Documentos de Académico
Documentos de Profesional
Documentos de Cultura
Team
M. Chadi Alraies
Chief Medical Resident
St. Vincent Charity Hospital/Case Western Reserve
University
Sunday, February 10, 2008
Acknowledgment
Critical Care Committee
Dr. J. Sopko
Krystyna Strozewski
Karen Komondor R.N.
Dr. Abdul Alraiyes
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100,000 Lives Campaign
Objectives
(December 2004 – June 2006)
Save 100,000 lives
Enroll more than 2,000 hospitals in
the initiative
Build a reusable national
infrastructure for change
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The 100,000 Lives Campaign
Scorecard
An estimated 122,300 lives saved by
participating hospitals
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Campaign Objectives
(Summer and Fall
2006)
Save 100,000 lives.
Enroll more than 2,000 hospitals in the
initiative.
Build a reusable national infrastructure
for change.
Raise the profile of the problem - and our
proactive response.
Complete implementation of all six
Campaign interventions in
participating hospitals by January
2007. M Chadi Alraies 7
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Prevent Pressure Ulcers
Reduce Methicillin-Resistant Staphylococcus
aureus (MRSA) Infection.
Prevent Harm from High-Alert Medications...
starting with a focus on anticoagulants, sedatives,
narcotics, and insulin
Reduce Surgical Complications... by reliably
implementing all of the changes in care
recommended by the Surgical Care Improvement
Project (SCIP)
Deliver Reliable, Evidence-Based Care for
Congestive Heart Failure…to reduce
readmissions
Get Boards on Board….Defining and spreading
the best-known leveraged processes for hospital 9
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Boards of Directors, so that they can become far
What is Rapid Response
Team?
RRT is a team of clinicians who bring
critical care expertise to the patient
bedside (or wherever it is needed)
Based on three problems which can lead
to failure to rescue:
Failures in planning (assessments, treatments,
and
goals)
Failure to communicate (patient to staff, staff
to staff and staff to physician, etc.)
Failure to recognize deteriorating patient
condition M Chadi Alraies 10
What difference can the
RRT make?
50% reduction in non ICU arrests.
Buist MD et al. in BMJ. 2002; 324: 387-390.
Reduced post operative emergency
ICU transfers (58%) and deaths
(37%).
Bellomo R et al. in Crit Care Med. 2004; 32: 916-921
Reduction in arrest prior to ICU
transfer (4% vs. 30%).
Goldhill DR et al. Anesthesia. 1999;54(9): 853-860.
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Why we are
initiating RRT?
Why we are initiating
RRT?
Between 48,000 –96,000 lives are lost due
to medical error each year.
Fortunately, only a small fraction of errors
and accidents actually result in harm.
Patient Harm May Occur For A Variety Of
Reasons.
Medication Errors
Procedure Errors
Infection Harm
Accidents
Equipment Failures
Communication breakdowns are causally
implicated in a majority of errors and
accidents. M Chadi Alraies 13
Why we are initiating
RRT?
Often when you review the chart of
several patients that suffered cardiac
or respiratory arrest in our hospital
you will find alterations in:
Subjective complaints,
Vital signs,
Telemetry changes,
Nursing documentation that precede the
event from hours to days in advance.
Right?
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In establishing a
rapid response
team, the goal is
To respond to
a “spark”
before it
becomes a
“forest fire”
background
Known by some as the Medical
Emergency Team.
The purpose of the RRT is to bring
critical care expertise to the patient
bedside (or wherever it’s needed).
Team is not intended to take the
place of immediate consultation with
the physician if needed.
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background
After consultation with the Rapid
Response Team, a call is placed to
the appropriate physician.
The intention is to help patients in
the time window of clinical instability
and not to replace physician
involvement in that process.
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To Err Is Human:
Building a Safer Health System
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Crossing the Quality Chasm: A
New Health System for the 21st
Century
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Crossing the Quality Chasm: A
New Health System for the 21st
Century
Six primary aims:
Safer,
More effective,
Efficient,
Patient-centered,
Timely, and
Equitable.
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failure to rescue
Three main systemic issues
contribute to the problem:
– Failures in planning (includes
assessments, treatments, goals)
– Failure to communicate (patient to
staff, staff to staff, staff to physician,
and sign outs, etc.)
– Failure to recognize deteriorating
patient condition
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Rapid Response Team
Results
Measure Before After RRR
No. cardiac 63 22 65%
arrests
(p=.001)
Deaths from 37 16 56%
cardiac
arrest (p=.005)
No. days in 163 33 80%
ICU post
arrest (p=.001)
No. days in 1363 159 88%
hospital post
arrest (p=.001)
Inpatient 302 222 25%
Deaths
(p=.004)
Bellomo R, Goldsmith D, Uchino S, et al. A prospective before-and-after trial of a medical emergency team. Medical Journal
of Australia. 2003;179(6):283-287.
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In our hospital
RRT Trigger
Criteria
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Respiratory
New Respiratory rate less than 8 or
greater than 28
New Acute change in oxygen
saturation less than 90%
New Threatened airway
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Cardiovascular
New Acute change in systolic BP to less
than 90mmHg
New Acute sustained increase in diastolic
BP greater than 110mmHg
New Acute change in HR less than 50 or
greater than 120
New onset chest pain or chest pain
different than admission assessment
New Acutely cold, pulseless or cyanotic
extremity
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Neurologic
New Confusion, agitation, or delirium
New Unexplained lethargy/difficult to
arouse
New Difficulty speaking or difficulty
swallowing
New Acute change in pupillary
response
New seizure
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Other
New Temperature greater than 39.0
Celsius
New Uncontrolled pain (if different
than admission pain assessment)
New Acute change in urine output
less than 50ml/4 hours
New Acute bleeding (i.e., bleeding
with a change in vital signs, urine
output or mental status)
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When to activate the
RRT call
1. When on of the above criteria
deteriorate significantly (very fast).
2. Two or more of the above criteria
fulfilled.
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Three key features of the team
members
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RRT team member
ICU on-call resident/floor on-call
resident
Nurse supervisor
???Respiratory Therapist
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How to activate RRT
Overhead page
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Primary physician
notification
After patient assessment by RRT
ICU oncall resident/nurse supervisor has
to notify the PCP about the RRT plan
Taking actions before notifying the
PCP is acceptable if the patient
fulfilled the criteria.
If PCP didn’t response…
Please notify Dr. Sopko
8195908 M Chadi Alraies 35
Teaching/non-teaching
patients
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Rapid Response Team
Record
This tool was developed to:
Document,
Analyze, and
Share …
Why the Rapid Response Team
was called?
What interventions took place?
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Rapid Response
Team Education
Checklist
Rapid Response Team Education
Checklist
Medical Staff Education
General information
Benefits
RRT Education
ACLS or advanced critical care training
Communication skills
Appropriate expectations
Importance of responding in a timely manner
Importance of providing non-judgmental, non-
punitive feedback to call initiator.
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Rapid Response Team Education
Checklist
Nursing Staff Education
Criteria for calling
Notification process
Communication and teamwork skills
SBAR, Assertiveness / Critical Language
Appropriate expectations
Importance of calling even when unsure
Non-judgmental, non-punitive nature of the
Rapid Response Team
Have information available for Rapid
Response Team (chart, medication
administration record, etc.)
Role as a member
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Alraies 47
Questions?
References
Bellomo R, Goldsmith D, Uchino S, et al. A prospective
before-and-after trial of a medical emergency team.
Medical Journal of Australia. 2003;179(6):283-287.
Move Your Dot™: Measuring, Evaluating, and Reducing
Hospital Mortality Rates (Part 1). IHI Innovation Series
white paper. Boston: Institute for Healthcare
Improvement; 2003.
Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR,
Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH.
Incidence of adverse events and negligence in
hospitalized patients. Results of the Harvard Medical
Practice Study I. N Engl J Med. 1991;324(6):370-376.
Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR,
Barnes BA, Hebert L, Newhouse JP, Weiler PC, Hiatt H.
The nature of adverse events in hospitalized patients:
Results of the Harvard Medical Practice Study II. N Engl J
Med. 1991;324(6):377-384.
Buist MD et al. in BMJ. 2002; 324: 387-390.
M Chadi Alraies 49
Bellomo R et al. in Crit Care Med. 2004; 32: 916-921