Rapid Response Team

pickledpepperRN · Aug 16, 2005

I usually bring my food for the night I have when unable to leave the unit or a patient had a can of Ensure. The black cherry flavor is gritty. Better than working 12+ hours on coffee and H2O.

Perhaps one of these evidence based studies will influence management somewhere. I have found that the threat of the truth made public is more influential. Kind of like the Linda Aiken study. Those who claimed to want staffing studies done didn't like that one at all.

http://www.ahrq.gov/research/nursestaffing/nursestaff.htm

"Lower Staffing Levels Are Linked to Higher Adverse Outcome Rates"

"Pneumonia Rates Are Especially Sensitive to Staffing Levels"

Mortality May Be Associated with Staffing Levels - "Failure to rescue" is defined as the death of a patient with a life-threatening complication for which early identification by nurses and medical and nursing interventions can influence the risk of death.

While inadequate staffing levels place heavy burdens on the nursing staff and adverse events are painful for patients, there is also a considerable financial cost to be considered

"Hospitals that increase their nurse staffing ratios either across all units or within individual units have reason to be concerned about the impact of such steps on their finances. However, a new study finds that increased staffing of RNs does not significantly decrease a hospital's profit, even though it boosts the hospital's operating costs. A 1-percent increase in RN full-time equivalents increased operating expenses by about 0.25 percent but resulted in no statistically significant effect on profit margins. In contrast, higher levels of non-nurse staffing caused higher operating expenses as well as lower profits." - 21. McCue M, Mark BA, Harless DW. Nurse staffing, quality, and financial performance. J Health Care Finance 2003 Summer 29(4):54-76.

Conclusion

The largest of the studies discussed here found significant associations between lower levels of nurse staffing and higher rates of pneumonia, upper gastrointestinal bleeding, shock/cardiac arrest, urinary tract infections, and failure to rescue.6,7 Other studies found associations between lower staffing levels and pneumonia, lung collapse, falls, pressure ulcers, thrombosis after major surgery, pulmonary compromise after surgery, longer hospital stays, and 30-day mortality.

http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat1a.section.9714

See page 8 of this document - http://www.ics.ac.uk/downloads/clinStandCriticalcare.pdf

"Mortality increased when the nurse:patient ratio increased, there was no full-time medical director for the ICU, fewer than 50% of the ICU attending physicians were certified in critical care, or there were no daily rounds by an ICU physician. (3(p1312)) Increased LOS was associated with not having a full-time medical director, a nurse:patient ratio of more than 1:2 during the evening shift, not having monthly review of ICU mortality and morbidity, and routine extubation in the OR. Another researcher extended the previous study and found 33% more respiratory complications in ICUs with low-intensity nurse staffing and 78% more cardiac complications in ICUs with medium-versus high-intensity nurse staffing after controlling for patient and organizational characteristics." - http://www.findarticles.com/p/articles/mi_m0FSL/is_3_81/ai_n13477156

pickledpepperRN · Aug 16, 2005

Yes, almost 60 years

History of Critical Care Nursing

Although very ill and severely injured patients have always existed, the concept of critical care is relatively modern. As advances have been made in medicine and technology, patient care has become much more complex. To provide appropriate care, nurses needed specialized knowledge and skills, and the care delivery mechanisms needed to evolve to support the patients' needs for continuous monitoring and treatment. The first intensive care units emerged in the 1950s as a means to provide care to very ill patients who needed one-to-one care from a nurse. It was from this environment that the specialty of critical care nursing emerged.

http://www.aacn.org/AACN/mrkt.nsf/vwdoc/AboutCriticalCareNursing?opendocument

Singapore Critical Care Nurses Chapter:

http://www.sna.org.sg/cms/publish/printer_25.shtml

History of AACN:

http://www.aacn.org/AACN/mrkt.nsf/vwdoc/HistoryofAACN?opendocument

Dinith88 · Aug 17, 2005

I usually bring my food for the night I have when unable to leave the unit or a patient had a can of Ensure. The black cherry flavor is gritty. Better than working 12+ hours on coffee and H2O.
Perhaps one of these evidence based studies will influence management somewhere. I have found that the threat of the truth made public is more influential. Kind of like the Linda Aiken study. Those who claimed to want staffing studies done didn't like that one at all.
http://www.ahrq.gov/research/nursestaffing/nursestaff.htm
"Lower Staffing Levels Are Linked to Higher Adverse Outcome Rates"
"Pneumonia Rates Are Especially Sensitive to Staffing Levels"
Mortality May Be Associated with Staffing Levels - "Failure to rescue" is defined as the death of a patient with a life-threatening complication for which early identification by nurses and medical and nursing interventions can influence the risk of death.
While inadequate staffing levels place heavy burdens on the nursing staff and adverse events are painful for patients, there is also a considerable financial cost to be considered
"Hospitals that increase their nurse staffing ratios either across all units or within individual units have reason to be concerned about the impact of such steps on their finances. However, a new study finds that increased staffing of RNs does not significantly decrease a hospital's profit, even though it boosts the hospital's operating costs. A 1-percent increase in RN full-time equivalents increased operating expenses by about 0.25 percent but resulted in no statistically significant effect on profit margins. In contrast, higher levels of non-nurse staffing caused higher operating expenses as well as lower profits." - 21. McCue M, Mark BA, Harless DW. Nurse staffing, quality, and financial performance. J Health Care Finance 2003 Summer 29(4):54-76.
Conclusion
The largest of the studies discussed here found significant associations between lower levels of nurse staffing and higher rates of pneumonia, upper gastrointestinal bleeding, shock/cardiac arrest, urinary tract infections, and failure to rescue.6,7 Other studies found associations between lower staffing levels and pneumonia, lung collapse, falls, pressure ulcers, thrombosis after major surgery, pulmonary compromise after surgery, longer hospital stays, and 30-day mortality.
http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat1a.section.9714
See page 8 of this document - http://www.ics.ac.uk/downloads/clinStandCriticalcare.pdf
"Mortality increased when the nurse:patient ratio increased, there was no full-time medical director for the ICU, fewer than 50% of the ICU attending physicians were certified in critical care, or there were no daily rounds by an ICU physician. (3(p1312)) Increased LOS was associated with not having a full-time medical director, a nurse:patient ratio of more than 1:2 during the evening shift, not having monthly review of ICU mortality and morbidity, and routine extubation in the OR. Another researcher extended the previous study and found 33% more respiratory complications in ICUs with low-intensity nurse staffing and 78% more cardiac complications in ICUs with medium-versus high-intensity nurse staffing after controlling for patient and organizational characteristics." - http://www.findarticles.com/p/articles/mi_m0FSL/is_3_81/ai_n13477156

Thats a nice array of studies. However, my question wasnt regarding staffing levels/ratios (i think that staffing ratios affecting pt mortality/outcomes is a no brainer thats been studied alot). I was curious if there'd been any studies that directly implicate ICU nurses reponding to Codes as a factor in increased patient mortality/complications. I dont think there has been...and i think it would be great if someone did. (any takers?? )

Anyway, if you know of any studies that have, i'd be highly appreciative if you could point me in their direction!

Cheers!

pickledpepperRN · Aug 17, 2005

Thats a nice array of studies. However, my question wasnt regarding staffing levels/ratios (i think that staffing ratios affecting pt mortality/outcomes is a no brainer thats been studied alot). I was curious if there'd been any studies that directly implicate ICU nurses reponding to Codes as a factor in increased patient mortality/complications. I dont think there has been...and i think it would be great if someone did. (any takers?? )
Anyway, if you know of any studies that have, i'd be highly appreciative if you could point me in their direction!
Cheers!

I don't know of any either.

You're right. It would make an important study.

My thinking is that since patients conditions can change so suddenly that would be likely to be missed by the nurse responsible for twice as many patients. Leading to 'failure to rescue' caused mortality.

I don't think a retrospective study could be done unless some units keep excellent records of the timing of codes, who went, and what their assignment was.

I remember once being asked to go to the ERto assist with an acute MI. I gave the supervisor report on my patients so they became hers.

I was gone about 45 minutes. When I got back one patients BP was next to nothing, her A-line alarm ringing. I quickly checked her and asked this supervisor to go into my other patients room with the call light on.

Patient #1 got her head lowered and Dopamine increased.

Patient #2 was alert and angry in a wet bet. She was on a vent but able to write legibally and use the call light. Receiving Lasix caused her to need the bedpan often as I had reported to the supe.

This woman was reading a tabloid paper as alarms and call lights sounded.

Might as well not have had relief. (Clearly her skills were not current. She shouldn't have assumed responsibility for the patients)

Patient #1 became septic and did not leave the hospital alive. Was it due to the extreme preventable untreated hypotension? I think it may be. Can't prove it.

I think someone smarter than I am can construct the study you suggest.

What a great idea!

darienblythe79 · Aug 17, 2005

Thats a nice array of studies. However, my question wasnt regarding staffing levels/ratios (i think that staffing ratios affecting pt mortality/outcomes is a no brainer thats been studied alot). I was curious if there'd been any studies that directly implicate ICU nurses reponding to Codes as a factor in increased patient mortality/complications. I dont think there has been...and i think it would be great if someone did. (any takers?? )
Anyway, if you know of any studies that have, i'd be highly appreciative if you could point me in their direction!
Cheers!

The RRT I belong to is piloting a research study looking at pt mortality/morbidity r/t response and utilization of this team. We have a dedicated code team already from the ER. ICU nurses do not repond to codes outside of the units. Your suggestion would be quite an undertaking, but you sound motivated to do something at least within your own facility. Good luck with that.

ZASHAGALKA, RN · Aug 17, 2005

The problem and management's rationale is going to be that there aren't enough critical care nurses NOW, much less dedicating slots for critical care nurses that don't take patients.

When busy (more often than not), my unit probably hands out 30-40 overtime shifts a week, plus an equal number of turn downs on being begged to come in on your day off.

Even if a dedicated code and/or RRT team were established, if they weren't the first on the cutting block during the next wave of 'consultants', there would certainly be a 'coverage' creep (we don't have enough nurses, so we need you to take a patient in the meantime). . .

And just try having a dedicated RRT in house when a salaried manager has to cover a shift. Shoot, I even agree - if I were a manager being forced to work extra without extra pay, I'd raise a fit if there were a critical care nurse available and not taking the patients I was called in to take . . .

The problem is that these programs aren't being designed with user input. Any good product is designed with input of the end user in order to complement that user.

RRT COULD be a great program, if only the people implementing it would seek the RIGHT input, first. I'm glad IHI is recommending proactive steps to improve care, but who knows better about improving care than those actually providing it!

~faith,

Timothy.

JustMe · Aug 17, 2005

Our facility just started the RRT program, so it's still being evaluated. The first RRT call took the nurse from CICU for over an hour! We were told it should take no longer than 20 minutes. Obviously someone isn't doing their job. But then I heard it took the doc over 30 minutes just to return the call! Maybe the docs need to get an inservice as well.

darienblythe79 · Aug 17, 2005

The problem and management's rationale is going to be that there aren't enough critical care nurses NOW, much less dedicating slots for critical care nurses that don't take patients.
When busy (more often than not), my unit probably hands out 30-40 overtime shifts a week, plus an equal number of turn downs on being begged to come in on your day off.
Even if a dedicated code and/or RRT team were established, if they weren't the first on the cutting block during the next wave of 'consultants', there would certainly be a 'coverage' creep (we don't have enough nurses, so we need you to take a patient in the meantime). . .
And just try having a dedicated RRT in house when a salaried manager has to cover a shift. Shoot, I even agree - if I were a manager being forced to work extra without extra pay, I'd raise a fit if there were a critical care nurse available and not taking the patients I was called in to take . . .
The problem is that these programs aren't being designed with user input. Any good product is designed with input of the end user in order to complement that user.
RRT COULD be a great program, if only the people implementing it would seek the RIGHT input, first. I'm glad IHI is recommending proactive steps to improve care, but who knows better about improving care than those actually providing it!
~faith,
Timothy.

We are paid out of an entirely different department instead of nursing, so when as ususal the ICUs run short, I cannot get pulled into the census to take patients. I do see your point though. I would be pretty steamed if I was a unit manager and I was staffing the unit. Our hospital prides itself on being nurse-first. We have a Staff Nurse Council with at least one representative from every pt care area in house. The council discusses issues pertinent to the bedside nurse, and present these issues to the Nurse Executive Council and so on. We don't always get our way, but there is usually some sort of compromise that we can come to. It has really helped establish the bedside nurse as a power to really help improve the workplace because your absolutely right, "who does know better about improving care than those actually providing it!"

Dinith88 · Aug 19, 2005

The problem and management's rationale is going to be that there aren't enough critical care nurses NOW, much less dedicating slots for critical care nurses that don't take patients.
When busy (more often than not), my unit probably hands out 30-40 overtime shifts a week, plus an equal number of turn downs on being begged to come in on your day off.
Even if a dedicated code and/or RRT team were established, if they weren't the first on the cutting block during the next wave of 'consultants', there would certainly be a 'coverage' creep (we don't have enough nurses, so we need you to take a patient in the meantime). . .
And just try having a dedicated RRT in house when a salaried manager has to cover a shift. Shoot, I even agree - if I were a manager being forced to work extra without extra pay, I'd raise a fit if there were a critical care nurse available and not taking the patients I was called in to take . . .
The problem is that these programs aren't being designed with user input. Any good product is designed with input of the end user in order to complement that user.
RRT COULD be a great program, if only the people implementing it would seek the RIGHT input, first. I'm glad IHI is recommending proactive steps to improve care, but who knows better about improving care than those actually providing it!
~faith,
Timothy.

Well said...

Dinith88 · Aug 19, 2005

The RRT I belong to is piloting a research study looking at pt mortality/morbidity r/t response and utilization of this team. We have a dedicated code team already from the ER. ICU nurses do not repond to codes outside of the units. Your suggestion would be quite an undertaking, but you sound motivated to do something at least within your own facility. Good luck with that.

I beleive there've been a few notable studies that suggest the RRT improves mortality/morbidity, etc. (first coming out of Australia??)...

Anyway, actually the study i would *like* to see done isnt so much another "does RRT improve pt outcomes" but rather a "do icu nurses responding to codes (or rrt, etc) adversely affect pt outcomes"-type study. I dont know if anything like that has ever been done.

By the way, do your dedicated code ER nurses take patients? If they do, then thats not exactly what i meant by 'dedicated'. I was meaning dedicated in a 'stand-by' type role.

darienblythe79 · Aug 19, 2005

I beleive there've been a few notable studies that suggest the RRT improves mortality/morbidity, etc. (first coming out of Australia??)...
Anyway, actually the study i would *like* to see done isnt so much another "does RRT improve pt outcomes" but rather a "do icu nurses responding to codes (or rrt, etc) adversely affect pt outcomes"-type study. I dont know if anything like that has ever been done.
By the way, do your dedicated code ER nurses take patients? If they do, then thats not exactly what i meant by 'dedicated'. I was meaning dedicated in a 'stand-by' type role.

they are dedicated by your definition. they just come from the er not icu

christianRN · Aug 30, 2005

Our hospital has had a RRT for about 4 mos. The ICU charge nurse and an RT carry a beeper, and if a nurse from another unit wants "another set of eyes and ears," to check on a pt, she can call the RRT. Often times the RRT may think of something else (let's check her blood sugar, etc.) and it's not a big deal. Sometimes the RRT calls a code immediately after assessing the scene. Sometimes the RRT talks to the family and/or pt about DNR status.

The goal of the RRT is to prevent actual codes before they happen. Overall, I think our team has been very successful. We have some freedom as far as we can do an ABG, CXR, labs, give O2, or do an EKG, etc. before calling the doc.