Published in the August 2015 issue of Today’s Hospitalist
WHILE RAPID RESPONSE TEAMS (RRTs) have been championed as a way to prevent hospital codes, consistent evidence backing their effectiveness at lowering mortality has proved elusive.
But new research from the University of California, San Diego, found that a novel RRT model introduced in 2007 reduced not only the number of in-hospital arrests, but hospital mortality rates as well.
Looking at before-and-after data, researchers found that the number of non-ICU arrests was slashed 60%, from 2.7 to 1.1 per 1000 discharges. (The number of arrests in the ICU remained the same.) Meanwhile, hospital mortality fell 18% from 2.12% to 1.74%. Results were published in the June issue of the Journal of Hospital Medicine.
The innovation featured a new RRT configuration. In addition to a dedicated critical care nurse and respiratory therapist, the third member of UCSDs RRT is the charge nurse of each particular unit. The charge nurses receive the same training as the RRT’s critical care nurse.
“That set up a culture of ownership in which the responsibility for deteriorating patients was shifted to each individual unit,” says Daniel Davis, MD, an emergency physician who helped design not only UCSD’s novel RRT configuration, but the comprehensive training program behind it.
Also, Dr. Davis points out, it was a conscious decision to exclude physicians from the initial RRT response. “Too often, nurses have the perception that physicians are being bothered or are not receptive,” he says. “We wanted to underscore that nursing owned the rapid response team, which is a big reason why we achieved early traction.”
But the RRT makeup was only one element in an institution-wide program to transform how front-line clinicians are trained. That training covers not only resuscitation, but also strategies to prevent arrests from occurring.
Engaging the frontline
In addition to their RRT role, charge nurses on each unit conduct rounds on high-risk patients twice a day at shift changes.
They’re also taught to engage bedside nurses in ongoing surveillance of those patients. It is the bedside nurses obtaining regular vital signs who keep tabs on patients’ blood pressure and heart and respiratory rates.
Constant surveillance is one goal of the UCSD initiative. To make that level of surveillance possible, Dr. Davis “who until this summer directed UCSD’s Center for Resuscitation Science “and his colleagues threw out the standard American Heart Association basic life support and advanced cardiac life support classes (BLS/ACLS), which hospital personnel everywhere receive. Instead, the hospital devised a radically different training program called advanced resuscitation training (ART).
All clinicians and staff receive between four and six hours of ART every year. Dr. Davis says several key differences separate ART from BLS/ACLS courses.
For one, ART goes beyond information on how to reverse cardiac arrest, which is the focus of BLS/ACLS. “Two-thirds of each class is focused on prevention,” he says.
“We’re relying on these people to recognize patterns and act before an arrest occurs, so it’s a paradigm shift.”
ART also represents a big shift away from what Dr. Davis calls “generic resuscitation training.” Instead of all staff members and clinicians taking the same class, “each person has a different role in reducing preventable death, so we tailor each class to the needs and expectations of that type of provider.”
There are, Dr. Davis adds, at least two dozen formal ART classes, with slide sets, skill exercises and simulations geared toward whichever group of doctors, nurses or housestaff is taking a particular class. But “I ask up-front what types of providers are in the class and then steer it to their needs,” he points out “There are literally hundreds of different classes because that’s how many we hold each year, and each class is unique.”
Training is also tailored to specific units. Dr. Davis and his team have, as they wrote in their study, studied “the taxonomy of our in-hospital cardiac arrests.”
“We divide hospital arrests or deaths into categories, and there are 10 or 12 common ones we focus on for most classes,” he says. “Year over year, we can tell which units will have a certain type of arrest, like sepsis or obstructive apnea from narcotics, so we target training for those arrest types.”
An example: “In our surgical ICU, we saw a cluster of arrests from unrecognized extubation,” says Dr. Davis. “We developed a curriculum that drilled those nurses on what that looks like, the warning signs, and how they can recognize in seconds, not minutes, when it occurs.”
Bringing ART to other hospitals
According to Dr. Davis, one hurdle to adopting ART was regulatory. While the Joint Commission mandates some form of inpatient resuscitation training, the American Hospital Association ruled that ART courses didn’t qualify as BLS/ACLS classes.
However, the Joint Commission “learned about what we were doing, witnessed a code first-hand and came away incredibly impressed,” he points out. ART became a Joint Commission best practice model.
Another hurdle relates to taking ART into other hospitals. Dr. Davis has piloted ART training not only in other University of California sites but in hospitals and EMS agencies around the country. The challenge, he explains, is standardizing the approach to bringing new hospitals on board, given that the ART program has to adapt to the needs of individual institutions.
“We’re still refining what steps to take when we come into a hospital,” he notes. “What’s the first thing to do, and who do we have to get on board?”
Many of the key stakeholders, Dr. Davis adds, “have never sat in the same room together and suddenly, they’re comanaging a program. When we go into a hospital, we feel like we’re battling to overcome the inherent dysfunction that has permeated medicine.”
He finds less of that dysfunction in community hospitals. “Nonacademic hospitals are more progressive at integration and multidisciplinary cooperation than teaching centers,” which still have strong divisions among academic departments, he notes.
This summer, Dr. Davis left UCSD to devote his time to the company he founded “Medical X Technologies ” that is partnering with UCSD. The company is bringing ART to other hospitals via both face-to-face interactions and Web-based platforms. Facilities can integrate ART elements either in addition to or in place of existing life-support training.
“The big mistake hospitals make is focusing all their training on the code team or RRT,” he says. “You have to educate all front-line providers in rapid response concepts.”
The possible payoff, he says, is huge. Just at UCSD, Dr. Davis estimates that ART has saved between $3 million and $4 million a year in lower lawsuit payouts and better performance on value-based purchasing and pay-for-performance metrics because of lower risk-adjusted mortality rates.
As for reducing the number of arrests and related deaths, “if you replicate our results across the country based on our hospital volume and number of beds, you could reduce preventable deaths by almost 400,000 a year,” he points out. “We just have to get the program out in play.
Phyllis Maguire is Executive Editor of Today’s Hospitalist.