Implementing a Rapid Response Team in Outpatient Clinics

¶ … Rapid Response Team Protocol be Developed in the Outpatient Setting? Today, there are approximately 7,100 outpatient centers which are also known as urgent care centers, immediate care centers, walk-in care centers as well as others (Size of industry, 2015) that compete for patients in need of medical care.

Outpatient care has assumed a new level of importance in the American healthcare infrastructure following the passage of the Affordable Care Act as well as the changing needs of the American population for health care services that demand more efficient community-based health care resources (Ferenc, 2013). For instance, Brandenburg and Gabow (2015) emphasize that, "While excellent clinical care remains the expectation, health care consumers are now seeking health care and supporting systems that are respectful of individuals" (p. 3).

Respecting individuals, of course, also means also respecting their time, but anecdotal accounts and the studies to date confirm that patients are kept waiting longer than necessity dictates for myriad reasons that all relate to an apparent lack of concern for patient welfare (Ferenc, 2013). According to the vice president of planning and design for Kaiser Permanente, John Kouletsis, the move towards the provision of outpatient services actually began several years ago, but the move has intensified since hospital emergency rooms have become notoriously overcrowded.

In this regard, Kouletsis emphasizes that, "The primary drivers for many years have to do with ease of access, meeting expectations of the patients and their families, to offer high quality care. There's a huge move to providing care in the outpatient world" (cited in Ferenc, 2013, p. 22).

In fact, the demand for outpatient clinic services has increased to the point where health care providers are contemplating transforming shipping containers into low-cost clinics that can be deployed quickly into communities in need in the same manner these containers are being transformed into modern housing units (Ferenc, 2013). There have been some attempts to improve the efficiency of outpatient clinics in recent years to improve the quality of health care services provided.

For instance, Hamrock and Hopkins (2013) report that, "Some models of outpatient clinics aim to improve patient flow, reduce wait times, maximize staff utilization, and accomplish other gains in efficiency. These outpatient models are tested through changes to patient scheduling, patient routing, and internal work processes" (p. 111). Notably absent from these initiatives, however, is an effort to develop a rapid response team protocol that can handle seemingly non-urgent patients who develop emergent problems after arrival at an outpatient clinic.

While rapid response teams are routinely used in hospital emergency departments, there has been less effort directed towards developing these protocols for outpatient clinics to date (Rapid response team, 2015). According to the Institute for Clinical Systems Improvement, "The purpose of a rapid response team protocol is to provide a suitable method that enables health care staff, patients and families to directly request additional assistance from a specially trained group of individuals known as a rapid response team" (2015, p. 3).

Although the outpatient setting differs dramatically from hospital-based emergency rooms due to the types and severity of conditions that are most commonly treated, it is reasonable to posit that some of the patients that seek non-urgent care are in fact in need of emergency treatment. Likewise, family members and friends of patients may develop medical conditions that require emergency intervention during their visit to the outpatient clinic. In addition, staff members themselves may experience these types of emergencies.

The rapid response team protocols that have been developed by the Institute for Clinical Systems Improvement are set forth in Table 1 below. Table 1 Rapid response protocols for hospital emergency rooms Protocol Description/Response Recognition that an individual is experiencing a worrisome/acute clinical change (Annotation #1) The individual may be anyone in the health care facility. Is the individual experiencing a behavioral health emergency? (Annotation #2) Each organization should consider developing a behavioral emergency response team (BERT) to assist staff in proactively de-escalating patients who may be exhibiting potentially violent behaviors.

Is the individual progressing toward or experiencing a cardiopulmonary arrest? (Annotation #4) • If the recognizer is a licensed health care professional, a quick assessment should be made to determine if the individual is in cardiopulmonary arrest. • If the recognizer is a family member, he/she should activate the rapid response team regardless of the individual's status.

Does the individual meet criteria for rapid response team or demonstrate an elevated early warning score? (Annotation #6) The health care professional should also determine if the individual's status meets the criteria for activating the rapid response team. Activate rapid response team (Annotation #8) • Each organization should consider a communication system that notifies the appropriate rapid response team personnel. • Each organization should use a communication system that is efficient and reliable. • Each organization must determine when the patient's primary provider will be contacted.

• Organizations should consider establishing a mechanism for patients and families to directly activate the rapid response team. Rapid response team assesses and initiates appropriate interventions, consults with appropriate provider and develops a continuing plan of care (Annotation #9) • A response time of less than five minutes is expected. • Team members should be selected based on their clinical skills. • Good communication skills and use of Situation, Background, Assessment, Recommendation (SBAR) format is recommended. • A positive attitude and respectful and supportive behavior are recommended.

• The composition of the rapid response team is based on the institution's resources and needs. • The rapid response team record must be initiated and included as part of the patient's permanent medical record. • Rapid response team members should be trained to initiate interventions needed to stabilize the patient. • If the patient is not currently an inpatient, the patient may need transfer to the emergency department. • An order set may be helpful in initiating treatment.

• Once the patient is assessed and/or stabilized, it is recommended that the patient's primary provider be contacted and given an update, unless the primary provider has already been contacted and/or is present. • The update to the primary provider should be given using the Situation, Background, Assessment, Recommendation (SBAR) format. • Determine with the primary provider if the inpatient needs to be transferred to a higher level of care.

Follow-up (Annotation #17) • A member of the rapid response team may follow up in person with the patient to assess his or her status and his or her response to the interventions. • Complete documentation of the rapid response team record. • Provide education when appropriate to the staff and patient at the event. • Review plan of care with bedside nurse and patient. • Provide rapid response team evaluation form to the initiator.