At the second drill, the main problem was documentation. The ICU nurse was so busy documenting that he wasn’t involved with the patient. Because the expertise of the ICU nurse is essential (in fact, there are times when this RN is the most experienced person on the team) we restructured the response so that the primary nurse would document and the ICU nurse was free to provide the hands-on care required.
At the final mock RRT, the major problem was again communication; that is, everyone spoke at once. The team members were encouraged to direct all comments to the team leader and keep any other conversation to a minimum.
A Successful RRT
The following case example, which describes the successful use of our OV-UCLA’s RRT, provides an illuminating look at its effectiveness. In this case, the RRT comprised the ICU nurse, the ICU physician, and the respiratory therapist. The team carried the following equipment: a patient monitor, medications, an IV start, blood sampling tubes, a central line, oxygen masks, and suctioning equipment.
The case began when the primary nurse activated the call. The patient—a 36-year-old HIV-positive male with acute rectal bleeding—was found to have a systolic blood pressure (SBP) reading of 70 and a heart rate of 144. The patient was admitted for anal warts but was noted to have acute bright red blood per rectum. The primary physician team had been called, but had not yet arrived. The primary nurse used the bedside phone to call X4415, and the RRT arrived within three minutes.
Upon arrival, the RRT started a wide bore IV and a central line. The team then called for O-negative blood from the blood bank. The transfusion began seven minutes after the team’s arrival in the patient’s room. The patient was transferred to the ICU and was discharged to the floor the following day.
Results
In four-and-a-half months, we have had 43 calls. The warning signs that precipitated the calls include:
- Respiratory distress: 14 (resulting in eight intubations);
- Cardiac problems: six;
- Altered mental status: four;
- Hypotension: four;
- Post-procedure oversedation: three;
- Vomiting: two;
- Bleeding: two;
- Gastrointestinal: one;
- Mouth bleeding: one;
- Hypoglycemia: one; and
- Unclear etiology: five. TH
Dr. Stein is the medical director, Intensive Care Unit/SDU, at Olive View UCLA Medical Center.
References
- Bellomo R, Goldsmith D, Uchino S, et al. A prospective before-and-after trial of a medical emergency team. Med J Aust. 2003 Sep 15:179(6):283-287
- The Institute for Healthcare Improvement’s 100,000 Lives Campaign. Available at: www.ihi.org. Last accessed July 10, 2006.
- Leonard MS, Graham S, Taggart B. The human factor: effective teamwork and communication in patient strategy. In: Leonard M, Frankel A, Simmonds T, eds. Achieving safe and reliable health care strategies and solutions. 1st ed. ACHE Management Series; 2004. p.37-65.
- Schein RM, Hazday N, Pena M, et al. Clinical antecedents to in-hospital cardiopulmonary arrests. Chest. 1990;98:1388-1392.
- Franklin C, Matthew J. Developing strategies to prevent-in hospital cardiac arrest: analyzing responses of physicians and nurses in the hours before the event. Crit Care Med. 1994;22(2):244-247.