Overview

Patients who experience a heart attack in the hospital have a poor chance of survival, even when they are resuscitated. Missouri Baptist Medical Center has joined a growing number of hospitals that are reducing the incidence of in-hospital heart attacks and other significant events by empowering nurses to call a critical care team when a patient shows signs of clinical deterioration.

Issue: On average, only 17 percent of patients survive an in-hospital cardiac arrest,[1] yet many exhibit measurable signs of clinical deterioration preceding the event. [2] Several hospitals in Australia have demonstrated improved outcomes by establishing teams of critical care specialists that floor nurses call for help before patients need resuscitation. [3] A controlled before-and-after trial conducted at Melbourne's Austin and Repatriation Medical Centre, for example, found that the introduction of a medical emergency team was associated with relative risk reductions of:

• 65 percent in cardiac arrests,
• 56 percent in deaths attributable to cardiac arrests,
• 26 percent in deaths hospital-wide,
• 88 percent in hospital bed days among cardiac arrest survivors,
• 58 percent in the rate of serious adverse outcomes after surgery, and
• 37 percent in postoperative deaths.

In addition, the hospital's average length of stay following major surgery decreased by four days. As a result of outcomes like these, the rapid response model has attracted interest and stimulated efforts to replicate it other nations, including the U.S.

Objective and Intervention: Missouri Baptist Medical Center aimed to improve patient outcomes by enhancing its capability to intervene when patients show signs of medical deterioration and thus prevent emergency response crises such as cardiac or respiratory arrest.

Organization: Missouri Baptist Medical Center is a 489-bed acute care hospital located in St. Louis, Missouri, and a member of BJC HealthCare, a non-profit health system serving greater St. Louis and the nearby areas.

Date of Implementation: After a six-week pilot in one ward, Missouri Baptist instituted a hospital-wide rapid response team in April 2004.

Target Population: The rapid response team answers calls throughout the hospital.

Process of Change: Before the intervention, Missouri Baptist had an existing, two-tier emergency response system: a traditional "code blue" team for cardiac arrests and ICU-based physician assistants who responded to other critical events such as respiratory arrests. The hospital's management found the evidence of the benefits of rapid response teams compelling and decided to undertake a similar effort. Collaborative calls led by the Institute for Healthcare Improvement provided managers with insights drawn from the experience of prior adopters, particularly the Baptist Memorial Hospital–Memphis, in Tennessee.

The rapid response team includes a physician assistant, who acts as the team leader, a critical care nurse, and a respiratory therapist. All team members have flexible duties in the hospital that allow them to be available when needed. The team is empowered to take action, within their scope of practice, to stabilize a patient, reporting to and consulting with the hospital's ICU physician intensivist as needed. The patient's attending physician is notified of the team's assessment and can order additional tests at their discretion. Patients are transferred to the ICU when appropriate or to an intermediate care unit if their needs do not warrant critical care.

The rapid response team was established using a gradual approach that involved starting on one unit during the day shift for three weeks, expanding to 24 hours on that unit for an additional three weeks, and then expanding throughout the hospital. Everyone who called the rapid response team was surveyed during the first six months of implementation and their feedback was used to refine the process.

Hospital staff members were educated about the purpose and use of the rapid response team prior to its implementation. Specific clinical criteria are used to help nursing staff identify when a patient's condition warrants a call for help. In addition, anyone caring for a patient can summon the rapid response team if they are concerned about a patient's status.

Results: After two months of full implementation, calls to the rapid response team reached about 70 to 80 per month. The team's average response time is 1.5 minutes. Respiratory problems are the most frequent reason the team is called. Emergency calls for respiratory arrest and similar crisis events have declined by 60 percent and cardiac arrests have declined by 15 percent, suggesting that the approach is beneficial in averting adverse events.

As of June 2004, the survival rate among patients assessed by the rapid response team was 81 percent. The cost-benefits of the initiative, including its effect on the overall hospital mortality rate, will be evaluated after one year's experience. Anecdotal feedback from family members indicates that they are impressed and gratified by the efforts that have been made on behalf of patients.

Lessons Learned: John Krettek, M.D., vice president of medical affairs, and Nancy Sanders, R.N., performance improvement coordinator, offer the following critical success factors based on their experience:

• Missouri Baptist was able to create a rapid response team composed of existing staff members. The hospital already had assigned physician assistants to respond to emergency calls. Staffing the rapid response team with ICU staff and respiratory care therapists who have other, flexible duties ensured their availability for calls.
• The purpose of a rapid response team is to rescue patients from sliding into a critical or decompensated state—not to resuscitate them after the fact. It's like "putting out a brush fire before it becomes a forest fire," says Sanders.
• Collecting data on the rapid response team's calls is important to assess the intervention's impact. For example, the team records information about each call for trend analysis. Copies of these call reports are sent to the originating unit's manager and shared with floor staff for feedback and learning. In addition, Missouri Baptist's performance improvement coordinator gets beeped along with the team so that she can track calls.
• Educating hospital staff about the purpose and operation of the rapid response team is key to its successful take-up. Reinforcement is needed to change habits, as some nurses continue to seek help using traditional channels. Sharing feedback on incidents and success stories builds support for the rapid response team's efficacy.
• The rapid response team should be considered a support resource for frontline staff. For example, incidents can be used as opportunities for ICU nurses to share insights with floor nurses, sharpening their assessment skills and teaching them how to respond proactively to similar events in the future.

Related Results: A doubling in use of a medical emergency team at the University of Pittsburgh Medical Center Presbyterian Hospital, the first U.S. hospital to institute the rapid response model, was followed by a 17 percent decrease in cardiopulmonary arrests. [4] Baptist Memorial Hospital–Memphis has seen its total number of in-hospital heart attacks drop by 26 percent, an improvement in survival from 13 percent to 24 percent of those who had a heart attack in the hospital, and a 31 percent relative reduction in the hospital's overall mortality rate.[5]

Implications: Rapid response teams bridge the divide between hospital units by bringing the expertise of emergency and critical care specialists to the hospital ward. In meeting their primary objective to improve the care and safety of individual patients, rapid response team interventions also provide an opportunity for on-the-job learning by floor nurses as they participate in the team's response to a particular clinical event. In this way, rapid response teams can promote a culture of safety by building teamwork and spreading knowledge and skills throughout a hospital.

For More Information: Contact Nancy Sanders, R.N., performance improvement coordinator for Missouri Baptist Medical Center, at nks0065@bjc.org.

References
1. M. A. Peberdy et al. (2003) Cardiopulmonary Resuscitation of Adults in the Hospital: A Report of 14720 Cardiac Arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation 58, 297–308.
2. M. D. Buist et al. (1999) Recognising Clinical Instability in Hospital Patients Before Cardiac Arrest or Unplanned Admission to Intensive Care. Med. J. Aust. 171, 22–25.
3. R. Bellomo et al. (2003) A Prospective Before-and-After Trial of a Medical Emergency Team. Med. J. Aust. 179, 283–287; R. Bellomo et al. (2004) Prospective Controlled Trial of Effect of Medical Emergency Team on Postoperative Morbidity and Mortality Rates. Crit. Care Med. 32, 916–921.
4. M. A. DeVita et al. (2004) Use of Medical Emergency Team Responses to Reduce Hospital Cardiopulmonary Arrests. Qual. Saf. Health Care 13, 251–254.
5. Rapid Response Teams: Heading Off Medical Crises at Baptist Memorial Hospital-Memphis. Boston: Institute for Healthcare Improvement.

January 2005

This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Fund-sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied organizations' experiences in ways that may aid their own efforts to become high performers. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case studies series is not an endorsement by the Fund for receipt of health care from the institution.