Rapid Response

[PMFB-RN, RN]

12:19 pm by [COLOR=#003366]ready4nu

PMFB-RN, how did you go about becoming a rapid response nurse? What do you do during the time that there is no need for a rapid response?

We are a small group in my hospital. 5 of us full time with another 3 or 4 MICU and SICU RNs who are cross trained to cover for sick calls, vacation, etc.

Turn over is very low. Because of that we don't really try to train anyone to RRT, but rather look for and hire nurses who already have the skill set we are looking for. There are two main skill sets we are looking for. The first (and easiest to find) is clinical skills. We like nurses who have extensive background in critical care, at least 5 years adult ICU experience. In addition we like some ER and PICU experience 2 oe 3 years in each would be perfect. The best experience is transport nursing. I came to the job from a transport nursing job. Only one RRT RN has been hired since I got my job and they had everything we were looking for except peds experience and so, because she was such a great candidate otherwise, the hospital invested quite a bit of time in training her in PICU and peds ER. Obviously they would prefer not to do that.

We are required to stay current with BLS, ACLS (instructor and or ACLS for the experienced provider), PALS, NRP, Emergency Nurse Pediatric course, TNCC or ATCN, Fundamentals of Critical Care course, and the Physician's Advanced Airway Management course. We only take that once then maintain our intubation competency through a hospital course taught by our chief CRNA. We do 30 supervised intubations a year as part of that. All of us are instructors in several of the above. In addition we take a hospital based training program for the insertion of PICCs, arterial lines, IO's and IJ central catheters. Another job we do is run the SimMan lab for nurses and residents, teach "The First 5 Minutes" course to new RNs and teach RNs and residents to place IOs.

There is only one of us scheduled at night. Days shift has two RRT RNs scheduled 2 or 3 days a week and the extra RRT RN takes classes, teaches classes, runs SimMan labs for residents or nurses, teaches in the Critical Care Nurse Residency, etc. In addition we all have students, nurse residents, or new hire ICU & ER orientees with us nearly every shift.

When not on RRT calls we do a variety of jobs. We also check on all ICU transfers q4 for 24 hours, and check on all new admissions to the hospital, occasionally help out in one of the ICU's or ER, especially when there is a trauma team activation. of course since we nearly always have a nurse resident or student with us there is always teaching going on. In addition on nights we will do the skills test portion of ACLS and BLS for night shift nurses and residents. who renewed online. In addition to all that every night several of the attending physicians or NPs will give us sign out on any patients they are worried about and want us to "keep our eye on". This varies from one or two patient, to getting sign out on all the adult and peds patients for a whole medical or surgical service, depending on who the night resident is and how much the attending trusts them. We also get a lot of "hey can I run something by you", or "hey do you know how to..." and "I called the doctor and he is being a jerk, can you talk to him/her" calls from staff nurses. We will also get called on any combative patient. Every once in a while we get to sit with our feet up and do nothing except wait for the phone to ring! It sounds like a lot when I write it out but we are not a very big hospital.

I am not sure why they call us the Rapid Response Team. When an RRT is called all you get is one of us, not like a while team shows up.

In our health system we are called "Expanded Roll RNs". We have our own policies and standing orders that do not apply to any other nurses in the hospital.

The other thing we look for, and what is harder to find and teach than clinical skills, is a person who has the right interpersonal skills. We are often in the position of telling residents that their patient must be transferred to a higher level of care. We have a protocol that allows us to transfer to step down or ICU on our own without doctors orders, BUT, we are not supposed to do it unless we have to in order to protect the patient. We are supposed to help the residents "see the light" and transfer the patient themselves. We are often talking to attendings on the phone who are not expecting to get calls from nurses at night because they are supposed to have residents to deal with these things. That takes tact.

We also need a person who will not belittle, or be condescending to staff nurses when we get a call for something that seems stupid for us. We need nurses who are nurturing and will treat those calls as teachable moments. We need people who are VERY approachable by all staff who need our help or advice.

Because of the autonomy and higher pay we receive there is very little turn over of the RRT team.

[ready4nu]

Thank you for such a complete and informative answer, I appreciate it.

[rnkaytee]

Wow - that is an incredible set of skills! At our hospital we just started a Pediatric RRT group that consists of whoever didn't call "not it" fast enough. Basically we were handed a set of standing orders and a big bag of stuff and told us to go for it.

[PMFB-RN, RN]

Wow - that is an incredible set of skills! At our hospital we just started a Pediatric RRT group that consists of whoever didn't call "not it" fast enough. Basically we were handed a set of standing orders and a big bag of stuff and told us to go for it.

LOL! I wasn't around for the start of our RRT team but I know originally it was a couple of ICU charges nurses who got handed a pager. However we have very good data to support our team. We have dramatically reduced the ICU bounce back rate for all three patient population (medical, surgical and peds). We have saved the hospital vast amounts of money in reduced ICU days. Enough that they reduced the number of SICU beds by 4, the MICU beds by 2 and the PICU by 2.

Our data is very comprehensive. Enough so that we can even see trends for individual physicians. Some doctor's patients have more RRT calls than others. We average 100-130 calls a month. Obviously that is a lot of calls, but since we do not have our own patients and everybody knows that we are available 24/7, and that we won't beat them up for calling, we get a lot of calls. I average 12-15 calls a nights, 3 or 4 of which are actually RRT calls. The rest being false alarms, nurses, RTs or physicians calling for advice, help with IVs or other skills and consults. We are the IV, NG, IO, art line, and central line placers of last resort. If nobody else can get it then we get called. We are the first call for emergent intubations but a CRNA is usually, though not always paged as well and is our expert back up. However since we are a small hospital (about 250 beds) and only have one CRNA on at night they may not always be available when needed.

We also the code administrators. that means we are held responsible for the proper running of any code outside the ER (where the ER docs are responsible). Usually a resident runs the code and we help them if they need it (usually just suggestions), though often the residents are very good and we just push meds or whatever. Occasionally we will run the whole code. A while back I had to take over the running of a code from a resident who got excited and was unable to make himself understood in English.

Our residents and staff physicians are accountable for how they respond to an RRT. This means that when we call them we get their attention promptly. Try to blow off the RRT RN and they will find themselves standing in front of the chief of staff (who was instrumental in starting RRT and is a huge supporter and who is the RRT medical director) and explaining their actions, or lack of.

We occasionally get some push back from doctors or PAs who resent our intrusion into what they see as their domain. However the combination of improved patient outcomes (makes them look good) and support for RRT from the top usually overcomes this.

The best part of my job is that we are very popular with the staff RNs. They know we are only there to help and are not supervisors. We always get the call whenever a ward or unit is having a pot luck or celebration of some kind.

[nrsang97, BSN, RN]

We have 4 FT RRT RN's and 3 contingent RRT RN's. We had 91 calls last month. Some were false alarms, others were true patients in distress and needed higher level of care. We do tons of IV's and lab draws. Some we aren't able to get. We are not able to intubate or place lines such as art lines, central lines, or PICC lines. Most patients I am able to get an IV in or get their labs. We can do art sticks for ABG's. We are also code team, and to be activated with red level traumas.

Most of us have at least 3 years of adult ICU experience (we don't have any peds in our hospital). The majority of us came from our larger sister hospital and we are experienced at taking critical patients to and from testing. Most nights I can get up to 10-15 calls, some being false alarms, some being IV and blood draws, and others being true rapid responses.

[PMFB-RN, RN]

We have 4 FT RRT RN's and 3 contingent RRT RN's. We had 91 calls last month. Some were false alarms, others were true patients in distress and needed higher level of care. We do tons of IV's and lab draws. Some we aren't able to get. We are not able to intubate or place lines such as art lines, central lines, or PICC lines. Most patients I am able to get an IV in or get their labs. We can do art sticks for ABG's. We are also code team, and to be activated with red level traumas.

Most of us have at least 3 years of adult ICU experience (we don't have any peds in our hospital). The majority of us came from our larger sister hospital and we are experienced at taking critical patients to and from testing. Most nights I can get up to 10-15 calls, some being false alarms, some being IV and blood draws, and others being true rapid responses.

I am thrilled that there seems to be more and more full time RRT nurse positions. Do you have anything to do with the patients who transfer out of the ICU? We check on them q 4 for 24 and by doing to have drastically cut back on ICU bounce backs and saved the hospital a ton of money (not to mention better outcomes for patients). I ask because that money we save the hospital is a big selling point for keeping full time RRT RNs whenever there is talk of budget cutting.

[Butterfly41]

WOW I wish ours was this advanced and organized. Our RRT is the ICU charge nurse that's it. Soon they are placing bulletins in every patient room with an explanation of what the RRT is for and how even the family or patient themselves can call the RRT with the ICU charge nurse phone ext listed. I'm imagining calls like my nurse still hasn't brought me my pain meds I requested 5 minutes ago and I'm getting worse. Also I have concerns about the volume of phone calls preventing me from doing my charge nurse duties like backing my nurses insuring we have what we need to care for our patients, dealing with unhappy family members, doctors, patients, and nurses, educating where needed. I don't mind going on RRT calls even if it's just a please come make sure we did this right but I fear that doing both something is going to be missed. I am only one nurse and although very skilled and experienced I do have my limits. I don't wish to fail my nurses or patients. Any suggestions and is this a common practice?

Butterfly41 using allnurses.com

[nrsang97, BSN, RN]

PMFB-RN we round on our patients that were discharged from the ICU/CCU 24 hours after they leave the ICU/CCU. We do occasionally have some bounce back. Our issue is ER patients that come up and go to ICU right away.

[nrsang97, BSN, RN]

Butterfly41 we have that posted too and I have never received one of those calls. I have never received a call from a family stating that their family member was in trouble either.

Some days when our regular rapid crew isn't on (off day for us regulars and contingent not available, as well as we have a FT nurse on maternity leave right now). Our ICU charge nurse is our coverage. That day they make sure ICU has a full staff and charge has no assignment.

[Butterfly41]

We are free charge full staff that is on my wish list lol. Sometimes we charge 2 ICU units medical and cv/neuro units. I would love to be just RRT member I really enjoy the challenge of assessing and stabilizing patients, and helping and educating fellow nurses. But I also get a lot of satisfaction from being an ICU charge nurse.

[PMFB-RN, RN]

WOW I wish ours was this advanced and organized. Our RRT is the ICU charge nurse that's it. Soon they are placing bulletins in every patient room with an explanation of what the RRT is for and how even the family or patient themselves can call the RRT with the ICU charge nurse phone ext listed. I'm imagining calls like my nurse still hasn't brought me my pain meds I requested 5 minutes ago and I'm getting worse. Also I have concerns about the volume of phone calls preventing me from doing my charge nurse duties like backing my nurses insuring we have what we need to care for our patients, dealing with unhappy family members, doctors, patients, and nurses, educating where needed. I don't mind going on RRT calls even if it's just a please come make sure we did this right but I fear that doing both something is going to be missed. I am only one nurse and although very skilled and experienced I do have my limits. I don't wish to fail my nurses or patients. Any suggestions and is this a common practice?

Butterfly41 using allnurses.com

Your concerns are common and valid. JACO decided that everybody needed RRT and so many (most) hospitals simply made up some policies and pamphlets and handed an ICU nurse a pager. You are right you can't do both well. Most hospital get around this by simply discouraging anyone from calling RRT. In those hospitals RRT becomes more of a pre-code team. It's a shame because they are not realizing the potential benefits in better patient outcomes and cost savings.

We too have a poster in every patient room telling about RRT and our number and we do get calls from family members occasionally. I have to say that they rarely abuse RRT and almost every call from family members has been for a serious situation.

My advice is that you should advocate to create a full time RRT team. If you need policies or protocols or anything let me know.

[Butterfly41]

Thank you PFMB-RN for the information I appreciate it. I have already suggested a full time RRT position. Also reading some of the roles you take on in this position has given me ideas to make it more appealing an option for my hospital. Hopefully I will be contacting you soon for the protocols and such. Thanks wish me luck.