Published in the September 2012 issue of Today’s Hospitalist
WHILE MANY HOSPITALS have embraced the use of rapid response teams (RRTs), the evidence is still not conclusive on whether or not RRTs save lives in the hospital.
One of the latest studies to be published on RRTs, which was posted online in March by BMJ Quality & Safety, adds another dimension to that discussion. The study “conducted by a team of researchers at Yale-New Haven Hospital “didn’t try to quantify mortality benefits or any other RRT-related clinical outcome.
Instead, researchers delved into how RRTs affect workload, communication and morale among physicians, nurses and housestaff. Through open-ended interviews with nearly 50 clinicians and administrators, researchers got an earful, opening a window into some simmering tensions.
Uncovering those problems is exactly what qualitative research and process improvement are all about, says study co-author Andrea Benin, MD. At the time of the study, Dr. Benin was executive director of performance management for Yale New Haven Health. Since February, she’s been the senior vice president for quality and patient safety at Connecticut Children’s Medical Center in Hartford.
“Where hospitals fall down,” Dr. Benin says, “is putting innovations in place but not critically reviewing them.” When hospitals don’t try different iterations of projects like RRTs or don’t look at potential barriers, she notes, “innovations are not going to be effective long term.”
Pros: nurse morale, physician skills
First, the good news, and the study revealed quite a bit. Dr. Benin and her team learned that the RRTs were functioning exactly as they were intended to: allowing patients to be transferred to the ICU in a more streamlined fashion.
“The way RRTs have worked well is to facilitate early ICU transfers,” Dr. Benin says. “And for some patients, we’re able to stabilize them before they need the ICU.”
Another advantage prominently highlighted during the interviews was the perceived benefits of RRTs to nurses. Having the ability to call in skilled back-up, the nurses reported, not only improved their morale and workload, but boosted nursing retention.
Hospital administrators liked the fact that patients being stabilized on the floor might have otherwise needed an in-demand ICU bed. And attending hospitalists, who head up the RRTs, enjoyed the kind of acuity they were being called upon to deal with.
(In addition to a hospitalist, RRTs at Yale-New Haven Hospital consist of a critical care nurse and a respiratory therapist. At Dr. Benin’s new hospital, by comparison, RRTs are staffed by residents, not attendings “a decision, she notes, that the hospital may soon revisit.)
Tensions and disruptions
But the interviews also revealed a lot of RRT-related problems. While hospitalists appreciated the acuity, they reported that RRTs wreaked havoc with their schedule and workload, pulling them away for an hour or more to attend to a deteriorating patient about whom they may know nothing. That disruption was particularly extreme on nights and weekends.
Residents and interns also voiced strong objections, noting that they could be pushed out of the way when an RRT was called instead of being able to use the episode for education. Housestaff also wanted to make sure that they “as members of the patients’ primary team “were called first. Some even suggested that RRTs were sometimes called too soon.
While Dr. Benin and her colleagues found no evidence of RRTs being called inappropriately, nurses did reveal some longstanding communication problems with housestaff. They reported that some interns and residents didn’t attend to nursing concerns about a patient until an RRT was called.
“In an academic setting, there are some inherent differences of perspective between the residents and interns and nurses, who also have to make independent decisions,” Dr. Benin says. “There is a natural conflict that can play out in lots of different ways and is not always unhealthy.”
Conflict can be constructive, she adds, if it leads to “a healthy discussion of how to get teams to work together.” But the fact that some primary attendings and residents objected to the timing of some RRT calls added to nurses’ tension. At least one reported being reprimanded by an attending because she had called an RRT.
In addition, several nurses commented that residents in particular made the mistake of feeling that having an RRT called for a patient was somehow an indictment of their treatment. Researchers, however, found that such a perceived slight seemed to dissipate over time.
Fast forward four years since those interviews were conducted, and RRTs have now become what study co-author Grace Jenq, MD, medical director of inpatient medicine at Yale-New Haven Hospital, calls “second nature.”
During the study in 2008, Dr. Jenq recalls, some attendings and residents were “vehemently against nurses being able to call an RRT. Since then, those type of comments have gone to zero.”
With more than 100 RRTs now being called throughout the academic center every month, Dr. Jenq says that it’s become common for residents themselves to initiate an RRT call instead of leaving it up to nurses.
At the same time, several changes have been put in place to defuse the types of tensions the study uncovered. For one, says Dr. Jenq, hospitalists carrying the RRT pager are given a somewhat lighter census.
The hospital has also moved to geographic units so that every month, a set group of hospitalists, housestaff and nurses all work together on one unit.
“They’re all playing with one another in the same sandbox,” Dr. Jenq notes, “and that certainly builds a lot of trust. When RRTs are called, they know each other much better.”
As for residents feeling shut out, nurses initiating an RRT are expected to not only call the hospitalist attending, but the housestaff team as well. “We always expected them to page the housestaff team, but the process never quite got smoothed out,” Dr. Jenq says.
“Now, both teams are being called consistently.” In addition, a discussion of RRT calls and their resolution is now a regular part of morning report. A training program for residents that will begin this year will rely on scenarios that simulate RRTs.
And the hospital has physically posted what Dr. Jenq calls a “chain of command” for both nurses and doctors on every floor to use to address any conflicts they can’t resolve. For physicians, that chain runs from residents to attendings, then floor leader, vice chair of medicine and chief of staff. The one for nurses goes all the way up to director of nursing.
“For any disagreement about clinical decision-making,” says Dr. Jenq, “we’ve made the way to resolve that conflict transparent.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.