Implementation of critical care response team.

Analyses of hospital deaths have indicated that a significant proportion of the reported deaths might have been prevented had the patients received intensive level care early enough. Over the past few decades the critical care response team has become an important means of preventing these deaths. As the proactive arm of intensive care delivery, the critical care response team places emphasis on early identification of signs of clinical deterioration, which then prompts the mobilization of intensive care brought right to the patient's bedside. However, the setting up of a critical care response team is a difficult undertaking involving different levels of cooperation between all service stakeholders, and a bringing together of professional expertise and experience in its operations. The implementation of a critical care response team often involves a high-level restructuring of a hospital's service orientation. In the present work, the various factors and different models to be considered in implementing a critical care response team are addressed.

INTRODUCTION

In 2004, a group of sixty-four intensive care units (ICUs) in the United States of America pooled together the mortality data obtained in their different ICUs, which was subsequently analyzed using a mortality diagnostic test - the 2 × 2 matrix (pronounced “2 by 2”).[1] This was a concerted effort to identify any specific pattern in the ICU trend, determine the major non-pathological reason why patients die in the hospital, and consider ways such deaths might at least be reduced. The employed 2 × 2 matrix extrapolates a “yes/no” answer to the question of whether the expired patients were admitted into an ICU facility, and whether or not they were only provided comfort care (an example is the comfort care administered to terminally ill patients whose status is deemed unlikely to improve with medical treatment). The answers from these two questions regarding the past fifty deaths recorded in each of these American ICUs (more than 3,000 deaths analyzed in total) were then correlated and applied to a 2 × 2 matrix [Table 1] showing the relative significance of each answer. The analysis revealed that almost fifty percent of the total hospital mortalities analyzed occurred in non-ICU units and included patients that were neither admitted for comfort care nor admitted into the ICU of the respective health institutions [Table 1]. Looking at this in a different light, about half of the patients who were admitted for medical conditions not expected to culminate in death (otherwise they might have been admitted into the ICU) resulted in death.[1] Which begs the question: could some of these unexpected deaths have been prevented from occurring if the patients’ deterioration in status been recognized earlier and they had been transferred in time to the ICU where they could receive the appropriate critical care, instead of being managed in the medical wards? Are there recognizable signals from critically deteriorating patients that could constitute warning signs for impending death?

Table 1

Mortality diagnostic test

As expected, this pattern will present hospital-specific variations, just as the specific factors culminating in this lapse in critical care are also expected to differ among the hospitals. However, one of the common denominators to the mortality pattern is what has been referred to as ‘failure to rescue’ (FTR). Described as a failure to prevent rapidly deteriorating patients’ conditions from culminating in in-hospital death,[2] FTR embodies three principal factors: (1) The care provider's failure in treatment design; (2) Presence of either complete breakdown or stunted communication among different clinicians and between clinicians and patients; and (3) The failure of the system to quickly identify deteriorating patient and to mobilize acute care interventions quickly enough to prevent a full code and death.[1] It is in the recognition of such lapses in critical care that the first critical care response team, called the Medical Emergency Team (MET) in the originating institution, was implemented at Liverpool Hospital in Sydney, Australia in 1990.

The critical care response team (CCRT) is a major intervention response instituted with the primary aim of plugging this hole in critical care delivery. Interchangeably referred to as the medical emergency team (MET), a CCRT is a multidisciplinary team of clinical personnel constituted and equipped with the relevant competence to bring critical care to the patient's bedside, thus preventing the patient's status from degenerating into cardiac arrest.[14] The strict attention of the CCRT to a rapid response in its operations can be supported by the fact that most CCRT teams are trained to reach the decompensating patient's side within five to fifteen minutes of being summoned by a distress call. In the following sections, a detailed description of the CCRT, its design and composition in terms of personnel and founding objectives, and its training and mode of operation will be examined, as well as the steps to follow in creating a CCRT.

Could patients have been rescued: Signs of clinical instability preceding arrest

Just before a patient's health status degenerates into arrest or another critical consequence, the event is usually preceded by a number of warning symptoms[3] which, without the expertise and experience of (especially) critical care staff clinicians, may go undetected. The timely identification of these signs prompting the deployment of ICU-type care to the patient represents the foundation of objectives of the CCRT. The observed signs of decompensation constitute a pattern of clinical instability observed primarily to precede cardiac arrest and death. Some of the reported signs include: A compromise of the respiratory function characterized by a respiration rate of less than ten breaths per minute or greater than 30 breaths per minute, or a progressively worsening dyspnea; a compromise of the cardiovascular system characterized by a heart rate lower than 45 beats per minute or greater than 125 beats per minute, a mean arterial blood pressure less than 70 mmHg or greater than 130 mmHg, or a symptomatic arrhythmia;[5] and a compromise of the neurological functions with signs including seizures, delirium and diminished responsiveness. Other warning signs include rapidly developing kidney failure, gastrointestinal bleeding, thrombosis and embolism, intractable pain and a progressively worsening condition despite standard treatment, shock, and eventual cardiopulmonary arrest.[2] According to Franklin and Mathew, a good number of these signs may be observed roughly six hours before a patient eventually progresses into a full cardiac arrest.[6] Other studies by these authors, and by Schein et al., have respectively reported sixty-six and seventy percent of reviewed patients as presenting with any one or a combination of the warning signs before cardiac arrest.[1]

These symptoms indicate very critical conditions which should ideally be addressed in an intensive or critical care facility where they can be adequately managed. However, this is not always the case for various reasons; hence, the CCRT. In 1990 the first rapid response team (RRT) was developed at Liverpool Hospital in Sydney, Australia was an effort based principaly on identifying these early warning signs and it represents a mobile critical care unit that can be deployed within minutes, a feat not likely to be achieved if the patient was made to go through the lengthy process involving the attending nurse trying to contact the physician-in-charge, who for several reasons that include competing clinical responsibilities, may not be available to prevent the patient from spiraling down to a fatal consequence.

The rapid response team

After the first CCRT was implemented in Australia in 1990, the number of in-hospital cardiac arrests was reportedly halved, while instances of mortality were reported to be reduced by 22 percent.[78] About one-quarter of ICUs in the United States alone presently have a CCRT implemented, even though the first such team did not come into being until seven years after the Sydney implementation. Several health institutions around the world have some form of CCRT implemented. In order to measure the effectiveness of CCRTs a number of indicators have been employed, including the total number of cardiac arrests, the number of arrest-related fatalities, the number of cases transferred to the ICU, and the total number of deaths in the hospital.[8] Bellomo et al. also reported a thirty-seven per cent reduction in deaths, with a 26% reduction in hospital-wide and a 56% reduction in post-cardiac arrest deaths.[4] Cumulative number of codes over a defined period of time is another measure that has been employed as a means to measure the effectiveness of CCRTs. Lastly, the perceived improvement in interpersonal interactions should be factored in, which includes improvement in staff satisfaction and nurse retention, as well as better interpersonal interactions among different staff member groups and patients involved (nurse-nurse, nurse-physician, patient-clinician).[8]

Despite several reports relating the many positive effects of CCRTs on the outcome of critical care, it is difficult to accurately quantify the significance.[9] Subjecting CCRTs to traditional evaluation by evidence-based medicine has not been of much help. In one such study (MERIT study) Medical Emergency Response Improvement Team, the CCRT failed to show any statistically significant benefit to treatment outcome.[10] Explaining why employing the traditional evidence-based medicine investigation method might be inappropriate for assessing CCRTs, Jeffrey Bruckel contended that employing a CCRT involves an extensive restructuring of the entire hospital's service structure, an approach aimed at achieving a single objective by improving the entire service process.[9] Moreover, this far-reaching service redesign goes beyond the immediate critical care response team, described as merely an efferent limb within a more elaborate critical care delivery system.[3] The entire system consists of a structure that identifies clinical instabilities and triggers the critical care response system (CCRS); another structure that responds to the distress call and brings critical care to the patient's bedside to forestall progression to cardiac arrest; and a process improvement subsystem and an administrative arm that respectively evolve the service towards better service delivery and perform the required administrative operations.[3] In short, the operational philosophy behind the establishment of the CCRT targets the whole service framework and not just individual patients, making it outside the immediate purview of tradition EBM.[11]

The multidisciplinary leaning of the CCRT ensures that the members who comprise the group possess the required competence and experience needed to stabilize a deteriorating patient before the physician-in-charge arrives. In some cases, depending upon the specific composition of the team, intensive treatment may be started in the absence of the attending physician. It is important that the team be able to integrate its operations into the existing service system and work hand-in-hand with non-team staff members for a successful discharge of their duties. The use of already available facilities significantly reduces startup costs. This will require effective communication with non-team members, a factor that should be actively considered when deciding which prospective members will serve on the team. With a good rapport with other hospital staff members in place, it will be easy getting the much-needed cooperation for the system to succeed, considering the fact that its operation relies heavily on registered nurses who are required for identifying warning signs and triggering the rapid response system once the outlined criteria have been met.[9]

Implementing a rapid response team

Review and planning

Before a CCRT is created, a CCRT implementation committee is needed to perform an appraisal of critical care delivery in the hospital to determine the effectiveness and adequacy of the existing service, with particular attention paid to preventable ICU deaths. Factors contributing to these will be considered in specific detail with the objective of considering how the CCRT will be structured to address the different identified factors. It is recommended that the membership of the committee involve senior clinical personnel, preferably departmental leaders with extensive experience in critical care. One such implementation committee engaged clinicians drawn mainly from the ICU, including a director of ICU medical services, a nursing manager, a respiratory therapist and a quality assurance specialist, among other members.[5] Because the activities of the CCRT are necessarily aimed at process improvement, its establishment should be found on an adequate knowledge of the situations and lapses in critical care provision. While a literature review should be undertaken, it is important that the committee recognizes that cross-clinic comparison of the experience of CCRTs may be biased, giving greater weight to their outcomes regarding in-house record evaluations. This highly unique nature of different ICUs has been cited by Jeffrey Bruckel as a major reason why the (MERIT) study failed to identify the benefits of RRT implementation by choosing hospitals with greatly varying operational profiles”.[9]

The particular areas reviewed will necessarily depend on each individual institution, but since the overarching purpose is eliminating delay in critical care delivery it should cover the average response time of the physicians[1], the type and quality of care provided to pre-code patients, the specific expertise typically available for handling deteriorating patients, the existing code initiation procedure, and the RNs’ understanding of the criteria for calling a code.[12]

Once the key issues have been identified, the implementation committee can proceed with drafting the operational policies, protocols, and guidelines for initiating codes. The committee should be sure to avoid ‘reinventing the wheel’, instead maximizing facilities, structures and relationships already available at the health institution, especially in the critical care unit. This can significantly ease transition from traditional critical care delivery to a new care philosophy whose success crucially depends on all service stakeholders. In this light, there is a great need for effective communication and it is an advantage to have committee members skilled at interacting with other clinicians that can help to ensure that no group of caregivers feels slighted or ignored. The guidelines for initiating a call to the CCRT should clearly and unambiguously specify the clinical criteria required to activate the CCRT. Criteria, although there are slight differences between ICUs, mainly revolve around signs of rapid physiologic shut-down in the respiratory, circulatory and neurologic systems. An effort by the committee to avoid using confusing and highly technical or unit-specific terminologies will eliminate the possibility of the warning signs being missed by the afferent[3] arm of the rapid response system. (Table 2 shows a sample list of clinical criteria for initiating a CCRT call.) In the early phase of implementation, the committee should make it their goal to encourage the use of the response system by including more relaxed CCRT initiation call criteria, instead of putting emphasis on the appropriateness of the CCRT calls made. With time, and after the hospital has successfully incorporated the new system into its service structure, a review of CCRT operations can help to limit these to fewer critical signs of decompensation. The attending nurses are also usually encouraged to activate the system when they are concerned about the health condition of their patients even if none of the listed criteria have been explicitly met. This helps boost confidence in the CCRT.

Table 2

Guidelines on warning signs physiologic instability required to activate the RRT.5

Finally, the committee should draft a list of the materials that are required for the team's operation, as well as designing the team members’ shifts in such a way as to consider the available hands while at the same time ensuring that (ideally) 24-hour coverage is provided. These typically include IV and airway management supplies, a list of which should be continuously reviewed and updated as the team's experience grows.

Team membership

As regards CCRT composition, there are different models that have been employed in different clinical settings, partly as a reflection of inter-hospital differences and partly due to the lack of a specifically approved team structure from the International Consensus Conference on Medical Emergency Teams (ICMET).[3] Therefore, an important task of the committee is to identify the appropriate model that adequately addresses and satisfies the CCRT founding objectives. It is worth mentioning that, while the name CCRT has been interchangeably used to represent the different models of rapid response teams, certain advocates prefer the use of the term ‘MET’ (i.e., medical emergency team) to designate a physician-led team capable of initiating intensive care right at the very point of need.[3] In the same respect, the MET activities also includes advanced respiratory intervention, prescribing of treatment, and establishment of central venous access.[3] The term CCRT has been applied to a nurse-led rescue team. The composition decided upon by the committee should be reflective of the hospital size[13] and the intensive care structure, while at the same time taking into consideration the expertise available at its disposal. In any event however, the CCRT is expected to have as a minimum requirement, ICU nurses with extensive experience in critical care and respiratory therapists.[813] A medium to large-sized ICU should further include at least an intensive/critical care physician, resident doctors, intensivists, and anesthesiologists.[13] The competency coverage of the CCRT (e.g., whether it can directly initiate critical care at the patient's bedside, or it can only stabilize the deteriorating patient/condition while awaiting the attending physician) will ultimately depend upon the composition of the team. Consultation with the hospital legal department will ensure the responsibility assignment between team members respects their individual professional training.[13]

The training phase

There are two common goals associated with CCRT set up early identification of potentially fatal physiologic instability and ensuring that intensive level care is immediately available at the bedside of the patient.[2] This constitutes the guiding philosophy of the education process. The process of education to be undertaken in implementing a CCRT broadly consists of three levels: the training of the CCRT members; the training of the nursing staff involved in initiating CCRT calls; and the training of the entire hospital staff with the main objective being to create an awareness of the rescue system. The training of the CCRT members basically centers around the treatment of different aspects of clinical instabilities (respiratory, cardiovascular, and neurological instabilities) they will be seeing in real situations. Guidelines by the Institute of Healthcare Improvement (IHI) have advocated comprehensive training of the CCRT members with respect to their individual responsibilities within the team.[13] This will usually cover both general and specific responsibilities with a special emphasis on the need to deliver timely rescue services with a very low margin for errors. It is crucial to include attending physicians in the training process and participants should be made to understand that the CCRT is neither intended to replace existing code systems already in place, nor to usurp the responsibilities of the physician-in-charge. It is primarily to stabilize critically deteriorating patients until the attending physicians are available.

Active role-playing and simulation of actual clinical situations are strongly recommended during training, and the facilitators should ensure the classes are as interactive and inclusive as possible. Operational structures and procedures designed by the implementation committee, including computer software, algorithms and communication technologies for receiving calls placed to the CCRT service station, should be introduced and the facilitator should ensure the members adequately understand how these work.[5] Lastly, the members should be trained in the designated procedures for ensuring proper documentation of their activities, which usually includes the use of reporting forms and/or record books.

The nursing staff's direct interaction with the patients qualifies them for the task of initiating the CCRT calls; for this same reason they should also be properly trained. The training should cover the vital roles of the nursing staff in the rapid rescue system, the type of clinical signs presented by critically deteriorating patients that constitute the criteria for calling the CCRT, the crucial need for placing the call as soon as those signs are identified, and the established procedure for initiating a call. The process should make use of the drafted list of initial signs of clinical instability, and the nurses should be introduced to the founding goals of the CCRT.[2] Furthermore, nursing staff members have been of immense help towards the success of the CCRT by assisting in care delivery and providing important information about the patient's condition.[5] In recent developments, nurses have also been at the vanguard of instructing relatives of patients on how to activate the RRS.[14] For this, concisely written and easy-to-follow instructions (preferably multilingual) displayed in patients’ rooms have served both as a reminder and a quick guide for relatives on what to do to activate the rescue system. This new dimension to CCRT, an attempt at employing all available means to speed up the arrival of intensive care during critical health deterioration, is still in its infancy and a survey revealed that only 27 percent of families instructed on how to activate the RRS really understood the mechanism.[14] However, the fact that all the CCRT calls made by relatives necessitated a transfer to the pediatric ICU suggest that the initiative is a promising one and deserves further study.[1415]

Finally, the entire hospital staff members should be made aware of the system via institution-wide introductory workshops, presentations targeted at individual departments, and posters displaying simple steps needed to active the CCRT.

Launching out

The final launching of the team involves an initial pilot stage of between one to three months (which may be extended up to six months), allowing the team to get settled into actual clinical situations. This should be restricted to one or two units where the benefits of the CCRT can be easily assessed.[13] At the same time, this also allows the entire staff to become familiar with the team. During this period, frequent debriefing ensures that the team learns from every operation conducted, and data gathered from its activities are continuously employed for improving service delivery. After full transition to an established CCRT service, it is important that continuous appraisal and education of the members be continued to ensure progressive improvement.

CONCLUSION

The CCRT is an important care construct providing timely intervention to critically ill patients with rapidly deteriorating health conditions. By helping to stabilize the patient and delivering critical level care directly to the patient's bedside, the CCRT helps in decreasing both ICU mortality and number of cardiac arrests. The CCRT is highly institution-dependent, and some clinics also extend the activities of the team to include preemptive efforts via a critical care outreach (CCO)[3] model with an overarching aim of reducing ICU re-admission. Whichever model the implementation committee adopts for the CCRT, continuous education, fostering of cooperation among clinicians, and outcome evaluation are necessary for sustaining the benefits of a CCRT.