Colorado hospital evaluates 'missed opportunities’ in rapid response teams

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Colorado hospital evaluates ‘missed opportunities’ in rapid response teams

After reading this article, you will be able to:

  • Identify the training techniques used by SACH to educate staff on rapid response teams

Over the past five years, rapid response teams (RRT) have been brought to the forefront of American hospitals. In 2004, the Institute for Healthcare Improvement (IHI) launched its 100,000 Lives Campaign, of which RRTs were a focal point, and in 2008, The Joint Commission added a National Patient Safety Goal requiring hospitals to have a process to recognize and respond to patients who are deteriorating. Those requirements are now located in standards PC.02.01.19, HR.01.05.03, and PI.01.01.01.

Both of these initiatives sparked interest in RRTs among hospitals, especially at St. Anthony Central Hospital (SACH) in Denver, which began to develop its own RRT in conjunction with the IHI initiative.

However, in 2008, SACH officials began to notice a trend of patients who were meeting the criteria for RRT, but for a variety of reasons, the team was not called.

A subgroup of 17 missed opportunities (including deaths) was identified in the first half of 2008. With the help of simulation training and debriefing interviews, SACH was able to lower that number to nine for the second half of 2008 out of 2,400 trauma-related admissions for the year. That number was cut again for 23 total missed opportunities and no resulting patient deaths out of about 2,400 trauma-related admissions in 2009.

Education and simulation training

In 2008, Pamela Bourg, RN, MS, ANP, CNS, director of trauma services, first noticed a trend developing across the trauma patients at SACH. There were particular instances where patients met the criteria for an RRT, but nurses were not calling a team to follow through.

Bourg teamed up with two colleagues, Julie Benz, RN, MS, clinical nurse specialist, and Melissa Richey, RN, BS, clinical nurse for trauma services, to educate the staff at SACH to be more knowledgeable about when to call the RRT and more comfortable in doing so.

Working with the Wells Center in Colorado, a facility that provides state-of-the-art patient simulation tools, Bourg, Benz, and Richey rented a simulation-training dummy.

“Wells Center supplied us with the simulation mannequins, along with the nurse driver,” says Bourg. “But we were able to use our own nurse educators and advance practice nurses to help facilitate the groups.”

The nurse driver helped run the simulation, but SACH staff wrote the script for the missed opportunity scenarios. During the simulation training, a nurse performed an assessment of a patient. Then, based on what the nurse observed, he or she called an RRT.

“The purpose of the simulation training is to help the nurses recognize the signs and symptoms, identify the patients at greater risk, and then distinguish if they need to call an activation of the RRT,” says Bourg.

The staff members at SACH first participated in the simulation training in July 2008. Between August and December 2008, the women analyzed missed opportunities that took place after the simulation training and saw a drop in the number.

Results not typical from simulation training or education

Bourg’s team discovered that when the nurses appropriately identified a patient in need of an RRT, there were acute changes in the patient’s condition. But when the changes to the patient were not as acute and more subtle, the nurses did not notice them quite as readily.

Even though the number of missed opportunities decreased toward the end of 2008, as 2009 began, Bourg watched the numbers increase, despite staff members having gone through simulation training. “We sat down and knew there were other issues we needed to identify because the numbers were increasing,” she says.

At first, Bourg thought it might have something to do with new graduates working at SACH. But after looking at things more closely, she discovered that other factors contributed to the missed opportunities.

“In addition to the huge changeover we saw at SACH, staff members who had been with us for over two years were failing to activate an RRT,” says Bourg.

In hopes of improving the number of missed opportunities, Bourg and her colleagues went back and began interviewing staff members who failed to activate an RRT. They developed a debriefing tool using a variety of nursing literature to help understand why nurses were failing to activate the RRT.

“We try to make sure that when a missed opportunity presents itself, we contact the nurse within 24 to 48 hours to ask them more about the situation,” says Bourg. 

When a nurse has a missed RRT opportunity, an advance practice nurse conducts a debriefing interview, not the manager. 

During the interview, the nurse is asked questions about what was going on at the time of the missed opportunity, what kind of patient report he or she received from the previous nurse, whether there were competing priorities, and so on.

“We are not trying to assign any blame,” says Bourg. “We are trying to create a culture of safety so people are willing to come forward and give us the information to help make our practice better.” In addition, staff went through simulation training again in July 2009.

More ways to encourage the activation of RRT

IHI faculty member Kathy Duncan says the education SACH provides for nurses is a good way of cutting down on missed opportunities. It is also helpful to take opportunities to encourage staff members and let them know that by calling the RRT, they did the “right thing.”

For example, one facility Duncan worked with had a trophy that rotated between units based on which unit had the most calls for an RRT and the least amount of codes.

“Staff members may work for three months and never call a team, but if they see a graph showing the calls other units have made, or see fellow staff members getting gift cards to coffee shops for calling the most RRT, it reminds them that the rapid response system is still in place and rescuing patients,” says Duncan.

Even if it is not clear what is wrong with the patient, but there are some subtle changes, it’s important to communicate to staff that it is always good to have another set of eyes on the patient, says Duncan.

“If the RRT comes in and assesses the patient occasionally, additional information can be gathered or there can be a quick consult or discussion of opportunities to help the patient,” says Duncan.

This tactic is also beneficial because if for some reason the nurse calls the RRT again, the team will know the patient has had previous issues and may work more quickly to assess and intervene.

Looking to the future of missed opportunities

Bourg says SACH will now use simulation training with staff every quarter, as opposed to once per year. 

“The simulation training has provided the most bang for the buck,” says Bourg. “It has shown staff members to no longer consider the least-case scenario, but to instead look into the worst-case scenario.”

Even though SACH saw a reduction in missed opportunities in 2009, the number was still too high, she says. “In 2010, we look to better our number and eventually get down to zero.”


Adapted from Patient Safety Monitor (Briefings on Patient Safety), April 2010, HCPro, Inc.