengths of stay are dropping across the country.

RRTs expanded to multiple specialties The goal of the RRT is to get the right resources working together quickly to benefit the patient who may be declining rapidly. The team takes steps to reverse the decline and head off a potential code call.

The beauty of this model is its simplicity. The team includes a critical care nurse, respiratory therapist and primary care physician. (The patient’s attending physician is the first call, but a pulmonary critical care or surgical critical care intensivist is always on call for the RRT, as well.) Rather than taking control of the patient, these staff members provide additional resources to the nurses and other providers at the bedside. The model worked so well that the hospital expanded the concept to include seven different RRTs, focusing on specialized needs. Often the general RRT begins the call and brings in one of the specialty teams as indicated.

1. General RRT

  • Experienced critical care nurse
  • Experienced respiratory therapist
  • Attending physician or intensivist
  • Current care providers

2. Stroke RRT

  • Neuroscience-specific ICU nurse (stroke nurse)
  • Vascular neurologist
  • Current care providers

3. STEMI RRT

  • Cardiovascular ICU nurse
  • Interventional cardiologist
  • Two cath lab technicians
  • Cath lab nurse
  • Rounding cardiologist
  • EKG tech
  • Current care providers

4. Behavioral RRT

  • Nurse manager
  • Police
  • Psychiatric nurse liaison
  • Current care providers

5. Trauma RRT

  • Trauma resource nurse from surgical ICU
  • Trauma surgeon
  • Trauma chief
  • Surgical resident
  • ED staff

6. Burn RRT

  • Burn unit nurse
  • Trauma resource nurse from surgical ICU
  • Trauma surgeon
  • Trauma chief
  • Surgical resident
  • ED staff

7. Pediatric Rapid Response and Code Team

  • Pediatric ICU nurse
  • Lead physician
  • Anesthesiologist
  • 2 respiratory therapists
  • House resident
  • 2 nurses
  • Nurse technician

Continuous improvement

Like every process at the hospital, the RRT process is constantly under scrutiny for potential improvement. A multidisciplinary team of more than 30 staff members meets twice monthly to review code blue and RRT activations.

  • We analyze every RRT case that occurs at less than 12 hours from admission, and we drill down into the results of those that come in within 6 hours and those that result in death. Often, these cases are transfer patients who arrive at the hospital too late.
  • We are working to ensure better bed availability, improving the process for identifying the most critical patients and acting quickly.
  • We analyze satisfaction among all staff members involved with RRT activations to understand and continuously improve the staff's service to the patient and to one another.
  • We are constantly on the lookout for RRT trends. For example, we may see a trend in narcotic-related problems and recommend medication protocol adjustments.
  • We've recently piloted a program using CareVeillance™, a software tool that works with the electronic medical record to provide real-time clinical surveillance and reporting. The system can help identify characteristics that point to potential patient decline toward problems such as venous thromboembolism and sepsis. Nurses specializing in quality improvement monitor the data daily to identify and address these characteristics, which may require RRT activation, earlier in their progression. We plan to expand the program soon to include dedicated staffing and more frequent monitoring.

*Fictional name assigned to an actual patient

Timothy Williamson,

MD, vice president of quality and safety, pulmonary care specialist

Carol Cleek

RN, MSN, CCNS, CCRN, emergency and critical care services director

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