Proactive Rounding and Family Initiated RRT

[Pprwrk]

I am looking into developing a proactive rounding aspect to our Rapid Response system. I am also looking into developing a process for patients and visitors to activate the rapid response team. The proactive rounding would have the ICU nurse/RRT nurse (we have no dedicated RRT nurse) round to each inpatient unit at least once per shift, to talk to the floor nurses and see if there are any concerns about patient conditions (not yet an RRT call, but may be heading that way) and help to address the concerns of the nurse, facilitate interventions for the patient, and get the patient on the ICU 'radar' (what this would entail as far as ICU physician follow-up or contact with the floors' medicine teams/surgeons, I do not know yet). What are YOUR experiences with proactive rounding and/or patient and visitor initiated RRT calls??

Thanks.

[sallyrnrrt, ADN, RN]

My personal experience is that family members are more likely to call a rapid response if the patient doesn't get ice on time or if the nurse doesn't smile enough than if the patient is having an actual emergency. I have had family members hit the code button because the patient was hungry and they knew that would get people in the room, too.

However, there have been a few times that family was on the money with the call. It is probably worth it for the rare occasions that the family members use it appropriately.

As far as proactive rounding... how many RRT people do you have on a shift at any given time? We have a primary and a secondary person, from different ICUs, but even with two there is no way to go up to all the units and just talk to the nurses. Some nights both RRT people are tied up all night long and don't even get a chance to take a lunch break.

post bypass and only several hours on steps down, my husband went into the usual SVT, that frequents rica grafts, but when his bp, tanked to 80 systolic, and I was the only one monitoring his vs..... I went to his nurse, in my most 4decades of experience, stated, "you will get his heart rate under control, or I am calling RRT, you can explain to administration why family had to call A RRT. She honestly said to me, "0im going to start a cardizyme drip, but do not know how much bonus to give"; I had to quit being the knowledgeable concerned wife, and directed her to give 50%bolus and start the drip she could alway give more....... I know that most family members do not have over four decades of critical care experience...but my husband was symptomatic for several hours....I did not become the "pain in" until his BP dropped.....she had six mos. post grad experience, but had been thru 6wk critical care course of orientation......

so yea yea I can see where family can call RRT..... It really does not take a policy, just picking up phone and telling operator RRT, room 412S

[nutella, MSN, RN]

post bypass and only several hours on steps down, my husband went into the usual SVT, that frequents rica grafts, but when his bp, tanked to 80 systolic, and I was the only one monitoring his vs..... I went to his nurse, in my most 4decades of experience, stated, "you will get his heart rate under control, or I am calling RRT, you can explain to administration why family had to call A RRT. She honestly said to me, "0im going to start a cardizyme drip, but do not know how much bonus to give"; I had to quit being the knowledgeable concerned wife, and directed her to give 50%bolus and start the drip she could alway give more....... I know that most family members do not have over four decades of critical care experience...but my husband was symptomatic for several hours....I did not become the "pain in" until his BP dropped.....she had six mos. post grad experience, but had been thru 6wk critical care course of orientation......

so yea yea I can see where family can call RRT..... It really does not take a policy, just picking up phone and telling operator RRT, room 412S

Ok - that is outright scary and the best example of why this patient should have been a rapid response - to get knowledge and resources to the bedside. Again, a RR is to prevent worsening of condition and if possible correct something and avoid intensive care or a late response with adverse effect.

[sallyrnrrt, ADN, RN]

Family initiated rapid responce... please do not do it. Just PLEASE.

Families are not able to notice, understand and analyze the clinical situation, period. Not only they will call incessantly for water with no fresh ice and no "adult fun" available on tv, but there will be missed deteriorations with patient appearing to snooze peacefully.

I know there were couple of cases that appear to justify family-initiated rapid responce, but those were exclusions. If you do not want families running your unit as they see it fits, simply make sure that nurses react promply on alerts and educate family right upon admission about who is doing what here.

Katie, not all families are without knowledge....I speak from 44years critical care experience......

remember, not all family are "lay people". Some of us have decades more experience

[FurBabyMom, MSN, RN]

Where I used to work we our rapid response team calls could be initiated by staff (nursing assistants, PT/OT, radiology techs, licensed nursing staff, etc) or patients/family members. We had specific criteria of what should trigger the rapid response team call. We had specific things that staff would notice/see and patients would complain of/about plus changes in vital signs (we had parameters but also if vitals were more than a specific amount of change from baseline not explained by activity/etc). There were specific examples given to patient/families at admission...shortness of breath/can't catch breath, chest pain, altered mental status/change in LOC - with specifics included. Our hospital operator would record who called in - staff via hospital mobile phone, staff via patient bedside phone, patient/family via bedside phone. I don't feel like we had more rapid response calls than in similar facilities... I do know that the licensed nursing staff used to have issues obtaining orders from residents - and after a certain amount of time would rapid response patients for orders (certain number of unreturned pages too).

[sallyrnrrt, ADN, RN]

Oh, and let's not leave out, they waited one hour from beginning of symptomology to call me, and it took me one hour drive to get to the hospital from my farm...... I would of never left the hospital if I had not been assure, he will not be transferred to stepdown, till tomorrow, and yes it was 1am, and with no sleep I had to give these ultimatums to his nurse.... Awg....... Best practice , this just does not happen

[TriciaJ, RN]

Family initiated rapid responce... please do not do it. Just PLEASE.

Families are not able to notice, understand and analyze the clinical situation, period. Not only they will call incessantly for water with no fresh ice and no "adult fun" available on tv, but there will be missed deteriorations with patient appearing to snooze peacefully.

I know there were couple of cases that appear to justify family-initiated rapid responce, but those were exclusions. If you do not want families running your unit as they see it fits, simply make sure that nurses react promply on alerts and educate family right upon admission about who is doing what here.

I can see hospitals jumping on Family-Initiated Rapid Response just like putting alarms on every bed and chair. Just another work-around instead of staffing with a safe and appropriate number of RNs.

If there were simply enough of us, we wouldn't need to rely on families to put out our fires.

[Susie2310]

Family members/the general public are very often quite capable of recognizing a situation where their family member is either deteriorating/at risk of deteriorating or where something else is wrong with the care their family member is receiving. They should have the means available for them to summon help if needed.

I have seen signs posted on the walls of patients rooms informing patients/family of the RRT phone number with a message that encourages patients/family to call if they have concerns about the patient's condition and/or about the care they are receiving. Interestingly, I did not observe the signs on all of the patient units my family member received care on, just certain one/s.

I have also seen at another facility the RRT phone number with a message encouraging people to call if one is concerned about the patient's condition or the care the patient is receiving given to patients/family as part of their admission documentation/information.

It's not rocket science.

[nutella, MSN, RN]

I can see hospitals jumping on Family-Initiated Rapid Response just like putting alarms on every bed and chair. Just another work-around instead of staffing with a safe and appropriate number of RNs.

If there were simply enough of us, we wouldn't need to rely on families to put out our fires.

I want to add that imo safe staffing, while important, will not prevent patient harm on all levels.

A multimodal approach is important. I have seen patients go downhill or code despite the fact that the nurse had only few patients or less than the "usual". Of course the system plays a role and providing sufficient staffing is very important but it does not address other problems enough. For example - if a nurse is still on the newer side or has a "blind spot" she/he may think "respiration rate of 36 is not so bad" focusing on the number on the monitor while the family member might say "my loved one looks horrible, hardly able to breath, bluish nails - I want a doctor to see him/her".

There will be always some "fires" - even with sufficient staffing.

In times of patient-centered care families should have the possibility to voice valid concerns in a way the results action.

[sallyrnrrt, ADN, RN]

Katie, in my situation, at least I took my husband's bp, which had not been documented for two hours, even with him on telemetry and demonstrating heart rate 140-160...... Clue the bp might be low, all families are not without acceptable knowledge, his fairly new BSN, was without adequate critical thinking skills....... She actually verbalized to my husband, Your are just doing this to yourself, related to his apprehension, with a 140 heart rate, feeling of breathlessness , and then his nurse taking over an hour to call, me..& took me a physical hr to get there, before appropriate intervention was done ! .remember, it was still two hours after symptomology of SVT, and dropped bp, response from his nurse, "I'm going to start a drip, but don't know how much bolus to give"...... Yea some families need to call the RRT

[sallyrnrrt, ADN, RN]

Ps I am not picking on Katie, just the content of her response,

[nrsang97, BSN, RN]

Speaking as a rapid response nurse here, we have the capability of families to call a rapid response. Our operators are trained to ask what the concern is and that the appropriate help will be dispatched. It is called a "code help". Honestly no one has ever used it. If a family member brings a concern to the nurse and the nurse is concerned they will go ahead and page for a rapid response.

Our hospital has a dedicated rapid response nurse so we do round each shift. Sometimes concerns are brought to my attention as I am rounding, and other times I am called or paged. If someone calls for my opinion and I feel a rapid response is warranted I tell them to call the operator and ask for a rapid response to be called to that room and I will be on my way there.

In addition to calls for patients with a change in condition such acute mental status changes, falls, elevated HR >130, HR 180, SBP 30 or

[hawaiicarl, BSN, RN]

We started the family initiated RRT a couple years ago, and I had a lot of the same concerns that the people above mentioned. None of them came to pass, it was just another piece of paper in that admission packet that all the patients ignore. I try to round on tele every shift just to keep tabs on potential patients, some shifts I am too busy with patient care, so it gets missed. I also have a great set of RTs, so if they are seeing a patient heading to crumptown they always give me a heads up.

Cheers