- Email: [email protected]
Dedicated, Proactive, Nurse Practitioner Rapid Response Team Eliminating Barriers
The Journal for Nurse Practitioners xxx (xxxx) xxx
Contents lists available at ScienceDirect
The Journal for Nurse Practitioners journal homepage: www.npjournal.org
Brief Report
Dedicated, Proactive, Nurse Practitioner Rapid Response Team Eliminating Barriers Erin Burrell, MSN, ACNP-BC, April Kapu, DNP, ACNP-BC, Elizabeth Huggins, MSN, ACNP-BC, Katie Cole, MSN, ACNP-BC, Jennifer Fitzsimmons, MSN, ACNP-BC, Nina Collins, MSN, ACNP-BC, Liza Weavind, MBBCh, MMHC a b s t r a c t Keywords: critical care nurse practitioners nurse retention nurse satisfaction rapid response teams unexpected ICU transfers
Rapid response teams (RRT) have become an expected component in response to acute clinical deterioration of patients outside of the intensive care unit. Even with this support, many RRTs are not activated despite a high level of nursing concern that patients are decompensating. Bedside nurses may be discouraged from appropriately activating RRT due to fear of reprimand. Instituting a proactive, dedicated RRT of nurse practitioners who developed relationships and improved communication with nurses led to an increase in RRT activations for general nursing concern. Early recognition of acute clinical change allowed for prompt intervention by the RRT and decreased intensive care unit transfers. © 2019 Elsevier Inc. All rights reserved.
Introduction Rapid response teams (RRTs) have become ubiquitous in United States hospitals, allowing hospitals to meet Joint Commission requirements and enabling staff to obtain help when a patient deteriorates in a setting outside of the intensive care unit.1 Despite RRTs being an integral part of patient care and safety, barriers remain that delay or prohibit appropriate and timely nurse activation of these teams. Barriers to nurse activation of an RRT include delayed recognition of clinical deterioration, fear of being ridiculed or being reprimanded for calling for help, incomplete understanding of the role of the RRTs, and perceived lack of support from nursing leadership.2,3 Although these barriers have been well documented in the current literature, they are difficult to minimize or change. Our institutional rapid response model was established in January 2011 and includes an intensive care unit (ICU) nurse practitioner (NP), ICU nurse, and respiratory therapist, who all respond from their respective clinical locations. In January 2011, Kapu et al4 described the impact of adding NPs to the rapid response model in our institution, which include improved diagnostic expertise and treatment at the bedside, the ability to facilitate transfer of a patient to the ICU, provide effective communication with teams, and provide education and support for bedside nurses. However, since the initiation of the program in 2011, the number of rapid response calls initiated each year in our institution rose from approximately 1300 activations in 2011 to more than 2100 https://doi.org/10.1016/j.nurpra.2019.07.013 1555-4155/© 2019 Elsevier Inc. All rights reserved.
activations in 2017 (Figure 1). Concurrently, the ICU NPs have experienced an increased level of ICU patient care responsibilities with rising patient volume and acuity. Higher ICU acuity combined with a higher volume of rapid response activations has negatively affected the amount of time the ICU NP can remain at the bedside on a rapid response activation to resolve the clinical situation before needing to return to the ICU. These competing responsibilities of the ICU NPs supporting patients in 2 locations has affected their ability to facilitate patient care on the floor during an RRT activation and created further hesitancy for nurses to call the RRT to help manage patients who were clinically deteriorating. In 2017, we instituted a pilot dedicated NP RRT consisting of experienced critical care NPs with support from a virtual (available by TeleICU) critical care physician. As a part of their workflow, the RRT NPs rounded daily on all floors to discuss any patient concerns that the bedside nurses had identified. An unintended consequence of having a consistent, proactive RRT present for daily rounds allowed for the development of relationships with floor nursing staff, who began to reach out to the team for clinical advice and support. We evaluated the impact the proactive team had on patterns of rapid response calls between the “curbside” calls and the traditional calls and on decreasing barriers for nursing staff to call RRT. Methods A dedicated team of experienced, critical care NPs, with no other patient care responsibilities and working under the supervision of a virtual critical care intensivist, responded to rapid response calls to
2
E. Burrell et al. / The Journal for Nurse Practitioners xxx (xxxx) xxx
RRT Acvaons 2011-2017 2500
2000
1500
1000
500
0 2011
2012 CVICU Team
2013 MICU Team
2014 NICU Team
2015
2016 SICU Team
2017 Total
Figure 1. Trend in rapid response team (RRT) activations (RRT) from 2011 to 2017. (CVICU ¼ cardiovascular intensive care unit; MICU ¼ medical intensive care unit; NICU ¼ neurosurgery intensive care unit; SICU ¼ surgical intensive care unit).
cardiovascular, surgical, and neurologic floors in a large, 750-bed, adult, academic hospital from 7 AM to 7 PM, 7 days per week, for 9 months. The RRT pilot NPs quickly responded to the bedside when an RRT was called and the intensivist was present virtually, using the electronic medical records (EMRs) to gain situational awareness of the patient. After a rapid response call had been resolved, the dedicated RRT NPs would follow-up with the bedside nurse on the floor within 4 hours of the call to ensure the patient continued to progress well or to update the floor nurse on the patient’s condition if transferred to the ICU.
Another role of the RRT NPs was to round on all floors daily to discuss any patient concerns that the bedside nurses had identified. The bedside nurses had access to a direct phone line that they used to “curbside consult” the RRT NPs for nursing concerns that did not meet traditional RRT triggers (Figure 2). If a patient was brought to the attention of the RRT NPs on daily rounds or by phone call, the RRT would evaluate the patient through medical record review and physical examination. If the patient met traditional triggers for rapid response, the RRT would activate a formal rapid response consult and assess and treat the patient appropriately. If no
Figure 2. Rapid response triggers. (CNS ¼ central nervous system.)
E. Burrell et al. / The Journal for Nurse Practitioners xxx (xxxx) xxx
interventions were needed, the RRT NPs would use the opportunity to validate and educate the bedside nurses and reinforce the plan of care for the patient. At the initiation of the pilot RRT, we introduced ourselves and educated the floor nursing staff to the new process of rapid response with the dedicated RRT. A component of the education included the introduction of comment cards as a means to help us improve the RRT process. The comment cards were distributed to each of the 15 nursing floors by members of the pilot team to obtain timely feedback for the pilot, both positive and negative. The title of the card was “Rapid Response Pilot Team Comment Card,” and it simply asked the nursing staff to answer, “Here’s what I experienced” with room to write comments and suggestions. The writer was given the option to write their name and the date at the bottom of the card. The cards were left at the nurses’ desks with a box to collect them in. The RRT team collected cards on their daily rounds on the floors. The feedback given was used to adjust our workflow process as needed. The RRT team reviewed the comment cards, and the common themes that emerged were nursing satisfaction with the increased support and validation of their concerns, increased patient safety, timely and quality of care, and proactive rounding and prevention by the dedicated RRT. Results Of the 516 patients evaluated by the pilot RRT, 95 (18%) were evaluated using curbside request, and 421 (88%) were seen with a traditional rapid response call. An initial spike in curbside calls is shown in Figure 3, with a return to the more traditional RRT process with progression of the pilot RRT. Summaries of the reasons for RRT activation, unexpected ICU transfers, death during hospitalization, and hospital length of stay during the period reported are shown in the Table. The rate of patients seen due to general concern in the curbside group was higher (43.2%) than in the traditional rapid response group (4.0%). Furthermore, there were fewer neurologic and cardiac calls in the curbside group (6.3% and 33.7%, respectively) than there were in the traditional group (20.9% and 48.5%, respectively). Overall rates of other types of calls (such as a bleeding skin tear) were low (3.5%), with none of those for patients in the curbside group. The unexpected ICU transfer rate was lower in the curbside group than in the traditional group (26.3% vs 37.3%). Owing to the small number of patients evaluated in the pilot program, none of the differences were powered to show statistical significance. The comment cards showed overall nurse approval of the RRT pilot program. Of the 72 cards collected, 92% had positive responses to the new, dedicated team. Of the comment cards with positive responses, 47 cards (65%) referenced increased nursing satisfaction, 33 cards (45%) referenced increased safety, timely and quality of care, and 21 cards (28%) referenced proactive rounding and prevention by the dedicated team. Of the total cards collected, 6 cards (8%) had negative comments and referenced timeliness of arrival of the team and difficulty obtaining echocardiograms during an RRT. The breakdown of the comment cards can be seen in Figure 4. Discussion Shortly after the initiation of the dedicated pilot RRT, the NP team had an unexpected increase in curbside consults on patients who met increased nursing concern (43% vs 4% for traditional RRT) but who had not yet had a formal RRT activation. Upon evaluation of these patients by the RRT, 26.3% of these patients were escalated to the ICU for ongoing care, which is indicative that the nurses are astute in noticing clinical changes in their patients before physiologic rapid response triggers occur. It is well documented that
3
Curbside vs Tradi onal RRT 60 50 40 30 20 10 0
Curbside
Tradi onal
Figure 3. Number of curbside calls versus traditional calls from January to September 2017. (RRT ¼ rapid response team.)
delaying evaluation of a patient by the RRT leads to increased death, morbidity, and length of stay, yet nurses continue to be hesitant to activate a rapid response call without physiologic changes.5,6 Massey et al7 in 2014 reported 2 of the major barriers to activation of the RRT were the nurses’ fear of reprimand for activating a call and their misunderstanding of the role of the RRT. We feel that having the proactive RRT, available for consult and responsive to nurse concerns regarding their patient’s clinical condition, negated these 2 barriers, which led to the increase in nurse confidence to curbside the RRT for nursing concerns for their patients. The topic most often discussed on the comment cards collected at the initiation of the project was the increased nursing satisfaction with the dedicated team, specifically, communication with, validation of, and support of nursing staff. We believe the original increase in curbside calls due to general concern was a direct result of our proactive approach to the RRT and the increased nursing comfort with asking for help, without fear of reprimand or ridicule. The dedicated team’s standard practice to proactively round on the floors daily, follow-up on interventions, and provide education, support, and feedback to the nursing staff allowed for meaningful communication and relationship building with this group. As the project progressed, nursing staff began to activate more traditional rapid response calls because the RRT team educated them regarding the RRT process and limited the fear of reprimand from medical teams or overcommitted ICU NPs. Although our pilot study was not powered to compare or evaluate significant differences in clinical outcomes, such as overall organ dysfunction or death, we believe this small pilot program highlights the bedside nurses as a sensitive and early-warning system to subtle but concerning changes in their patient’s condition. Although “nurse concern” is one of our RRT triggers, we found Table Comparison of Traditional versus Curbside Rapid Response Activation Variablea
RRT activation General concern Neurologic Cardiac Respiratory Other call ICU transfer Died during hospital stay Length of stay, d (range)
Traditional
Curbside
% (N ¼ 421)
% (N ¼ 95)
4 20.9 48.5 22.3 4.3 37.3 8.6 9.0
43.2 6.3 33.7 16.8 0 26.3 9.5 8.0
(17) (88) (204) (94) (18) (157) (36) (5-15)
(41) (6) (32) (16) (0) (25) (9) (6-13)
P Valueb
<.001 .001 .009 .238 .04 .043 .773 .663
ICU ¼ intensive care unit; RRT ¼ rapid response team. a Data are shown as percentage (number) or as median (interquartile range). b Bold values are statistically significant (P < .05).
4
E. Burrell et al. / The Journal for Nurse Practitioners xxx (xxxx) xxx
Comment Cards 0%
10% 20% 30% 40% 50% 60% 70%
NURSING SATISFACTION
47
INCREASED SAFETY/TIMELY/QUALITY CARE
33
ROUNDING/PREVENTION
NEGATIVE COMMENTS
21
6
Figure 4. Themes from comment cards.
that it was infrequently the reason for activating the traditional RRT. During our daily rounding process, we uncovered a high level of nurse concern for their patients. And an evaluation of these patients showed many of them needed an intervention or escalation of care to prevent further deterioration. We removed the barrier of having to formally activate an RRT with proactive rounding and allowed nurses to voice their patient care concerns in a nonthreatening environment. The similarity in rates of transfer to the ICU between the patients with RRT activation due to physiologic triggers and those who triggered RRT due to nurse concern led to the conclusion that the patients evaluated by this proactive, curbside approach validated the bedside nurses ability to recognize the need for rescue before physiologic changes. This small, descriptive pilot study has many limitations in our ability to draw any statistically significant conclusions regarding nursing barriers to activating RRTs. The pilot outcome metrics were not specifically focused on the nursing barriers to RRT activation, but once the process was initiated, it became clear that nurses were the key to early patient evaluation and rescue and that they felt marginalized in the standard RRT process (nurse feedback to the RRT). The comment cards, which were initially designed for RRT process improvement, were noted to be a nursing satisfaction and patient safety validation tool. The small numbers of comment cards are limitations in allowing us to draw conclusions regarding nurse retention and the ability of a dedicated RRT to bring down RRT activation barriers, but we showed that empowering nurses and validating their patient concerns are effective mechanisms to improving early recognition and intervention for patients at risk. Further research is needed with a specific focus on supporting floor nurses with a proactive RRT as a mechanism to impact nurse retention, satisfaction, and patient safety. Conclusion A proactive, dedicated NP-led RRT was able to round daily on the floor, spend more time on calls due to lack of additional
responsibilities, follow-up on interventions, and provide support, feedback, and education for nursing staff. As a result, relationships were built between the nursing staff and the dedicated RRT, thereby reducing the major barrier of nursing staff fear and increasing the number of patients proactively evaluated by the RRT before major clinical deterioration. The results of the study suggest that bedside nurses are a valuable and sensitive “monitor” to identify subtle clinical changes before hemodynamic compromise. Another unanticipated outcome for a dedicated RRT may be increased nursing satisfaction. Our pilot program was not powered to look at this outcome, but anecdotally, the bedside nurses appreciated the support, care, and validation they received from this program as evidenced by the overwhelming positive comment cards collected. Further research with this dedicated, proactive RRT approach is needed to determine how to have a meaningful impact on clinical outcomes and nursing retention.
References 1. Stolldorf DP, Jones CB. Deployment of rapid response teams by 31 hospitals in a statewide collaborative. Jt Comm J Qual Patient Saf. 2015;41(4):186-192. https:// doi.org/10.1016/S1553-7250(15)41024-4. 2. Astroth KS, Woith WM, Jenkins SH, Hesson-McInnis MS. A measure of facilitators and barriers to rapid response team activation. Appl Nurs Res. 2017;33: 175-179. 3. Jenkins SH, Astroth KS, Woith WM. Non-critical-care nurses’ perceptions of facilitators and barriers to rapid response team activation. J Nurses Prof Dev. 2015;31(5):264-270. 4. Kapu AN, Wheeler AP, Lee B. Addition of acute care nurse practitioners to medical and surgical rapid response teams: a pilot project. Crit Care Nurse. 2014;34(1):51-59. http://ccn.aacnjournals.org/content/34/1/51.long. 5. Barwise A, Thongprayoon C, Gajic O, Jensen J, Herasevich V, Pickering BW. Delayed rapid response team activation is associated with increased hospital mortality, morbidity, and length of stay in a tertiary care institution. Crit Care Med. 2016;44(1):54-63. 6. Chen J, Bellomo R, Flabouris A, Hillman K, Assareh H, Ou L. Delayed emergency team calls and associated hospital mortality: a multicenter study. Criti Care Med. 2015;43(10):2059-2065. 7. Massey D, Chaboyer W, Aitken L. Nurses’ perceptions of accessing a medical emergency team: a qualitative study. Aust Crit Care. 2014;27(3):133-138. https:// doi.org/10.1016/j.aucc.2013.11.001.
Erin Burrell, MSN, ACNP-BC is a critical care float nurse practitioner and assistant in Division of Critical Care with the Department of Trauma and Surgery at Vanderbilt University School of Medicine, Nashville, TN, and can be contacted at erin.burrell@ vumc.org. April Kapu, DNP, ACNP-BC, FAANP, FCCM, is associate nursing officer for advanced practice at Vanderbilt University Medical Center and professor at Vanderbilt University School of Nursing. Elizabeth Huggins, MSN, ACNP-BC, is a critical care float nurse practitioner and instructor, Vanderbilt University School of Nursing. Katie Cole, MSN, ACNP-BC is a critical care float nurse practitioner, assistant in Division of Critical Care with the Department of Trauma and Surgery at Vanderbilt University School of Medicine. Jennifer Fitzsimmons, MSN, ACNP-BC is a critical care float nurse practitioner and instructor, Vanderbilt University School of Nursing, Nashville, TN. Nina Collins, MSN, ACNP-BC, is tracheotomy and percutaneous endoscopic gastrostomy NP for Vanderbilt University Medical Center, assistant in surgery for the Division of Trauma and Surgery, Critical Care at Vanderbilt University School of Medicine. Liza Weavind, MBBCh, MMHC, FCCM, is professor of anesthesiology and surgery, associate division chief, Anesthesiology Critical Care Medicine, associate chief of staff, and director of TeleICU, Nashville. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.
Contents lists available at ScienceDirect
The Journal for Nurse Practitioners journal homepage: www.npjournal.org
Brief Report
Dedicated, Proactive, Nurse Practitioner Rapid Response Team Eliminating Barriers Erin Burrell, MSN, ACNP-BC, April Kapu, DNP, ACNP-BC, Elizabeth Huggins, MSN, ACNP-BC, Katie Cole, MSN, ACNP-BC, Jennifer Fitzsimmons, MSN, ACNP-BC, Nina Collins, MSN, ACNP-BC, Liza Weavind, MBBCh, MMHC a b s t r a c t Keywords: critical care nurse practitioners nurse retention nurse satisfaction rapid response teams unexpected ICU transfers
Rapid response teams (RRT) have become an expected component in response to acute clinical deterioration of patients outside of the intensive care unit. Even with this support, many RRTs are not activated despite a high level of nursing concern that patients are decompensating. Bedside nurses may be discouraged from appropriately activating RRT due to fear of reprimand. Instituting a proactive, dedicated RRT of nurse practitioners who developed relationships and improved communication with nurses led to an increase in RRT activations for general nursing concern. Early recognition of acute clinical change allowed for prompt intervention by the RRT and decreased intensive care unit transfers. © 2019 Elsevier Inc. All rights reserved.
Introduction Rapid response teams (RRTs) have become ubiquitous in United States hospitals, allowing hospitals to meet Joint Commission requirements and enabling staff to obtain help when a patient deteriorates in a setting outside of the intensive care unit.1 Despite RRTs being an integral part of patient care and safety, barriers remain that delay or prohibit appropriate and timely nurse activation of these teams. Barriers to nurse activation of an RRT include delayed recognition of clinical deterioration, fear of being ridiculed or being reprimanded for calling for help, incomplete understanding of the role of the RRTs, and perceived lack of support from nursing leadership.2,3 Although these barriers have been well documented in the current literature, they are difficult to minimize or change. Our institutional rapid response model was established in January 2011 and includes an intensive care unit (ICU) nurse practitioner (NP), ICU nurse, and respiratory therapist, who all respond from their respective clinical locations. In January 2011, Kapu et al4 described the impact of adding NPs to the rapid response model in our institution, which include improved diagnostic expertise and treatment at the bedside, the ability to facilitate transfer of a patient to the ICU, provide effective communication with teams, and provide education and support for bedside nurses. However, since the initiation of the program in 2011, the number of rapid response calls initiated each year in our institution rose from approximately 1300 activations in 2011 to more than 2100 https://doi.org/10.1016/j.nurpra.2019.07.013 1555-4155/© 2019 Elsevier Inc. All rights reserved.
activations in 2017 (Figure 1). Concurrently, the ICU NPs have experienced an increased level of ICU patient care responsibilities with rising patient volume and acuity. Higher ICU acuity combined with a higher volume of rapid response activations has negatively affected the amount of time the ICU NP can remain at the bedside on a rapid response activation to resolve the clinical situation before needing to return to the ICU. These competing responsibilities of the ICU NPs supporting patients in 2 locations has affected their ability to facilitate patient care on the floor during an RRT activation and created further hesitancy for nurses to call the RRT to help manage patients who were clinically deteriorating. In 2017, we instituted a pilot dedicated NP RRT consisting of experienced critical care NPs with support from a virtual (available by TeleICU) critical care physician. As a part of their workflow, the RRT NPs rounded daily on all floors to discuss any patient concerns that the bedside nurses had identified. An unintended consequence of having a consistent, proactive RRT present for daily rounds allowed for the development of relationships with floor nursing staff, who began to reach out to the team for clinical advice and support. We evaluated the impact the proactive team had on patterns of rapid response calls between the “curbside” calls and the traditional calls and on decreasing barriers for nursing staff to call RRT. Methods A dedicated team of experienced, critical care NPs, with no other patient care responsibilities and working under the supervision of a virtual critical care intensivist, responded to rapid response calls to
2
E. Burrell et al. / The Journal for Nurse Practitioners xxx (xxxx) xxx
RRT Acvaons 2011-2017 2500
2000
1500
1000
500
0 2011
2012 CVICU Team
2013 MICU Team
2014 NICU Team
2015
2016 SICU Team
2017 Total
Figure 1. Trend in rapid response team (RRT) activations (RRT) from 2011 to 2017. (CVICU ¼ cardiovascular intensive care unit; MICU ¼ medical intensive care unit; NICU ¼ neurosurgery intensive care unit; SICU ¼ surgical intensive care unit).
cardiovascular, surgical, and neurologic floors in a large, 750-bed, adult, academic hospital from 7 AM to 7 PM, 7 days per week, for 9 months. The RRT pilot NPs quickly responded to the bedside when an RRT was called and the intensivist was present virtually, using the electronic medical records (EMRs) to gain situational awareness of the patient. After a rapid response call had been resolved, the dedicated RRT NPs would follow-up with the bedside nurse on the floor within 4 hours of the call to ensure the patient continued to progress well or to update the floor nurse on the patient’s condition if transferred to the ICU.
Another role of the RRT NPs was to round on all floors daily to discuss any patient concerns that the bedside nurses had identified. The bedside nurses had access to a direct phone line that they used to “curbside consult” the RRT NPs for nursing concerns that did not meet traditional RRT triggers (Figure 2). If a patient was brought to the attention of the RRT NPs on daily rounds or by phone call, the RRT would evaluate the patient through medical record review and physical examination. If the patient met traditional triggers for rapid response, the RRT would activate a formal rapid response consult and assess and treat the patient appropriately. If no
Figure 2. Rapid response triggers. (CNS ¼ central nervous system.)
E. Burrell et al. / The Journal for Nurse Practitioners xxx (xxxx) xxx
interventions were needed, the RRT NPs would use the opportunity to validate and educate the bedside nurses and reinforce the plan of care for the patient. At the initiation of the pilot RRT, we introduced ourselves and educated the floor nursing staff to the new process of rapid response with the dedicated RRT. A component of the education included the introduction of comment cards as a means to help us improve the RRT process. The comment cards were distributed to each of the 15 nursing floors by members of the pilot team to obtain timely feedback for the pilot, both positive and negative. The title of the card was “Rapid Response Pilot Team Comment Card,” and it simply asked the nursing staff to answer, “Here’s what I experienced” with room to write comments and suggestions. The writer was given the option to write their name and the date at the bottom of the card. The cards were left at the nurses’ desks with a box to collect them in. The RRT team collected cards on their daily rounds on the floors. The feedback given was used to adjust our workflow process as needed. The RRT team reviewed the comment cards, and the common themes that emerged were nursing satisfaction with the increased support and validation of their concerns, increased patient safety, timely and quality of care, and proactive rounding and prevention by the dedicated RRT. Results Of the 516 patients evaluated by the pilot RRT, 95 (18%) were evaluated using curbside request, and 421 (88%) were seen with a traditional rapid response call. An initial spike in curbside calls is shown in Figure 3, with a return to the more traditional RRT process with progression of the pilot RRT. Summaries of the reasons for RRT activation, unexpected ICU transfers, death during hospitalization, and hospital length of stay during the period reported are shown in the Table. The rate of patients seen due to general concern in the curbside group was higher (43.2%) than in the traditional rapid response group (4.0%). Furthermore, there were fewer neurologic and cardiac calls in the curbside group (6.3% and 33.7%, respectively) than there were in the traditional group (20.9% and 48.5%, respectively). Overall rates of other types of calls (such as a bleeding skin tear) were low (3.5%), with none of those for patients in the curbside group. The unexpected ICU transfer rate was lower in the curbside group than in the traditional group (26.3% vs 37.3%). Owing to the small number of patients evaluated in the pilot program, none of the differences were powered to show statistical significance. The comment cards showed overall nurse approval of the RRT pilot program. Of the 72 cards collected, 92% had positive responses to the new, dedicated team. Of the comment cards with positive responses, 47 cards (65%) referenced increased nursing satisfaction, 33 cards (45%) referenced increased safety, timely and quality of care, and 21 cards (28%) referenced proactive rounding and prevention by the dedicated team. Of the total cards collected, 6 cards (8%) had negative comments and referenced timeliness of arrival of the team and difficulty obtaining echocardiograms during an RRT. The breakdown of the comment cards can be seen in Figure 4. Discussion Shortly after the initiation of the dedicated pilot RRT, the NP team had an unexpected increase in curbside consults on patients who met increased nursing concern (43% vs 4% for traditional RRT) but who had not yet had a formal RRT activation. Upon evaluation of these patients by the RRT, 26.3% of these patients were escalated to the ICU for ongoing care, which is indicative that the nurses are astute in noticing clinical changes in their patients before physiologic rapid response triggers occur. It is well documented that
3
Curbside vs Tradi onal RRT 60 50 40 30 20 10 0
Curbside
Tradi onal
Figure 3. Number of curbside calls versus traditional calls from January to September 2017. (RRT ¼ rapid response team.)
delaying evaluation of a patient by the RRT leads to increased death, morbidity, and length of stay, yet nurses continue to be hesitant to activate a rapid response call without physiologic changes.5,6 Massey et al7 in 2014 reported 2 of the major barriers to activation of the RRT were the nurses’ fear of reprimand for activating a call and their misunderstanding of the role of the RRT. We feel that having the proactive RRT, available for consult and responsive to nurse concerns regarding their patient’s clinical condition, negated these 2 barriers, which led to the increase in nurse confidence to curbside the RRT for nursing concerns for their patients. The topic most often discussed on the comment cards collected at the initiation of the project was the increased nursing satisfaction with the dedicated team, specifically, communication with, validation of, and support of nursing staff. We believe the original increase in curbside calls due to general concern was a direct result of our proactive approach to the RRT and the increased nursing comfort with asking for help, without fear of reprimand or ridicule. The dedicated team’s standard practice to proactively round on the floors daily, follow-up on interventions, and provide education, support, and feedback to the nursing staff allowed for meaningful communication and relationship building with this group. As the project progressed, nursing staff began to activate more traditional rapid response calls because the RRT team educated them regarding the RRT process and limited the fear of reprimand from medical teams or overcommitted ICU NPs. Although our pilot study was not powered to compare or evaluate significant differences in clinical outcomes, such as overall organ dysfunction or death, we believe this small pilot program highlights the bedside nurses as a sensitive and early-warning system to subtle but concerning changes in their patient’s condition. Although “nurse concern” is one of our RRT triggers, we found Table Comparison of Traditional versus Curbside Rapid Response Activation Variablea
RRT activation General concern Neurologic Cardiac Respiratory Other call ICU transfer Died during hospital stay Length of stay, d (range)
Traditional
Curbside
% (N ¼ 421)
% (N ¼ 95)
4 20.9 48.5 22.3 4.3 37.3 8.6 9.0
43.2 6.3 33.7 16.8 0 26.3 9.5 8.0
(17) (88) (204) (94) (18) (157) (36) (5-15)
(41) (6) (32) (16) (0) (25) (9) (6-13)
P Valueb
<.001 .001 .009 .238 .04 .043 .773 .663
ICU ¼ intensive care unit; RRT ¼ rapid response team. a Data are shown as percentage (number) or as median (interquartile range). b Bold values are statistically significant (P < .05).
4
E. Burrell et al. / The Journal for Nurse Practitioners xxx (xxxx) xxx
Comment Cards 0%
10% 20% 30% 40% 50% 60% 70%
NURSING SATISFACTION
47
INCREASED SAFETY/TIMELY/QUALITY CARE
33
ROUNDING/PREVENTION
NEGATIVE COMMENTS
21
6
Figure 4. Themes from comment cards.
that it was infrequently the reason for activating the traditional RRT. During our daily rounding process, we uncovered a high level of nurse concern for their patients. And an evaluation of these patients showed many of them needed an intervention or escalation of care to prevent further deterioration. We removed the barrier of having to formally activate an RRT with proactive rounding and allowed nurses to voice their patient care concerns in a nonthreatening environment. The similarity in rates of transfer to the ICU between the patients with RRT activation due to physiologic triggers and those who triggered RRT due to nurse concern led to the conclusion that the patients evaluated by this proactive, curbside approach validated the bedside nurses ability to recognize the need for rescue before physiologic changes. This small, descriptive pilot study has many limitations in our ability to draw any statistically significant conclusions regarding nursing barriers to activating RRTs. The pilot outcome metrics were not specifically focused on the nursing barriers to RRT activation, but once the process was initiated, it became clear that nurses were the key to early patient evaluation and rescue and that they felt marginalized in the standard RRT process (nurse feedback to the RRT). The comment cards, which were initially designed for RRT process improvement, were noted to be a nursing satisfaction and patient safety validation tool. The small numbers of comment cards are limitations in allowing us to draw conclusions regarding nurse retention and the ability of a dedicated RRT to bring down RRT activation barriers, but we showed that empowering nurses and validating their patient concerns are effective mechanisms to improving early recognition and intervention for patients at risk. Further research is needed with a specific focus on supporting floor nurses with a proactive RRT as a mechanism to impact nurse retention, satisfaction, and patient safety. Conclusion A proactive, dedicated NP-led RRT was able to round daily on the floor, spend more time on calls due to lack of additional
responsibilities, follow-up on interventions, and provide support, feedback, and education for nursing staff. As a result, relationships were built between the nursing staff and the dedicated RRT, thereby reducing the major barrier of nursing staff fear and increasing the number of patients proactively evaluated by the RRT before major clinical deterioration. The results of the study suggest that bedside nurses are a valuable and sensitive “monitor” to identify subtle clinical changes before hemodynamic compromise. Another unanticipated outcome for a dedicated RRT may be increased nursing satisfaction. Our pilot program was not powered to look at this outcome, but anecdotally, the bedside nurses appreciated the support, care, and validation they received from this program as evidenced by the overwhelming positive comment cards collected. Further research with this dedicated, proactive RRT approach is needed to determine how to have a meaningful impact on clinical outcomes and nursing retention.
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Erin Burrell, MSN, ACNP-BC is a critical care float nurse practitioner and assistant in Division of Critical Care with the Department of Trauma and Surgery at Vanderbilt University School of Medicine, Nashville, TN, and can be contacted at erin.burrell@ vumc.org. April Kapu, DNP, ACNP-BC, FAANP, FCCM, is associate nursing officer for advanced practice at Vanderbilt University Medical Center and professor at Vanderbilt University School of Nursing. Elizabeth Huggins, MSN, ACNP-BC, is a critical care float nurse practitioner and instructor, Vanderbilt University School of Nursing. Katie Cole, MSN, ACNP-BC is a critical care float nurse practitioner, assistant in Division of Critical Care with the Department of Trauma and Surgery at Vanderbilt University School of Medicine. Jennifer Fitzsimmons, MSN, ACNP-BC is a critical care float nurse practitioner and instructor, Vanderbilt University School of Nursing, Nashville, TN. Nina Collins, MSN, ACNP-BC, is tracheotomy and percutaneous endoscopic gastrostomy NP for Vanderbilt University Medical Center, assistant in surgery for the Division of Trauma and Surgery, Critical Care at Vanderbilt University School of Medicine. Liza Weavind, MBBCh, MMHC, FCCM, is professor of anesthesiology and surgery, associate division chief, Anesthesiology Critical Care Medicine, associate chief of staff, and director of TeleICU, Nashville. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.