Rapid Response Teams

[Stitch]

Does anyone have experience with these or have them in place? I heard that JACHO will be pushing for hospitals to put these teams in place, but we don't yet. We recently had a grand rounds by a speaker from Hopkins who did a bunch of research on RRTs, and she was awesome.

According to the data she presented, RRTs cut respiratory arrests in half, but make no difference in cardiac arrests. The idea seems to be it gets kids critial care evaluation before they code so you're not trapped in the 'not PICU material' vs 'why didn't you call us sooner' hole that seems to come up at M&M a lot.

Any thoughts?

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[AmoryBlaine]

They confuse the heck out of me. I have seen 2 incarnations...

1. MICU nurse/RT there to evaluate patients who might be headed for the ICU. How this helps out the ICU residents is unclear to me. When you would call an RRT instead of an ICU consult is uclear to me. It seems like part of the rationale was that an RN could call for a RRT if the service didn't feeling like an ICU consult was warranted. I never saw it happen despite 2 years working in a hospital that theoretically had RRTs....

2. Patient satisfaction team - at another place I worked the RRT was like a nurse manager and a public relations person who responded immediately to patient complaints. It was unclear to me if this "RRT" was also there for acute care consultation i.e. maybe it was set up to respond to ANY problem in the hospital be it impending respiratory arrest or lack of creamer for the morning coffee. Either way I found it confusing and never saw it used.

 

[Stitch]

They confuse the heck out of me. I have seen 2 incarnations...

1. MICU nurse/RT there to evaluate patients who might be headed for the ICU. How this helps out the ICU residents is unclear to me. When you would call an RRT instead of an ICU consult is uclear to me. It seems like part of the rationale was that an RN could call for a RRT if the service didn't feeling like an ICU consult was warranted. I never saw it happen despite 2 years working in a hospital that theoretically had RRTs....

2. Patient satisfaction team - at another place I worked the RRT was like a nurse manager and a public relations person who responded immediately to patient complaints. It was unclear to me if this "RRT" was also there for acute care consultation i.e. maybe it was set up to respond to ANY problem in the hospital be it impending respiratory arrest or lack of creamer for the morning coffee. Either way I found it confusing and never saw it used.

Interesting. I imagine the RRT would be fairly busy if any RN who was 'concerned' called them in. The reason you'd call them is because it seems that in a lot of institutions getting and ICU consult isn't that easy. Here at least, we're often told 'doesn't sound like PICU material' or they refuse the transfer until the pt actually codes. I don't know what others experience is with that mentality however.

But for an RRT to work, I think it should really be only for medical urgency and definitely not for patient satisfaction kind of stuff. Of course, that's the kind of thing JCHO really loves.

 

[michigangirl]

I did peds residency at hopkins and started intern year when Dr. Hunt (i'm assuming the person who came to talk to you at grand rounds) directed the institution of the rrt. its a great thing..serves many purposes. the most recent rrt i remember was a POD 10 s/p tet repair on the floor infant-- nurses were concerned about respiratory rate and retractions...sats were still 100%. they called rrt and it was a nice, calm, peaceful evaluation of the patient in conjunction with the picu fellow-- we ended up transferring patient to the picu, she got intubated within a few hours-- all was well.

bottom line-- it prevents chaos when the kid really does crump. enables conversations between the nurses and docs as to what the next course of action should be before the patient is in real danger. And one of the most important things is that the nurses often don't feel they are getting adequate responses/concern from the surgical junior residents covering their patients, so they call RRTs before this becomes very detrimental.

To my surprise, there weren't many more RRTs than code calls. but it seemed the actual "codes" severely diminished.

I'm a big fan. and as a future picu fellow, i'm sure that will continue to grow.

 

[bensadic]

Sharek P, et al. Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a Children's Hospital. JAMA. 2007 Nov 21;298(19):2267-74

"CONCLUSION: Implementation of an RRT was associated with a statistically significant reduction in hospital-wide mortality rate and code rate outside of the pediatric ICU setting."

As a PICU fellow at the children's hospital in this paper, and someone who goes to these rapid response calls, I definitely think that they are a good thing. Better overall for patient safety. I definitely see a difference between the number of codes called here, as compared to where I did my residency (where they were in the process of forming an RRT when I left).

 

[jonb12997]

interesting... the small community hospital where I'm doing my third years has a "rapid assessment team" (they call a "RAT code" overhead, it's very funny). It's basically the head ICU nurse, 1 PCU nurse, 1 nursing manager (who often isn't useful), a resp therapist, and whichever resident/FP/IM/surgeon happens to be around at the time (remember I said small community hospital), and someone hopefully brings a Max Cart, but that's another issue entirely... It seems to work pretty well. i've seen some VERY sick people be kept from coding and then transferred to ICU or PCU. so it's probably a very similar thing in a bigger pediatric hospital.

 

[Complications]

We started RRTs in the fall. Not sure we've collected all the data yet, but it really does appear that codes have fallen off.

Our RRTs can be called by any staff, RNs, etc.

The team consists of Peds Hospitalist, PICU fellow, resp therapist, PICU nurse (I think that's it).

Some places are pushing families being able to call RRTs ... it's interesting.

The only thing I don't like is the way our teams are currently structured there is no resident on the RRT, though I think that's changing. From a patient safety perspective it is a ton better. From a learning perspective ... codes on the floor were certainly learning opportunities, mock codes are not the same no matter how good the simulators are.

 

[bensadic]

There aren't any residents on our RRT either, which I don't necessarily think is a bad thing. If the fellow is leaving the unit, someone from the PICU needs to stay behind (particularly at night) that knows the patients.

That being said, we try to take advantage of the "teachable moments" that rapid responses present. So in terms of learning, the floor team that has the patient in question should get something out of the experience. It could be learning the physiology leading up to the situation, what the next steps in management are as the patient gets prepared for transfer to the ICU (or to prevent such a transfer) or how a different management approach might have prevented the rapid response from being called in the first place.

 

[Stitch]

interesting... the small community hospital where I'm doing my third years has a "rapid assessment team" (they call a "RAT code" overhead, it's very funny). It's basically the head ICU nurse, 1 PCU nurse, 1 nursing manager (who often isn't useful), a resp therapist, and whichever resident/FP/IM/surgeon happens to be around at the time (remember I said small community hospital), and someone hopefully brings a Max Cart, but that's another issue entirely... It seems to work pretty well. i've seen some VERY sick people be kept from coding and then transferred to ICU or PCU. so it's probably a very similar thing in a bigger pediatric hospital.

Any thoughts on how do operate or implement an RRT in a hospital that doesn't have PICU fellows? Who comes and assesses or gives orders? Our PICU attendings don't stay in house unless there are post op hearts (first night), so they aren't routinely available either. When I run into problems as a night senior, I will ask the PICU RT or nurse to come take a look at the patient for another set of eyes. They're wonderfully helpful, but it's not quite the same.

 

[oldbearprofessor]

Any thoughts on how do operate or implement an RRT in a hospital that doesn't have PICU fellows? Who comes and assesses or gives orders? Our PICU attendings don't stay in house unless there are post op hearts (first night), so they aren't routinely available either. When I run into problems as a night senior, I will ask the PICU RT or nurse to come take a look at the patient for another set of eyes. They're wonderfully helpful, but it's not quite the same.

ER attending? In many smaller places that's the only attending in house 24/7. If you're part of an adult hospital they'll also be anesthesia in-house 24/7, but not at stand alone hospitals. ER folks might not like it, but either they or anesthesia are your best choices to go with the house senior, RT and nurse.

 

[CrazyPeds527]

We started RRTs in the fall. Not sure we've collected all the data yet, but it really does appear that codes have fallen off.

Our RRTs can be called by any staff, RNs, etc.

The team consists of Peds Hospitalist, PICU fellow, resp therapist, PICU nurse (I think that's it).

Some places are pushing families being able to call RRTs ... it's interesting.

The only thing I don't like is the way our teams are currently structured there is no resident on the RRT, though I think that's changing. From a patient safety perspective it is a ton better. From a learning perspective ... codes on the floor were certainly learning opportunities, mock codes are not the same no matter how good the simulators are.

Bump this thread...we are in the process of implementing our own RRT, in conjunction with a warning score system and I am looking for thoughts from residents, fellows and attendings on their RRT (or MET, code silver, or whatever) and for what things could be improved.

Thanks guys!

 

[TexasRose]

Bump this thread...we are in the process of implementing our own RRT, in conjunction with a warning score system and I am looking for thoughts from residents, fellows and attendings on their RRT (or MET, code silver, or whatever) and for what things could be improved.

Thanks guys!

As an intern, I really love the RRT system for several reasons.
1-I like knowing that ICU backup is a phone call away when I'm uncertain whether I can manage a patient on the floor. A great thing about our RRT's is that everyone is supportive, even when the decision is made to keep the patient on the floor. No berating for "unnecessary" calls, which means how other physicians will react does not play into the decision making process.
2- It's also a good teaching tool for how to handle a patient who might be heading south because you start the workup and then an ICU fellow shows up when the RRT is called and goes through the thought process with you. They'll go over the xrays, lab results at bedside while making the decision to escalate care or not.
3- Nurses can call RRT's. If a patient is heading south quickly, they can page me and the RRT at the same time, thus not wasting time waiting for me to arrive and make the decision.

I can't think of any downsides at this point.

Clear communication is important, however, and the system can easily be abused. It's awkward, too, when you as the physician think the patient is stable and nursing calls an RRT anyway.

 

[pedidoc]

We had an RRT for all of the hospitals where we rotated, but none of the hospitals had any PICU fellows. I know that in the largest hospital we did ICU in, the RRT was really good. We had a lot of liver and small bowel transplants and more often than not, the nurses weren't feeling like their patients were being taken care of by the surgery team. To be fair, the surgery residents were completely swamped and no one was really available to evaluate the patient. So, the nurse would initiate the RRT and we (the peds residents) went to all of the events even if we didn't have a formal consult from surgery or the ICU doc. It really helped facilitate transfer to the ICU because you were seeing the patients before they coded, whereas before, the surgery resident would tell you we're coding a patient and they're coming down to the ICU.

Of course, without a PICU fellow (just the peds residents covering the ICU), there were times that it was impossible to be in two places at once and you just had to prioritize. I would often send the intern to the RRT and then have them fill me in over the phone while I stayed in the ICU.

Just my two cents.

 

[PICUfellow]

I think it is difficult to have RRTs in a hospital that has no PICU fellows. I'm not sure of the usefulness of residents responding to RRTs. The whole point of an RRT is that someone with a little experience is coming to evaluate a patient that is deteriorating. If you have a 3rd year resident on the floor who calls an RRT, he might not have any use for the 2nd year resident that responds to the RRT.

This was how it was where I did residency - and basically the RRT was really just the initiation of a patient transfer to the ICU, and not necessarily that help was on the way.

I'm now in a PICU fellowship (hence my name!), and it makes so much more sense. Fellows respond to RRTs, and when we get up there, we may do anything from intubation to calling codes to reassurance/education of the residents. It just makes so much more sense for the responder to have a little more experience than the ones who called. Of course it helps that we always have multiple fellows on service in the unit at any given point in time - so if one fellow leaves to respond to an RRT, the unit is covered.

 

[CrazyPeds527]

Thanks for all of your responses! This will be interesting to help put this together.

Of course it helps that we always have multiple fellows on service in the unit at any given point in time - so if one fellow leaves to respond to an RRT, the unit is covered.

What are your thoughts when, at night, we only have one fellow in house. Would you have the fellow go for the RRT and the on-call PICU resident cover the unit? Who would serve back up if an RRT is called and you have a sick patient in the unit; call in the attending for the unit??

I can imagine sending an intern for an RRT being not all that helpful, for reasons stated previously by others; you want the experience there, not necessarily just an extra set of hands. Thoughts?

 

[kmzoe]

I'm an MS4 and did a PICU rotation at a place with RRT. We had no PICU fellows, but there was a PICU attending in house 24/7. For RRT, the attending, a nurse, an RT, and the 3rd year resident would respond. During the day, there are at least 2 attendings in house, and many residents, so the unit stays well covered. At night, there are always 2 residents on call and one attending. The attending and most senior resident on call (always at least a 2nd year, no interns) go to RRTs. This leaves one resident in the unit, and on some nights an NP. I never saw any issues with there not being enough people left behind in the unit. I felt like all the RRTs were good learning experiences for both the person calling it (anyone can call--I saw one called by a parent, one a nurse, and the rest were residents) and the resident responding with attending backup.