Textbook of Rapid Response Systems - Concept and Implementation

Preface

Contents

Contributors

Part I:RRSs and Patient Safety

Chapter 1: Rapid Response Systems History and Terminology

Principles

Terminology

Summary

References

Chapter 2: RRS’s General Principles

Introduction

Overview

Summary

References

Chapter 3: Measuring and Improving Safety

Introduction

Approach for the Organizational Evaluation of Patient Safety

Measuring Defects

How Might We Improve Safety?

A Framework to Improve Reliability

Why RRSs Can Improve Safety

Summary

References

Chapter 4: Integrating a Rapid Response System into a Patient Safety Program

Overview

Creating and Sustaining Safety

Definition and Relevance of Human Factors Engineering

The MET as a Driving Force for a Patient Safety Program

Root Cause Analysis

Failure Mode and Effect Analysis

Safety Culture and High-Reliability Organizations

Patient Safety Overall

Summary

References

Chapter 5: Acute Hospitalist Medicine and the Rapid Response System

History of the Hospitalist Movement

Models of Hospitalist Care

Benefits of Hospitalist Systems

Hospitalists as Acute Providers

Thoughts for the Future

References

Chapter 6: Medical Trainees and Patient Safety

Healthcare, Healthcare Facilities and Medical Trainees

The Healthcare Environment

Medical Trainees: The Undergraduate Years

Medical Trainees and Patient Safety: The First Few Years

Provision of Care for Identified Illnesses

Provision of Care for Medical Incidences

Improving Patient Safety in Institutions with Medical Trainees

Postgraduate Training and Specialization

Summary

References

Chapter 7: Rapid Response Systems: A Review of the Evidence

Introduction

Evaluating the Evidence

Identifying the Deteriorating Patient, the RRS Afferent Limb

The Efferent Limb: The Responding Team

The Rapid Response System: Is It Effective?

Summary

References

Chapter 8: Healthcare Systems and Their (Lack of.) Integration

Identification of the Seriously Ill At-Risk Patient

Response to the Seriously Ill Patient

Education

Evaluation

Support

References

Chapter 9: Creating Process and Policy Change in Healthcare

Introduction

Changing Healthcare Policy

References

Chapter 10: The Challenge of Predicting In-Hospital Cardiac Arrests and Deaths

Introduction

Organizational Crisis Theory: Hazards, Defenses and Latent Conditions

Iatrogenic Patient Death: Individual or Organizational Accident?

Can We Predict Hospital Iatrogenic Death?

Prevention of Futile Clinical Cycles with Hard Defenses

Communication Technology as a Hard Defense

References

Chapter 11: The Meaning of Vital Signs

Introduction

Pulse Rate

Blood Pressure

The Shock Index

Temperature

Respiratory Rate

Oximetry

Age and Vital Signs

Combining Vital Signs

Summary

References

Chapter 12: Matching Illness Severity with Level of Care

Evidence of Incorrect Placement of Patients

Definitions of Levels of Care

Identifying a Patient’s Level of Illness

Response to Acute Illness

Knowledge and Experience of Ward Staff

Potential Impact of Staffing Levels and Patient Flow on Outcomes

New Approaches to Matching Care with Patient Severity of Illness

New Patient Admission Processes

Early Treatment of Patients in the Emergency Department

New General Medicine Specialists

Rapid Response and Medical Emergency Teams

Better Decisions About Limitation of Care and Resuscitation

Summary

References

Chapter 13: Causes of Failure to Rescue

Introduction

Causes of FTR: Patient-Level Factors

Causes of FTR: Hospital- or System-Level Factors

Summary

References

Part II:Creating an RRS

Chapter 14: Impact of Hospital Size and Location on Feasibility of RRS

Introduction

Antecedents to Serious Adverse Events and Cardiac Arrests, and Criteria for RRS Activation

Models, Location and Size

Teaching Hospitals and Academic Medical Centers

Secondary Referral Centers

District General Hospitals

Small City Hospitals with an Intensive Care Unit

Summary

References

Chapter 15: Barriers to the Implementation of RRS

Introduction

Sources of Obstacles and Inertia

Foundations for System Change

Impediments Within the Hospital

Strategies to Overcome Hurdles

Summary

References

Chapter 16: An Overview of the Afferent Limb

Introduction

Improving the Function of the Afferent Limb

Improving Regular Monitoring and Assessment

Ensuring Vital Signs Measurements Are Accurate

Ensuring Vital Signs Measurements Are Accurately Recorded

Systems for Identifying the Sick or Deteriorating Patient

Aggregate Weighted Track-and-Trigger Systems

Single Parameter Track-and-Trigger Systems

Efficiency of Aggregate Weighted and Single Parameter Track-and-Trigger Systems

Other Clinical Observations that May Be Used to Trigger Rapid Response Systems

The Value of Monitoring Systems for Improving Detection of Critical Events in Low-Risk Populations

Calling for Assistance

The Role of Technology

Summary

References

Chapter 17: The Impact of Delayed RRS Activation

Background: Principles of the Rapid Response System

How Often Is RRS Activation Delayed?

What Are the Consequences of Delayed MET Activation?

How Should Delayed MET/RRT Activation Be Classified?

What Are the Causes of Delayed Response Activation?

How Can Delayed RRS Activation Be Avoided?

References

Chapter 18: The Case for Family Activation of the RRS

Introduction

The Origins of Patient- and Family-Activated Rapid Response: Condition H

Patient- and Family-Activated Rapid Response in Legislation, Accreditation, and Safety Organizations

Features of Patient- and Family-Activated Rapid Response Systems

Administration and Design

Patient Education

Triggering Criteria

Screening

Team Composition

Follow-Up and Data Collection

Gauging Success

Summary

References

Chapter 19: RRT: Nurse-Led RRSs

Identification of Hospital Resources

Nursing Leadership of RRTs

Support for the Nurse-Led Rapid Response Team

Communication Tools

Specific Protocols

Chain of Command Process

Benefits of a Nurse-Led RRT

Nursing Leadership and Mentoring After the RRT Call

Data Collection

Efficacy

Summary

References

Chapter 20: MET: Physician-Led RRSs

Introduction

Principles Underlying the Physician-Led MET

What is a Physician-Led MET?

What Does the Physician-Led MET Do?

Why Do Patients Need MET Calls?

What Are the Advantages and Disadvantages of Physician-Led METs?

References

Chapter 21: Pediatric RRSs

Introduction

Development and Operation of Pediatric Rapid Response Systems

Operational Team Responses: One-Tier Vs. Two-Tier

Recognition of Children with Critical Illness

Activation Triggers or Calling Criteria

Early Warning Scores

Outcomes of Some Pediatric Rapid Response Systems

Barriers to Implementation and Use of Rapid Response Systems

References

Chapter 22: Sepsis Response Team

Introduction

Early Goal-Directed Therapy

Implementing EGDT

Barriers to Implementation of EGDT

Summary

References

Chapter 23: Other Efferent Limb Teams: (BAT, DAT, M, H, and Trauma)

Basic Condition Response

Stroke Team

Trauma Team

Blood Administration Team

Chest Pain Team

Condition L (Lost Patient)

Difficult Airway Team

Pediatric Response Team

Condition M

Summary

Chapter 24: Other Efferent Limb Teams: Crisis Response for Obstetric Patients

Background and Justification

Design and Introduction

Staff Education

Response Team Training

Data Collection, Review, and Process Improvement

Usage of Condition O at Magee-Womens Hospital and Discussion

Summary

References

Chapter 25: Personnel Resources for Responding Teams

Introduction

Shortcomings of the Current System

How Organization Can Help in Crisis Response

Rethinking the Thinking

Structure

Human Resources

Activation of the RRS

The Ad Hoc Team

Changing the Existing Culture

Operating Room Crisis Teams

Summary

References

Chapter 26: Equipment, Medications, and Supplies for an RRS

Introduction

Institutional Oversight of Equipment

Personnel Response

Nursing Responder Equipment

Airway Equipment

Emergency Cart Standardization

Selecting an Emergency Cart

Need for Specialty Carts

House-Wide Crash Cart

Medication Selection

Pharmacy Emergency Cart Exchange Process

Restocking Medications in the Emergency Cart

Additional Methods for Supplying Emergency Medications

Obstacles to Implementation

Supply Standardization in the Emergency Carts

Summary

References

Chapter 27: The Administrative Limb

Why Is an Administrative Arm Needed?

What Should the Aims and Objectives of the Administrative Arm Be?

What Are the Components of the Administrative Limb?

The Intensive Care MET Administrative Group

Coordinating the Efferent Limb

Monitoring of Outcomes

Directing Future Research

Linking with the Clinical Governance Unit

The Role of Hospital Administration

References

Chapter 28: The Second Victim

Identifying Emotional Vulnerability and Recognizing Second Victims

Immediate Support During the Crisis

Support Long After the investigation

Emotional First Aid When Entire Teams Are Suffering

How to Formalize a Support Network

Putting It All Together

References

Part III:Monitoring of Efficacyand New Challenges

Chapter 29: RRSs in Teaching Hospitals

Introduction

Implementing RRSs in Teaching Hospitals

The Afferent Limb

The Efferent Limb

Hospital Culture and Management

Experiences with the RRS

Summary

References

Chapter 30: The Nurse’s View of RRS

Introduction

The Nurse’s Point of View

Steps to Ensuring a Successful Rapid Response System

Summary

References

Chapter 31: Resident Training and RRSs

Introduction

Origins of Rapid Response Systems: A Solution to a Real Problem

Concerns Over Implementing Medical Emergency Teams and Rapid Response Systems

Opportunities for Resident Involvement in METs/RRSs

A Win–Win Situation

What a Rapid Response System Can Teach Residents About Patient Safety

Summary

References

Chapter 32: Optimizing RRSs Through Simulation

Introduction

Unique Aspects of Hospital Crisis Teams

The Ad Hoc Nature of Crisis Teams

Simulation of Crises as Diagnostic Tool

What to Teach

Goals of Crisis Response Teams

Designated Roles: Assignment and Definition

Communication

Leadership

Debriefing

What to Measure

Summary

References

Chapter 33: Evaluating Effectiveness of Complex System Interventions

Characteristics of Complex System Interventions

Defining the Components of Complex System Evaluation

Choosing the Appropriate Research Methodology

Sub-system Interactions After a Complex System Intervention

Cost and Cost-Effectiveness

Interpreting Study Results of Complex System Interventions

Summary

References

Chapter 34: RRS Education for Ward Staff

Introduction

The Challenge for Ward Staff

The Evidence for Improving Education of Ward Staff in Acute Care

What General Ward Staff Need to Know

Challenges in Training Ward Staff in the Immediate Management of Acute Illness

Education Essential to the Implementation of an RRS

Current Initiatives in Acute Care Education

Short Courses in Acute Care

The Role of the Response Team in Educating Ward Staff

Evidence for Benefit in Acute Care Educational Interventions

Summary

References

Chapter 35: Standardized Process and Outcome Assessment Tool

Introduction

Standardization of the RRS Process

Initiating RRS

Data Collection

Evaluation

Outcome

Summary

References

Chapter 36: The Impact of RRSs on Choosing “Not-for-Resuscitation” Status

Background

Not-for-Resuscitation Decision Making

Rapid Response Teams and Not-for-Resuscitation Orders

Evidence for the Impact of Rapid Response Teams on Not-for-Resuscitation Orders

Summary

References

Chapter 37: The Costs and the Savings

The Cost of Adverse Events

Evolution of the Rapid Response System

Costs Associated with a Rapid Response System

Efferent Arm Costs

Afferent Arm Costs

Quality Improvement Arm Costs

Administrative Arm Costs

Societal Costs

Potential Hidden Costs

Savings

Hospital Savings

“Societal” Savings

Summary

References

Index