Proactive Rounding and Family Initiated RRT

twss2323 · May 21, 2016

I don't have any first hand experience, but patient/family initiated RRT sounds like a giant can of worms. What may seem like an "emergency" to a patient or family member could be a giant waste of time and resources. Imagine someone initiating an RRT because the nurse hasn't gotten them their pain meds fast enough or the aide got busy and forgot to refill their water pitcher?

twss2323 · May 21, 2016

Proactive rounding sounds like a good idea. It could take care of problems before they are bigger problems and actually warrant going to the ICU. I'd be really interested in hearing others' experiences with that.

sandytoes · May 21, 2016

I think the rounding sounds like an excellent idea. I work on a high acuity unit with a high proportion of RRT vs the rest of the hospital. Would be great to see the RRT and also get to know them outside of an urgent/emergent situation.

Pprwrk · May 21, 2016

From what I am reading, the Patient/Family initiated RRT call is presented in different ways (through posters, brochures, explanation by the nurse) as something to be initiated by the concerned family/patient in situations ranging from 'something isn't right' to 'like calling 911' and also including specifics such as 'you have already addressed concern with nurse and physician but still feel like there is something wrong/problem not addressed' and even further specifics such as 'change in breathing, change in mental status' etc. It seems to depend on the facility. There are calls that turn out to be non-emergent, but from what I am reading, it has not blossomed into a general abuse of the system. HOWEVER, I have not heard from nurses first-hand about the realities of this in their facilities.

As for the rounding, I have only heard from a few nurses who spoke of a facility that actually has a dedicated RRT nurse, who does rounds and acts as a resource and an extra set of hands on all inpatient units unless an RRT is called. Our ICU nurse would not have that luxury. The feedback I have gotten from our ICU nurses is that the process would take too much of the ICU nurse's time, and the floor nurses would depend on the ICU nurses too much to address problems. The floor nurses, overall, see relieved to have someone from the ICU come around to check in. I, too, am already sensing that the rounds I have done (informal, trying to get feedback), are something that the charge nurse or nurse manager should be doing. Also, I checked in at 5:30 am, but that did not prevent a RRT at 1pm. Things are constantly changing, and I am wondering how effective the program would be for patient care, aside from uncovering knowledge gaps in nursing policy/procedure in the bedside nurses, and inefficiencies in interns and residents addressing problems; uncovering systems problems, not patient condition issues.

Pprwrk · May 21, 2016

So far, just seeing my face, getting to know me, knowing that the support is there HAS been positive for the floor nurses. Some of them feel very unsupported and crave a better relationship with the ICU, and greater sense of 'all hospital nurses as a team' instead of 'ICU vs ER vs this floor vs that floor'.

RainMom · May 21, 2016

We have the family/pt initiated RR but I've never heard of it being used as intended. I did hear how one pt used it in the middle of the night when he wasn't happy with his pain medication. We have a brochure we give & when I do an admission, I try to emphasize to call for the nurse first unless it is truly a 911 type of emergency (but still call us too! We are the closest help!)

As far as rounding, the shift supervisor does that as they respond to any RR as well. Also there is a meeting each shift (charges, supervisor, etc) to identify any potential problems, whether pt, equipment, or staffing related. So the supervisor will know who the highest risk pts are to follow up.

offlabel · May 21, 2016

I guess I'm missing why the ward nurses might need a "middleman" with regard to concerns they have over certain patients. If they need someone to facilitate communication with the patient's doctor for whatever reason, that is what should be addressed, IMO. Further, if there is a knowledge deficit as to when help needs to be called, that needs to be fixed.

As practiced where I am, while unexpected declines in medical status do occur, often RRT calls are made because someone missed something. These rounds would be to assess issues that have not been missed, correct?

Here.I.Stand, BSN, RN · May 22, 2016

From what I am reading, the Patient/Family initiated RRT call is presented in different ways (through posters, brochures, explanation by the nurse) as something to be initiated by the concerned family/patient in situations ranging from 'something isn't right' to 'like calling 911' and also including specifics such as 'you have already addressed concern with nurse and physician but still feel like there is something wrong/problem not addressed' and even further specifics such as 'change in breathing, change in mental status' etc.

Honest question...what's wrong with the family notifying the bedside RN if they are concerned? Why skip straight to an RR call, to be responded to by RNs who have not gotten any sort of report on the pt, and leave the primary RN clueless as to the concern? With a staff-initiated RR call, the primary nurse IS giving the RR nurse a brief report with the background and assessments, all that jazz. Besides, the bedside RN s already on the floor. They will almost always get to the pt's room before the RR RN would. Not the most efficient system for getting help fast.

I can also see it being a huge drain on resources. One example, just the other day a family member came running to the desk, freaking out about the pt's low BP. I went into the room and immediately figure out the problem: BP is 92/88 with a flat arterial waveform. So I gave the line a quick flush, gave the family an explanation about the imperfections of art lines, and show them on the monitor that it's now reading 130s/70s with a waveform that shows me it is accurate. This family was probably nervous enough to activate a RR had that been available...but they got a response and a solution from me in about 30 seconds.

Here.I.Stand, BSN, RN · May 22, 2016

As for the proactive rounding, is this a dedicated ICU RN we're talking about? Or is it an RN with pts -- I don't know how this would work? Round with the floor RNs in between caring for his/her own ICU pts? What I have heard about this kind of system where an RN rounds on pts who have a higher likelihood of complications, said rounding is done by the RR RN.

Elliot.Kane · May 22, 2016

Isn't all rounding proactive? Usually a good nurse would let the hospitalist know first and then if they thought it was serious they'd contact the intensivist first. The intensivist would then probably go put eyes on this patient as a courtesy to determine if they are critical, or a basic floor level fix. You don't have to create a system for a system that already exists. Indeed, you may simply complicate an already simplified system that the family is unlikely to appropriately use.

Furthermore, maybe this is simply a necessary reminder to reteach your nurses to use the chain of command. You can't get in trouble for calling a rapid. But you'd be better advised to seek help before a rapid is called, if you can. Also, the way this question is framed in a way that supposes you sit behind a desk that exposes you to little clinically and that you're seeking a kudos for the paperwork you create.

Pprwrk · May 22, 2016

I am imagining this happening. and so are the other nurses and physicians. But I am wondering what the reality is in hospitals that already uses this approach, not just what we are afraid might happen.