Rapid response teams: structure, function, and effectiveness

Staff Nurses' Perceptions of the Advantages and Disadvantages of Rapid Response Teams

Rapid Response Teams (RRT) are critically important in hospital settings to reduce the failure to resuscitate patients however, there are questions as to the perceptions of nurses concerning RRTs.

The significance of this study is the knowledge that will be added to the existing base of knowledge on the perceptions of nurses of RRTs.

The work of Heintz and Schreiner (2007) entitled "Improving Patient Safety Through the Use of Rapid Response Teams" states in relation to the perceptions of nurses to rapid response teams that staff nurses "… may be fearful that RRT members will criticize their clinical judgment." In a separate work entitled "Rapid Response Teams: Reducing Codes and Raising Morale" it is reported that many hospital nurses like the idea of a Rapid Response Team and in fact "an addition to their significant value as a clinical tool, Rapid Response Teams are also changing hospital culture. Nurses are encouraged and empowered to ask for help without fear of appearing incompetent, there's more emphasis on shared learning, and everyone gets the message that support is a critical component in clinically challenging situations. All these benefits are expected to have a positive impact on nursing recruitment, retention, and satisfaction." (Institute for Healthcare Improvement, 2010)

It is stated that long-time nurses state that the Rapid Response Team concept "draws on the kind of collaboration that has always been part of the profession, but that has been harder to maintain as nurses have gotten busier with more and sicker patients." (Institute for Healthcare Improvement, 2010) One nurse, Mary Therriault, RN, stated:

"When I began in nursing, I was surrounded by people with different levels of education and experience, and I would always ask someone to give me their opinion about things like a patient's color or mental status… "It felt like team care, and I think we got away from that. This brings back the team concept." (Institute for Healthcare Improvement, 2010)

The idea is stated to be to attract new nurses and so much that they state "they only considered jobs at hospitals that have Rapid Response Teams…" (Institute for Healthcare Improvement, 2010) In fact, one new nurse stated that one of her greatest fears was having to work the night shift "and having no one to go to if a patient's condition changes." (Institute for Healthcare Improvement, 2010) According to nursing program chair at Richmond Heights Hospital;

"The average age of our students is 32," she says. "These somewhat older students may be new to nursing, but they often bring well developed critical thinking skills and many have gained self-confidence in another career and aren't afraid to ask for help. They aren't insecure and worried about appearing inadequate." (Institute for Healthcare Improvement, 2010)

The faculty expert, Kathy Duncan states that the nursing community is excited as the word about the Rapid Response Team spreads and states specifically:

"The appeal of the Rapid Response Team is that nurses don't have to go it alone anymore," she says. "It means they don't have to feel alone when they have an inkling that something might be wrong. It means they can get a colleague or several to validate their concerns or put them to rest." (Institute for Healthcare Improvement, 2010)

Duncan goes on to state as follows: "his kind of support might be the antidote to the frustration many new nurses reportedly feel, says Duncan, "when we throw them out there with several really sick patients and no tools to help them take care of those patients." This frustration and the accompanying fear of making a mistake is likely one of the reasons that a 2001 report published in Health Affairs found about a third of nurses under the age of 30 reported plans to leave their hospital nursing jobs within a year." (Institute for Healthcare Improvement, 2010) Duncan additionally stated that one of her nurses informed the Chief Nursing Officer "that the Rapid Response Team is one of the best things she's ever done for nursing and for patients." (Institute for Healthcare Improvement, 2010)

According to Cathy Pfeil, RN, BSN, CCRN, "Director of Critical Care Nursing at Tallahassee Memorial Hospital, a VHA-member hospital that has had Rapid Response Teams in place since 2003. Tallahassee Memorial has also been a part of IHI's RWJF-funded Pursuing Perfection program. Data bears out the nurses' perception: in less than two years the hospital saw a 16% reduction in mortality and a 72% reduction in codes outside the ICU." (Institute for Healthcare Improvement, 2010) This type of collaboration in the provision of care to a patient in a situation where the patient "needs it most has helped bridge an age-old cultural divide between ICU nurses and floor nurses." (Institute for Healthcare Improvement, 2010) Lisa Leach, LPN, an ICU nurse at UHHS Richmond Heights Hospital who serves on her hospital's Rapid Response Team stated:

"There's always been a little bit of tension between the two, but with the Rapid Response Team, the ICU nurses get a better understanding of what the floor nurses are dealing with. We care for two critically ill patients in the ICU; they have a demanding patient load and it is spread throughout the floor…says, the floor nurses grow to respect the expertise of their ICU colleagues, and begin to learn from them. "Now the nurses are better prepared when we get there. They are part of our team." (Institute for Healthcare Improvement, 2010)

According to Leach "…floor nurses will sometimes come to the ICU to check on a patient who was transferred there as a result of the Rapid Response Team call. Before, they would never come in the ICU. It just wasn't their territory. Now those barriers have been broken down." (Institute for Healthcare Improvement, 2010)

Sharon Garretson of Richmond Heights Hospital in Cleveland reports:

"…the initial resistance there has given way to strong support. If we said today we were going to get rid of the Rapid Response Team, we'd probably have a mutiny on our hands. Part of the key to that attitude change is data showing the impact of the Team." (Institute for Healthcare Improvement, 2010)

It is stated by Mary Beth Rauzi, RN, MSN, Manager of Learning Services at Richmond Heights:

"We have decreased cardiac arrests per 1,000 discharges by 44%, and cardiac arrests outside the ICU by 67%. Our total mortality is down 14%. When nurses see results like that, they see that they are making good calls, their judgment is being validated, and they are proud to be part of this change." (Institute for Healthcare Improvement, 2010)

It was stated by Barbara Rogness at St. Joseph's in Milwaukee that the following comments were given when she evaluated each Rapid Response Team:

This was a great experience, with great ideas put into place quickly.

The team asked for my needs, and then together we dealt with the patient's needs.

Several suggestions made the patient outcome improve.

Although this patient's assessment was unremarkable, the x-ray the team ordered was instrumental in diagnosing his worsening heart failure. (Institute for Healthcare Improvement, 2010 )

These types of comments are reported by Kathy Duncan to be heard in hospitals all across the United States and Duncan states:

"What nurses are discovering is that this is not just a tool to rescue patients. It's a tool to help colleagues support one another. The more I see it in practice and the more I study it, the more convinced I am that this represents a dramatic change in the culture of nursing, and an exceptionally good teaching tool. What a new nurse can learn on one Rapid Response call will help her and her patients for the next 20 years." (Institute for Healthcare Improvement, 2010)

Studies examining the performance of hospitals in regards to the failure to rescue acutely ill patients show that this failure is "strongly associated with serious adverse events, cardiac arrest or death. Rapid response systems (RRSs) and their efferent arm, the medical emergency team (MET), provide early specialist critical care to patients affected by the 'MET syndrome': unequivocal physiological instability or significant hospital staff concern for patients in a non-critical care environment." (Tee, et al., 2008) This intervention has as its aim the prevention of serious adverse events, cardiac arrests and unexpected deaths. While this intervention is "clinically logical and relatively simple, its adoption poses major challenges." (Tee, et al., 2008)

The effectiveness concerning Rapid Response Systems is difficult to ascertain. It is difficult to implement a complex intervention like a Rapid Response System poses challenges including:

(1) political;

(2) cultural;

(3) logistic; and (4) financial challenges. (Tee, et al., 2008)

Double-blinded randomized controlled trials of RRS are not possible. It is concluded that the use of RRS and evidence being accumulated in various settings and situations "will increase the rationale and logic of RRS. Patients that are treated in hospitals are reported to be "increasingly complex patients…" and it is stated that despite the growth of technology and the development of new medications, 10% to 20% of hospitalized patients develop adverse events, with an overall hospital mortality of 5% to 8%. The problem is that 37% of these events are said to be very likely to be preventable. It is reported that key in the life threatening situation is to recognize it early. There are physiological warning signs of instability when a cardiac arrest is impending however it is stated that "the hospital's response is often late and inadequate…" and moreover, "The outcome of this approach has not improved in 50 years." (Tee, et al., 2008)

It is reported however, that clear evidence of inadequate ward care was provided by a study from the UK which states findings that ," prior to intensive care unit (ICU) admission, suboptimal management of oxygen therapy, airway, breathing, circulation, and monitoring occurred in over half of patients. These errors were essentially due to the failure to apply or appreciate the need for basic resuscitation measures. Major causes of suboptimal care included failure of organization, failure to appreciate clinical urgency, and failure to seek advice. In summary, there is much evidence that 'failure to rescue' is common in patients at risk for major adverse events. There is also evidence that failure to appreciate the clinical urgency of situations is common, that the knowledge and skills to deal with such situations are limited among ward doctors and nurses, and that, in most patients, there are warning signs for a long enough period to allow appropriate action to be taken. (Tee, et al., 2008)

The work of Johal (2008) states that survival of patients in non-critical care units of acute care hospitals is often dependent on the decisions of nurses to call for emergency assistance. (paraphrased) Nurses are those in closest proximity to their patients and are likely to be the individual most likely to recognize that the patient's condition is deteriorating and that they patient is in need of immediate attention. Nurses in critical care units are generally trained for identification of early deterioration in the condition of a patient however, nurses "who work in lower acuity units of the hospital are less likely to have adequate training and experience." (Johal, 2008)

Patient care units in acute care hospitals have been identified as "particularly dangerous areas where cardiac arrest and cardiopulmonary resuscitation are associated with poor outcomes and there is a concern that the problem is escalating." (Johal, 2008) Johal's study examined "the perceptions of a sample of registered nurses about the influence of Rapid Response Teams (RRTs) a newly introduced support system, on their learning outcomes." (2008) The goal of RRTs is to 'bring critical care resources to any area of a hospital, which includes clinicians and equipment." (Johal, 2008) RRT intervention "can lead to a decrease in cardiac and respiratory arrests, avoid Intensive Care Unit (ICU) admission, facilitate timely admission or avoid inappropriate treatment .(Johal, 2008)

A rapid response team is normally comprised by a registered nurse (RN), Respiratory Therapist (RT) and physician and other health care staff. The various structures of RRTS include:

(1) ICU RN and RT; ICU RN, RT, physician and resident;

(2) ICU RN, RT, physician; ICU RN, RT and physician assistant

The RRT responds similarly to a cardiac arrest team following telephone/pager activation. RRTs are approved by the Institute of Healthcare Improvement (IHI) and the National Registry of Cardiopulmonary Resuscitation. (Johal, 2008) Johal (2008) states that the role of the RRT is to "assess, stabilize, assist with communication, educate, and support and assist with transfer, if necessary." Johal writes "Although some studies indicate staff nurses are satisfied with these teams and feel that they are beneficial to their practice, the literature on the effectiveness of RRTs is mixed. Some studies show that the teams are effective in decreasing mortality rates and improving knowledge and satisfaction of nurses, but others show no differences." (2008)

Johal states that Kirk (2006) holds that "…extended training is needed to provide nursing staff with a clear understanding of what to expect in terms of specific roles and function of the team and when to call on them. Since the RRT provides education and guidance, it is expected that new mental models about early detection and rapid response to patients' conditions can be developed." (Johal, 2008)

The work of Johal (2008) reports a study with the purpose of: (a) exploring the relationship between the frequency of use of Rapid Response Teams (RRTs) by hospital staff nurses and the support received from RRTs; (b) to investigate staff nurses' perceptions of their individual level, group level and organizational level learning as a result of single of multiple exposures to the RRT; (c) to identify predictors of learning outcomes and (d) to identify overall impressions and advantages and disadvantages of the RRT. The study reports having used a mail survey, which was answered by 33% of 131 of registered nurses. Findings of the study specifically state as follows:

"The results of Pearson r correlation suggest that a high frequency of access of RRTs was positively related to process support (r = .25, p < .01). Also, perceived content and process support from RRTs was positively related to maintenance and building of staff nurses' mental models regarding patient deterioration pertaining to self, group and organization. Multiple regression analyses show that sociodemographic and independent variables predict organizational learning outcomes (mental model maintenance and building)." (Johal, 2008)

Overall impressions of the RRTs were reported to be high and a content analysis of the comments of nurse indicated: "…there were more advantages to having the RRTS than disadvantages." (Johal, 2008) Suggested by the findings is that RRTS are influential in changing the perceptions of nurses about the management of patient deterioration. Programs for training RRTS need to include "both content and process support, which may enhance building and maintaining mental models." (Johal, 2008)

According to Johal (2008) there are several previous studies on RRTs, which suggest that "…some sociodemographic factors may present barriers to decisions to call the RRT for help. Level of experience appears to play an important role when calling the RRT." Johal (2008) writes that Cioffi (2000a) found that "…less experienced nurses sought the opinions of other more experienced nurses when unsure about calling the RRT. More experienced nurses often discussed the decision with their peers and colleagues. Feelings of fear also play an important role in calling the RRT."

Additionally reported by Johal (2008) is that Cioffi (2000a) states findings that contributing to the nurses' feelings of nervousness and anxiety about "…what was happening to the patient and what would be expected of them when the RRT arrived" was the "uncertainty of decision-making situations. Some nurses felt panic because they did not want the patient to die." Johal reports that this panic was "associated with reflections on past experiences of not being able to resuscitate patients in the days when the emergency team was only called after a patient had actually arrested. Calling the RRT also can be emotionally charged. The element of emergency can also make nurses on the wards more nervous because it is not within their norm to work under such stressful circumstances (Cioffi, 2000a)." (2008)