The origin of the RRT can be found in medical emergency teams (METs). METs began in Australia as a result of the realization that earlier intervention could lead to better outcomes.1 In December 2004, in response to persistent problems with patient safety, the Institute for Healthcare Improvement launched its “100,000 Lives Campaign.”2 The Institute’s key plan for saving some of these 100,000 lives was to create RRTs at every participating medical center. Participating facilities would also submit data on mortality.
Olive View-UCLA Medical Center (OV-UCLA) signed on to participate in the campaign, and part of that effort was the creation and implementation of an RRT. We joined a University Health Consortium “Commit to Action” team, which assisted us by providing support as we began the creation and implementation of the RRT. What follows is the story of how we created an RRT.
We chose team members from all disciplines that were to be part of the RRT response—both at and behind the scenes: RNs, nursing administrators, hospital administrators, ICU attendings, house staff, laboratory personnel, nursing educators, radiology technicians, and hospital operators. The group was further organized into specific teams to solve problems and present solutions. At this point we learned our first important lesson: We needed to meet individually with all inpatient department chairs to discuss the effect of RRTs.
Activation and Notification
How would the RRT call be activated—overhead or beeper? Who could call, and what would the indications be? The OV-UCLA activation and notification team decided that the RRT could be activated by any staff member. Criteria, including vital signs, mental status, or simply “concern about the patient,” were created and posted. A telephone line in the ICU (X4415) was dedicated for RRT calls, and all other activation was overhead due to the lack of an adequate beeper system. (Other than code pagers, our beeper system can’t be simultaneously activated, and ancillaries don’t have beepers.)
The primary nurse’s responsibilities included calling the primary team or cross-covering team and obtaining a fingerstick glucose on all patients while waiting for the team. In discussions the primary team, we learned our second important lesson: As we presented the RRT to the hospital staff, everyone was concerned about the primary team. Ensuring that a mechanism for notifying the primary team was in place and reassuring staff that the primary team would be involved emerged as essential tasks. It was also imperative to identify the chain of command.
With this need in mind, we decided the primary team would always be the captain and would, therefore, have the authority to dismiss whomever they wanted from the RRT. An ICU attending was assigned to RRT call as supervision for the ICU resident responder. At OV-UCLA, our attending is not in-house and, to date, has not been called.
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Documentation
The OV-UCLA documentation team was called on to answer the following questions: How would the RRT call be documented? How would medication orders be sent to the pharmacy? How would quality indicators (QI) and data be collected on the calls?
The team’s solution involved creating a one-page, primarily check-based document. The ICU nurse who answered the X4415 telephone in the ICU would begin documentation, which included the time of the call and the chief complaint. When the RRT reached the patient, however, the documentation duties were transferred to the primary RN. All providers were to document on the same page—similar to a code sheet. The RRT nurse and the attending doctor were to check vitals and perform the physical exam, as all information was called out to the documenter.