How To Become A Rapid Response Nurse

Figure

FOR Nearly 25 YEARS, rapid response teams (RRTs) have been assessing and managing patients who experience acute clinical deterioration.¹ Nurses perform a vital role in the role of the squad. This article reviews the team members, responsibilities, and common challenges of RRTs.

Acute clinical deterioration

Mr. P, 64, was admitted to the medical-surgical unit from the ED with worsening dyspnea and productive cough over the last two days. He'd been diagnosed with squamous cell not–small cell lung cancer, but he wasn't a surgical candidate. Instead, he was planning to undergo palliative radiation therapy. Mr. P's history included atrial fibrillation (AF), eye failure, blazon ii diabetes, hypertension, and dyslipidemia. His vital signs were temperature, 97.8° F (36.5° C); eye rate (HR), 98 beats/minute (AF); respiratory charge per unit, 16 breaths/minute; BP, 136/89 mm Hg; and SpO_two, 98% on two L nasal cannula. The chest X-ray obtained in the ED showed a left basilar infiltrate consistent with pneumonia. White blood cell counts were elevated, merely serum electrolytes were within normal limits. Arterial claret gas (ABG) analysis on room air in the ED revealed the post-obit: pH 7.46 (normal, 7.35 to 7.45); PaCO₂, 45 mm Hg (normal, 35 to 45 mm Hg); PaO₂, 77 mm Hg (normal, lxxx to 100 mm Hg); HCO_iii ^–, 32 mEq/L (normal, 22 to 26 mEq/L).

3 hours subsequently he'd arrived at the medical-surgical unit of measurement, Mr. P was found sitting in a tripod position with labored breathing. His SpO₂ dropped to 86% on 2 L nasal cannula. The principal RN contacted the doc, and Mr. P was placed on 100% non-rebreather mask (NRM), just his SpO₂ remained at 86%. He continued to be dyspneic, tried to remove the NRM, and was in rapid AF at 140 beats/minute.

The RRT was activated. The ICU RN and respiratory therapist arrived to find Mr. P with declining mentation. His vital signs were Hour, 110 beats/minute (AF); respiratory rate, 28 breaths/infinitesimal; BP, 120/64 mm Hg; and SpO₂, 92% on 100% NRM. The RRT gathered data from Mr. P'south primary nurse about the electric current state of affairs.

The respiratory therapist auscultated coarse crackles and expiratory wheezes throughout the right lung, and diminished jiff sounds in the left lung. The ICU RN paged the covering hospitalist to the event. ABGs on 100% NRM were pH, 7.21; PaCO₂, 108 mm Hg; PaO₂, 205 mm Hg; HCO₃ ^–, 35 mEq/L. The hospitalist consulted the intensivist, and the RRT coordinated a rapid transfer to the ICU for endotracheal intubation and further intensive care. Iii days afterwards, Mr. P was extubated and returned to the medical-surgical unit.

Improving patient outcomes

Mr. P's case is i instance of the many assessments and interventions performed by RRTs across the country every day. Nurses serve vital roles on these teams in acute care institutions around the globe.¹

RRTs are designed to provide rapid cess and intervention to whatsoever non-ICU patient who's experiencing acute clinical deterioration. The goal of early intervention during clinical deterioration is to improve patient outcomes. Rapid response systems have been shown to reduce both cardiopulmonary arrests outside of the ICU and infirmary mortality.^2,iii The impact of RRTs on patient outcomes is evolving. More data are needed on long-term outcomes for patients treated by an RRT, including functional outcomes and quality of life.^iv

An RRT functions inside the rapid response system, which has two principal functions: recognize urgent unmet patient needs and activate the RRT (afferent arm); and initiate an RRT response for assessment, intervention, and patient triage (efferent arm).⁵

RRT activation: Afferent arm

Much attention has been paid to the afferent arm of the rapid response system. Optimum patient care relies on timely identification of clinical deterioration and prompt activation of the team. Despite positive attitudes toward RRTs, delays in activation, known equally afferent limb failure, are nevertheless a problem. These delays can increase bloodshed and morbidity.^6,seven Frequency of delay ranges from 21% to 56% of all calls.^7,viii

Reasons for these delays fall into three chief areas: failure to monitor, failure to recognize, and failure to escalate.⁹ Identification and activation often rely on established single clinical triggers or multiple weighted clinical triggers mediated by early warning systems (EWS). Many of the triggers used are physiologic, such as 60 minutes, BP, and respiratory rate. Others may be diagnostic information such every bit lab values. EWS part past identifying clinical deviations from normal, which are and then weighted and provided every bit a total run a risk score. These scores can be used by the provider to help place patients at run a risk for astute clinical deterioration. EWS scores can predict cardiac abort and bloodshed within 48 hours; however, the impact of EWS on health outcomes and resources utilization is less clear.¹⁰ (Run across Monitoring for clinical deterioration.)

Alterations in physiologic parameters may not be the just indication that a patient is deteriorating. Some institutions have incorporated "worried/concerned" criteria, based on nurse intuition, into their EWS or RRT activation criteria. Causes of worry include such indicators as pain, agitation, patient non progressing, and patient indicating he or she isn't feeling well.¹¹ Nurses may incorporate this subjective feeling into their assessment and decision to activate an RRT. The intuitive nature of this assessment makes information technology difficult to quantify. New worry indicator scores such as the Dutch-Early on-Nurse-Worry-Indicator-Score are existence developed and evaluated.¹² If these prove reliable and valid, they could be incorporated into EWS.^xiii

With the advent of betoken-of-care and continuous monitoring, vital sign documentation has improved, but referral for assist remains suboptimal.^xiv Several factors can lead to failure to escalate clinical deterioration to the RRT. Lack of information, scarcity of resource, breezy hierarchical culture, fright of criticism that the patient wasn't sick plenty, and calling the covering provider before activating the RRT are all causative factors of delays in escalation and barriers to activation.^fifteen-17

The case study described at the beginning of this article provides an example of a delay in escalation because the nurse contacted the patient'southward healthcare provider before activating the RRT. Individual organizations should examine their facility's barriers and factors affecting delays in RRT activation.

RRT activation: Efferent arm

The functioning of the team (efferent arm) also affects the overall outcomes of the rapid response system. The composition of an RRT is multidisciplinary and varies by institution, but it commonly includes an ICU nurse, a respiratory therapist, and the nursing supervisor. A disquisitional care nurse often is the ICU charge nurse who may not have an assignment or may have the primary role of rapid response nurse; this nurse attends all RRT activations.¹⁸ Respiratory therapists are vital to the team because many activations require patient ventilation or supplemental oxygen.

Pharmacists may attend all calls or respond as consultants. Adding a chemist to the RRT can reduce medication assistants time as well equally optimize medication pick and dosing.^xix

A provider is an important RRT fellow member. The provider may be a hospitalist, who may or may non be the patient's attending dr.. In some RRT models, the provider automatically responds to every RRT activation. In many institutions, the provider doesn't respond to every activation simply is available as needed.^xviii

Typically, a critical care nurse is responsible for leading the initial and ongoing patient assessment and, together with the balance of the team, initiates canonical protocols and elevates the telephone call to the provider if necessary. These protocols are a means to begin treatment before provider arrival and tin can include interventions such equally providing supplemental oxygen, obtaining a 12-lead ECG and lab specimens, and administering medications based on the presence and type of cardiac dysrhythmias.

The respiratory therapist is responsible for initial and ongoing respiratory assessment and basic airway management such as administering supplemental oxygen, airway clearance, and in some cases, noninvasive positive pressure ventilation.^twenty

The nursing supervisor is responsible for arranging disposition of the patient to a higher level of care if necessary, profitable with documentation, facilitating interventions, and providing general support.

The patient's chief nurse is a valuable fellow member of the team. The primary nurse should remain at the bedside with the team to provide data, such as what prompted RRT activation, and pertinent patient history including current medications, recent diagnostic exam results, and code condition.

5 keys to success

The entire team must piece of work collaboratively to provide intendance. Five key categories have been identified every bit important to the RRT's effectiveness: organizational civilization, team structure, expertise, communication, and teamwork.²¹

The organization in which the RRT operates must support a culture of patient safety and all team members must possess a solid understanding of the role of the RRT, the design of the team, and the role of each of the squad members. Members must possess clinical expertise and crisis direction skills.

Interdepartmental relationships often improve with the utilise of an RRT. At events, the disciplines piece of work together to ameliorate patient outcomes and tin feel first-hand the valuable contribution of each member. For example, a disquisitional care nurse who attends events outside the ICU may go more aware of what nurses experience in medical-surgical units.¹⁸ Constructive teamwork relies on shared purpose, familiarity, and collaboration.

After RRT activation, reviews or debriefing tin help teams reverberate on operation. Positive reinforcement for the primary nurse on a job well done and encouragement to use the team again in the future can be achieved in these debriefings; this is particularly important for novice nursing staff.

Several studies accept examined attitudes toward RRTs.^{fifteen,22,23} Nursing staff who use an RRT find it a positive feel. Nurses believe the process reduces cardiopulmonary arrests and prevents pocket-sized problems from becoming major issues. They too believe that RRTs are helpful in managing sick patients, and they experience safer knowing that an RRT is available in their infirmary. Despite early concerns, staff members don't believe that these teams increment workload and recall the assistance of the team can improve their own skills in managing deteriorating patients. Staff members oftentimes welcome the expertise of the RRT and the risk to collaborate with colleagues to manage deteriorating patients. The RRT provides an chemical element of emotional back up that reassures nursing staff involved in tenuous clinical situations.^15,22,23

Many situations provide existent-time education for the medical-surgical nurse, and this has been identified as a major benefit of the rapid response organisation.¹⁸ The RRT nurse often mentors and coaches nurses who are developing their assessment and critical-thinking skills. Advice skills are too fostered as the medical-surgical nurse observes interactions between squad members. Standing education can improve identification of clinical deterioration by nurses and provide opportunities for RRTs to practice teamwork, communication, and leadership skills.

Recently, a systematic review was conducted to study the impact of education on staffs' recognition and direction of deteriorating patients.²⁴ Educational programs that incorporate medium- to high-fidelity simulation accept improved recognition and direction of patient deterioration. In situ simulation (simulation that takes place in the participants' clinical environment) provides a level of realism that tin can incorporate real-earth distractions and organizational cultural norms, enhancing the learning. Web-based simulation also improves recognition of patient deterioration.²⁵

Patient and family participation

Although many rapid response systems include a patient and family activation process, the literature is limited almost whether patient and family participation results in improved patient outcomes. Some data advise increased patient or family unit calls, besides known as consumer calls, result in before intervention for patient deterioration.²⁶ Clinicians take raised concerns that allowing the patient and family to activate the RRT might effect in a meaning increase in calls, some of which may be unrelated to clinical deterioration. This fear that consumer-based activation will overwhelm staff and resources isn't supported by research.^26,27

More research is needed to determine how the participation of patients and families tin can be used in conjunction with clinician judgment for optimal patient outcomes. The essential elements of a successful patient/consumer RRT activation process for clinical deterioration include staff pedagogy and grooming about the program and patient teaching by the nursing staff. Educational materials must be clear, piece of cake to read, and bachelor in a range of media.²⁶ The nurse acting as a member of the RRT tin play an active office in educating staff and developing educational materials for patients and families.

Finish-of-life issues

RRTs are increasingly involved in clinical deterioration associated with end-of-life (EOL) events. This may require members of the RRT to make hard decisions. In fact, 24% to 33% of all RRT activations involve EOL decision making.^28,29 Many signs and symptoms at EOL correlate with RRT activation triggers. Fifty-fifty though palliative care consults may have occurred before RRT activation, the patient and family may not take made their final decisions. Particular challenges during these events include decision-making time constraints and the severity of the patient'south clinical status when the team arrives. This is frustrating to the unit staff as well equally RRT members, who may exist forced to drag care to a higher level, knowing that the risk of a positive outcome is minimal.

During an acute clinical decompensation, the patient may not be in a position to make decisions. Members of the RRT may not be skilled at engaging in EOL conversations with family and, due to the episodic nature of RRT activation, typically haven't established a relationship with the family.

To address these challenges and knowledge gaps in EOL care, an organization in the United kingdom of great britain and northern ireland has started a training programme for RRT members about patients who don't want to exist resuscitated.³⁰ Each fellow member participates in a high-allegiance simulation involving EOL conversations with professional actors who play the function of the patient or family members. Colleagues spotter via live-stream video. Debriefing follows the simulation, and the squad members reflect on their experiences and the challenges of the event. Included in the debriefings are the legal, religious, and ethical elements of resuscitation decisions. To date, evaluations of the program have been largely positive.³⁰

Overcoming barriers

In an effort to mitigate barriers to activation and avert failure-to-rescue events, some RRTs or RRT members proactively round on patients discharged from the ICU. These critical care transition programs are also referred to as ICU consult teams, critical care outreach, or ICU liaison nurses.

Testify about the patient outcomes of these transition programs is conflicting. 1 systematic review provided evidence that, in patients discharged from the ICU to a general hospital unit, these transition teams reduced the gamble of ICU readmission.³¹ In contrast, a study evaluating the effects of rounding by a disquisitional care multidisciplinary ICU squad (physician, nurse, and respiratory therapist) post-ICU belch establish readmission to ICU and mortality after ICU discharge didn't better with the rounding procedure.³²

Butcher and colleagues also evaluated the effect of proactive RRT rounding on patients discharged from the ICU.³³ Outcomes evaluated were ICU readmission rate, average ICU length of stay, and in-infirmary mortality of patients discharged from the ICU. The proactive rounding didn't ameliorate patient outcomes.

In the ICU nurse liaison model, the nurse provides follow-up to patients discharged from the ICU equally well as full general surveillance of patients at chance for deterioration. In comparing multidisciplinary teams such as an ICU consult team with an individual nurse program, risks of readmission to the ICU were similar and didn't depend on the presence of an intensivist.³¹

About of the activities of the ICU liaison nurse are directed at providing expert consultation to the primary nurse. These liaisons as well provide existent-time staff education in areas such as patient safety, nursing assessment, device management, care planning, and patient/family support.³⁴ The ICU liaison nurse identifies patients who were discharged from the ICU based on referrals from unit staff or nursing assistants. Referrals to the ICU liaison nurse are often done through routine ICU discharge follow-up, paging, or face-to-face communication.³⁵

With the widespread use of the EMR and EWS, data mining, coupled with proactive surveillance past the RRT nurse or ICU liaison nurse, is possible and productive. In some models, the nurse on the RRT periodically reviews early on warning scores from patients on each unit and, based on an algorithm of intendance, either calls to discuss the patient with the primary nurse, visits the unit to assess the patient, or activates the RRT.^33,36

These notifications can exist done in real time and/or sent to pagers. This proactive approach leverages computerized surveillance and expert nursing knowledge to support the primary nurse in identifying and managing early clinical deterioration. Each organization must evaluate the financial and staffing resource needed to implement some of the more avant-garde RRT options.

Nurses play a vital role

For near 3 decades, multidisciplinary teams accept been responding to circumstances of acute clinical deterioration to assist the nursing staff in non-ICU settings and provide improved care for these patients. Positive patient outcomes take been realized due to the efforts of the RRT.

Nurses play a vital office on this team. As rapid response systems evolve, nurses will contribute their knowledge in expanding areas such as educating staff and patients to recognize clinical deterioration and participating in proactive assessments on patients at risk for deterioration.

Monitoring for clinical deterioration

Early warning systems

Several types of EWS exist, ranging from difficult re-create scoring systems to those involving continuous monitoring and automatic run a risk score calculation. Early on versions of EWS used manual pen-and-paper calculations. Mitt calculations of scores were cumbersome and unsustainable. With the recent healthcare information technology regulatory initiatives, many institutions are moving to an electronic medical record (EMR) where monitoring parameters utilized by EWS are routinely entered. Many EWS now provide an automatic score when physiologic parameters are entered into the EMR.

Inputting and utilizing the EMR data finer increases the efficiency of the EWS. However, several studies take identified key vital sign and assessment data routinely missing in the EMR. In a study aimed at describing the current practice of measuring and documenting vital signs, researchers studied all vital sign parameters that were collected and documented in the 48 hours preceding a astringent adverse event.³⁷ Pulse rate and systolic BP were measured in 72% and 73% of cases, respectively. Respiratory rate was recorded in only 23% of cases. This is peculiarly concerning because considerable evidence shows that an abnormal respiratory charge per unit is an early on indicator of clinical deterioration.³⁸

The timing of data entry is also important to ensure early on identification of deterioration. Significant delays have been reported in documentation of vital signs and early warning scores by RNs.³⁹ Cited reasons included lack of calculator availability, poor computer functionality, excessive log-in times, and preferences for not documenting in forepart of families. An excessive workload may crusade an RN to batch data entry at the end of the shift, defeating the real-fourth dimension benefit of the EWS.

Electronic bedside monitors

In an effort to address the delay in documentation and chance alert scoring, investigators take evaluated point-of-intendance electronic devices meant to tape vital signs, summate a hazard score, and escalate care per the institution's protocol. These electronic bedside monitors measure patient temperature, BP, Hour, and SpO₂. The monitor can prompt the nurse to manually enter respiratory rate and other unit-specific optional parameters such as urine output.

Once the data are entered, the monitor automatically calculates the early warning score at the bedside and recommends an activeness customized to the establishment's astute deterioration protocol, which oftentimes includes activation of the RRT. These bedside monitors have been studied to decide their effect on frequency, type, and treatment of RRT calls; survival to infirmary discharge or to 90 days for RRT call patients; overall type and number of serious adverse events; and length of hospital stay. Findings demonstrate an improvement in the proportion of RRT calls triggered by abnormal respiratory signs, improved in-hospital survival of patients receiving RRT calls, and decreased time required for vital sign measurement and recording.^twoscore

Continuous electronic monitoring

Even when bedside devices are used to prompt nursing assessment and automatically calculate an early alarm score, periods still remain when patients aren't monitored. As vital sign and EWS documentation practices are studied, revealing omissions and delays in entry, continuous electronic measurement may aid. Continuous monitoring provides an ongoing representation of the patient's clinical status, in dissimilarity to intermittent monitoring, which may miss early deterioration signals between acquisition times.⁴¹ Nursing staff can escalate intendance based on the continuously trended data.

Patient feedback on continuous monitoring systems has been very positive.⁴¹ Reports of nursing satisfaction with the continuous monitoring system are besides positive, ranging from lxx% to 92% satisfied.^41,42 Withal, this technology has the potential to increment alarm fatigue. Organizations must ensure alarm parameters aren't as well sensitive and that nurses are customizing alarms to the patient clinical condition to avoid desensitization.

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