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MASSACHUSETTS NURSE NEWSLETTER ::
September 2007
Rapid Response Teams: Passing fancy or future standard?
By Dorothy McCabe, RN, MS, M.Ed.
Director, MNA Divisions of Nursing
and Health and Safety
According to the Robert Wood Johnson Foundation, “A Rapid Response Team [RRT] is a group of experienced clinicians, that nurses and other hospital employees—and, in some cases, patients and their family members—can call on to intervene if a patient’s condition is deteriorating.”
When searching the term “Rapid Response Team” online in preparation for this article, 83 Web pages worth of information came up as hits. While RRTs are not included in the Standards of the 2007 JCAHO Manual of Comprehensive Accreditation, JCAHO has sponsored conferences entitled “Using Rapid Response Teams to Save Lives” throughout the country in both 2006 and 2007. The fee for the program is $395 and the faculty consists of a nurse and a respiratory consultant, employed by JCAHO, and a nurse faculty member.
This concept of faculty makeup leads us to some very serious questions:
- Why aren’t the direct care staffs from facilities who have implemented Rapid Response Teams presenting the programs?
- Surely there are a few experts in the 1,600 hospitals who have implemented RRTs?
- Are RRTs really working?
Rapid Response Teams: a brief history
More than 1,600 facilities across the United States now have rapid response programs in place, which, according to a recent article in The Patriot Ledger, is up from about 100 programs a year ago.
A Boston Globe article from Nov. 27, 2005 (“Hospitals try to break a Deadly Code”) discussed the efforts of several Massachusetts hospitals to establish RRTs. Apparently, the rationale for hospitals to establish these teams is that there are inexperienced nurses who are unable to recognize the subtle changes in a patient that could represent a life threatening event.
Inexperienced RNs working without the guidance of experienced RNs
According to the “Patients First Program” developed by the Massachusetts Hospital Association and the Massachusetts Organization of Nurse Executives, every hospital develops a staffing plan to ensure that patients in their hospitals receive appropriate care. There is no mention that staffing plans should include a mix of experienced and inexperienced nurses working together.
One of the reasons Rapid Response Teams are viewed as necessary is that staffing plans frequently place inexperienced nurses on the evening and night rotations without expert nurses to guide them when staffing numbers are reduced throughout the hospital.
If this is a fact, why are the nurse executives allowing this to happen in their divisions of nursing? Why aren’t there criteria for staffing based on experience?
All is not well in the land of Rapid Response Teams
Recently a large hospital in Massachusetts decided to move slower in its implementation of a rapid response program. Cited as the reason why was the cost of hiring additional nurses and doctors to serve on the teams and the lack of researched evidence that supported implementing the team.
Other hospitals across the nation have also refrained from establishing these teams due to lack of evidence from randomized controlled trials—which are the gold standard of evidence in research backing evidenced-based practice.
Meanwhile other hospitals have gone full steam ahead, utilizing staff assigned to patients in the ICU, ER or other areas leaving those areas poorly staffed when the team is called into action.
A hospital in Boston has designated its ICU staff as part of its hospital’s Rapid Response Team. The ICU staff member assigned to the RRT is expected to carry a beeper to respond to urgent situations that occur in the hospital. This creates unsafe patient care for both the nurse and the ICU patients since the nurse must leave assigned patients to cover the RRT call.
A hospital in Hawaii recently received a million dollar grant to create a rapid response program aimed at increasing patient safety. The grant will be administered over five years. How many additional nurses could this hospital hire to improve patient ratios and to provide training in specific cardiopulmonary intervention procedures?
In Australia, where “Rapid Response Teams” were pioneered, a study was done which compared hospitals with RRTs to hospitals without RRTs. The results were similar, perhaps because both groups knew they were being studied.
So what does this mean?
An article by Joshua L. Jacobs, MD, entitled “Automated Clinical Inference and Rapid Response Teams Improve Patient Safety” in the November-December publication Patient Safety and Quality Healthcare referred to several studies that found that 76 percent of patients with cardiac arrest or unplanned ICU admissions displayed signs of instability more than one hour prior to the critical event (mean 6.5 hours). The article goes on to state that, “In one third of these events, the signs had been present for more than 24 hours.”
This raises several questions of real concern:
- Why are we spending money for consultants and others to put together another system that doesn’t work?
- Why are we spending time and energy to develop a “Patients First” program that includes clinicians other than nurses simply to deny the fact that safe nurse-to-patient ratios are essential?
- Why are we spending millions of dollars on developing RRTs to augment unsafe staffing ratios?
The real answer to reducing mortality lies in Linda Aiken’s research and her conclusion about nurse staffing: One nurse to four patients constitutes a safe ratio on general med/surg floors.
A nurse executive connected to a large for profit system, in a presentation entitled “Rapid Response Teams: Nursing Implications,” questions the effect of an RRT on the direct care nurse in terms of the nurse’s self concept as an inadequate care giver or capable crisis manager.
This executive also believes that an RRT should take the role of teacher both during and after the event in order to best help the inexperienced nurse and eliminate the need for a system that is costly and unfamiliar with the patient’s condition. He further concludes that many RRTs are formed with little understanding of the role, its implementation or established clinical protocols.
A recent editorial in the American Journal of Nursing, written by Diana Mason, PhD, questions the development of new initiatives for patient safety when the solution is more nurses at the bedside. She cites an editorial in the September-October 2006 issue that stated “certain initiatives, such as electronic medical records, rapid response teams and executive walking rounds, are being promoted as patient-safety strategies without evidence to support either their usefulness or their cost effectiveness. The same cannot be said about the effects of nurse staffing on patient outcomes.”
Think about it, examine the RRT in your hospital and evaluate its processes.
Share your RRT story
If your hospital has a Rapid Response Team in place and you are interested in sharing information about its implementation, please contact David Schildmeier at 781-830-5717 or via e-mail at dschildmeier@mnarn.org.
Rapid Response Teams:
No substitute for safe staffing plans
Inherent in the plan proposed by the Massachusetts Hospital Association and Massachusetts Organization of Nurse Executives, the “Patients First” Web site
www.patientsfirstma.org states that staffing is predicated on hours worked per patient day. These plans can include spiritual services, patient transports, clinical pharmacists, social services, physical therapy, etc.
But in reviewing the “Patients First” site, it is evident that many hospitals do not plan their staffing patterns to correlate with the research of Linda Aiken, Ph.D., RN, et al in her groundbreaking 2002 article, “Hospital Nurse Staffing and Patient Mortality, Nurse Burnout and Job Dissatisfaction.”
This article reviewed the association between the nurse-to-patient ratio and patient mortality, failure to rescue (deaths following complications) among surgical patients and factors related to nurse retention. Among her conclusions, in a sample of 168 Pennsylvania hospitals—in which the mean nurse-to-patient ratio ranged from 4:1 to 8:1—4,535 of the 232,342 surgical patients with defined medical history co-morbidities died within 30 days of being admitted.
Her results implied that had patient-to-nurse ratios across these Pennsylvania hospitals been 4:1, “possibly 4,000 of these patients may have died while more than 5,000 of them may have died with a nurse-to-patient ratio of 8:1.” This study concludes that high nurse-to-patient ratios lead to job-related burnout and dissatisfaction compared with nurses in hospitals with the lowest nurse-to-patient ratios. The study also found that burnout and dissatisfaction can predict a nurse’s “intention to leave their current job within one year,” which can correlate to the lack of experienced nurses in hospitals.
Elaborate, unproven plans
Why would a hospital implement programs like “Patients First” or “Rapid Response”—complete with campaigns and elaborate Web sites—when the evidence for staffing ratios has been researched and proven?
- Is it the cost?
- Is it power?
- Is it because administrators perceive nurses as a threat?
The Institute of Healthcare Improvement, as part of its “100,000 Lives Campaign” (now “5 Million Lives Campaign”), has a getting started “Rapid Response” kit for hospitals—complete with a primer on self analysis, statistics, structure, training and protocols. The Robert Wood Johnson Foundation awarded grants to nine hospitals to increase adoption of Rapid Response Teams in conjunction with the efforts of other groups involved with patient safety.
But the question remains: Why are we developing unproven systems when we know the answer is staffing ratios?}
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