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Colorado Hospital Evaluates 'Missed Opportunities' in Rapid Response Teams

Patient Safety Monitor (Briefings on Patient Safety), May 4, 2010

Over the past five years, rapid response teams (RRT) have been brought to the forefront of American hospitals. In 2004, the Institute for Healthcare Improvement (IHI) launched its 100,000 Lives Campaign, of which RRTs were a focal point, and in 2008, The Joint Commission added a National Patient Safety Goal requiring hospitals to have a process to recognize and respond to patients who are deteriorating. Those requirements are now located in standards PC.02.01.19, HR.01.05.03, and PI.01.01.01.

Both of these initiatives sparked interest in RRTs among hospitals, especially at St. Anthony Central Hospital (SACH) in Denver, which began to develop its own RRT in conjunction with the IHI initiative.

However, in 2008, SACH officials began to notice a trend of patients who were meeting the criteria for RRT, but for a variety of reasons, the team was not called.

A subgroup of 17 missed opportunities (including deaths) was identified in the first half of 2008. With the help of simulation training and debriefing interviews, SACH was able to lower that number to nine for the second half of 2008 out of 2,400 trauma-related admissions for the year. That number was cut again for 23 total missed opportunities and no resulting patient deaths out of about 2,400 trauma-related admissions in 2009.

Education and simulation training
In 2008, Pamela Bourg, RN, MS, ANP, CNS, director of trauma services, first noticed a trend developing across the trauma patients at SACH. There were particular instances where patients met the criteria for an RRT, but nurses were not calling a team to follow through.

Bourg teamed up with two colleagues, Julie Benz, RN, MS, clinical nurse specialist, and Melissa Richey, RN, BS, clinical nurse for trauma services, to educate the staff at SACH to be more knowledgeable about when to call the RRT and more comfortable in doing so.

Working with the Wells Center in Colorado, a facility that provides state-of-the-art patient simulation tools, Bourg, Benz, and Richey rented a simulation-training dummy.

"Wells Center supplied us with the simulation mannequins, along with the nurse driver," says Bourg. "But we were able to use our own nurse educators and advance practice nurses to help facilitate the groups."

The nurse driver helped run the simulation, but SACH staff wrote the script for the missed opportunity scenarios. During the simulation training, a nurse performed an assessment of a patient. Then, based on what the nurse observed, he or she called an RRT.

"The purpose of the simulation training is to help the nurses recognize the signs and symptoms, identify the patients at greater risk, and then distinguish if they need to call an activation of the RRT," says Bourg.

The staff members at SACH first participated in the simulation training in July 2008. Between August and December 2008, the women analyzed missed opportunities that took place after the simulation training and saw a drop in the number.

Results not typical from simulation training or education
Bourg's team discovered that when the nurses appropriately identified a patient in need of an RRT, there were acute changes in the patient's condition. But when the changes to the patient were not as acute and more subtle, the nurses did not notice them quite as readily.

Even though the number of missed opportunities decreased toward the end of 2008, as 2009 began, Bourg watched the numbers increase, despite staff members having gone through simulation training. "We sat down and knew there were other issues we needed to identify because the numbers were increasing," she says.

At first, Bourg thought it might have something to do with new graduates working at SACH. But after looking at things more closely, she discovered that other factors contributed to the missed opportunities.

"In addition to the huge changeover we saw at SACH, staff members who had been with us for over two years were failing to activate an RRT," says Bourg.

In hopes of improving the number of missed opportunities, Bourg and her colleagues went back and began interviewing staff members who failed to activate an RRT. They developed a debriefing tool using a variety of nursing literature to help understand why nurses were failing to activate the RRT.

"We try to make sure that when a missed opportunity presents itself, we contact the nurse within 24 to 48 hours to ask them more about the situation," says Bourg.

When a nurse has a missed RRT opportunity, an advance practice nurse conducts a debriefing interview, not the manager.

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