- Email: [email protected]
Rescue Me: Saving the Vulnerable Non–ICU Patient Population
The Joint Commission Journal on Quality and Patient Safety Codman Awards
Rescue Me: Saving the Vulnerable Non–ICU Patient Population Mary Kay Bader, R.N., M.S.N., C.C.N.S.; Beverly Neal, R.N., M.S.N., C.C.R.N.; Linda Johnson, R.N., M.S.N., N.E.A.-B.C.; Kirsten Pyle, R.N., C.C.R.N.; Jan Brewer, R.N., Ph.D.; Michele Luna, R.N., Ph.D.; Connie Stalcup, R.N., M.S.N.; Margie Whittaker, R.N., M.S.N.; Michael Ritter, M.D.
M
ission Hospital, a 304-bed acute care hospital, provides services to 621,168 persons in south Orange County, California. As a trauma center, cardiac receiving center, and Joint Commission–certified Primary Stroke Center, the hospital offers advanced care in a variety of comprehensive patient care services. Mission Hospital is one of five hospitals located in south Orange County and is part of the Sisters of Saint Joseph of Orange Hospital system, which includes 14 hospitals located in California and Texas. During the past decade, hospitals in the United States have experienced a need for more ICU and telemetry beds as well as more skilled personnel.1 In addition, the acute in-patient bed shortages result in a higher volume of emergency department (ED) patients waiting for beds.1 Recent advances in the management of stroke, myocardial infarction, and sepsis are pressing the ED further with the need to provide rapid workup and ICU–level nursing care. As a result of the limited number of monitored beds, higher-acuity patients are occupying medical-surgical beds. When deterioration in their clinical condition occurs, such non–ICU patients are vulnerable and at great risk for increased mortality. In a study that explored suboptimal care to patients admitted to the ICU from the floor, more than half of the patients sustained less than optimal management of airway, breathing, circulation, and monitoring. Thirty-nine percent of the patients sustaining acute emergencies were admitted to the ICU late in the clinical course,2 reflecting the failure to recognize clinical deterioration or to seek advice from an expert, lack of knowledge, and lack of adequate supervision of practitioners on medical-surgical units.2 These factors can lead to a failure to act quickly to “rescue” patients before they proceeded to full arrest. In short, patients were dying in our hospitals, and their deaths are considered potentially “preventable.” A review of the literature demonstrates that the majority of patients exhibit symptomatology of impending arrest up to six to eight hours before the actual arrest.2–4 The Joint Commission’s National Patient Safety Goal 16 highlights the need to identify patients with
April 2009
Article-at-a-Glance Background: From 2003–2005, a comprehensive review
of all cardiac/respiratory arrests at Mission Hospital (Mission Viejo, California) uncovered deficits in knowledge and judgment in the hours preceding 75% of our non-ICU patients. Nearly half of all arrests were occurring outside the ICU, with an overall mortality rate of 60%. In addition, transfers into ICU from the floor averaged 96 patients per month. Methods: A multidisciplinary team met for 12 months to develop a specialized nurse-driven rapid response team (RRT) to reduce the incidence and mortality of non–ICU arrests, reduce transfers to the ICU from the floor, and provide ICU–level nursing care for emergency department (ED) patients in extremis. The team developed an RRT protocol, a methodology for rounds and calls, and a data collection system. After gaining consensus among the nursing managers, 4.2 full-time equivalent (FTE) RRT nurse positions were created by each unit contributing portions of an FTE. Results: Prospective data collected demonstrated an inpatient call frequency averaging 118 calls per 1,000 discharges; 138 calls per month were in support of the ED. Floor codes were reduced from 36 to 17 per year, and the mortality rate in the floor-code patients decreased from 61% to 26%. Unanticipated transfers from the floor units to the ICU decreased significantly. Discussion: The RRT initiative delivered measurable outcomes demonstrating the hospital’s commitment to saving the vulnerable hospitalized patient population. In addition, the identification of critical system and clinical issues resulted in efforts to improve processes and identify patient subpopulations at risk (for example, patients with congestive heart failure, end-stage heart disease, high-dose narcotics).
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The Joint Commission Journal on Quality and Patient Safety worsening conditions.5* The resuscitation committee (RC) performs a 100% review of all arrests quarterly. In June of 2005, a cumulative review of Mission’s cardiac/respiratory arrests from January 2003 to June 2005 revealed a 67.2% overall mortality following arrest; 46% of all arrests (85 of 186) occurred in non–ICU/ED settings; and 60% (51 of 85) of the patients died when the arrest occurred outside the ICU/ED. The RC investigated each case in more detail. Like Ernest Codman, who found “errors due to lack of knowledge or skill, surgical judgment, lack of care or equipment, and lack of diagnostic skill,”6 the RC uncovered errors in knowledge and judgment in the hours preceding 75% of non–ICU patients’ arrests. The RC believed that these errors represented a “failure to rescue” and that immediate action was required to reduce the incidence of arrests and mortality associated with the non–ICU patients. Further investigation revealed a subpopulation of patients admitted to non–ICU beds who were deteriorating after hospital admission and were being transferred into ICU beds at a high rate of 80 to 173 patients per month. High-acuity patients entering the ED were requiring quick intervention by nurses with critical care skills to assist the ED team facilitate the rapid diagnostic and interventional workup. This required a 1:1 level of nurse staffing, which strained existing ED resources. The inability to meet these patients’ critical needs spurred a core team of RC nurses and physicians to action. The team had three goals: 1. Provide a specialized nurse-driven rapid response team (RRT) to reduce the incidence and mortality of non–ICU arrests by 50%. 2. Intervene on high-risk non–ICU floor patients prior to deterioration of their condition in an effort to prevent transfer to an ICU. 3. Provide immediate ICU–level nursing care for ED patients in extremis.
Methods FORMATION OF TEAM The quality leadership council (QLC) entrusted the leadership of the initiative to the chief nursing officer (CNO) [L.J.]. In June 2005, she appointed an RRT leadership team to explore and implement the program. Team members consisted of an ED physician [M.R.], the CNO, the director of quality— research and outcomes [J.B.], a quality manager [M.L.], the * Goal 16: “Improve recognition and response to changes in a patient’s condition.” [p. NPSG-19]
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director of critical care/trauma services [C.S.], three advanced practice nurses [including M.K.B.], nurse manager of critical care [M.W.], and the director of respiratory services. Later additions to the team included staff nurses [K.P., B.N.].
PERFORMANCE IMPROVEMENT ACTIVITIES Following the QLC meeting, approval was obtained to accomplish the following: develop a budget to staff the RRT, develop a methodology to identify high risk-vulnerable patients for proactive patient rounds, develop RRT standardized procedure (SP) and job description, define criteria for documenting RRT calls for analysis, integrate the RRT nurse into the ED team to help care for critical patients, and collect prospective data from RRT rounds and calls. The RRT SP was developed as incorporating two major sections. The first section addressed an innovative approach to RRT by identifying high-risk, vulnerable patient populations for the RRT nurse to proactively round on each shift. These populations included transfers out of ICU with a length of stay greater than four days; high-risk diagnoses including hypoxic respiratory failure, upper gastrointestinal (GI) bleeding, unstable angina, arrhythmias, tracheostomy, altered mental status, inability to communicate needs, and/or aphasia; and designated 1:3 staffing. The second section addressed the specific physiologic criteria for calling the RRT. The evidence-based literature served as a rich source, listing criteria for activation of the RRT. The SP went a step further in its scope by including initial diagnostic and treatment interventions that could be initiated by the RRT nurse (Figure 1, page 201). Phone consultation with the primary physician was included in the SP. The criteria for RRT response to the ED was included in the call criteria, provided in Table 1 (page 202). The RRT nurse would dedicate approximately 50% of the call response time to the ED. The RRT job description was developed and required a skill set that included expert clinician, communicator, educator, and certification in critical care or ED. A rapid-cycle test of the RRT was successfully conducted in December 2005 to determine the practicality of the proactive rounding component, educate floor nursing staff on the role of RRT, and intervene on deteriorating patients. The benefits of the trial included staff mentoring, real-time education, availability of a consultant role in which nurses could ask for second opinions on critical patients, building of relationships between disciplines, and enhanced communication among care givers. Funding of the RRT was provided by the CNO and directors/managers of all units. No additional full-time equivalents (FTEs) were to be added to the hospital’s budget and bottom
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Copyright 2009 Joint Commission on Accreditation of Healthcare Organizations
The Joint Commission Journal on Quality and Patient Safety Documentation and Interventions for Rapid Response Team (RRT) Nurse
Figure 1. Orders in green are included in the RRT standardized process. SP, standardized procedure; ECG, electrocardiogram; O2, oxygen; IV, intravenous; g, gauge; BP, blood pressure; P, pulse; R, respiration; NVD, neck vein distension; EKG, electrocardiogram; LOC, level of consciousness; NTG, nitroglycerine; SL, sublingual; D. Pedis, dorsalls pedis; ABG, arterial blood gas; po/pr, by mouth/by way of the rectum; pH, hydrogen ion concentration; PaO2, partial pressure of oxygen in arterial blood; PaCO2, partial pressure of carbon dioxide in arterial blood; TCP, total circulating protein; prev, previous; HC03, carbonic oxide; SBP, systolic blood pressure; BE, base excess; Cath, catheter; CBC, complete blood count; Neb, nebulizer; TX, treatment; Bipap, Bi-level positive airway pressure; MD, physician; H, hemoglobin; H, hematocrit; PT, prothrombin time; PTT, partial thromboplastin time; INR, International Normalized Ratio; BNP, brain natriuretic peptide hormone; Na, sodium; K, potassium; Cl, chloride; CO2, carbon dioxide; Mag, magnesium; Ca, calcium; Creat, creatinine; BUN, blood urea nitrogen; GCS, Glasgow Coma Scale; CT, computerized tomography; BG, blood glucose; NIHSS, National Institute of Health Stroke Scale; D50, 50% dextrose in water; PERRLA, pupils equal, round, and reactive to light and accommodation; BMP, basic metabolic panel; IVP, intravenous push; PFA, platelet function assay; TEMP, temperature; WBC, white blood cell count; HR, heart rate; sat, saturation; RR, respiration rate; NA, not applicable; RN, nurse.
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The Joint Commission Journal on Quality and Patient Safety Table 1. When to Call Rapid Response* If the patient demonstrates any of the following signs/symptoms at any time: ■ Airway Respiratory distress and threatened airway ■ Breathing: Acute change in Respiratory rate > 30 or < 10 Pulse oximeter < 92% Difficulty speaking due to shortness of breath ■ Circulation: Acute change in Systolic blood pressure < 90 mm Hg Heart rate < 40 or > 130 Urine output to < 50 mL in 4 hours Color change of patient (pale, dusky, gray, or blue) Complaint of nontraumatic chest pain ■ Neurologic: Decrease in level of consciousness Acute change in mental status Seizure New onset arm/leg weakness or droopy smile or problem talking ■ Sepsis: Suspect infectious process with two or more SIRS criteria: Temp > 38⬚ C or 100.4⬚ F Heart rate > 90 Respiratory rate > 20 WBC > 12,000, < 4,000, or > 10% bands ■ RN is worried or concerned about patient Uncontrolled pain Failure to respond to treatment Unable to obtain prompt assistance for unstable patient * WBC, white blood count; SIRS, systemic inflammatory response syndrome; RN, registered nurse.
line. Individual meetings between the CNO and nursing directors were held to discuss the positive impact RRT would have on their respective units and to gain consensus for labor-hour contribution. Each hospital unit contributed 0.2–0.4 FTEs from its budget, and 4.2 FTEs were allocated to fund the RRT 24 hours a day, 7 days a week. The leadership team obtained RRT SP approval from medical staff committees and the interdisciplinary committee. Education and credentialing of the RRT nurses occurred in August 2006. The RRT program was launched in September of 2006. The RRT nurses conducted education of all nursing personnel during September 2006. Internal communication strategies included posters and key chains with the RRT phone number. The RRT leadership team met twice monthly with the RRT staff to monitor progress and resolve any issues that surfaced. Monthly reporting of data to the Nursing Leadership group and Medical Staff committees occurred. A quarterly reporting structure to the QLC was established. 202
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Table 2. Rapid Response Team (RRT) Data Elements Collected on All Calls* ■ Patient identifier, location ■ Admit date, # of days from admit to RRT call; date of call; time: day or night shift ■ Response time for RRT RN to arrive at location and duration of call ■ RRT nurse ■ Type of call: pulmonary, arrhythmia, hypotension, unstable angina, altered level of consciousness, nurse consult, code trauma, code sepsis, code stroke, code blue, or code STEMI ■ Interventions: specify ■ Emergent or urgent ■ Education needed ■ Outcome: condition improved (stayed on unit), condition requires transfer to higher level of care, code blue, or expired ■ Significant event avoided, outcome and any vital additional information * RN, registered nurse; STEMI, ST elevation myocardial infarction
An RRT documentation tool and a prospective database with indicators (Table 2, above) was created. Quantitative data from rounds were captured daily by the RRT nurses. The neuro/critical care clinical nurse specialist [M.K.B.] reviewed the medical record on significant calls monthly. Arrest data from the previous 12 months (numbers of arrests/mortality of floor arrests) were documented and served as the pre–RRT arrest outcome data. Post–RRT arrest data were to be collected by the RC. Transfers to ICU were investigated for September 2005 through August 2006 (pre–RRT), data that were to serve as the baseline data.
PERFORMANCE MEASUREMENT Data elements were collected on all calls (Table 2). The cases were reviewed after patient discharge to determine if the interventions affected the patient’s clinical course. Trending of specific clinical diagnoses was done to determine if any at-risk patient populations existed. In addition to the raw RRT data elements, data from a 100% review of all cardiac/respiratory arrests were collected by the RC on a quarterly basis. The number of codes occurring outside of the ICU/ED and mortality were documented. All arrests that occurred outside of the ICU and ED were further analyzed to determine if any significant events might have been avoided. The following three types of measures were developed to test the effectiveness of the RRT initiative: process compliance measures, safety (balancing) measures, and outcome measures.
Volume 35 Number 4
Copyright 2009 Joint Commission on Accreditation of Healthcare Organizations
The Joint Commission Journal on Quality and Patient Safety Rapid Response Team (RRT) in Patient Calls per 1,000 Discharges, Mission versus IHI Monthly Average, September 2006–June 2008
Figure 2. Mission’s rate of RRTs in patient/1,000 discharges (blue solid line) increased from 60 to 184, compared with an average rate for organizations for 19 organizations participating in the Institute for Healthcare Improvement’s (IHI) 5 Million Lives Campaign (red dotted line) of 15–29 RRT calls. The small standard deviations reflect the large numbers of patients represented in the data. UCL, upper control limit; LCL, lower control limit.
Data collected and reported monthly included RRT calls per 1,000 discharges, mortality rate for codes that occurred on the medical-surgical floors, and percent of transfers to the cardiac ICU per hospital discharge.
Results CHARACTERISTICS OF RRT CALLS The RRT responded to an average of 338 calls (range, 174–440) monthly (RRT calls are reported on a national basis, via the Institute for Healthcare Improvement [IHI] 5 Million Lives Campaign, as calls per 1,000 discharges). Mission’s data, compared against 19 organizations across the United States, revealed the average IHI rate per month from September 2006 to June 2008 was between 15 and 29 RRT calls/1,000 discharges; Mission’s rate increased from a starting point of 60 to 184 RRT calls/1,000 discharges (Figure 2, above). Statistical analysis showed a favorable special-cause variation within the process over time (improvement in the number of calls/discharge) as well as a statistically significant difference against the comparative group each month (1-tailed; p < .05). Also, a monthly average of 138 (range, 91–185) calls were made in support of critical patients in the ED. The average RRT response time was 2 minutes, with calls averaging 44 minutes in length. The most frequent in-patient calls were related to nurse consults, pulmonary, hypotension, changes in level of consciousness, and arrhythmias. Twenty per cent of all calls occurred on the day of admission, with an aver-
April 2009
age of eight patients per month transferred to the ICU; 55% of all calls occurred within 48 hours of admission to the hospital.
OUTCOMES The initiative resulted in a statistically significant reduction of non–ICU arrests from 36 per year pre–RRT to 17 per year post–RRT. As shown in Figure 3 (page 204), the mortality associated with non–ICU arrests decreased from 61% pre–RRT to 26% post–RRT (p < .05). Tracking of transfers to the cardiac ICU since the introduction of the RRT revealed a decrease in transfers per month (Figure 4, page 205; 1- and 2-tailed, p < .05). Two episodes of special cause were identified in trending data related to overcapacity of hospital/critical care beds. Patients requiring critical care admission were either held in the ED for an extended period of time or upon reevaluation were cleared for admission to a monitored stepdown unit. An increase in calls with transfer into critical care occurred during this time. There has been a steady decrease in the proportion of transfers to critical care per RRT call over time.
ANALYSIS Anecdotal evidence and lessons learned over time led to process changes, protocol revisions, and increased efficiency. Data continue to be interpreted on a monthly basis. The quantitative data remain strong, with numbers of calls per month remaining high, a consistently significant number of adverse events avoided, and a low number of unanticipated transfers to
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The Joint Commission Journal on Quality and Patient Safety “Floor” Code Blue Mortality, Pre– and Post–Rapid Response Team (RRT)
Figure 3. The mortality associated with non–ICU arrests decreased from 61% pre–RRT to 26% post–RRT (p < .05). UCL, upper control limit; LCL, lower control limit.
the ICU. Beyond the quantitative data, analysis of trends in RRT calls enabled the RRT nurses and the neuro/critical care clinical nurse specialist to identify significant qualitative issues. Clinical issues related to the management of sepsis patients admitted to the floors, narcotic overdoses in high-risk/elderly patients, endof-life care issues, and an increase in arrests occurring in elderly end-stage cardiac disease patients on one unit were reported to the QLC and the medical staff committees. The issues discovered through RRT data analysis highlighted vulnerable patient populations, allowing the hospital to focus efforts on reducing morbidity/mortality. System issues were identified, including physicians communication, delay in accessing emergency medications from automated dispensing cabinets in non–ICU areas, and education needs of charge nurses. The qualitative clinical and system issues were reported to the QLC, were promptly resolved through the cooperation of the medical staff and multiple departments, and were then reported to the appropriate committees.
Discussion This RRT initiative demonstrated the ability of a community hospital to garner the necessary resources from an existing infrastructure and staff to create a 24-hour/7-day-a-week RRT program. The quantitative data on number of monthly calls, unanticipated transfers to the ICU, and incidence of non–ICU arrests confirmed the validity of the program. Perhaps the most valuable outcome of the RRT implementation was the identification of clinical and system issues. Organizations attempting to implement an RRT program must consider their specific needs on the basis of existing infra204
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structure. The RRT leadership team at Mission Hospital discussed the pros and cons of the physician model—the medical emergency team–and reached consensus that a nursing model with a dedicated fully staffed RRT with no unit or patient assignment was required to effectively implement the program. The model would also best serve the ED, whose patient population required additional immediate clinical support in critical situations. The hospital wanted to design a program with relevant, demonstrated quantifiable value and a long-term impact on patient care. One of the greatest challenges was funding the RRT concept, but creative solutions were found. As clinical improvement opportunities were recognized, the RRT staff supported the initiatives and promoted the change in practice. In the first six months of the RRT’s implementation, the nurses rescued a high number of unidentified sepsis patients on the floor units. Given the demonstrated need for increased surveillance, the RRT leadership team had the RRT screen all infectious admissions to the floor units for the first 48 hours, a practice that continues. Evaluation of the RRT data revealed other vulnerable subpopulations. From 6 to 12 months into RRT implementation, RRT calls were received for patients with congestive heart failure, end-stage heart disease, and high-dose narcotics. Strategies were then developed to identify clinical changes earlier through increased surveillance by the RRT and by education of nurses. In the second year of RRT implementation, patients presenting with pancreatitis and patients deteriorating on the day of admission to the floor have been scrutinized for clues to earlier detection of physiologic changes. RRT nurses now screen all pancreatitis admissions on rounds in the first 48 hours; findings of positive Ranson’s criteria and heart rates of
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Copyright 2009 Joint Commission on Accreditation of Healthcare Organizations
The Joint Commission Journal on Quality and Patient Safety Inpatient Transfers to Critical Care per Rapid Response Team (RRT) Calls, September 2006–June 2008
Figure 4. When the RRT was partially staffed, 523 transfers occurred, for an average of 21%, as compared with the 2,858 transfers, for an average of 14%, that occurred when it was fully staffed (1- and 2-tailed, p < .05). Special-cause variations were identified for the four of the five points beyond one standard deviation (S.D.) and the two of the three beyond 2 S.D.s during partial RRT staffing and the two of the three points beyond 2 S.D.s in November/December 2007. UCL, upper control limit; LCL, lower control limit.
> 120 led to notification of physicians. More patients were “rescued” as more subpopulations were identified and strategies were initiated to reduce their vulnerability. The rescues—and interventions—occurred earlier in the clinical course, preventing transfer to a higher level of care.
Postscript The RRT initiative has served as an example for other organizations attempting to increase their RRT calls. In April 2008, the initiative was presented at health system quality and physician meetings with representatives from all of Mission’s 14 hospitals. Mission’s quality departments and the hospital CNOs have encouraged adoption of the Mission model. At present, one hospital has officially changed to the Mission model, with the others evaluating resources needed to implement it. J
Mary Kay Bader, R.N., M.S.N., C.C.N.S., is Neuro/Critical Care Nurse Specialist, Mission Hospital, Mission Viejo, California; Beverly Neal, R.N., M.S.N., C.C.R.N., is a Rapid Response Team (RRT) Nurse/Surgical ICU Clinical III Nurse; Linda Johnson R.N., M.S.N., N.E.A.-B.C., is Chief Nursing Officer; Kirsten Pyle, R.N., C.C.R.N., is Sepsis Coordinator/Surgical ICU Staff Nurse; Jan Brewer, R.N., Ph.D., is Director of Quality–Research and Outcomes; Michele Luna, R.N., Ph.D., is Quality Manager;Connie Stalcup, R.N., M.S.N., is Director, Critical Care/Trauma Services; Margie Whittaker, R.N., M.S.N., is Surgical ICU Nurse Manager; and Michael Ritter, M.D., is an Emergency Department physician. Please address requests for reprints to Mary Kay Bader, [email protected].
April 2009
This initiative, titled “In the Nick of Time: Rapid Response to the Rescue,” was presented at the American Association of Critical Care Nurses’ annual National Teaching Institute and Critical Care Exposition, Chicago, May 7, 2008.
References 1. The Joint Commission: Health Care at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis (white paper). http://www.jointcommission.org/NR/rdonlyres/5C138711-ED76-4D6F909F-B06E0309F36D/0/health_care_at_the_crossroads.pdf (last accessed Mar. 2, 2009). 2. McQuillan P., et al.: Confidential inquiry into the quality of care before admission to intensive care. BMJ 316:1853–1858, Jun. 20, 1998. 3. Schein R.M., et al.: Clinical antecedents to in-hospital cardiopulmonary arrest. Chest 98:1388–1392, Dec. 1990. 4. Kause J., et al.: A comparison of antecedents to cardiac arrests, deaths, and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom—the ACADEMIA study. Resuscitation 62:275–282, Sep. 2004. 5. The Joint Commission: 2009 Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace: Joint Commission Resources, 2008. 6. Neuhauser D.: Heroes and Martyrs of Quality and Safety: Ernest Amory Codman MD. Qual Saf Health Care 11(1): Mar. 2002. http://qshc.bmj.com/cgi/content/full/11/1/104 (last accessed Mar. 2, 2009). 7. Institute for Healthcare Improvement: Deploy Rapid Response Teams. http://www.ihi.org/IHI/Programs/Campaign/RapidResponseTeams.htm (last accessed Mar. 2, 2009). 7. South Western Sydney Area Health Service (SWSAHS): Implementation of the MET System into Your Hospital: A Window of Opportunity. Liverpool, Australia: SWSAHS, 2000. 8. Bellomo R., et al.: Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med 32:916–921, Apr. 2004. 9. Bion J., Heffner J.: Challenges in the care of the acutely ill. Lancet 363:970–971, Mar. 20, 2004. 10. Merit Study Investigators: Introduction of the medical emergency team (MET) system: A cluster-randomized controlled trial. Lancet 365:2091–2097, Jun. 18, 2005.
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Rescue Me: Saving the Vulnerable Non–ICU Patient Population Mary Kay Bader, R.N., M.S.N., C.C.N.S.; Beverly Neal, R.N., M.S.N., C.C.R.N.; Linda Johnson, R.N., M.S.N., N.E.A.-B.C.; Kirsten Pyle, R.N., C.C.R.N.; Jan Brewer, R.N., Ph.D.; Michele Luna, R.N., Ph.D.; Connie Stalcup, R.N., M.S.N.; Margie Whittaker, R.N., M.S.N.; Michael Ritter, M.D.
M
ission Hospital, a 304-bed acute care hospital, provides services to 621,168 persons in south Orange County, California. As a trauma center, cardiac receiving center, and Joint Commission–certified Primary Stroke Center, the hospital offers advanced care in a variety of comprehensive patient care services. Mission Hospital is one of five hospitals located in south Orange County and is part of the Sisters of Saint Joseph of Orange Hospital system, which includes 14 hospitals located in California and Texas. During the past decade, hospitals in the United States have experienced a need for more ICU and telemetry beds as well as more skilled personnel.1 In addition, the acute in-patient bed shortages result in a higher volume of emergency department (ED) patients waiting for beds.1 Recent advances in the management of stroke, myocardial infarction, and sepsis are pressing the ED further with the need to provide rapid workup and ICU–level nursing care. As a result of the limited number of monitored beds, higher-acuity patients are occupying medical-surgical beds. When deterioration in their clinical condition occurs, such non–ICU patients are vulnerable and at great risk for increased mortality. In a study that explored suboptimal care to patients admitted to the ICU from the floor, more than half of the patients sustained less than optimal management of airway, breathing, circulation, and monitoring. Thirty-nine percent of the patients sustaining acute emergencies were admitted to the ICU late in the clinical course,2 reflecting the failure to recognize clinical deterioration or to seek advice from an expert, lack of knowledge, and lack of adequate supervision of practitioners on medical-surgical units.2 These factors can lead to a failure to act quickly to “rescue” patients before they proceeded to full arrest. In short, patients were dying in our hospitals, and their deaths are considered potentially “preventable.” A review of the literature demonstrates that the majority of patients exhibit symptomatology of impending arrest up to six to eight hours before the actual arrest.2–4 The Joint Commission’s National Patient Safety Goal 16 highlights the need to identify patients with
April 2009
Article-at-a-Glance Background: From 2003–2005, a comprehensive review
of all cardiac/respiratory arrests at Mission Hospital (Mission Viejo, California) uncovered deficits in knowledge and judgment in the hours preceding 75% of our non-ICU patients. Nearly half of all arrests were occurring outside the ICU, with an overall mortality rate of 60%. In addition, transfers into ICU from the floor averaged 96 patients per month. Methods: A multidisciplinary team met for 12 months to develop a specialized nurse-driven rapid response team (RRT) to reduce the incidence and mortality of non–ICU arrests, reduce transfers to the ICU from the floor, and provide ICU–level nursing care for emergency department (ED) patients in extremis. The team developed an RRT protocol, a methodology for rounds and calls, and a data collection system. After gaining consensus among the nursing managers, 4.2 full-time equivalent (FTE) RRT nurse positions were created by each unit contributing portions of an FTE. Results: Prospective data collected demonstrated an inpatient call frequency averaging 118 calls per 1,000 discharges; 138 calls per month were in support of the ED. Floor codes were reduced from 36 to 17 per year, and the mortality rate in the floor-code patients decreased from 61% to 26%. Unanticipated transfers from the floor units to the ICU decreased significantly. Discussion: The RRT initiative delivered measurable outcomes demonstrating the hospital’s commitment to saving the vulnerable hospitalized patient population. In addition, the identification of critical system and clinical issues resulted in efforts to improve processes and identify patient subpopulations at risk (for example, patients with congestive heart failure, end-stage heart disease, high-dose narcotics).
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The Joint Commission Journal on Quality and Patient Safety worsening conditions.5* The resuscitation committee (RC) performs a 100% review of all arrests quarterly. In June of 2005, a cumulative review of Mission’s cardiac/respiratory arrests from January 2003 to June 2005 revealed a 67.2% overall mortality following arrest; 46% of all arrests (85 of 186) occurred in non–ICU/ED settings; and 60% (51 of 85) of the patients died when the arrest occurred outside the ICU/ED. The RC investigated each case in more detail. Like Ernest Codman, who found “errors due to lack of knowledge or skill, surgical judgment, lack of care or equipment, and lack of diagnostic skill,”6 the RC uncovered errors in knowledge and judgment in the hours preceding 75% of non–ICU patients’ arrests. The RC believed that these errors represented a “failure to rescue” and that immediate action was required to reduce the incidence of arrests and mortality associated with the non–ICU patients. Further investigation revealed a subpopulation of patients admitted to non–ICU beds who were deteriorating after hospital admission and were being transferred into ICU beds at a high rate of 80 to 173 patients per month. High-acuity patients entering the ED were requiring quick intervention by nurses with critical care skills to assist the ED team facilitate the rapid diagnostic and interventional workup. This required a 1:1 level of nurse staffing, which strained existing ED resources. The inability to meet these patients’ critical needs spurred a core team of RC nurses and physicians to action. The team had three goals: 1. Provide a specialized nurse-driven rapid response team (RRT) to reduce the incidence and mortality of non–ICU arrests by 50%. 2. Intervene on high-risk non–ICU floor patients prior to deterioration of their condition in an effort to prevent transfer to an ICU. 3. Provide immediate ICU–level nursing care for ED patients in extremis.
Methods FORMATION OF TEAM The quality leadership council (QLC) entrusted the leadership of the initiative to the chief nursing officer (CNO) [L.J.]. In June 2005, she appointed an RRT leadership team to explore and implement the program. Team members consisted of an ED physician [M.R.], the CNO, the director of quality— research and outcomes [J.B.], a quality manager [M.L.], the * Goal 16: “Improve recognition and response to changes in a patient’s condition.” [p. NPSG-19]
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director of critical care/trauma services [C.S.], three advanced practice nurses [including M.K.B.], nurse manager of critical care [M.W.], and the director of respiratory services. Later additions to the team included staff nurses [K.P., B.N.].
PERFORMANCE IMPROVEMENT ACTIVITIES Following the QLC meeting, approval was obtained to accomplish the following: develop a budget to staff the RRT, develop a methodology to identify high risk-vulnerable patients for proactive patient rounds, develop RRT standardized procedure (SP) and job description, define criteria for documenting RRT calls for analysis, integrate the RRT nurse into the ED team to help care for critical patients, and collect prospective data from RRT rounds and calls. The RRT SP was developed as incorporating two major sections. The first section addressed an innovative approach to RRT by identifying high-risk, vulnerable patient populations for the RRT nurse to proactively round on each shift. These populations included transfers out of ICU with a length of stay greater than four days; high-risk diagnoses including hypoxic respiratory failure, upper gastrointestinal (GI) bleeding, unstable angina, arrhythmias, tracheostomy, altered mental status, inability to communicate needs, and/or aphasia; and designated 1:3 staffing. The second section addressed the specific physiologic criteria for calling the RRT. The evidence-based literature served as a rich source, listing criteria for activation of the RRT. The SP went a step further in its scope by including initial diagnostic and treatment interventions that could be initiated by the RRT nurse (Figure 1, page 201). Phone consultation with the primary physician was included in the SP. The criteria for RRT response to the ED was included in the call criteria, provided in Table 1 (page 202). The RRT nurse would dedicate approximately 50% of the call response time to the ED. The RRT job description was developed and required a skill set that included expert clinician, communicator, educator, and certification in critical care or ED. A rapid-cycle test of the RRT was successfully conducted in December 2005 to determine the practicality of the proactive rounding component, educate floor nursing staff on the role of RRT, and intervene on deteriorating patients. The benefits of the trial included staff mentoring, real-time education, availability of a consultant role in which nurses could ask for second opinions on critical patients, building of relationships between disciplines, and enhanced communication among care givers. Funding of the RRT was provided by the CNO and directors/managers of all units. No additional full-time equivalents (FTEs) were to be added to the hospital’s budget and bottom
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The Joint Commission Journal on Quality and Patient Safety Documentation and Interventions for Rapid Response Team (RRT) Nurse
Figure 1. Orders in green are included in the RRT standardized process. SP, standardized procedure; ECG, electrocardiogram; O2, oxygen; IV, intravenous; g, gauge; BP, blood pressure; P, pulse; R, respiration; NVD, neck vein distension; EKG, electrocardiogram; LOC, level of consciousness; NTG, nitroglycerine; SL, sublingual; D. Pedis, dorsalls pedis; ABG, arterial blood gas; po/pr, by mouth/by way of the rectum; pH, hydrogen ion concentration; PaO2, partial pressure of oxygen in arterial blood; PaCO2, partial pressure of carbon dioxide in arterial blood; TCP, total circulating protein; prev, previous; HC03, carbonic oxide; SBP, systolic blood pressure; BE, base excess; Cath, catheter; CBC, complete blood count; Neb, nebulizer; TX, treatment; Bipap, Bi-level positive airway pressure; MD, physician; H, hemoglobin; H, hematocrit; PT, prothrombin time; PTT, partial thromboplastin time; INR, International Normalized Ratio; BNP, brain natriuretic peptide hormone; Na, sodium; K, potassium; Cl, chloride; CO2, carbon dioxide; Mag, magnesium; Ca, calcium; Creat, creatinine; BUN, blood urea nitrogen; GCS, Glasgow Coma Scale; CT, computerized tomography; BG, blood glucose; NIHSS, National Institute of Health Stroke Scale; D50, 50% dextrose in water; PERRLA, pupils equal, round, and reactive to light and accommodation; BMP, basic metabolic panel; IVP, intravenous push; PFA, platelet function assay; TEMP, temperature; WBC, white blood cell count; HR, heart rate; sat, saturation; RR, respiration rate; NA, not applicable; RN, nurse.
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The Joint Commission Journal on Quality and Patient Safety Table 1. When to Call Rapid Response* If the patient demonstrates any of the following signs/symptoms at any time: ■ Airway Respiratory distress and threatened airway ■ Breathing: Acute change in Respiratory rate > 30 or < 10 Pulse oximeter < 92% Difficulty speaking due to shortness of breath ■ Circulation: Acute change in Systolic blood pressure < 90 mm Hg Heart rate < 40 or > 130 Urine output to < 50 mL in 4 hours Color change of patient (pale, dusky, gray, or blue) Complaint of nontraumatic chest pain ■ Neurologic: Decrease in level of consciousness Acute change in mental status Seizure New onset arm/leg weakness or droopy smile or problem talking ■ Sepsis: Suspect infectious process with two or more SIRS criteria: Temp > 38⬚ C or 100.4⬚ F Heart rate > 90 Respiratory rate > 20 WBC > 12,000, < 4,000, or > 10% bands ■ RN is worried or concerned about patient Uncontrolled pain Failure to respond to treatment Unable to obtain prompt assistance for unstable patient * WBC, white blood count; SIRS, systemic inflammatory response syndrome; RN, registered nurse.
line. Individual meetings between the CNO and nursing directors were held to discuss the positive impact RRT would have on their respective units and to gain consensus for labor-hour contribution. Each hospital unit contributed 0.2–0.4 FTEs from its budget, and 4.2 FTEs were allocated to fund the RRT 24 hours a day, 7 days a week. The leadership team obtained RRT SP approval from medical staff committees and the interdisciplinary committee. Education and credentialing of the RRT nurses occurred in August 2006. The RRT program was launched in September of 2006. The RRT nurses conducted education of all nursing personnel during September 2006. Internal communication strategies included posters and key chains with the RRT phone number. The RRT leadership team met twice monthly with the RRT staff to monitor progress and resolve any issues that surfaced. Monthly reporting of data to the Nursing Leadership group and Medical Staff committees occurred. A quarterly reporting structure to the QLC was established. 202
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Table 2. Rapid Response Team (RRT) Data Elements Collected on All Calls* ■ Patient identifier, location ■ Admit date, # of days from admit to RRT call; date of call; time: day or night shift ■ Response time for RRT RN to arrive at location and duration of call ■ RRT nurse ■ Type of call: pulmonary, arrhythmia, hypotension, unstable angina, altered level of consciousness, nurse consult, code trauma, code sepsis, code stroke, code blue, or code STEMI ■ Interventions: specify ■ Emergent or urgent ■ Education needed ■ Outcome: condition improved (stayed on unit), condition requires transfer to higher level of care, code blue, or expired ■ Significant event avoided, outcome and any vital additional information * RN, registered nurse; STEMI, ST elevation myocardial infarction
An RRT documentation tool and a prospective database with indicators (Table 2, above) was created. Quantitative data from rounds were captured daily by the RRT nurses. The neuro/critical care clinical nurse specialist [M.K.B.] reviewed the medical record on significant calls monthly. Arrest data from the previous 12 months (numbers of arrests/mortality of floor arrests) were documented and served as the pre–RRT arrest outcome data. Post–RRT arrest data were to be collected by the RC. Transfers to ICU were investigated for September 2005 through August 2006 (pre–RRT), data that were to serve as the baseline data.
PERFORMANCE MEASUREMENT Data elements were collected on all calls (Table 2). The cases were reviewed after patient discharge to determine if the interventions affected the patient’s clinical course. Trending of specific clinical diagnoses was done to determine if any at-risk patient populations existed. In addition to the raw RRT data elements, data from a 100% review of all cardiac/respiratory arrests were collected by the RC on a quarterly basis. The number of codes occurring outside of the ICU/ED and mortality were documented. All arrests that occurred outside of the ICU and ED were further analyzed to determine if any significant events might have been avoided. The following three types of measures were developed to test the effectiveness of the RRT initiative: process compliance measures, safety (balancing) measures, and outcome measures.
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The Joint Commission Journal on Quality and Patient Safety Rapid Response Team (RRT) in Patient Calls per 1,000 Discharges, Mission versus IHI Monthly Average, September 2006–June 2008
Figure 2. Mission’s rate of RRTs in patient/1,000 discharges (blue solid line) increased from 60 to 184, compared with an average rate for organizations for 19 organizations participating in the Institute for Healthcare Improvement’s (IHI) 5 Million Lives Campaign (red dotted line) of 15–29 RRT calls. The small standard deviations reflect the large numbers of patients represented in the data. UCL, upper control limit; LCL, lower control limit.
Data collected and reported monthly included RRT calls per 1,000 discharges, mortality rate for codes that occurred on the medical-surgical floors, and percent of transfers to the cardiac ICU per hospital discharge.
Results CHARACTERISTICS OF RRT CALLS The RRT responded to an average of 338 calls (range, 174–440) monthly (RRT calls are reported on a national basis, via the Institute for Healthcare Improvement [IHI] 5 Million Lives Campaign, as calls per 1,000 discharges). Mission’s data, compared against 19 organizations across the United States, revealed the average IHI rate per month from September 2006 to June 2008 was between 15 and 29 RRT calls/1,000 discharges; Mission’s rate increased from a starting point of 60 to 184 RRT calls/1,000 discharges (Figure 2, above). Statistical analysis showed a favorable special-cause variation within the process over time (improvement in the number of calls/discharge) as well as a statistically significant difference against the comparative group each month (1-tailed; p < .05). Also, a monthly average of 138 (range, 91–185) calls were made in support of critical patients in the ED. The average RRT response time was 2 minutes, with calls averaging 44 minutes in length. The most frequent in-patient calls were related to nurse consults, pulmonary, hypotension, changes in level of consciousness, and arrhythmias. Twenty per cent of all calls occurred on the day of admission, with an aver-
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age of eight patients per month transferred to the ICU; 55% of all calls occurred within 48 hours of admission to the hospital.
OUTCOMES The initiative resulted in a statistically significant reduction of non–ICU arrests from 36 per year pre–RRT to 17 per year post–RRT. As shown in Figure 3 (page 204), the mortality associated with non–ICU arrests decreased from 61% pre–RRT to 26% post–RRT (p < .05). Tracking of transfers to the cardiac ICU since the introduction of the RRT revealed a decrease in transfers per month (Figure 4, page 205; 1- and 2-tailed, p < .05). Two episodes of special cause were identified in trending data related to overcapacity of hospital/critical care beds. Patients requiring critical care admission were either held in the ED for an extended period of time or upon reevaluation were cleared for admission to a monitored stepdown unit. An increase in calls with transfer into critical care occurred during this time. There has been a steady decrease in the proportion of transfers to critical care per RRT call over time.
ANALYSIS Anecdotal evidence and lessons learned over time led to process changes, protocol revisions, and increased efficiency. Data continue to be interpreted on a monthly basis. The quantitative data remain strong, with numbers of calls per month remaining high, a consistently significant number of adverse events avoided, and a low number of unanticipated transfers to
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The Joint Commission Journal on Quality and Patient Safety “Floor” Code Blue Mortality, Pre– and Post–Rapid Response Team (RRT)
Figure 3. The mortality associated with non–ICU arrests decreased from 61% pre–RRT to 26% post–RRT (p < .05). UCL, upper control limit; LCL, lower control limit.
the ICU. Beyond the quantitative data, analysis of trends in RRT calls enabled the RRT nurses and the neuro/critical care clinical nurse specialist to identify significant qualitative issues. Clinical issues related to the management of sepsis patients admitted to the floors, narcotic overdoses in high-risk/elderly patients, endof-life care issues, and an increase in arrests occurring in elderly end-stage cardiac disease patients on one unit were reported to the QLC and the medical staff committees. The issues discovered through RRT data analysis highlighted vulnerable patient populations, allowing the hospital to focus efforts on reducing morbidity/mortality. System issues were identified, including physicians communication, delay in accessing emergency medications from automated dispensing cabinets in non–ICU areas, and education needs of charge nurses. The qualitative clinical and system issues were reported to the QLC, were promptly resolved through the cooperation of the medical staff and multiple departments, and were then reported to the appropriate committees.
Discussion This RRT initiative demonstrated the ability of a community hospital to garner the necessary resources from an existing infrastructure and staff to create a 24-hour/7-day-a-week RRT program. The quantitative data on number of monthly calls, unanticipated transfers to the ICU, and incidence of non–ICU arrests confirmed the validity of the program. Perhaps the most valuable outcome of the RRT implementation was the identification of clinical and system issues. Organizations attempting to implement an RRT program must consider their specific needs on the basis of existing infra204
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structure. The RRT leadership team at Mission Hospital discussed the pros and cons of the physician model—the medical emergency team–and reached consensus that a nursing model with a dedicated fully staffed RRT with no unit or patient assignment was required to effectively implement the program. The model would also best serve the ED, whose patient population required additional immediate clinical support in critical situations. The hospital wanted to design a program with relevant, demonstrated quantifiable value and a long-term impact on patient care. One of the greatest challenges was funding the RRT concept, but creative solutions were found. As clinical improvement opportunities were recognized, the RRT staff supported the initiatives and promoted the change in practice. In the first six months of the RRT’s implementation, the nurses rescued a high number of unidentified sepsis patients on the floor units. Given the demonstrated need for increased surveillance, the RRT leadership team had the RRT screen all infectious admissions to the floor units for the first 48 hours, a practice that continues. Evaluation of the RRT data revealed other vulnerable subpopulations. From 6 to 12 months into RRT implementation, RRT calls were received for patients with congestive heart failure, end-stage heart disease, and high-dose narcotics. Strategies were then developed to identify clinical changes earlier through increased surveillance by the RRT and by education of nurses. In the second year of RRT implementation, patients presenting with pancreatitis and patients deteriorating on the day of admission to the floor have been scrutinized for clues to earlier detection of physiologic changes. RRT nurses now screen all pancreatitis admissions on rounds in the first 48 hours; findings of positive Ranson’s criteria and heart rates of
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The Joint Commission Journal on Quality and Patient Safety Inpatient Transfers to Critical Care per Rapid Response Team (RRT) Calls, September 2006–June 2008
Figure 4. When the RRT was partially staffed, 523 transfers occurred, for an average of 21%, as compared with the 2,858 transfers, for an average of 14%, that occurred when it was fully staffed (1- and 2-tailed, p < .05). Special-cause variations were identified for the four of the five points beyond one standard deviation (S.D.) and the two of the three beyond 2 S.D.s during partial RRT staffing and the two of the three points beyond 2 S.D.s in November/December 2007. UCL, upper control limit; LCL, lower control limit.
> 120 led to notification of physicians. More patients were “rescued” as more subpopulations were identified and strategies were initiated to reduce their vulnerability. The rescues—and interventions—occurred earlier in the clinical course, preventing transfer to a higher level of care.
Postscript The RRT initiative has served as an example for other organizations attempting to increase their RRT calls. In April 2008, the initiative was presented at health system quality and physician meetings with representatives from all of Mission’s 14 hospitals. Mission’s quality departments and the hospital CNOs have encouraged adoption of the Mission model. At present, one hospital has officially changed to the Mission model, with the others evaluating resources needed to implement it. J
Mary Kay Bader, R.N., M.S.N., C.C.N.S., is Neuro/Critical Care Nurse Specialist, Mission Hospital, Mission Viejo, California; Beverly Neal, R.N., M.S.N., C.C.R.N., is a Rapid Response Team (RRT) Nurse/Surgical ICU Clinical III Nurse; Linda Johnson R.N., M.S.N., N.E.A.-B.C., is Chief Nursing Officer; Kirsten Pyle, R.N., C.C.R.N., is Sepsis Coordinator/Surgical ICU Staff Nurse; Jan Brewer, R.N., Ph.D., is Director of Quality–Research and Outcomes; Michele Luna, R.N., Ph.D., is Quality Manager;Connie Stalcup, R.N., M.S.N., is Director, Critical Care/Trauma Services; Margie Whittaker, R.N., M.S.N., is Surgical ICU Nurse Manager; and Michael Ritter, M.D., is an Emergency Department physician. Please address requests for reprints to Mary Kay Bader, [email protected].
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This initiative, titled “In the Nick of Time: Rapid Response to the Rescue,” was presented at the American Association of Critical Care Nurses’ annual National Teaching Institute and Critical Care Exposition, Chicago, May 7, 2008.
References 1. The Joint Commission: Health Care at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis (white paper). http://www.jointcommission.org/NR/rdonlyres/5C138711-ED76-4D6F909F-B06E0309F36D/0/health_care_at_the_crossroads.pdf (last accessed Mar. 2, 2009). 2. McQuillan P., et al.: Confidential inquiry into the quality of care before admission to intensive care. BMJ 316:1853–1858, Jun. 20, 1998. 3. Schein R.M., et al.: Clinical antecedents to in-hospital cardiopulmonary arrest. Chest 98:1388–1392, Dec. 1990. 4. Kause J., et al.: A comparison of antecedents to cardiac arrests, deaths, and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom—the ACADEMIA study. Resuscitation 62:275–282, Sep. 2004. 5. The Joint Commission: 2009 Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace: Joint Commission Resources, 2008. 6. Neuhauser D.: Heroes and Martyrs of Quality and Safety: Ernest Amory Codman MD. Qual Saf Health Care 11(1): Mar. 2002. http://qshc.bmj.com/cgi/content/full/11/1/104 (last accessed Mar. 2, 2009). 7. Institute for Healthcare Improvement: Deploy Rapid Response Teams. http://www.ihi.org/IHI/Programs/Campaign/RapidResponseTeams.htm (last accessed Mar. 2, 2009). 7. South Western Sydney Area Health Service (SWSAHS): Implementation of the MET System into Your Hospital: A Window of Opportunity. Liverpool, Australia: SWSAHS, 2000. 8. Bellomo R., et al.: Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med 32:916–921, Apr. 2004. 9. Bion J., Heffner J.: Challenges in the care of the acutely ill. Lancet 363:970–971, Mar. 20, 2004. 10. Merit Study Investigators: Introduction of the medical emergency team (MET) system: A cluster-randomized controlled trial. Lancet 365:2091–2097, Jun. 18, 2005.
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