Published in the August 2008 issue of Today’s Hospitalist
Uzma Vaince, MD, is a strong believer in the value of rapid response teams (RRTs). In the one year that her hospitalist group at Lehigh Valley Hospital in Allentown, Pa., has staffed the hospital’s RRT program, she says, the facility has seen its number of codes drop by 20%.
But while rapid response teams have been a success at Lehigh, Dr. Vaince can’t escape the feeling that as a hospitalist, she is being taken advantage of. Sometimes in the middle of the night, she explains, primary care physicians, after being called several times, will instruct nurses to simply “call an RRT” so they’ll no longer be disturbed. Or busy primary physicians during office hours don’t respond when a hospitalist calls after stabilizing one of their patients.
Then there are times when a physician in Dr. Vaince’s group responds to an RRT call “even though the primary attending is in the hospital. “They refuse to come up and see their patient,” says Dr. Vaince, who is director of the hospitalist program.
In just a few short years, heading up a rapid response team has become an important item in hospitalists’ growing job description. Like Dr. Vaince, many hospitalists find that these teams often reduce the number of patients who need to go to the ICU and improve nursing satisfaction.
But increasingly, hospitalists working on these teams say that their involvement can lead to unintended consequences. Turf issues and time constraints, for instance, can be challenges.
Some physicians grapple with the question of if and when hospitalists should be part of the initial response, for instance. Others are ironing out exactly when teams should be called or are drawing a line to more precisely define their roles on an RRT. And many hospitalists are trying to figure out how patients should be transitioned to other attendings once patients are stabilized.
What’s the right role for hospitalists?
One reason that hospitalists in community hospitals are feeling so much heat from rapid response teams has to do with the way these teams are being staffed, according to Sumant Ranji, MD, an assistant professor of medicine at University of California, San Francisco (UCSF), who frequently speaks about hospitalist RRT involvement.
While academic facilities have the luxury of staffing rapid response teams with critical care fellows, community hospitals typically lean on hospitalists to staff their teams. A nurse or nurse practitioner and respiratory therapist are often the initial responders in community hospitals, with a hospitalist or intensivist as either an initial or backup responder.
“A lot of hospitalists are being asked to act as initial responders, and there’s pushback about that,” Dr. Ranji says. “A lot of those calls, frankly, require somebody to triage to determine the level of physician input necessary. That may not be the best role for a hospitalist who’s already seeing 15 to 17 patients a day.”
However, some veteran hospitalists believe that a hospitalist or intensivist should be among the initial responders “as long as the facility can spare those resources.
“By definition, these patients are unstable,” says hospitalist Winthrop Whitcomb, MD, a founder of the Society of Hospital Medicine who is now vice president of quality improvement for the Sisters of Providence Health System in Springfield, Mass. “The two sets of skills that should be brought to bear on the initial stages of the rapid response are best provided by physicians.”
In his mind, those include the technical skills to assess vital signs, oxygenation and mental status, and the ability to secure the technical support that’s needed. The second set of skills involves the integrative know-how to decide what interventions and medications are needed.
Making time for education
As a result, Dr. Whitcomb “who says hospitalists are part of the initial response in his hospital system “feels that the presence of a hospitalist on an RRT may save lives. “There is always a subset of rapid responses where timely assessment by a physician will affect the outcome,” he says, “whether that’s somebody who has cardiac tamponade or some other emergent condition that’s difficult to diagnose.”
There is, however, another school of thought. Hospitalists at Baystate Franklin Medical Center in Greenfield, Mass., for instance, sometimes serve as initial responders. But often, they’ll come in as the second wave after a senior critical care nurse and a respiratory therapist have assessed the patient. Kathleen McGraw, MD, medical director of the seven-member hospitalist program, says that arrangement allows nurses to get the education they need.
“We don’t have a lot of codes here, so our RRT is primarily a nursing-support function,” Dr. McGraw says of the two-year-old initiative. “Having a very experienced nurse respond first gives less experienced nurses a venue for asking questions” in a non-threatening environment, she adds. “But if there’s trouble brewing, our hospitalists step in.”
Whose patient is it?
Even at hospitals where physicians are always part of the initial response, hospitalists are beginning to question exactly when their presence is really required. Demetria Austin, MD, a hospitalist at Gaston Memorial Hospital in Gastonia, N.C., says that when rapid response codes take place in the early hours of the morning, a hospitalist is called to respond, even if the patient’s primary physician is in-house.
She wonders whether she’s really the best physician to treat a patient she’s never met “and knows almost nothing about “when the attending is minutes away. “It doesn’t make sense to have us responding to patients when we’re not involved in their case at any other time, except when they’re having a bad event,” Dr. Austin says.
She’s also concerned what kind of message hospitalists are sending by agreeing to do what’s in essence another physician’s work. “In a community hospital where there is still a presence of primary doctors,” Dr. Austin notes, “you don’t want to be the easy person.”
The hospital has put in place a protocol that spells out when nurses should page an attending on an RRT call. “But our director and the administration are still working out those issues,” Dr. Austin says.
Transitions: a delicate matter
Once the team has responded to a rapid response call, there’s another issue that weighs heavily on hospitalists: How “and when “to give patients back to an attending, when that attending is not part of the hospitalist service.
For Dr. Vaince at Lehigh Valley, that issue crops up in terms of community physicians who are either slow to take over a patient’s care post-RRT or who are, in her words, part of the “old school” who don’t want to resume care for that patient at all.
“They want us to take over the patient’s care after the patient has been stabilized,” she says. “That’s not our role at all.”
Her group doesn’t just have problems handing patients back to primary care physicians. Because several hospitalist groups work at the hospital, Dr. Vaince and her team often end up handling rapid response calls for patients being treated by other hospitalist services. Once the patient has been stabilized, however, it can be difficult to track down some of the other physicians to hand off the patient, in part because not all the hospitalist groups provide 24/7 coverage.
Dr. Vaince also notes that these types of patient transition problems have come up “repeatedly” at department meetings that have been held to try and hash out attendings’ obligations. The program is now meeting one-on-one with a primary care group with whom “we’ve have multiple instances of lack of response,” she says. “It’s a delicate matter, and we have to take an individual approach.”
In the meantime, Dr. Austin at Gaston Memorial says that when she is transitioning an RRT patient, she is careful to hold the line.
“There is that temptation for the medical staff to get you to do more than you really should,” she explains. When nurses call for some additional service for a patient who’s already stable, “I say, ‘No, you need to call the attending.’ I’ll even write in the notes, ‘These are the labs I ordered. Please call Dr. So-and-So with all these results.’ ”
Another challenge hospitalists face when working on rapid response teams is ensuring that teams aren’t being called too late or too soon.
At the 200-bed Salem Community Hospital in Salem, Ohio, for instance, the new hospitalist group joined the rapid response team this February after the initiative was up and running for more than a year. According to Anita Hackstedde, MD, the vice president of medical affairs who oversees the four-hospitalist group, “we have to improve how we define ‘sudden’ or ‘urgent’ patient needs” that might not warrant calling an RRT. One example: A hospitalist-led team was called to treat a patient’s elevated blood pressure, a call that the patient’s primary care physician would have preferred to field instead.
However, the opposite dilemma seems to be more widely reported: Teams aren’t called as soon as they should be. In part, that lag time may be due to the fact that hospitalists are more available and are called before an official RRT page is issued.
“Our perception, so far, is that we may have a lot of potential RRT calls that should be called earlier,” says Carmella Cole, MD, who directs the hospitalist program at Washington Hospital Center in Washington, D.C. To correct that, hospitalists this summer have started conducting unannounced “RRT rounds” to check patients’ vital signs and identify those who may meet rapid response criteria. Each hospitalist is now making such rounds once a month, a time commitment of between 60 and 90 minutes.
“We’re trying to figure out,” Dr. Cole says, “whether nurses know the criteria and when they should call.”
Ensuring the right support
Experts say that the number of RRT calls will be approximately twice a hospital’s rate of codes. In facilities with seasoned teams, rapid response interventions will run about 50 events per 1,000 patients.
Robert Wachter, MD, chief of hospital medicine at UCSF, says that those estimates are “a reasonable starting point” for hospitalists trying to predict their rapid response team volume. If very few calls are likely, hospitalists might assume the duty without additional funding. Otherwise, Dr. Wachter cautions, hospitalists should plan “and negotiate “accordingly.
He adds that hospitalists also need to know where clinical support will come from when they need help. “You don’t want to be the only first responder trying to manage a patient who’s deteriorating with help from a floor nurse who’s also managing seven other patients,” Dr. Wachter says. “That’s a position that most hospitalists would not want to put themselves in.”
To make sure that physicians aren’t stretched too thin when taking RRT calls, the hospitalist group at Washington Hospital relieves those physicians of handling admissions for that shift. The group learned the hard way, Dr. Cole recalls, that one hospitalist can’t handle both duties in the same shift.
On average, the hospital’s rapid response team fields between three and four calls every 24 hours. “But there have been times when we’ve had three in a 10 minute period,” Dr. Cole says. “You need a back-up mechanism.” At Washington Hospital Center, the group designates another hospitalist as the second responder.
A potential role for midlevels
At Lehigh Valley, Dr. Vaince says all group members working a particular shift are potential back-up because everyone receives the same rapid response page. But she is looking for ways to minimize the time hospitalists spend responding to calls.
“It takes us about eight minutes to walk from one corner of the hospital to another,” she explains. “We want to devise protocols so other staff can help stabilize a patient who’s seizing or having respiratory problems, even before we get there.”
She also wants to safeguard her physicians’ time in situations where “all we’re doing is waiting for the patient to be passed to the ICU,” she says. “I’m working with the rapid response committee to see if we can incorporate our midlevels as part of the rapid response team.”
Bonnie Darves is a freelance health care writer based in Lake Oswego, Ore.
Do you have the right skills to respond?
WHAT KINDS OF CLINICAL SKILLS do hospitalists need to serve on rapid response teams? According to Michael DeVita, MD, professor of critical medicine at the University of Pittsburgh Medical Center and a leading researcher on rapid response systems, some background in critical care medicine is key.
“Some hospitalists can place the large IV catheters that many of these patients require, and some hospitalists can also place airways,” Dr. DeVita explains. “This is a core skill for critical care. It’s an additional skill for most hospitalists.”
At Washington Hospital Center in Washington, D.C., which implemented a rapid response team two years ago, the issue of hospitalists’ skills has moved to the front burner.
Because team duties rotate among the six full-time hospitalists, reports Carmella Cole, MD, who directs the hospitalist program, all hospitalists as of last month are required to have advanced cardiac life-support certification.
“Even people who weren’t enthusiastic about that now see the need for it,” says Dr. Cole. “They’ve gotten into situations where patients are having arrhythmias and other cardiac events, and they need to know the current recommendations on treating them. Hospitalists don’t have time to go and look those up.”
What do teams run into?
WHAT DO RAPID RESPONSE TEAMS typically respond to? The few studies conducted on such teams have yielded the following information:
- When called, RRTs typically remain on-site for about 30 minutes.
- Between one-third and one-half of the patients that teams encounter require airway instrumentation, notes Michael DeVita, MD, professor of critical medicine at the University of Pittsburgh Medical Center.
- According to the Institute for Healthcare Improvement, other common invasive interventions include IV and arterial-line insertion, and central venous pressure line placement.
- The most common non-invasive interventions, besides airway suctioning and oxygen administration, include administering IV boluses of fluid or furosemide, and initiation of nebulized beta-agonists or non-invasive positive pressure ventilation.
RRT fast facts
- New patient safety goal. This year, The Joint Commission added a new patient safety goal that takes effect January 2009, requiring accredited hospitals to improve recognition of and response to possibly life-threatening changes in a patient’s condition.
- National commitment. Of the 3,800 hospitals enrolled in the 5 Million Lives campaign sponsored by the Institute for Healthcare Improvement, more than 2,700 have either implemented or are working on creating a rapid response team (RRT).
- Growing hospitalist role. In its 2005-06 survey, the Society of Hospital Medicine (SHM) found that 35% of responding hospitalists were involved in RRTs. SHM didn’t ask the question in its 2007-08 survey, but organization officials said that the number is likely much higher now.