From Reactive to Proactive: A Novel Rapid Response System

Q What strategies can ensure that calls for a rapid response are timely and effective?A Fiona A. Winterbottom, DNP, MSN, APRN, ACNS-BC, ACHPN, CCRN, replies:Rapid response teams (RRTs) have developed in hospitals to identify patients at risk of clinical deterioration and deliver resources for evaluation, stabilization, and transfer to a higher level of care. The RRT promptly determines the acute needs of patients and expedites care interventions.1 Rapid response comprises 4 parts: an afferent limb (detection), an efferent limb (response), an administrative (governance) limb, and a quality assurance limb. Symptoms of clinical deterioration often occur hours before staff members acknowledge and respond to the warnings.2,3 Interventions have been proposed to improve the timeliness and effectiveness of RRT activation, including continuous vital sign monitoring, early warning systems (EWSs), artificial intelligence (AI), and proactive rounding. The aim of these processes is to help staff members identify and treat patients at risk of clinical deterioration to prevent harm or death.In hospitals, routine vital sign assessment serves to detect and prevent clinical deterioration. The definition of a “complete” set of vital signs varies across the world. The vital signs most commonly reported in the literature are respiratory rate, oxygen saturation level, heart rate, blood pressure, temperature, and level of consciousness.4 Evidence shows that vital signs are not documented regularly, completely, or accurately as much as 80% of the time.5 This variability can lead to patient adverse events. Deficiencies in the collection and response to abnormal vital signs cause delays in care and can result in critical events such as cardiopulmonary arrest, unplanned intensive care unit (ICU) admission, or death.Various studies have indicated that the most frequently used predictor of clinical deterioration is respiratory rate, followed by heart rate, oxygen saturation level, temperature, systolic blood pressure, and level of consciousness.6 Tachycardia and tachypnea are sensitive but nonspecific early indicators of clinical deterioration. Hypotension and bradycardia are the most common triggers for RRT activation, and bradypnea and hypoxemia are the least common RRT triggers.6Several reviews have indicated intermittent documentation of respiratory rate as well as issues including high levels of bias, estimation, use of incorrect techniques, and lack of knowledge of the clinical significance of respiratory rate.7 In some cases, oxygen saturation level was used as a proxy for respiratory rate.7 Overall, findings suggest that nurses do not embed respiratory rate documentation into practice with sufficient frequency in clinical deterioration events.8 The omission of respiratory rate from vital sign documentation ranges from 0.8% to 81.5%.9 Other frequently missed vital signs are temperature and level of consciousness.7 Cardiovascular vital signs are more frequently documented and used to trigger RRTs than respiratory parameters. Studies have shown that the most commonly documented vital sign is blood pressure and the least frequently documented vital sign is respiratory rate, even though tachypnea is a more accurate and earlier indicator of deterioration than hypotension.7Early warning systems have evolved from efforts to identify patients at risk of deterioration early enough for actions to occur.2 These systems are prediction models that use vital signs to monitor patients and detect the likelihood of clinical deterioration. Early warning system trends and trigger warnings prompt escalation of interventions to prevent progression and stabilize the patient. Each patient should have an individual monitoring plan that includes the frequency and content of assessments and values that require action. A minimum standard for the frequency of vital sign assessment among acute care patients is every 12 hours.10 More frequent vital sign assessment is warranted in patients at higher risk for deterioration, or any time a patient shows signs of a change in status.Early warning systems combined with escalation protocols and RRTs provide a system of care with shared responsibility for clinical deterioration. Clinical studies have indicated improvement in outcomes with enhanced monitoring technologies, automated triggering of EWS scores, and escalation protocols.1 Recommendations for technologies include development of packages of visual and auditory cues with graduated alerts that monitor and provide decision support, as well as transferring, analyzing, and storing data.10 Application of AI and machine learning approaches outperform most historical EWSs when applied to retrospective data sets,1 holding promise for earlier detection of deterioration with fewer nuisance alarms that distract bedside clinicians. A key consideration is that clinical responses to elevated scores impact workload, and alert fatigue occurs if the EWS triggers unnecessarily. Health care manufacturers, leaders, and policy makers must consider alert fatigue when evaluating response strategies.6 The additional availability of an RRT can support staff members with early interventions and coaching. This collaborative approach to risk stratification reduces the burden and moral distress for clinicians, especially when it is linked to a debriefing program.Proactive RRT systems or pre–medical emergency team programs can remove barriers to nurse escalation of cases of clinical deterioration by creating a team approach to care. As staffing challenges increase and hospitalized patients become sicker, standardized interprofessional communication processes can encourage culture change that promotes safety.11 Barriers to escalation of cases of clinical deterioration include fear of ridicule or reprimand for calling for help, misunderstanding of the role of the RRT, and perceived lack of support. Facilitators of RRTs include standardized protocols that allow response teams to assess, triage, intervene, and escalate as the scope of nursing practice allows.12Proactive RRT systems are becoming more common and help to mitigate these barriers. These models move away from the consultation model, in which a critical care nurse is pulled away from the intensive care setting to help with a patient in a general medical-surgical unit. Proactive RRT systems employ a nurse to round on general medical-surgical units, respond to emergencies, follow up on interventions, and provide support, feedback, and education to nursing staff members. Proactive RRT models with clear role delineation allow relationships to be built between nursing staff members and other clinicians while reducing the barrier of nursing staff member fear. In this model, the number of patients proactively evaluated increases while reactive events and moral distress of patients, families, and staff members are reduced.13 The multipronged efforts of an RRT promote work collaboratives that enhance critical care outreach services, coaching, and debriefing.1Proactive RRT systems improve collaborative relationships among staff members from different specialties through teamwork. Because they do not have patient care responsibilities in critical care areas, staff members in proactive RRT roles can be more available to support staff outside the ICU. Novel models using EWSs, AI, and virtual nursing are replacing outdated ICU nurse consultation models. Proactive rounding or a pre–medical emergency team tier of RRT systems that is combined with AI holds promise for safety and staffing solutions. Understanding gaps in care processes, clinical practice, escalation protocols, and clinical interventions is essential to formulate strategies for improvement.14 Flexible staffing using remote surveillance has been used for reliable and timely patient care evaluation. Collaboration, communication, and trust between remote and on-site teams can off-load work from front-facing staff, improve documentation, and allow more time with patients and families.15 The RRT system can support staffing in a variety of ways, including capacity surge, clinical expertise, documentation, and communication.16 Interoperability of technology and teamwork can maximize the efficiency of RRTs to help them become more proactive and less reactive. This change can improve patient, staff, quality, and fiscal outcomes while optimizing care delivery.