Clinical Focus on Quality
Every day, people die unnecessarily in hospitals throughout the nation. Studies, as well as our own experience at Intermountain, have shown that failure to intervene prior to a life-threatening event is a significant problem and frequently due to failure to recognize, respond, and treat the early signs of clinical deterioration. (see 1, below)
Over the past few years, RRT — "Rapid Response Team" or, in some circles, a process of "Recognize, Respond, and Treat" — has been adopted in hospitals throughout the nation, as well as at Intermountain Healthcare. (You may also hear the acronym MET, which stands for "Medical Emergency Team," in place of RRT.) The RRT process serves as an early warning system, put into place to more reliably identify patients in trouble and to trigger the appropriate staff response.
This response, in many cases, involves notifying the Rapid Response Team to immediately go to the patient's bedside and determine what can be done to avoid further deterioration of the patient's condition. This is critical, because once a patient's condition deteriorates to the point of needing CPR, success of resuscitation is very low: Many, if not most, patients will die.
Several studies indicate that patients often exhibit signs and symptoms of physiologic instability for some period of time prior to cardiac arrest. Examples include:
- 70% (45/64) of patients show evidence of respiratory deterioration within eight hours of arrest. (see 2)
- 66% (99/150) of patients show abnormal signs and symptoms within six hours of arrest, and a physician is notified 25 % of the time. (see 3)
The key, then, is to recognize very early changes in the patient's clinical status so that treatment can take place quickly before lifesaving resuscitation efforts, such as CPR, are needed. In other words, we wish to recognize and respond to the "spark" before it becomes a large, uncontrollable "forest fire."
Essential elements of this early warning system include:
- Use of physiological measurements and observations (or criteria) to identify or recognize patients at risk. Examples of those criteria include:
- Changes in the heart or respiratory (breathing) rate.
- A drop in blood pressure (it gets much lower).
- Changes in urinary output (much more or much less urine).
- Confusion or other mental status (thinking) changes.
- When something just does not look or seem right with the patient to family and/or staff.
- Implementation of a process where a team of trained clinicians can immediately respond to that patient.
- Care is provided by the appropriate team that can alter the course of the patient's condition.
RRT implementation began at LDS Hospital in 2006. By 2008, all Intermountain hospitals had the RRT process in place. Implementation included a web-based data collection and reporting system in which clinicians could enter and track RRT calls. Even though we are in the early phases of measuring the impact of RRT on patient outcomes, we've already identified many areas where we've made measurable improvements in our care processes.
- J. Whittington, T. Simmonds, and D. Jacobsen, Reducing Hospital Mortality Rates, Part 2 [IHI Innovation Series white paper] (Cambridge, Mass.: Institute for Healthcare Improvement, 2005; available on www.IHI.org).
- R.M. Schein, N. Hazday, M. Pena, et al., "Clinical antecedents to in-hospital cardiopulmonary arrest," Chest 98 (1990): 1388-1392.
- C. Franklin and J. Mathew, "Developing strategies to prevent in hospital cardiac arrest: analyzing responses of physicians and nurses in the hours before the event," Crit Care Med 22, no. 2 (1994): 244-247.
Trustee Education Modules available on trustee website
Want to improve your knowledge of Intermountain's clinical quality programs? Trustees are encouraged to visit the trustee website and take short computer-based "micro-courses" on clinical quality topics. We're currently offering three Trustee Education Modules — the new one is on Adverse Drug Events. Taking the courses is a quick and easy way to become an "instant expert" — and a more effective advocate — on clinical quality.
To take the brief courses, visit the website at: