Introduction
Nearly all hospitalized adults receive care on the general medical/surgical nursing units at some time during their treatment. Yet, given the vulnerability of patients on these units, recognition and treatment of early clinical deterioration is often delayed.
Conventional RRS frequently focuses on the efferent arm or response team. This does little to improve event detection. Redesigning a RRS to be a complete four-arm system focused on the afferent arm or beside nurse will improve early event detection and patient outcomes.
Overview
Delay in recognition and treatment of unappreciated physiologic instability results failure to rescue with increase in preventable morbidity and mortality. This has led to broad implementation of Rapid response systems (RRS).
Problem
Unfortunately, even with mature well developed RRS, delayed or ineffective response to ward patient deterioration continues. One possibility for this shortcoming is that some hospitals have focused on the role and training of the response team with less focus and resources allocated to early identification of at-risk patients. Attempts to improve early recognition of deterioration by modifying and expanding key vital signs (VS) and other objective triggers have had variable benefit.
Solution
Successfully RRS have been described as having four distinct arms : 1) with the most focuses on early event detection or afferent arm’s clinical judgment of bedside nurse to acquire and understand subtle changes in patients physiology aided by manual or automated alerts; 2) an efferent response from a designated rapid response team (RRT); 3) performance improvement arm focused on data collection and analysis; and 4) an administrative arm that oversees and improves relevant polices and process.
Several successful models of RRS are detailed in the resource section. One such RRS is a critical element of the Advanced Resuscitation Training Program (ART) Program, developed at the University of California as comprehensive, integrated system focused on beside clinicians to recognize at-risk patients earlier. It employs a unique architecture that identifies institutional opportunities and provides a “customized” approach to improving clinical outcomes, through education, training and integrated technology. ART has been able to reduce hospital cardiac arrest rate to just under 1/1000 admissions, one of the lowest hospital cardiac arrest rates reported. ART covers prevention, resuscitation, and end-of-life issues. The prevention component includes risk screening, monitoring/surveillance, critical care, technical procedures and peri-arrest interventions. For most inpatient staff, the cardiac arrest component (the traditional focus of life-support training) is an important part of the curriculum, and survival rates have doubled or tripled in pilot institutions. However, the majority of lives saved come through effective strategies to prevent cardiac arrest and failure to rescue.
Goal
Kritikus approach includes multiple strategies to enhance early detection of the deteriorating patient as part of an integrated four-arm RRS program. Key elements included: comprehensive bedside nurse education; RRT and physician education; robust data collection and oversight for program compliance and performance improvement; changes to hospital policy and procedures; implementation of a new, tiered cluster of physiological measures (10 Signs of Vitality) for early at-risk patient detection and RRT activation.