Do RN led Rapid Response Teams Have Too Autonomy?

[Sweets, ADN, BSN, RN]

Hello everyone, thank you for taking the time to read this and hopefully send feedback. Here's a brief run down of the situation:

I work at a 800 bed teaching hospital, not University based, in NC. We have a dedicated, RN led, Rapid Response Team that uses a pre-approved order set/protocol, based on common emergencies. In the beginning, of course it was very basic & the order set/plan had to be presented & approved by our MAC (medical administration committee) before it was put into use. It was revised in 2009, and again had to be presented & approved, which it was. At that time we added an anaphylaxis reaction, sepsis, ACS & NPPV for respiratory distress subplan.

We have been using the order set/protocols for the past 9 years without problems. Then, couple years ago, we acquired new critical care management who now feel we have too much autonomy, or so it seems. This director wants the team to have to call the physicians before initiating orders from our order set, such as ABG's w/lactate, NPPV, IV fluid bolus ect...Of course the physicians are paged as soon as possible but sometimes stopping to page instead of treating the emergency can literally mean the difference on whether that patient codes or not.

So, my questions are, how does your Rapid Response Teams function? Do they have order sets they can institute prior to paging the physician? What is on them?

Basically, tell me how your team functions at your hospital please.

Thanks in advance.

[Kaisu]

I can't answer your question, but it seems bizarre to me that paramedics all operate under protocols and order sets, with far less education and the ability to perform invasive interventions ( IO infusions, jugular IVs, intubations, needle decompressions, crichs, and in some states, needle pericardiocentesis). Now that's autonomy.

[Buckeye.nurse]

I also work in a large teaching hospital. Our rapid response nurses are called the STAT team. They respond to ERTs, codes, stroke alerts/codes, and visitor emergencies. They also round on patients who flag in their sepsis monitoring system or have high MEWS scores. When rounding they will ask the charge RNs if there are any patients they are worried about. We can also call them to come see a patient if we are worried about them but don't feel that calling an ERT is warranted yet.

Our STAT team doesn't have protocols, but all the nurses on it have ICU or ER experience, and have the skills to be assertive with the physicians. Generally though, our medical teams know the role of the STAT nurse, and take their suggestions for interventions seriously. When we call an ERT the physician team is also paged and is expected to respond within 5 minutes. They problem solve along with the STAT nurse (and bedside nurse) and come to a consensus on the treatment plan for the patient going forward before we end the ERT.

[Sweets, ADN, BSN, RN]

Addendum: I forgot to mention our hospital only has this team for emergencies. Our Rapid Response team for this 800 bed hospital also are the Code Blue & Code Stroke RN's, and assists visitors with emergencies.

[PeakRN]

Rapid responses are managed by the ICU and PICU charge RN and house supervisor, though typically there are a few other nurses that respond. Since the goal is to keep the patient on the floor that they are from they will initially try to manage the patient within their current orders and resources on that floor, however they do have some standing orders and can easily call the adult or pediatric intensivist. We have a relatively low threshold for calling rapid responses and codes, so we try to intervene early to prevent needing to suddenly place new orders.

If patients are determined to need care beyond the capabilities of the floor they are on the ICU/PICU charge nurses have much greater scope with standing orders since they will be admitted under the intensivist. The determination is made by the ICU/PICU charge nurse who can also talk to the intensivists if then need help with determining the need for intensive care, however the floor physicians cannot refuse or stop evaluations by the ICU/PICU nurses or intensivists.

[JKL33]

It sounds primarily like you need to have the responsibility of paging out the appropriate service assigned to one of the RRT members. There's really no reason that someone can't be assigned to accomplish this STAT. I can't see how sending a page and taking care of the patient can't be accomplished simultaneously. If that isn't happening right now then an additional responding member needs to be added.

RRTs are fantastic, IMO, but one of the manifestations I've noticed is that since they operate off protocols, people tend to forget that the provider team responsible for the patient has a very vested interest in being involved in what is going on....rightfully. And it is in the patient's interest to have these individuals involved ASAP, too. RRT protocols were not meant to allow the team to begin extensive work-ups. They are there to get the ball rolling in the short interval until the responsible provider service responds.

I would push back against the idea that the providers need to give real-time permission for an appropriate and approved RRT protocol to be enacted, though. That's the whole point of a protocol. If they have issues with the protocols themselves, they need to take that up with the committee or director who approved them.

[EllaBella1, BSN]

Our RRT also operates under a set of MAC-approved protocol order sets. I honestly think that having to call the doctor to approve the orders defeats the purpose of having a rapid response team in a sense. I 100% agree with your point that having to stop to wait for a doctor to call back can be the difference of life or death for a patient. At the same time I also think that the rapid response team is sometimes over utilized on the floors, especially at nights, by nurses who don't want to call the doctor regarding a change in condition.

Does your hospital have an in-house ICU resident or fellow at all times? What we have done with some success is had a designated RRT cell phone that the resident who is in house carries. If we need orders for something that doesn't fall under our protocol sets or have an emergent concern we call that phone and get orders from the ICU resident. Eliminates some of the time crunch of having to put a stat page out, etc. Perhaps your hospital could adopt a similar approach? I still think that some protocols need to stand though for even that to work.

[Creamsoda, ASN, RN]

Ours operates the same. We have protocols. Basically though if I am feeling I need to use my RRT protocols, of course I am having someone page the primary at the same time. But at least I can get the ball rolling. It would be stupid to say, sorry I cant put you on the bipap untill the doctor calls me back when someone is clearly circling the drain. In a perfect world, we would all get calls back within a few minutes, but that doesnt happen. Anything can happen in that 5 minutes. Someone has crushing chest pain? Im ordering a stat EKG and starting down the ACS pathway while paging the doc at the same time.

We have sepsis based order sets- fluid bolus, blood cultures, lactate.

ACS- EKG, nitro

Stroke- Stat CT head, EKG, labs

General stuff like ABG, CXR, labs.

Nothing on the order sets are rocket science and there isnt any medications on them except for the anaphylaxis one which is IM epinephrine and also Narcan, but narcan is actually on a hospital wide policy and anyone can give it if indicated. Oh an 1 mg ativan for seizure.

In fact, I dont even think bipap is on our order sets, but if I think the patient needs it, im going to get that going. When im the RRT nurse I do what is common sense. I dont like to step on toes, but if I have to I will and i can utilize our intensivist if I have to. There is definately that fine line of letting the primary make the call on orders, but I know when a situation is non urgent vs urgent/ emergent and know when I have to make the call or I can allow a bit of time for them to. Im not that cowboy nurse who walks into a situation take over and just act like im the boss and order whatever the hell I want. But if I am forced to I can :). So simple protocols are not giving us too much autonomy.

I wonder where your directors line of thinking is coming from. Is this a physician? Are they new to your facility? Do they not know your RRT team very well? Maybe they are uncomfortable because of that. Our RRT has a solid rapport with our ICU docs and the hospitalist group. When I am calling them, they sure do listen to us because they know we make a difference and know our clinical judgement is pretty solid. I dont call them unless I need too. I would suggest organizing a meeting with your RRT members and the management team just to discuss the concerns and maybe they will be more open about what their concerns actually are.

[AnnieOaklyRN, BSN, RN, EMT-P]

I can't answer your question, but it seems bizarre to me that paramedics all operate under protocols and order sets, with far less education and the ability to perform invasive interventions ( IO infusions, jugular IVs, intubations, needle decompressions, crichs, and in some states, needle pericardiocentesis). Now that's autonomy.

Paramedics DO NOT have "far less education", we have more focused education on emergencies versus nurses who generally have a broader education on wide spread ongoing problems that patient's encounter!!!! We are educated in a different manner to work autonomously, not educated less! As a matter of fact my paramedic program was two years, kind of like your RN program. Imagine that!! Educate yourself before you speak of something you have zero experience with!

I am going to go on the assumption that you are yet another nurse who treats medics like they are beneath you. Most medics can run circles around any RN in an emergent situation!!

Annie