Colorado Hospital Evaluates Missed Opportunities in Rapid Response Teams

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 developed 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) were 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 at the facility, first noticed a trend developing across the trauma patients at SACH. There were particular instances where patients met the criteria for an RRT, but upon further investigation, Bourg found that the nurses were not calling a team to follow through.

Aware of this fact, and understanding the need for change, Bourg teamed up with two colleagues, Julie Benz, RN, MS, clinical nurse specialist, and Melissa Richey, RN, BS, clinical nurse for the trauma services. They worked together 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 to help the staff members at SACH gain experience through simulation.

"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, Bourg and her colleagues analyzed missed opportunities that took place after the simulation training and saw a drop in the number. They also analyzed the number of staff members who called an RRT.

Results not typical from simulation training or education

Bourg's team found that the majority of missed opportunities occurred in the off-hours of the hospital: on the weekends, before 7 a.m., and after 5 p.m.

Bourg also 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 despite the fact we had provided staff members with training," says Bourg.

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

"In addition to the huge changeover we saw at SACH, we also saw that 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. During the interview, the nurse is asked questions about:

• What was going on at the time of the missed opportunity


• What kind of patient report he or she received from the previous nurse


• Whether there were competing priorities


• Whether he or she was familiar with the patient's case

"We are not trying to assign any blame," says Bourg. "We are trying to create a culture of safety so people are willing to come forward and give us the information to help make our practice better." In addition, staff went through simulation training again in July 2009.

For more on this story and tips for successful RRTs, see the April issue of Briefings on Patient Safety, a product of Patient Safety Monitor.