SummaryThe medical response team at Baptist Memorial Hospital responds to nurse and family reports of early warning signs that patients are in cardiac or respiratory distress and moves quickly to rescue them before they develop medical emergencies. The medical response team has reduced the number of cardiac arrests by 26 percent and has saved lives by increasing nurses’ ability to recognize the early warning signs of patient distress, while empowering them to communicate with physicians and begin interventions earlier.Moderate: The evidence consists primarily of pre- and post-implementation comparisons of key quality measures, including overall mortality rates, number of cardiac arrests, and cardiac arrest and code survival rates.
Developing OrganizationsBaptist-Memorial Hospital, Memphis, TN
Date First Implemented2003
Vulnerable Populations > Intensive care unit patients
Problem AddressedOne systemic contribution to poor patient quality and safety is the failure to recognize a patient's deteriorating condition, which can lead to medical emergencies and sometimes death.
- Early warning signs are often unrecognized, leading to devastating results: Research shows that virtually all critical inpatient events are preceded by warning signs that occur approximately 6.5 hours in advance.1 However, clinician recognition of a patient's deteriorating condition is often delayed or managed inappropriately, resulting in late referral to critical care, avoidable intensive care admissions, and unnecessary patient deaths.2 Baptist Memorial Hospital experienced many of these problems as well. (See Context of the Innovation for more details.)
- Early response can help: Rapid response teams have been proven effective in identifying unstable patients and patients likely to suffer cardiac or respiratory arrest. If identified in a timely fashion, their deaths can often be prevented.1
Description of the Innovative ActivityThe Baptist Memorial medical response team is a small team headed by a critical care nurse experienced in assessing patients’ symptoms and their trajectory. The medical response team is available at all times to any provider who wants a second opinion about a patient, particularly a patient showing signs of change that could signal a potential decline. Key elements of the program include the following:
- Team composition: The medical response team consists of an experienced critical care nurse (from a pool of intensive care unit [ICU] nurses who rotate on and off the team), a respiratory therapist, and an intensivist if available (typically at night).
- Reasons for initiating the call: To assist symptom recognition, each floor nurse received a list of common reasons to call the medical response team, including simply being worried about the patient (e.g., the nurse has a “gut feeling” that something is wrong) and/or an acute change in systolic blood pressure, respiratory rate, heart rate, oxygen saturation, or level of consciousness. Families of patients can call the medical response team directly (a family call is known as "Condition H"). All newly admitted patients/families receive a pamphlet on Condition H, describing what it is and how to call the team; posters on the nursing units also describe Condition H and remind families how to call the team. In addition, beginning in February 2012, the medical response team is a member of the hospital's stroke team, and thus recieve calls for any patient that falls under the stroke criteria, including emergency room patients (note: the medical response team may not have to go to the emergency room, but is available to assist emergency personnel as needed.)
- Paging the team: Any clinician or family member can page the medical response team any time they are concerned that a patient's deteriorating health status warrants further evaluation. The critical care nurse who heads the medical response team and the lead respiratory therapist are either in the ICU or on call at all times, and always carry a pager. Information provided in April 2009 indicates that when a floor pages the team, the page now goes to both the critical care nurse and the lead respiratory therapist. Once paged, these medical response team members call the initiating party immediately, and the team reaches the bedside within 5 minutes.
- Assessing the situation and contacting the attending physician: The medical response team nurse does not take over a patient’s care but instead gathers complete information about the patient’s condition to communicate to the physician. The medical response team nurse assesses the patient with the floor nurse and reviews the patient’s chart. Either the floor nurse or the medical response team nurse contacts the physician with the pertinent information and a recommendation, using standard Situation-Background-Assessment-Recommendation (SBAR) communication protocols designed to ensure mutual understanding. If the medical response team nurse thinks the patient needs to be transferred to the ICU, he or she can start that process.
- Patient followup: Medical response team nurses on day and night shifts follow up on each other’s patients. If a patient on one medical response team nurse’s shift experienced a medical response team call on the previous shift, the nurse on the next shift goes to the patient’s room to check on his or her condition. If the patient is transferred back to the ICU from elsewhere in the hospital, the medical response team nurse writes a followup note on the medical response team record, which is computerized and viewable by anyone allowed to look at that patient's record (including the physician). Medical response team nurses also follow up with patients in person when they are transferred from the ICU to another unit, whether or not they experienced a code.
- Proactive monitoring: The medical response team monitors patients proactively. With the hospital's recent adoption of electronic documentation, the medical response team is now able to print a report every 4 hours that lists inpatients with abnormal vital sign values and abnormal lactic acid values; the patient's room number is also provided. The medical response team then uses that information to check on those patients before anyone pages the medical response team. This tool allows the medical response team to intervene with additional patients that may need the team’s assistance.
References/Related ArticlesThis profile is adapted from an Improvement Story by the Institute for Healthcare Improvement, available online at: http://www.ihi.org/knowledge/Pages/ImprovementStories/RapidResponseTeamsHeadingOffMedicalCrisesatBaptistMemorialHospitalinMemphis.aspx
Armitage M, Eddleston J, Stokes T, et al. Recognising and responding to acute illness in adults in hospital: summary of NICE guidance.vBMJ. 2007;335(7613):258-9. [PubMed]
Contact the InnovatorTrudy Henze, RN
Head Nurse, ICU
6019 Walnut Grove Road
Memphis, TN 38120
Phone: (901) 226-5804
Fax: (901) 226-5703
Innovator DisclosuresMs. Trudy Henze has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.
ResultsThe medical response team saved lives by increasing nurses’ ability to recognize early warning signs of patient distress, empowering them to communicate with physicians and begin interventions earlier. Between August 2003 and July 2007, the number of cardiac arrests declined by 26 percent while the survival rate for cardiac arrest patients increased from 13 to 24 percent, a rate that has been maintained through April 2009. Results are as follows:
Moderate: The evidence consists primarily of pre- and post-implementation comparisons of key quality measures, including overall mortality rates, number of cardiac arrests, and cardiac arrest and code survival rates.
- Fewer cardiac arrests and enhanced survival rates for cardiac arrests and codes: In the 4 years after implementation, the number of cardiac arrests dropped by 26 percent while the survival rate for those experiencing cardiac arrest almost doubled, from 13 to 24 percent; the 24 percent rate has been maintained through early 2009. Data provided in April 2009 indicate that the survival rate at discharge for those who experienced an medical response team call rose from 63 percent pre-implementation to more than 86 percent in 2006. Much of this success is due to better recognition of the early warning signs of a decline, which enables patients to get to the ICU (where the chances of survival are greater) before the event occurs. For example, the percentage of cardiac arrest patients who were in the ICU at the time of the event climbed from 36 to 64 percent in the 4 years since program implementation. The April 2009 average survival rate at discharge for a medical response team call was 75 percent.
- More appropriate use of the ICU: Information provided in April 2009 indicates that the percentage of patients transferred to the ICU after a consult with the medical response team has dropped from 82 to 46 percent over 1 year. This is attributed to the floor nurses calling the medical response team sooner and to the medical response team improving its ability to treat patient distress on the floor so the patient does not have to transfer to the ICU.
- Greater empowerment and enhanced respect: Responses to staff questionnaires suggest that floor nurses feel better able to recognize the early warning signs of trouble, thus enabling them to call the medical response team and get the patient help earlier. (The average number of calls has risen from less than 25/month at the program's inception to 108/month between March 2008 and March 2009.) Nurses also report increased confidence in communicating with physicians. In addition, the level of mutual respect between the ICU and the floor nurses has increased. The floor nurses report new-found respect for the ICU nurses’ critical care skills; the ICU nurses report enhanced respect for the floor nurses’ ability to care for and assess a large number of patients without the benefit of sophisticated technology.
Context of the InnovationBaptist Memorial Hospital, part of the Baptist Memorial Health Care System, is a 736-bed hospital that serves Memphis, TN, and surrounding areas. In June 2003, hospital staff participated in an Institute for Healthcare Improvement meeting on the failure to rescue patients and the use of rapid response teams. After the meeting, the hospital conducted a chart review that identified several deficiencies, including the following:
Modeled after other hospitals' successful experiences with rapid response teams, Baptist Memorial leaders designed and tested a process whereby ICU nurses were made available to staff on the medical/surgical floors. The successful results of this process led to the creation of the medical response team.
- Missed warning signs in patients who later experienced codes or other emergency situations.
- Frequent communication failures between nurses and physicians related to potential warning signs and/or emergency situations.
- Assignment of patients to the wrong level of care after transfer from the emergency department.
Planning and Development ProcessThe planning and development process included the following:
- Initial training: The medical response team began with an informal training program to explain the details of the new program for four to five float charge nurses, who were already accustomed to responding to cardiac arrests throughout the hospital.
- Introducing the team to the floor nurses: A sheet listing the common warning signs of patient distress and a one-page fact sheet introducing the medical response team was distributed to the staff on all floors. The medical response team received 10 calls from nurses in the first 3 days, with most calls reporting concerns about patients’ blood pressure, respiration, and other changes in conditions.
- Getting formal support: Although the ICU director and nurse manager were aware that the ICU nurses had informally formed an medical response team, the nurses did not have formal permission to launch the program, and most physicians were unaware of the medical response team's existence. At the hospital medical board meeting following the first week of informal operations, the ICU director described the experiment and noted the success of rapid response teams elsewhere. After hearing about each of the first 10 patients, administrators and physicians gave their formal support to the program.
- Creating a “trigger list”: As a guide for staff, ICU nurses created and circulated a broad list of warning signs and concerns that might indicate a patient’s worsening condition and trigger the need for a call to the medical response team.
- Facilitating communication: Nurses were trained to use SBAR communication techniques with physicians. The hospital hung SBAR posters in every nurse’s station on every floor and handed out blank SBAR sheets that nurses could fill out using guidance from the SBAR poster before calling the physician.
- Data collection: Baseline data came from chart reviews before the medical response team began. Once it started, medical response team nurses tracked the number of medical response team calls and cardiac arrests, their results, and where they occurred (e.g., ICU or floor). Medical response team nurses sent questionnaires to floor nurses to periodically assess whether the medical response team was meeting floor nurses' needs.
Resources Used and Skills Needed
- Staffing: In the beginning, the medical response team relied on existing resources in the 38-bed ICU, with a usual staff of 20 nurses. Over time, the hospital committed to devoting an ICU nurse to the medical response team at all times, which led to the hiring of between four and five new full-time equivalent (FTE) critical care nurses.
- Costs: The primary cost is the salary and benefits for the added FTE nurses.
Funding SourcesBaptist-Memorial Hospital, Memphis, TN
Tools and Other ResourcesGeneral information on rapid response systems is available at: http://psnet.ahrq.gov/primer.aspx?primerID=4.
Getting Started with This Innovation
- Begin with a simple pilot test: Keep the program simple and start with a pilot test on one unit.
- Develop a simple trigger list with clear instructions for activating the team: Keep the trigger list simple and encourage calls whenever there is doubt about a patient's condition. Nurses should be clear about when to call and should feel comfortable calling the medical response team whenever there is a change in the patient’s condition.
- Select team nurses carefully: Choose medical response team nurses who have strong personalities and an open, mentoring approach to teaching, as their primary role is to teach, support, and assure the floor nurses.
Sustaining This Innovation
- Expand the program after pilot success: Expand the program over time after success is proven on the pilot unit; other units will likely be eager to adopt the program after hearing of its potential to save lives.
- Remind staff of activation protocols: Use daily or weekly floor rounds and other communication vehicles (e.g., newsletters, posters) to remind staff about the availability of—and when to call—the medical response team.
- Incorporate information about the team into orientation for new nurses: Include instruction about the medical response team in the orientation for all new floor nurses.
Additional Considerations and Lessons
- The medical response team creates relationships and increases understanding between floor and ICU nurses.
Use By Other Organizations
- The Baptist Memorial Hospital medical response team program has spread to other, smaller hospitals throughout the Baptist Healthcare Corporation.
Armitage M, Eddleston J, Stokes T, et al. Recognising and responding to acute illness in adults in hospital: summary of NICE guidance. BMJ. 2007;335(7613):258-9. [PubMed]
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Service Delivery Innovation Profile
Original publication: December 12, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: August 28, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: August 21, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.