Rapid Response Reaps Remarkable Results

Hospitals are used to dealing with a crisis. But what if the crisis can be avoided altogether? A team in cardiology, working on the problem of cardiac patients who experience an in-hospital cardiac arrest, has taken this approach and seen a dramatic and unprecedented drop in mortality among these individuals: from 80 percent mortality to 10 percent in the first six months of 2008.

 

“This has really worked much better than we even imaged,” said Dr. Jeffery Kluger, Associate Director of Cardiology and Director of Arrhythmia Services at Hartford Hospital. The cardiology approach is now the template for a hospital-wide response plan aimed at timelier life-saving interventions.

 

Cardiac patients can have sudden, life-threatening cardiac arrests in the hospital.  Patients can do poorly even when the medical response is rapid, appropriate and by the book. Experts from Cardiology closely reviewed these so-called “cardiac alerts” at Hartford Hospital and determined that most of these patients were not instantly experiencing potentially fatal heart rhythms -- but rhythm patterns that suggested a much slower deterioration of their health status. The Cardiology group concluded that it might be possible to halt that deterioration, avoid the crisis and save more patients.

 

Kluger said that Cardiology, using existing resources, organized a task force, developed a proposal for a response team based in the cardiac intensive care unit. The department developed criteria and logistics for activating the team and then trained critical care nurses, respiratory therapists, cardiology fellows and cardiology hospitalists using the hospital’s SIM Center. The pilot program launched on Dec. 14.

 

Since the launch, about 40 percent of patients handled by the response team have had to be moved to intensive care and there have been only two cardiac alerts outside the ICU – meaning that most at-risk patients are being identified and given appropriate care earlier than before. The mortality rate has dropped sharply – from 80 percent to 10 percent.

 

Saving patients is the big win, noted Kluger, but there are other advantages, too. The last-minute cardiac alert typically involved “a dozen people working frantically for a dismal outcome.” The new response team is usually made up of three people: a critical care nurse, a respiratory therapist and a cardiology fellow or hospitalist. For nurses on the floors, the team provides a quicker, simpler and more supportive response.

 

“Nurses now know that they’re not alone,” observed Kluger. Under the old system, the floor nurse paged the doctor on call, waited for that doctor to respond and to give verbal orders over the phone. The nurse would carry out those orders if the patient continued to deteriorate. “Now that nurse has the security of knowing that they dial one number to the intensive care unit and they will get immediate help to stabilize that patient and move that patient to a higher level of care, if necessary. At the same time, the team notifies the attending physician to keep them apprised of what’s going and to get any further directions.”

 

Karen Habig, Nurse Director of Cardiology Services, confirmed that the new approach is providing superior care and better staff support. “The Cardiology nursing staff has found the Rapid Response Team to be a tremendous support for our patients and certainly a positive experience for our team,” she said. “This initiative has clearly contributed to the reduction in cardiac alerts on the cardiology units.

 

As of May, the program is no longer a pilot, but a way of life in Cardiology. And it looks to be a model for three more response teams based in the other adult ICUs that would expand the coverage of the ICU centric model. Other teams will be formed in non-ICU-related areas including Radiology, Women's Health, the Institute of Living and Perioperative Services that will provide hospital-wide coverage. Such coverage will be mandated by the Joint Commission beginning Jan. 1.

 

Dr. Jamie Roche, Vice President for Patient Safety and Quality, said that the evidence supporting the new approach is growing. However, even without a stack of studies, it’s the right move. “The notion of early identification of patients in need -- and the placement of patients at the appropriate level of care – makes complete sense from a patient-centered perspective.”

 

Kluger said that while other hospitals may have dedicated response teams, the idea of drawing these teams from existing ICU staff is novel. The economic advantage, of course, is that creating the teams involves little in the way of new resources. “We didn’t spend any new money whatsoever,” he said. “The concept is not complicated or revolutionary. Organizing your resources in a more efficient way and a more effective way is not reinventing the wheel.”