As healthcare evolves, we increasingly need Rapid Response teams in primary care.
This article was first published on Sunday, February 23, 2020 in MedPage Today.
By Fred N. Pelzman, MD, MedPage Today
Over the past few months, in our happy little outpatient world, we've had several episodes of really sick patients showing up for their appointments, and some patients who seriously and rapidly deteriorated during their brief time visiting with us.
As our patient population ages and gets more complex, with an ever greater list of health conditions and medications, we are seeing sicker and sicker patients in our office for routine care.
Patients that many years ago would've been taken care of in the inpatient world, are now being managed without hospitalization, with complex collaboration among multiple providers.
And patients who were evaluated in the emergency room and sent home with a careful follow-up plan often show up at our office with that plan not being fully carried out, and thus once again quite ill.
Despite the fact that we are right across the street from our hospital, we are very much an ambulatory outpatient site. Our patients show up, wait in the waiting room, see us in the exam room, get their labs and vaccines done, and then, for the most part, go home.
Every once in a while things don't go quite as planned.
Sure, there are the occasional slips and falls, the vasovagal syncope after a vaccine or phlebotomy, or the patient just a little dehydrated from their upper respiratory infection or diarrheal illness, but occasionally things go very far south very quickly.
Just over these past few months we've dealt with refractory hypoglycemia with altered mental status, unremitting seizures, severe asthma exacerbations requiring intubation, respiratory failure from COPD, and one patient who presented with a cough who was found to be in an unstable arrhythmia with severe hypotension.
Not your typical day at the office.
Our team has always responded well, but it's clear when we talk about these things afterwards that our systems could be better.
It's never a good sign when the providers taking care of the patients are as tachycardic and diaphoretic as the sick person they are attending to.
For most of this, we really are just out of practice at this stuff.
Our staff goes through mock drills, practicing all the tasks, but when the rare thing happens, it still sends a little shiver of panic down our spines.
It's kind of like that old line about anesthesiology: hours of boredom punctuated by moments of terror.
It's time we rethink and redesign a 21st-century Rapid Response team for clinical emergencies in the outpatient world.
When I was in high school, I got a summer internship working on a National Science Foundation project, helping to program a computer to calculate complex formulas of ocean temperature and salinity.
I remember the computer room where we had to take our punch cards, load them into the hopper, and then watch them feed one by one into the belly of this massive beast, hoping it wouldn't get jammed. The computer itself took up half the floor of the lab where we worked, enclosed behind walls in its own air-conditioned room, and you needed special permission to enter.
Today, my phone (and now even my watch!) have more computing power than that behemoth did.
This is the way I feel about the defibrillator we've had in our practice.
Hospital issued, it hasn't been upgraded in over a decade to the best of my knowledge, and sits waiting on a huge cart that we keep in the hallway of our practice.
Every morning, our charge nurse dutifully turns it on and runs its safety checks, and logs that it's in working order.
Never been used.
Thinking about this, I realized that every Starbucks and restaurant in New York City is better outfitted and prepared for sudden cardiac death than we were.
So I bought several shiny compact modern AEDs, and mounted them in each practice area around our office.
Everyone got an email about these, along with links to a website with instructional videos, and we reviewed how to use these devices at our faculty and staff meetings.
Just the other day, I surveyed our residents, staff, and faculty, and most did not know where they were, and did not recall how to use them.
Some did not even know we had them.
We need many of the items that are in the inpatient crash cart, but since we use them so rarely, they often expired as they lay waiting to be used, leading to huge costs and waste.
We need IV access, oxygen, and aspirin. We need Narcan for the opioid overdose that happens in the waiting room. We need D-50 for refractory hypoglycemia, along with glucagon.
We need point-of-care testing for glucose and electrolytes.
We need everyone to know where the defibrillators are, and how to use them.
We need everyone to keep BLS and ACLS certifications up-to-date.
We need trained teams, where everyone knows their roles, and everyone knows how to react.
On the inpatient world, over at the hospital, we've always had a Code Blue team for when things have gone wrong, and several years ago they developed a Rapid Response team as well, who are available to respond to any clinical deterioration proactively to avoid things going from bad to worse.
Most of us can hear the sounds of those overhead pages in our dreams: "Code Blue, cardiac team, 10 North"
Over in the hospital they had the advantage of that overhead paging system, and everyone wears a pager or has some telecommunication device that makes them instantly reachable.
Over here, no one carries a pager anymore, and while there are telephones in every room, our intercom system was disconnected many years ago.
We have a new team that's working to develop what our outpatient Rapid Response team should look like, and what it needs to have, but one critical thing we are challenged with at the moment is trying to figure out how to make everybody reachable.
Yes, we're right across the street from the hospital, and a quick call to 911 will bring paramedics to our door, but there certainly are things we want to do in the interim to prevent further clinical deterioration in those precious minutes.
Years ago we had what we used to call the "walk-in doc," a provider who was freed from other clinical duties and assigned to stand ready and waiting for clinical emergencies.
Eventually we retired this role, as it felt like that poor provider spent the whole day standing waiting for the acute MI or stroke to walk through our door, only to go home unrequited.
At this point I'm loathe to buy everybody yet another walkie-talkie device, or insist everyone start wearing their pagers again, or make them carry their cellphones all time.
Perhaps the solution is just reactivating our intercom system, so that help can be called to the place it's needed when it's needed.
So everyone knows they are needed, and everyone knows their role, and everyone has the tools they need when they need them.
Everyone come running.