Rapid Response Team Calls Research Articles

Documentation of limitation of medical therapy at the time of a rapid response team call

The aims of the present study were to: (1) describe the documentation process of limitation of medical therapy (LMT) orders at the time of a rapid response team (RRT) call; and (2) compare documented LMT orders not associated with an RRT call (control, Group 1) with LMT orders documented at the time of an RRT call (Group 2). A descriptive study, over a 6-month period (February-August 2011), involving the review of the medical records of patients prospectively identified as either Group 1 or Group 2. There were 994 RRT calls; of these, 50 patients (5%) had an LMT order documented by the RRT. A cardiac arrest was the trigger for the RRT for six patients (12%). Patients in Group 1 (n=50) and Group 2 were of similar median age (80.5 vs 78.5 years; P=0.30), LMTs were recorded at a similar time of day (15:30 vs 15:55 hours; P=0.52) and day of the week (weekend: 32% vs 35%; P=0.72). Comparing group 2 with Group 1, the RRT was less likely to document a not-for-resuscitation (NFR; 31 (62%) vs 49 (98%); P<0.01) or a not-for-ICU (NFICU; 18 (36%) vs 41 (82%); P<0.01) order, but more likely to document a not-for-RRT call (NFRRT; 31 (62%) vs 22 (44%); P=0.04) and modified RRT calling criteria (MRRT; 4 (8%) vs 0 (0%); P=0.04) orders. For Group 2 compared with Group 1 orders, involvement of the patient in the decision making process (9 (18%) vs 25 (50%); P<0.01) or the next of kin (29 (58%) vs 45 (90%); P<0.01) was documented less often. Documentation of LMT orders at the time of an RRT call is less likely to include documented involvement of patients or their next of kin, and is more likely to be an NFRRT or MRRT order. These findings have implications for overall clinical governance. What is known about the topic? RRT are not infrequently involved in documenting LMT orders. What does this paper add? This is the first study in Australasia to look into the timing and circumstances surrounding the issuing of a NFR order during an RRT call. The study findings clarify the type of LMT orders documented by RRT and to what extent patients, their carers and senior medical staff are involved. What are the implications for practitioners? Our findings indicate that, in the setting of a rapid response system, there is a need to consider beyond the narrow interpretation of the NFR order, when a NFRRT may also be appropriate. This will require standardisation of such nomenclature, and training and education of those involved in documenting and interpreting such orders. Equally, it will require a different approach to the discussion with patients and their carers as to what the implications of an NFRRT order are. The findings also have significant implications as to the senior medical oversight of LMT, in particular for RRT, for whom it is their first encounter with such patients. Finally, the findings suggest that consideration be given to better delineating the documentation of the role of nursing staff when setting LMT orders.

Hospital mortality predictive factors following Rapid Response Team activation

The Rapid Response Team (RRT) represents an important advance in the management of deteriorating ward patients and is recommended as a patient safety measure. Most studies on RRT evaluate the effects of its implementation on rate reduction of cardiopulmonary arrest outside the ICU and hospital mortality, with limited information on the criteria for RRT calls and predictive factors associated with hospital mortality [1],[2]. Therefore, our objective was to determine what factors are associated with hospital mortality for patients seen by the RRT at the Hospital Israelita Albert Einstein (HIAE).

The effect of rapid response teams on end-of-life care: a retrospective chart review.

A subset of critically ill patients have end-of-life (EOL) goals that are unclear. Rapid response teams (RRTs) may aid in the identification of these patients and the delivery of their EOL care. To characterize the impact of RRT discussion on EOL care, and to examine how a preprinted order (PPO) set for EOL care influenced EOL discussions and outcomes. A single-centre retrospective chart review of all RRT calls (January 2009 to December 2010) was performed. The effect of RRT EOL discussions and the effect of a hospital-wide PPO set on EOL care was examined. Charts were from the Ontario Ministry of Health and Long-Term Care Critical Care Information Systemic database, and were interrogated by two reviewers. In patients whose EOL status changed following RRT EOL discussion, there were fewer intensive care unit (ICU) transfers (8.4% versus 17%; P<0.001), decreased ICU length of stay (5.8 days versus 20 days; P=0.08), increased palliative care consultations (34% versus 5.3%; P<0.001) and an increased proportion who died within 24 h of consultation (25% versus 8.3%; P<0.001). More patients experienced a change in EOL status following the introduction of an EOL PPO, from 20% (before) to 31% (after) (P<0.05). A change in EOL status following RRT-led EOL discussion was associated with reduced ICU transfers and enhanced access to palliative care services. Further study is required to identify and deconstruct barriers impairing timely and appropriate EOL discussions.

Evaluation of rapid response team implementation in medical emergencies: A gallant evidence based medicine initiative in developing countries for serious adverse events.

Background:Rapid response team (RRT) has been implemented in developed countries with the aim of early recognition and response to critical care triggers for the better patient outcome. However, the data concerning their efficacy is hardly available until date from Indian subcontinent.Aims:To evaluate the impact of RRT implementation on patient outcome during medical emergencies.Settings and Design:Retrospective observational study of RRT records of in-bed patients of super specialty academic teaching hospital.Materials and Methods:RRT record forms during the first half of the year from January 2012 to June 2012 were included for all inpatients and out-patients irrespective of their age, gender and diseases profile after their inclusion in the system. Outcomes such as patient stayed in the room, patient transfer to intensive care unit (ICU), patient discharge and generation of code blue event, mortality and length of stay in hospital/ICU were measured.Statistical Analysis:Descriptive analysis was performed with the help of statistical software STATA 9.0 and R 2.13.2 (StataCorp LP, Lakeway Drive College Station, Texas, USA).Results:Analysis of 41 RRT calls showed decreased code blue calls by 2.44% and decrease in mortality by 4.88%. Average length of stay in ICU and hospital post RRT assistance for patients was 2.55 and 6.95 days respectively. Conversely percentage of patients requiring a higher level of care was more (75.61%) than those who stayed in their rooms/wards (24.39%).Conclusion:Implementation of RRT in this hospital was associated with reduced code blue events and its attendant mortality outside the ICU settings. However, more number of patient requiring higher levels of care delineates the need for a larger evidence based medicine study.

Tempering pediatric hospitalist supervision of residents improves admission process efficiency without decreasing quality of care.

Many academic pediatric hospital medicine (PHM) divisions have recently increased in-house supervision of residents, often providing 24/7 in-house attending coverage. Contrary to this trend, we removed mandated PHM attending input during the admission process. We present an evaluation of this process change. This cohort study compared outcomes between patients admitted to the PHM service before (July 1, 2011-September 30, 2011) and after (July 1, 2012-September 30, 2012) the process change. We evaluated time from admission request to inpatient orders, length of stay (LOS), frequency of change in antibiotic choice, and rapid response team (RRT) calls within 24 hours of admission. Data were obtained via chart abstraction and from administrative databases. Wilcoxon rank sum and Fisher exact tests were used for analysis. We identified 182 and 210 admissions in the before and after cohorts, respectively. Median time between emergency department admission request and inpatient orders was significantly shorter after the change (123 vs 62 minutes, P < 0.001). We found no significant difference in LOS, the number of changes to initial resident antibiotic choice, standard of care, or RRTs called within the first 24 hours of admission. Removing mandated attending input in decision making for PHM admissions significantly decreased time to inpatient resident admission orders without a change in measurable clinical outcomes.

Inside the Debriefing Room: Multidisciplinary Rapid Response Team Training Findings Revealed

BackgroundResearch indicates that, despite the intent to save lives through rapid response teams (RRTs), mortality and morbidity outcome data are variable. A reason for that may be a lack of proficient and consistent training and education. ObjectivesTo determine whether high-fidelity simulation is an effective instructional method for interdisciplinary RRT training. MethodsMultidisciplinary health care team members participated in high-fidelity simulation scenarios, were evaluated by the instructors during the simulation, and then were given the opportunity to give informal and formal feedback. ResultsThe results of an anonymous survey sent to all participants showed that a majority who completed the online survey (91.4%) found this instructional method to be either very effective or somewhat effective for teaching in the hospital setting. The majority of participants (63.6%) indicated that high-fidelity simulation was their preferred method of learning when compared with case studies, online learning modules, or classroom/lecture. Major themes and opportunities identified for additional training were communication, assessment skills, teamwork, critical thinking, cardiopulmonary resuscitation skill retention, and timely initiation of RRT calls. ConclusionsThis pilot study supports the current literature detailing the effectiveness of high-fidelity simulation and perceived learner outcomes. During crisis situations, there are significant communication barriers that can derail care providers from providing the most optimal care to the patient. As a result of debriefing, it was found that derogatory comments made by the RRT members during previous rapid response calls significantly impacted how early subsequent rapid responses were called by some participants.

The rapid response system and end-of-life care

To review the recent observational studies reporting the role of the rapid response team (RRT) in end-of-life care (EOLC) planning for hospitalized patients. Initial RRT studies focussed on its role in detecting and preventing avoidable morbidity. However, patients who are in the process of dying will also trigger RRT activation criteria. Single-centre studies from several countries reveal that up to 25% of RRT calls involve patients with a pre-existing limitation of medical therapy (LOMT) and 10% result in new implementation of a new LOMT. A recent seven hospital study revealed that such EOLC RRT calls occur in significantly older patients, who are less likely to be from home and more likely to be admitted with a nonsurgical condition. Importantly, almost 50% of patients subject to EOLC RRT call die in hospital, and in many cases the last RRT call occurs on the day of death. Up to one-third of RRT calls involve patients at the end of their life. Better understanding of the features of these patients may guide improved advance care and EOLC planning for hospitalized patients.

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Introduction: Approximately 84% of patients have an acute deterioration within 8 to 48 hours of cardiac arrest, most often manifested as hypotension or tachypnea. Accordingly, the Institute for Healthcare Improvement recommends implementation of rapid response teams as a part of their 100,000 Lives Campaign to reduce preventable hospital deaths. Currently at Froedtert Hospital, ACLS trained pharmacists respond to medical emergencies 24/7, but do not have a formal role on the rapid response team (RRT). Prior studies investigating pharmacist presence only evaluated interventions and team perceptions, but have not evaluate outcomes. Methods: This was a retrospective, pre-post interventional study that evaluated 161 patients before and 175 patients after pharmacist implementation on a rapid response team. Patients who were admitted as inpatients between August and October 2012 or between March and May 2013 were included in either the pre-interventional or pilot arm, respectively. Patients were excluded if they were an outpatient, a visitor, a clinic patient, an intensive care unit or emergency department patient or had a rapid response that progressed immediately into a medical emergency. The primary outcome was turnaround time for medication administration, with a goal turnaround time of less than 30 minutes. Pertinent descriptive secondary outcomes consisted of the most frequently administered medications, the indications for RRT, and the number of rapid responses that result in subsequent ICU admission and medical emergencies. RRT calls within 24 hours of admission or 48 hours of ICU discharge, total and post RRT call hospital length of stay, survival to hospital discharge, and pharmacist interventions on the RRT were also evaluated. Results: The addition of a pharmacist decreased medication turnaround time (mean = 45 min +/- 5 vs. 3 min +/- 4; median = 31 vs. 28 min, p = 0.278) and trended towards more patients with an acceptable turnaround time of under 30 minutes (49.1% vs. 57.1%, p = 0.155). The most frequently administered classes of medications were for the acute treatment of atrial fibrillation (22.1% vs. 15.1%), acute treatment of seizures (5.3% vs. 9.2%), analgesics (8.4% vs. 5.9%), antibiotics (8.4% vs. 12.6 %), reversal agents (14.7% vs. 17.6%), and other medications (41.1% vs. 39.5%, p = 0.52). No other variables were different between the two groups besides number of medication changes post-RRT, which were greater in the pre-interventional arm (43.4% vs. 56.1%, p = 0.002). Pharmacists documented on only 90/162 patients (55.5%), while 18/90 patients (20%) had documented a pharmacist intervention on dosing, preparing emergent medications, and drug/patient information. Conclusions: The addition of a pharmacist to a rapid response team reduced time to medication administration and helped improve the medication use process by identifying areas for improvement.

Limitations of medical treatment among patients attended by the rapid response team

Rapid response teams (RRTs) are called to deteriorating ward patients in order to improve their outcome. The involvement of the team also in end-of-life care issues needs to be addressed. Our objective was to evaluate the RRT with focus on limitations of medical treatment (LOMT). Observational cohort study of RRT calls from 2005 to 2010 at a university hospital. There were 2189 calls in 1818 admissions. Six hundred forty-two patients (35.3%) were assigned LOMT, and in 296 cases (46.1%) it was documented on the same day as the first RRT call. In total, 152 calls were for patients where a decision was already in place. Among patients with multiple calls, 44.6% received limitations. Hospital mortality was 25.6% in total, 60.6% for patients with limitations and 6.6% for patients without. Mortality at 180 days was 43.2% for the whole cohort, and 83.6% and 21.2% with and without limitations, respectively. Cardiac arrest rate has remained at the level of 0.82/1000 admissions since the introduction of the RRT. Patients attended by the RRT have high short- and long-term mortality. Distinction of when deteriorations may be amenable to treatment or when focus should be laid on palliative care is not always made in the wards. Many decisions of limitations are taken in close conjunction to the call, although limitations do not preclude repeated visits from the team, indicating a need to support wards that care for patients at end of life.

Rapid response team calls to patients with a pre-existing not for resuscitation order

ObjectiveCompare and contrast rapid response team (RRT) calls to patients with, and those without, a pre-existing not for resuscitation (NFR) order. MethodsRetrospective medical record and database review of adult inpatients with a hospital stay greater than 24h. Results198 (15.7%) of 1258 patients with a RRT call, had a pre-existing NFR order. Patients with, compared to those without a pre-existing NFR, were older (median years, 81 vs 70, p<0.01), similar gender (males, 56.6% vs 54.3%, p=0.55), the trigger be the worried criterion (48.5% vs 33.9%, p<0.01) and have had a prior RRT call (30.8% vs 18.0%, p<0.01).At time of RRT attendance, NFR patients had a higher respiratory rate (24 vs 20, p<0.01), lower SaO2 (93% vs 97%, p=0.02) and just as likely to receive a critical care (24.2% vs 25.8%, p=0.63) or ward type (88.9% vs 90.1%, p=0.61) intervention. NFR patients were less likely to be admitted to an ICU (2.0% vs 9.4%, p<0.01), more likely to be left on the ward (92.4% vs 80.3%, p<0.01), and be documented not for further RRT calls (2.5% vs 0.9%, p=0.06), but have a similar mortality (5.6% vs 3.5%, p=0.16), at time of RRT call. ConclusionsRRT calls to patients with pre-existing NFR orders are not uncommon. The worried criterion is more often the trigger, they have abnormal respiratory observations at time of call, a similar level of intervention, less likely to be admitted to the ICU and more likely to be documented not for further RRT calls.

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Introduction: Rapid response teams (RRTs) have become standard in American pediatric hospitals, but there is little guidance about their optimal structure and function. Hypothesis: We gathered data characterizing the standard of care across the country to identify factors that correlate with a reduced arrest rate. We hypothesized that an increased RRT dose (# RRTs/# hospital beds) and larger hospital size would correlate with a lower arrest rate. Methods: 62 question telephone survey, including a description of arrest and rapid response team composition and function, and number of events for 2011. Results: We collected data from 30 top American pediatric hospitals, all of which provide ECMO support, have a PICU fellowship, and 24 hour RRTs. A PICU doctor is part of 93% of arrest teams and 73% of RRTs. Of the 17 hospitals with only 1 PICU doctor (fellow or attending) in house overnight, 59% have the single PICU doctor on the RRT. 77% of institutions receive no additional staffing or financial support to run the RRT. 77% of responders have a family activated RRT program, but only 60% report having any family activated calls in 2011. 90% of institutions list “Respiratory” as the reason for most RRT calls. 55% of RRT calls result in a patient transfer to the PICU. The definition for “code event” varies drastically between hospitals, including hospitals belonging to the Children’s Health Corporation of America, which has provided a standard definition for codes outside the ICU. Only 60% of responders thought the presence of RRTs had decreased the number of non-ICU chest compressions or emergent intubations. For the 27 hospitals who tracked this data, the median number of RRT calls in 2011 was 130 (range 11 to 664). We found no correlation between RRT dose and arrest rate (r = 0.04). We found a weak correlation showing a decreased arrest rate in the hospitals with more total beds (r = 0.3). Conclusions: This study demonstrates the wide variability in RRT practice in American pediatric hospitals. Although larger hospitals show a weak correlation with lower arrest rates, RRT variability makes it difficult to identify which RRT characteristics are most important in realizing the ultimate goal of preventing floor arrests.

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Introduction: Alcohol withdrawal management in hospitalized patients is a challenging problem with implications on patient and staff safety, outcomes and overall cost of hospital stays. Hypothesis: Based on increasing reports of violent behavior and costly cases possibly related to alcohol withdrawal syndrome, our three hospital system formed a multidisciplinary team to optimize the alcohol withdrawal management protocol. The goal was to reduce violent behavior, protect staff, and improve patient outcomes by reducing rapid response team (RRT) calls related to oversedation or respiratory causes. The team also did extensive education to promote the use of the new order set to ensure appropriate monitoring and therapy. Methods: Improvements based on literature review were incorporated into alcohol withdrawal protocol in the electronic health record. The alcohol withdrawal risk screen was updated to include the CAGE questionnaire. The order of symptom assessment for the CIWA-Ar was changed to support symptom driven medication selection. Separate order sets were developed for prevention and treatment of withdrawal. Benzodiazepine treatment options were expanded to include more aggressive dosing schemes for severe acute withdrawal, promoting IV push dosing over continuous infusion benzodiazepines. Antipsychotic dosages were increased and criteria were designated for symptom driven administration. Clonidine was added as a treatment option for adrenergic symptoms. Results: An association was observed between the creation of an evidence based alcohol withdrawal prevention and treatment order set and a decrease in RRT calls. There was a 55.9% relative risk reduction in RRT calls related to oversedation or respiratory cases after implementation of the new protocol. Conclusions: By utilizing literature review and expert opinion, our team identified opportunities to improve the management of alcohol withdrawal by modifying nursing assessments to determine patient risk level and by directing pharmacologic therapy based on symptomatology. The protocol was widely used before and after improvements were made, leading to a decrease in RRT calls.

An assessment of the triage performance of the efferent arm of the rapid response system

ObjectivesTo measure the triage performance of the efferent arm of a rapid response system (RRS) by assessing the 24h outcome of patients triaged to remain on the ward after rapid response team (RRT) review. MethodsWe performed a retrospective observational study of all consecutive RRS activations between August 2005 and December 2011 in a university-affiliated hospital. Calls involving patients with documented limitations of medical therapy (LOMT) orders were excluded. We determined patients who were triaged to stay on the ward at the end of their first (index) call and analyzed their vital status and location 24h later. Finally, we reviewed medical charts of patients triaged to remain on the ward and had a cardiac arrest and/or died within 24h of RRT review. ResultsWe studied 8304 RRT calls. We excluded 1794 calls involving patients with LOMT, 2165 that were repeat calls, 20 where data was missing, 650 where patients were immediately transferred to a high dependency (HDU) or an intensive care unit (ICU) and 92 where calls were rapidly upgraded to cardiac arrest calls. Thus, we identified 3583 index calls at the end of which patients were triaged to remain on the ward. Within 24h, 454 (12.7%) of those had a repeat RRT activation and 378 were transferred to HDU/ICU. 12 (0.3%) suffered a cardiac arrest on the ward. Altogether, 14 (0.4%) patients died within 24h of the index RRT activation. Of those 6 had LOMT applied after the call, 4 had been admitted to ICU in a further call and 6 (0.2%) patients had unexpected cardiac arrest on the ward. ConclusionsThe rate of unexpected cardiac arrest in the 24h following RRT activation is very low for patients triaged to stay on the ward. Major triage errors by the RRT appear uncommon.

A controlled trial of electronic automated advisory vital signs monitoring in general hospital wards*

Deteriorating ward patients are at increased risk. Electronic automated advisory vital signs monitors may help identify such patients and improve their outcomes. A total of 349 beds, in 12 general wards in ten hospitals in the United States, Europe, and Australia. Cohort of 18,305 patients. Before-and-after controlled trial. We deployed electronic automated advisory vital signs monitors to assist in the acquisition of vital signs and calculation of early warning scores. We assessed their effect on frequency, type, and treatment of rapid response team calls; survival to hospital discharge or to 90 days for rapid response team call patients; overall type and number of serious adverse events and length of hospital stay. We studied 9,617 patients before (control) and 8,688 after (intervention) deployment of electronic automated advisory vital signs monitors. Among rapid response team call patients, intervention was associated with an increased proportion of calls secondary to abnormal respiratory vital signs (from 21% to 31%; difference [95% confidence interval] 9.9 [0.1-18.5]; p=.029). Survival immediately after rapid response team treatment and survival to hospital discharge or 90 days increased from 86% to 92% (difference [95% confidence interval] 6.3 [0.0-12.6]; p=.04). Intervention was also associated with a decrease in median length of hospital stay in all patients (unadjusted p<.0001; adjusted p=.09) and more so in U.S. patients (from 3.4 to 3.0 days; unadjusted p<.0001; adjusted ratio [95% confidence interval] 1.03 [1.00-1.06]; p=.026). The time required to complete and record a set of vital signs decreased from 4.1±1.3 mins to 2.5±0.5 mins (difference [95% confidence interval] 1.6 [1.4-1.8]; p<.0001). Deployment of electronic automated advisory vital signs monitors was associated with an improvement in the proportion of rapid response team-calls triggered by respiratory criteria, increased survival of patients receiving rapid response team calls, and decreased time required for vital signs measurement and recording (NCT01197326).

Evaluating a New Rapid Response Team

Evidence is needed to validate rapid response teams (RRTs), including those led by nurse practitioners (NPs). A descriptive-comparative mixed-methods study was undertaken to evaluate a newly implemented NP-led RRT at 2 Canadian hospitals. On the basis of data gathered on 255 patients who received an RRT call compared with the patient data for the previous year, no significant differences in the number of cardiorespiratory arrests, unplanned intensive care unit admissions, and hospital mortality were found. In addition, no significant differences in patient outcomes were identified between the NP-led and intensivist physician-led RRT calls. A paper survey revealed that ward nurses had confidence in the knowledge and skills of the NP-led RRT and believed that patient outcomes were improved as a result of their RRT call. These findings indicate that NP-led RRTs are a safe and effective alternative to intensivist-led teams, but more research is needed to demonstrate that RRTs improve hospital care quality and patient outcomes.

Evaluating a New Rapid Response Team

Evidence is needed to validate rapid response teams (RRTs), including those led by nurse practitioners (NPs). A descriptive-comparative mixed-methods study was undertaken to evaluate a newly implemented NP-led RRT at 2 Canadian hospitals. On the basis of data gathered on 255 patients who received an RRT call compared with the patient data for the previous year, no significant differences in the number of cardiorespiratory arrests, unplanned intensive care unit admissions, and hospital mortality were found. In addition, no significant differences in patient outcomes were identified between the NP-led and intensivist physician-led RRT calls. A paper survey revealed that ward nurses had confidence in the knowledge and skills of the NP-led RRT and believed that patient outcomes were improved as a result of their RRT call. These findings indicate that NP-led RRTs are a safe and effective alternative to intensivist-led teams, but more research is needed to demonstrate that RRTs improve hospital care quality and patient outcomes.

Rapid Response Team composition, resourcing and calling criteria in Australia

IntroductionRapid Response Teams (RRTs) have been introduced into at least 60% of Intensive Care Unit (ICU) – equipped Australian hospitals to review deteriorating ward patients. Most studies have assessed their impact on patient outcome and less information exists on team composition or aspects of their calling criteria. MethodsWe obtained information on team composition, resourcing and details of activation criteria from 39 of 108 (36.1%) RRT-equipped Australian hospitals. ResultsWe found that all 39 teams operated 24/7 (h/days), but only 10 (25.6%) had received additional funding for the service. Although 38/39 teams, were physician-led medical emergency teams, in 7 (17.9%) sites the most senior member would be unlikely to have advanced airway skills. Three quarters of calling criteria were structured into “ABCD”, and approximately 40% included cardiac and/or respiratory arrest as a calling criterion. Thresholds for calling criteria varied widely (particularly for respiratory rate and heart rate), as did the wording of the worried/concerned criterion. There was also wide variation in the number and nature of additional activation criteria. ConclusionsOur findings imply the likelihood of significant practice variation in relation to RRT composition, staff skill set and activation criteria between hospitals. We recommend improved resourcing of RRTs, training of the team members, and consideration for improved standardisation of calling criteria across institutions.

Abstract P295: Performance Management and Improvement: One Way to “ImPact” Outcomes

Background: Continuous quality improvement (CQI) in health care systems necessitates an approach to review care delivery processes, systems, group and individual performances, incidents and outcomes. A robust process should 1) be multidisciplinary, 2) occur in “real-time”, 3) provide detailed review and discussion of care processes, performance and outcomes and 4) generate actionable rapid cycle improvement opportunities. Aim: To craft a sustainable management process for CQI for all clinical operational units of the Vanderbilt Heart and Vascular Institute (VHVI). Methods: We convened a standing multidisciplinary biweekly managerial forum (termed ImPact - “Improving Patient Care Together”) of quality medical directors, key clinical physicians and nurses, nursing unit managers, hospital administrators, and quality consultants. ImPact follows a standing structured agenda: 1) all mortalities since last meeting, 2) morbidity including “major misses” and major adverse events, 3) rapid response team calls, 4) out of ICU “codes”, 5) events reported by staff in our hospital's anonymous reporting system, 6) events brought forward by any clinician or unit manager, 7) interval progress on ongoing rapid cycle improvement projects. Results: The topics for rapid cycle improvement that have surfaced to date are listed in the Table . In addition to facilitating and prioritizing rapid cycle quality improvement and patient safety efforts, ImPact provides a link to our regular morbidity and mortality (M&amp;M) conferences in cardiology and cardiac surgery. We have been able to identify common issues that extend beyond individual clinical care areas, allowing better understanding of vulnerabilities in systems of care Conclusions: A multidisciplinary, structured, regularly scheduled meeting of physician and nursing clinical and quality leaders, unit managers and administrators is a critical component of performance management and improvement. Quality Topics Identified Topics Contribution, n Percent Handoff and communication 9 27 Equipment 7 21 Medication administration 5 15 Education to staff (M&amp;M) 4 12 Patient transport 3 9 Blood product administration 2 6 Risk management 2 6 Vascular service integration 1 3

Clinical Action for Post Operative Respiratory Depression of Pacu Related Rapid Response Team (RRT) Calls

A PACU nurse is often faced with a challenge of balancing adequate pain management and airway management with adequate ventilation in the immediate post operative period. Data gathered from 2007 - 2008 yielded an increasing number of over sedation RRT calls to nursing units involving PACU patients. During a nine month time period, there were 48 incidences of post operative respiratory depression (PORD) perceived to be PACU related, ten of which were related to PACU.

Implementation of a Medical Intensive Care Unit Acute-Care Nurse Practitioner Service

Demands for critical care services are increasing, but the supply of qualified physicians is not. Moreover, there are mounting national expectations for continuous on-site, senior providers and for adherence to quality and safety practices. In teaching institutions, manpower shortages are exacerbated by shrinking trainee duty hours, and there is a growing desire to recoup the revenue lost when a non-credentialed provider delivers a service. Increasingly, hospitalists and acute-care nurse practitioners (ACNPs) are meeting these needs. This article describes the development of an ACNP service in a university hospital medical intensive care unit (ICU) designed to improve the range and quality of services and faculty staffing when the ICU expanded from 22 to 34 beds without adding physicians. Eight ACNPs were hired and, over 9 months, received didactic, procedural, simulation center, and supervised patient care training. Progressive workload and graded responsibility were used to transition to a 24-hour, in-house, resident-independent, attending-supervised service, which now admits just under half of all patients (3.4 ± 1.3 patients/day), cares for approximately one-fourth of the unit's critically ill patients (6.0 ± 1.4 patients/day), and responds to medical rapid response team calls daily (1.5 ± 1.7 calls/day). Over the first 5 months of operation, work output in all categories continued to increase, with ACNPs documenting an average of 11.1 ± 2.7 activities per day (all data mean ± standard deviation). Acute-care nurse practitioners also provide 40% of the daily resident core lectures and a monthly staff nurse conference. Insufficient data exist at this time, however, to report accurate billing or collection results. Specific areas discussed within this article include service structure, hiring and training, implementation, scheduling, supervision, problems encountered, productivity, monitoring, and future plans.