Improving Failure to Rescue Outcomes: A Rapid Response Team Program Review Kimberlee M. Jones College of Nursing, Michigan State University Doctor of Nursing Practice Project Dr. Jackeline Iseler March 30, 2023 2 Table of Contents Abstract ....................................................................................................................................................4 Introduction ..............................................................................................................................................5 Background ..............................................................................................................................................5 Significance..............................................................................................................................................6 Problem Statement ...................................................................................................................................7 Search Strategy ........................................................................................................................................8 Literature Synthesis .................................................................................................................................8 Change Theory .......................................................................................................................................12 Methods..................................................................................................................................................12 Project Site and Population ................................................................................................................12 Building a Relationship ......................................................................................................................12 Diagnosing the Problem .....................................................................................................................13 Acquiring Resources ..........................................................................................................................13 Choosing the Solution ........................................................................................................................14 Policy Revision ...............................................................................................................................14 Nursing Education ..........................................................................................................................14 Quality Data Collection ..................................................................................................................15 Timeline ..........................................................................................................................................15 Gaining Acceptance ...........................................................................................................................15 3 Facilitators and Barriers..................................................................................................................15 Ethical Considerations ....................................................................................................................16 Maintenance and Separation ..............................................................................................................17 Evaluation/Outcomes .....................................................................................................................17 Sustainability Plan ..........................................................................................................................17 Discussion ..............................................................................................................................................17 Conclusion .............................................................................................................................................18 References ..............................................................................................................................................19 Appendix A (Gap Analysis)...................................................................................................................23 Appendix B (Fishbone Diagram) ...........................................................................................................25 Appendix C (PRISMA Diagram) ...........................................................................................................26 Appendix D (Literature Synthesis Critique Table) ................................................................................27 Appendix E (Levels of Evidence Table) ................................................................................................35 Appendix F (Literature Synthesis Intervention Table) ..........................................................................36 Appendix G (Project Timeline)..............................................................................................................38 Appendix H (SWOT Analysis) ..............................................................................................................39 4 Abstract Title Improving Failure to Rescue Outcomes: A Rapid Response Team Program Review Background/Significance The average annual incidence of in-hospital cardiac arrests from 2008- 2017 was approximately 292,000, an increase of 81,000 since previous data was obtained for the years 2003-2007 (Holmberg et al., 2019). Early identification of patient decline and initiation of a Rapid Response Team (RRT) are necessary for improved patient outcomes, decreased length of stay, and decreased mortality (AHRQ, 2018; Andersen et al., 2019; Burke et al., 2022; IHI, 2022). According to the AHRQ (2019), complications of medical care are unavoidable, and it is the responsibility of the health care system to quickly identify and treat those complications. Methods A literature search was performed for articles published from January 2017 to July 2022 utilizing CINAHL and PubMed. Articles identified training and education, team composition, sociocultural/leadership, and outcome data to improve RRT outcomes. Utilizing Havelock’s Phases of Change model, a proposal to improve RRT performance was developed. Conclusion Ineffective RRT performance contributes to poor patient outcomes and increased mortality. Program evaluation of an RRT identified gaps and contributory factors which provided the basis for change. Existing resources and processes were used to help ensure sustainability. Upon successful implementation, an updated policy, comprehensive education plan, outcome data measures, and ongoing monitoring plan were in place to monitor progress toward improving RRT outcomes. 5 Improving Failure to Rescue Outcomes: A Rapid Response Team Program Review Rapid response teams (RRT) are specialized, multidisciplinary critical care teams activated to assemble at a patient’s bedside when a decline in condition is identified (Avis et al., 2016). Although team participants vary by institution, they often include a nurse, physician, and respiratory therapist (Hall et al, 2020). When needed, the team is activated and can immediately assess, diagnose, treat, and determine if the patient can be stabilized or requires transfer to a higher level of care such as the intensive care unit (ICU; Hall et al., 2020). Although RRTs are common in many hospitals in the United States, team composition, roles, training, and education vary and challenges and barriers to effective team dynamics remain (Burrell et al., 2020). This paper aims to explore evidence-based interventions of rapid response teams to ensure best practice measures are included in hospital policy and practice. Background The average annual incidence of in-hospital cardiac arrests from 2008-2017 was approximately 292,000, an increase of 81,000 since previous data was obtained for the years 2003- 2007 (Holmberg et al., 2019). The Institute for Healthcare Improvement (IHI) identified failure to rescue (FTR) as a significant contributory factor to in-hospital mortality and began to recommend the implementation of rapid response teams in 2004 (IHI, 2022). In 2008, the Joint Commission (JC) added a National Patient Safety Goal requiring a process for specially trained staff to assist when a patient’s condition deteriorates (Agency for Healthcare Research and Quality [AHRQ], 2018). Early identification of patient decline and initiation of RRT are necessary for improved patient outcomes, decreased length of stay, and decreased mortality (AHRQ, 2018; Andersen et al., 2019; Burke et al., 2022; IHI, 2022). Physiologic changes indicative of deterioration leading to cardiac arrest can be detected up to six hours prior to the event (Andersen et al., 2019; Avis et al., 2016; 6 Mitchell et al., 2019). RRT are composed of staff members specialized in managing the care of critically ill patients, bringing critical care expertise to the bedside quickly when a decline is identified (Mitchell et al, 2019). Significance According to the AHRQ (2019), complications of medical care are unavoidable, and it is the responsibility of the health care system to quickly identify and treat those complications. An RRT activation quickly allows the team to manage the complication and/or get the patient to the appropriate level of care before it progresses to cardiac arrest. Clinical deterioration prior to in- hospital cardiac arrest is common and considered preventable or avoidable with appropriate monitoring such as telemetry and/or trending of vital signs (Anderson et al., 2019). Hospitals that employ mechanisms to monitor and recognize deteriorating patients (e.g., education, monitoring, recognition of decline) as well as initiate timely interventions are more likely to prevent cardiac arrest (Andersen et al., 2019; IHI, 2022a). In the event of a witnessed cardiac arrest in the hospital in which early intervention (resuscitative measures) were implemented, the likelihood of survival to discharge was 25% in 2017, up from 20% in 2007 (Anderson et al., 2019). In acute care, the two most common complications associated with increased mortality from failure to rescue are hypoxia and hypotension, at 51% and 17% respectively (IHI, 2022). Approximately half of all in-hospital cardiac arrests occur on general inpatient units and are considered potentially avoidable. (Andersen et al., 2019). The goal of the RRT is to bring critical care expertise to the bedside to manage and stabilize an unstable patient (Mitchell et al., 2019). In a medium size midwestern hospital, a program evaluation of the RRT was performed and a gap analysis completed (see Appendix A). The clinical facility recently built a new hospital campus and consolidated two hospitals into one. An additional building attached to the hospital includes 7 outpatient care services such as a cancer center, endoscopy, magnetic resonance imaging, and outpatient infusion. RRT staff include one or two intensive care unit (ICU) nurses, one respiratory therapist, one ICU intensivist, a nursing supervisor, and a member of security. At times, an emergency department (ED) nurse and ED technician would also respond. The facility had an RRT policy in place that needed to be updated as two hospital campuses merged and outpatient care services were added. There was no dedicated group of RRT nurse responders with responding team members having an assignment in their respective units when a rapid response was activated. Data collection for RRT included total number of activations, symptoms requiring RRT intervention, and patient disposition. Data regarding RRT was provided by the 2021 chairperson for the code blue committee. In 2021 there were a total of 316 RRT activations. The top four complications requiring RRT activation were acute mental status change (16%) followed by dyspnea (15%), hypotension (14%), and tachycardia (10%). Data regarding disposition identified 53% of the patients remained in their room, 22% of the patients were transferred to the ICU, and 2% resulted in a code blue activation. There were inconsistencies in data metrics reported as the numbers did not match up with total RRT activation suggesting data collection could be improved. Additional factors contributing to effective performance during an RRT can be found in the fishbone diagram in Appendix B. Problem Statement This midwestern hospital has not been achieving effective RRT response due to multiple contributing factors. This project will use evidence-based strategies to improve RRT response and outcomes. The Donabedian model will be used to guide the theoretical framework of the project. It is a three-step model of improvement that focuses on structure, process, and outcomes with each component influencing the next (Jones & Roussel, 2020). Utilizing this model to create effective 8 structure and processes in this midwestern hospital can lead to positive patient outcomes within the system (Moore et al., 2015). Search Strategy A literature search was performed on July 7, 2022, using the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and PubMed. A university librarian assisted with the literature search terms. Search terms included “Rapid response team” OR “RRT” and train* OR effic* and NOT pediatric*. The search was limited to articles that were published in English, after 2017, and research focused. A total of 589 articles were identified. After removing duplicates, 527 articles remained for title and abstract review. Articles were included for the adult population in an acute care facility. Articles were excluded for wrong study design, or wrong study population leaving 41 articles for full review. During full article review, an additional 29 were identified as meeting exclusion criteria for wrong study design, wrong study population, or no text available. See Appendix C for preferred reporting items for systematic reviews and meta-analysis (PRISMA) diagram. Literature Synthesis A literature synthesis identified systematic reviews, narrative synthesis, meta-analysis, semi- structured interviews, electronic and internet surveys, and organizational interventions. Relevant articles were reviewed utilizing a critique table to identify design/purpose, sample/setting, results, level of evidence, strengths/weaknesses, and relevance to problem (see Appendix D). Level of evidence was evaluated with studies ranging from level V-VII (see Appendix E). An interventions table was developed to identify common themes (see Appendix F). Common themes were identified with the top four in more than half of the articles reviewed (seven or more) including training and education, team composition, sociocultural/leadership, and outcome data. Additional themes identified in less than half of the articles reviewed (six or less) include dedicated RRT nurse, 9 debriefing, bedside nurse activation of RRT, institutional policies, proactive rounding of at-risk patients, and collaborative resource for bedside nurses. Education and Training Hospitals that employ mechanisms to monitor, recognize deteriorating patients, and intervene promptly are more likely to prevent cardiac arrest (Andersen et al., 2019; IHI, 2022a). Education and training of both the bedside nurses and RRT staff to recognize deterioration and properly intervene are essential. Floor nurses Bedside nurses are the ones most likely to identify patient decline and need to understand the activation criteria (Avis et al., 2016; Hall et al., 2020; Moreira et al., 2018; Tanguay & Bartel, 2017; Winterbotton & Webre, 2021). Education and training of RRT activation should begin in orientation and be continuously reinforced (Avis et al., 2016). The role of the RRT and the activating nurse is shared with the goal of preventing deterioration or progression to cardiac arrest. The RRT does not assume care of the patient but rather provides an additional service to the patient. Roles should be clearly defined with the bedside nurse taking an active role as they have firsthand knowledge of what led to the decline/RRT activation and will continue to care for the patient once the team leaves or assist with the transfer to a higher level of care (Avis et al., 2016; IHI, 2022a). Bedside staff may miss early indicators of decline and delay the activation of the RRT which can lead to potentially negative outcomes (Avis et al. 2016; Winterbottom & Webre, 2021). Simulation training can be a useful tool for practicing and educating staff in a safe environment in which constructive feedback can be given (Avis et al. 2016; Le Guen & Costa-Pinto, 2021; Tanguay & Bartel, 2017). RRT team 10 The RRT functions as a resource to the organization with the goal of bringing critical care services to the bedside of a critically ill or deteriorating patient. The team should participate in regularly scheduled simulation training to improve performance and team dynamics (Avis et al. 2016; Le Guen & Costa-Pinto, 2021; Tanguay & Bartel, 2017; Winterbotton & Webre, 2021) Winterbottom & Webre (2021) expand beyond simulation to include didactic and evidence-based teamwork principles as well as skills-based competency validation. In addition to responding to RRT activations, the team serves as a clinical resource and can be used to provide education during and after an activation. Effective communication skills, the projection of teamwork, and willingness to help are important in building collaborative relationships between the RRT and hospital staff (IHI, 2022a; Le Guen & Costa-Pinto, 2021; Tanguay & Bartel, 2017). Team composition A multidisciplinary approach should be taken when determining team composition (Avis et al., 2016; Hall et al., 2020; Le Guen & Costa-Pinto, 2021). Team members should be experienced in critical care given the goal of an RRT is to bring critical care resources to the bedside (Hall et al., 2020; IHI, 2022a; Mitchell et al., 2019; Tanguay & Bartel, 2017; Winterbottom & Webre, 2021). Team composition will vary facility to facility with common team members including an intensive care nurse, respiratory therapist, and physician (Dukes et al., 2019; Hall et al, 2020; IHI, 2022a; Moreira et al., 2018). Organizations that have established a dedicated RRT nurse offer additional benefits to the organization such as proactive rounding of at-risk patients, education and support for nurses, and the building of a supportive, collaborative team (Avis et al., 2016; Dukes et al., 2019; Mitchell et al., 2019; Tanguay & Bartel, 2017; Winterbottom & Webre, 2021) Sociocultural/Leadership 11 Sociocultural influences and leadership contribute to team effectiveness and timely RRT activation which ultimately impacts outcomes. RRT are most effective when the staff have support from the leadership team to eliminate barriers and demonstrate a commitment to the program (Avis et al., 2016; Dukes et al, 2019; IHI, 2022a). When immediate help is needed at the bedside to evaluate a patient in need, nurses need to feel empowered to activate the RRT without fear of retaliation or intimidation by the response team (Avis et al, 2016; Dukes et al, 2019). Hierarchies between nurses and physicians should be eliminated and the clinical judgement of the bedside nurse in activating an RRT valued (Avis et al., 2016; Hall et al., 2020; Moreira et al., 2018). The responding team should value the bedside nurse assessment and arrive with a service driven mindset, focusing on the patient in need (Tanguay & Bartel, 2017; IHI, 2022a) When supported in the decision to activate an RRT, staff are more likely to activate them (Avis et al., 2016; Moreira et al, 2018) Outcome data Outcome data should be collected to identify trends, barriers, and opportunities for improvement and shared with appropriate stakeholders monthly (IHI, 2022a; Tanguay & Bartel, 2017; Winterbottom & Webre, 2021). The following outcomes can be measured to evaluate efficiency of RRT: • Time from activation to initiation of treatment (Hall et al., 2020; Tanguay & Bartel, 2017) • Information on reason for activation, location, time, and disposition (Avis et al., 2016; Hall et al., 2020; Tanguay & Bartel, 2017) • Barriers such as delayed recognition of decline, response team failure, and communication failures (Avis et al., 2016; Subbe et al., 20190 • Time to transfer to higher level of care if indicated (Olsen et al., 2019; Tanguay & Bartel, 2017) 12 • Decrease in cardiac arrest and code blue outside ICU (IHI, 2022a; Tanguay & Bartel, 2017; Winterbottom & Webre, 2021) • Codes per 1000 discharges or risk adjusted mortality index (IHI, 2022a; Scubbe et al., 2019; Winterbottom & Webre, 2021) Review of data and auding of records can identify opportunities for additional education and process improvement. Change Theory Havelock’s Phases of Change was used to guide the program evaluation project. This change theory uses a six-step linear process which emphasizes planning to ensure success. Havelock’s phases include building a relationship, diagnosing a problem, acquiring resources, choosing the solution, gaining acceptance, and maintenance/separation (Udod & Wagner, 2018). Methods Project Site and Population The RRT project took place at a midwestern tertiary teaching hospital. The hospital is a Level III Trauma Center and Primary Stroke Center with 240 acute care beds, 51-bed ED, with 30-bed ICU. The hospital is in a community with a 2021 population estimate of 112, 684 (United States Census Bureau, 2022). Building a Relationship • Chief Nursing Officer (CNO): Existing relationship already in place between the DNP student and CNO who was fully supportive of the RRT project review. CNO support was needed to help drive change and overcome barriers presented by nursing leadership and nursing staff. 13 • Quality Review Specialist (QRS): Existing relationship already in place between the DNP student and QRS that oversees RRT data collection. QRS is responsible for data collection and reporting at monthly committee meetings. • Clinical Education: Existing relationship already in place between the DNP student and the clinical education team. The clinical education team is responsible for the education and training of nursing staff upon hire, annually, and as directed by the department manager and/or CNO as educational needs are identified. Many of the ongoing education and training initiatives of this project are dependent upon the clinical education team for sustainability. • Nursing staff: Existing relationship already in place between the DNP student and many nursing staff within the hospital. Bedside nursing staff are responsible for monitoring and identifying changes in condition requiring RRT activation and critical care nursing staff are involved as members of the RRT. • Intensivist: Existing relationship already in place between the DNP student and intensivist from previous clinical rotation. Intensivist responds to RRT and is considered the team leader. Diagnosing the Problem A program review identified categories that lead to ineffective RRT response (see Fishbone Diagram Appendix B). Broad categories including people, policy, education, process, equipment, location and practice were identified as potential contributory factors to ineffective response. Acquiring Resources The primary resources required to implement the project were people and time. No new equipment was needed to implement the project. This DNP student was the project lead and coordinated the policy revision and development of education. Staff education and training was done utilizing existing resources including: 14 • New hire clinical orientation classes • New hire skills checklists • Annual competency validation • Monthly mock codes No additional tasks were added to the clinical education team as the DNP student updated all required materials and checklists. Discussions were incorporated into existing weekly and monthly clinical education team department meetings. RRT education was integrated into existing methods of education and training already in place. Monthly mock code simulation activities were already in place and modified to include RRT training. Specialty educators will oversee new hire orientation for RRT members within their respective departments to ensure new hire RRT orientation specific to their role as a responder is provided. QRS currently collects and reports RRT data and only the content of the data collected will be changing. Choosing the Solution Policy Revision The RRT policy was reviewed during monthly code blue committee meetings with input on proposed changes received by all members. Updates were made and submitted back to the committee for review and approval. The updated policy was forwarded to the policy review committee for final review and approval. Once approved, changes will be communicated to hospital leaders by email from the service line directors who will disseminate the information to their respective departments. Nursing Education Education and training for bedside nurses and nurses responsible for responding to RRT was developed and implemented. Appropriate stakeholders within the clinical education department 15 responsible for providing new hire and ongoing education were included to provide input. Education and training specific to RRT members was developed and implemented in collaboration with the ICU and ED educators, managers, director, and experienced RRT members. Quality Data Collection Quality data collection items were reviewed with the code blue chairperson who developed the initial RRT data collection tool. Evidence-based interventions were reviewed with the code blue committee and incorporated into the data collection and reporting tool used by the QRS. Data regarding RRT activation is being reported monthly at code blue committee meetings with dedicated agenda time and information on failure to rescue is being reported at monthly mortality meetings. Timeline Project implementation will begin with policy revision and education/training in October of 2022. Quality improvement data collection will begin November of 2022. Evaluation of quality improvement data and project sustainability will be completed through January 2023. See Appendix G for full project timeline. Gaining Acceptance Facilitators and Barriers There were many strengths and opportunities within the organization to support this initiative. The leadership team was committed to improving quality patient care and decreasing potentially preventable cardiac arrest. The hospital opened March 2022 with new equipment and designed to facilitate staff movement throughout the facility. There was an engaged clinical education department which includes many specialty educators including obstetrics, surgery, ED, and ICU. That allowed many resources to assist with initial and ongoing RRT education and simulation training. The hospital is part of a larger health system with many hospitals both in Michigan and Ohio with an expanded 16 network of resources and RRT policies. This Doctor of Nursing Practice (DNP) student was the program review project lead which decreased resources needed from the hospital. The DNP student brought resources and contacts from other health systems to provide information on RRT policies and procedures from other organizations. See Appendix H for a strengths, weaknesses, opportunities, and threats (SWOT) analysis. Weaknesses and threats have the potential to create barriers when implementing change. The hospital has had significant staffing challenges and often operated at a critical staffing level. The American Hospital Association (AHA; 2022) recognizes a critical shortage of staff to meet current healthcare demands. Staff burn out and pandemic related stress contributed to an increased turnover rate which compounded hospital staffing challenges (AHA, 2022). Managers are at times reluctant to require staff to attend mandatory education in lieu of maintaining work-life balance for staff that are mandated to work overtime. Critical staffing and competing priorities have resulted in frequent cancellations of code blue committee meetings to review data for challenges and opportunities. In addition to bedside nursing staff turnover, there were leadership changes at the manager, director, and chief nursing officer levels which brought additional challenges. Other leaders within the organization assume additional responsibilities and become overwhelmed and burdened with additional tasks. Maintaining day to day operational tasks becomes the priority with mandatory education often not considered a priority. Threats to the organization are minimal as it relates to this project and can be attributed to the ongoing effects of coronavirus disease of 2019 (COVID-19) and now the emergence of a new global threat, monkeypox (Centers for Disease Control and Prevention [CDC], 2022). Ethical Considerations The project was submitted to both the Michigan State University’s and hospital’s Internal Review Board (IRB) prior to implementation. All information was de-identified and no personal 17 health information was collected. Maintenance and Separation Evaluation/Outcomes Outcomes for the program review include an updated RRT policy which included evidence- based interventions. Development and implementation of an RRT training program for both bedside nurses and staff that respond on the RRT. Quality metrics for data collection were developed utilizing evidence-based guidelines in collaboration with the quality team and code blue committee. Standing agenda time was secured for both the code blue and mortality committee meetings to review outcome data. Sustainability Plan The facility had an RRT in place so the sustainability plan will focus on maintaining education and training as well as reporting and follow up of data. The education department conducts new hire orientation, annual education, and is responsible for mock code drills with RRT education integrated into each of those areas. Clinical educators for ED and ICU will oversee the orientation and training of RRT members new to their role and assist with simulation activities. Skills checklists for new hires were updated to include RRT education to ensure ongoing training of new hires at the department level continues to take place. Data reporting of RRT information was taking place and additional evidence-based metrics were incorporated and reported monthly at code blue and mortality committees. The overall goal for this project was to evaluate the RRT program to ensure evidence-based interventions were included in hospital policy and practice. Discussion 18 This project has the potential to improve RRT response based on the gap analysis and interventions specific to the institution. As data is collected, additional contributory factors and/or barriers should be investigated for evidence-based interventions as appropriate. Ongoing success of the project is dependent upon continued follow up and review of the data. Meetings to review RRT outcome data are often cancelled so alternative means to convey this information to the leadership team may need to be identified. It is difficult to generalize the results of this program evaluation to other hospitals and RRT programs. The findings and interventions are unique to the clinical site based on the gap analysis, SWOT analysis, existing policies, executive leadership support, education department involvement, RRT composition, and quality data support services. A facility needing to improve RRT response would need to have a program evaluation of their respective program. Although there may be common gaps identified, the underlying cause and solution may not be the same so this set of interventions will not apply. Conclusion Ineffective RRT performance can contribute to poor patient outcomes and increased mortality. Program evaluation of an RRT can identify gaps and contributory factors which provide the basis for change. Utilizing Havelock’s Phases of Change model, a proposal to improve RRT performance was developed and implemented. Existing resources and processes were used to help ensure sustainability. Upon successful implementation, an updated policy, comprehensive education plan, outcome data measures, and ongoing monitoring plan was put in place to monitor progress toward improving RRT outcomes. 19 References Ackley, B. J., Swan, B. A., Ladwig, G., & Tucker, S. (2008). Evidence-based nursing care guidelines: Medical-surgical interventions. (p. 7). St. Louis, MO: Mosby Elsevier. Agency for Healthcare Research and Quality. (2019, September 7). Patient safety network, failure to rescue. https://psnet.ahrq.gov/primer/failure-rescue Agency for Healthcare Research and Quality. (2018, July). 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Critical Care Nursing Quarterly, 44(4), 424-430. https://doi.org/10.1097/CNQ.0000000000000379 23 Appendix A Gap Analysis Current state Future state Gap Actions to close gap Policy in place for RRT Policy in place for RRT Policy does not define Update RRT policy includes new health care response to new areas reflective of new campus of the hospital and hospital and outpatient care areas outpatient care areas Multidisciplinary RRT Multidisciplinary RRT Multidisciplinary RRT Update RRT policy with team responders team is in place but to include team and roles clearly defined responders and roles responders and roles RRT nursing responders RRT has a dedicated team Responding RRT nurse Work toward have patient care of nursing staff to leaves a patient care developing assignment respond assignment to dedicated RRT participate in RRT. May nurse role. need alternate nurse to Additional tasks respond. could be given to dedicated RRT nurse such as proactive rounding on at risk patients, bedside nursing support, and staff education. Qualifications of RRT RRT nursing staff are No process to Formal process to nursing staff not verified trained in ACLS and determine RRT nurse determine RRT critical care responder has nurse has ACLS, at appropriate critical least 1 year in care and/or ACLS their role (after training orientation), and approved by their manager to respond No training for RRT Structured formal No education/training Develop initial and members simulation training for program has been ongoing training RRT team members developed program of RRT responders RRT documentation of Clinical and outcome data Need to update RRT Develop RRT tool clinical findings and care gathered on RRT documentation to and process for documentation form include not only care auditing and treatments but 24 additional data to help monitor outcomes RRT data tracking in place Measurable outcome Outcome data not Develop metrics data obtained and being measured for measurable reported monthly at code outcome data to blue committee meetings collect 25 Appendix B Fishbone Diagram People Policy Education Process Policy review/update for appropriate responders Formal education/training for No ICU manager RRT responders Data collection No dedicated RRT team (nurse leaves patient assignment to respond) Documentation of event Roles of responders Inpatient nurse education on RRT activation criteria Documentation Provider communication Policy review/update for new Who responds? facility layout/departments RRT responder may be a new nurse Inpatient nurse education Data collection on role during RRT No ICU educator RRT responder may not have ACLS certification Ineffective RRT response AED Cervical collar Elevator access Crash cart Identification of areas No debriefing covered by RRT Emergency medications Code committee Stretcher meetings cancelled Someone to hold door and guide responders Who brings equipment? ED not indicated as a RRT member for Location of covered outpatient public and non-patient care areas Glucometer areas Equipment Location Practice cy 26 Appendix C PRISMA Diagram (Page et al., 2021) 27 Appendix D Literature Synthesis-Critique Table Article Design/Purpose Sample/Setting Results Level of Evidence Strengths/ Relevance to (see Appendix E) Weaknesses Problem Avis et al. (2016) Redesign the RRT Academic medical Created a dedicated VII Single site Demonstrates to a dedicated team center team of ICU nurses intervention and positive impact of ICU nurses to to respond to RRT may not be a dedicated decrease the burden and support bedside RRT of ICU of ICU staff when a nurses with generalizable to nurses can make nurse with an additional quality other facilities to improve assignment is improvement patient care by pulled from the interventions supporting early department leaving (proactive rounding, recognition and the department resource nurse, interventions for short staffed education, and data non-ICU collection) to patients. promote early Additional tasks recognition and include intervention of non- proactive ICU patients rounding, staff education, and availability as a resource to bedside nurses. 28 Burke et al. (2022) Narrative synthesis 55 articles were Propose contributing VII None listed Utilizing the included in the factors for failure to four concepts Further the review rescue occur in recognize, relay, understanding of recognizing, react, and using variability in relaying, and correct outcomes and reacting to decline resources complication and establish the provide a management and framework to framework with suggest improve outcomes steps that can be recommendations implemented based on current and audited evidence 29 Dukes et al. (2019) Qualitative 158 hospital staff Differences V Provided insight Identified analysis, semi- members (nurses, identified in 4 into the differences in RRT structured physicians, domains: team organization and structure and interviews administrators, and design and function of RRT function in top- staff) at 9 hospitals composition, RRT from top- performing and Researchers were surveillance of at- performing non-top- blinded as to risk patients, hospitals performing whether the site bedside nurse hospitals that could was a top- Did not analyze empowerment to improve safety and performing or non- cost implications activate RRT, reduce unexpected top-performing site of implementing collaboration death in identified Evaluate hospitalized strategies differences in patients design and implementation of RRT at top performing and non-top- performing hospitals 30 Hall et al. (2020) Systematic review 10 articles were Moderate evidence V Studies lack Highlights the role included in the linking RRT with control groups so it organizational Synthesize review decreased mortality is difficult to culture plans in the evidence on the and non-ICU cardiac determine if the success of RRT, impact of RRT on arrest rates. decrease in FRT including in- mortality rates is hospital mortality Variability in RRT related to RRT and in-hospital composition with intervention or cardiac arrest little evidence to some other cause support physician- led teams have improved outcomes Benefit of RRT may take time to fully implement due to organizational culture IHI (2022a) How-to guide to NA Provides a resource VII Includes tips and Provides a detailed share best practice for RRT tricks as well as best practice interventions when implementation frequently asked resource to use as a implementing RRT questions guides when structuring and implementing RRT 31 Le Guen, M., & Self-administered 62 MET staff MET responders VII Study response Ongoing team Costa-Pinto, R. electronic survey members from strongly agreed that rate was high, training and (2021) multiple disciplines training was covered both education needed Assess learning in a single hospital valuable, would technical and non- including the use and education setting in Australia improve care, and technical skills, of simulation needs of medical should be and large range of emergency team multidisciplinary learning (MET) objectives. Single center study with a small sample size May not be generalizable to other hospitals Mitchell et al. Descriptive/prospe 103 hospital adult Demonstrated VI Limited number of Evidence-based (2019) ctive cross- RRT members variation in the hospitals surveyed. practice guidelines sectional, internet- from 103 hospitals structure and Survey completed on the structure based survey in 30 states in the function of RRT by a willing, and function of U.S. identified clinician RRT is needed to 80-item survey to and may resulted optimize outcomes obtain information in selection bias. from in hospital on the afferent and Disproportionate deterioration efferent limbs of number of large, the rapid response academic medical system centers on the east Evaluate RRT or west coasts of structure, the U.S. which composition, and may affect function across the application to United States smaller hospitals (U.S.) with limited resources. 32 Moreira et al. Meta-analysis Integrative review RRT reduced rates V Provide guidance Improved RRT (2018) of 19 scientific for hospital to health performance Review literature studies mortality but professionals and improves the care to determine the identified factors managers to of deteriorating main factors that that affect the identify flaws in patients and may interfere with the quality of outcomes RRT performance decrease ICU performance of including to improve admissions, length RRTs sociocultural outcomes of hospital stay, barriers, institutional and hospital No instruments policies, delayed mortality used to assess the RRT activation, methodological team composition quality of the including education studies and few and training, tools to controlled or identify clinical randomized deterioration clinical trials Olsen et al. (2019) Systematic review Qualitative review Clear protocols, V Provides Identification of of 21 articles from feedback, healthcare provider common Identify facilitators hospital-based evaluation, and perspective facilitators and and barriers within health systems training were barriers to rapid response Broad scope-10 identified as successful RRS systems (RRS) nations and more facilitators and requires than 20 hospital continuous Fear of reprimand, systems, evaluation for not understanding professions, and quality when to activate, levels of improvement alarm fatigue, and experience lack of integration within the hospital were identified as barriers 33 Subbe et al. (2019) Scoping review of Consensus 10 quality metrics VII International Provides a literature with conference with identified related to applicability framework for data potential metrics representatives structure, process, collection with identified and from 5 countries and outcomes for items described as modified Delphi to with participants RRT essential, arrive at applicable from varied recommended, metrics backgrounds optional, and including patients experimental to Identification of provide metrics for RRT standardized teams to monitor metrics to evaluate quality and RRT performance Tanguay & Bartel Implementation of Tertiary care center Successful VII Single site Includes the RRT (2017) an RN/RT RRT in Canada implementation of intervention and responding to model with the an RN/RT model may not be visitors. goal of early which was generalizable to Provides data intervention for replicated in other other facilities collection metrics deteriorating Canadian hospitals patients to prevent Data collection ICU admission or metrics identified death 34 Winterbottom & Implementation of Quaternary In addition to VII Single site Positive outcomes Webre (2021) a dedicated ICU academic medical responding to RRT intervention and of dedicated RRT nurse RRT model c center in the and code blue, may not be nurse include southern United dedicated RRT generalizable to additional States nurses proactively other facilities supportive tasks rounded on at risk such as proactive patients, provided rounding on at risk support and patients, providing education to bedside support and nurses. education to bedside nurses to Dedicated RN RRT improve outcomes showed a 65% in patient care decrease on cardiac arrest outside the ICU and 27%, 4.7% decrease in ICU admissions from an inpatient unit, and 27% reduction in the risk-adjusted mortality index for patients with proactive rounding encounters. 35 Appendix E Level of Evidence Table (Ackley et al., 2008) 36 Appendix F Literature Synthesis-Intervention Table Intervention Article Dedicated Team Training Proactive Collaborative Debriefing Bedside nurse Sociocultural Institutional Outcome RRT nurse composition and rounding of resource for activation of /leadership policies Data education at-risk bedside nurses RRT patients Avis et al. X X X X X (2016) Burke et al. X X X (2022) Kim Dukes et X X X X X X X al. (2019) Hall et al. X X X (2020) IHI (2022a) X X X X X X LeGuen & X X Costa-Pinto (2021) Mitchell, et al. X X X (2019) Moreira et al. X X X X X (2018) 37 Olsen et al. X X X X (2019) Subbe et al. X (2019) Tanguay & X X X X X Bartel (2017) Winterbottom X X X X X X X & Webre (2021) Total 5 8 10 2 2 4 4 7 2 7 38 Appendix G Project Timeline 39 Appendix H SWOT Analysis Strengths Weaknesses Leadership team committed to quality patient care Critical staffing levels New facility with state of the art equipment Staff turnover Engaged clinical education department with No formal RRT training dedicated ED and ICU educators Manager, Director, and CNO turnover Dedicated DNP student Code blue committee meetings frequently cancelled Opportunities Threats Ability to share information within a large health system Ongoing COVID-19 pandemic Ability to share information with external Global spread of monkepox health systems