Rochester General Hospital, Rochester
Deployment of Rapid Response Teams (RRTs)
Team Members:
· Mary Lu Daly, M.S., R.N., C.C.R.N., C.C.N.S., Clinical Nurse Specialist, Medical Intensive Care Unit (MICU)· Jeanne Powers, M.S., R.N., C.C.R.N., C.M.C., Clinical Nurse Specialist, MICU
· Vicky Orto, M.S., R.N., C.N.A.A., B.C., Director of Medical-Surgical Nursing
Goals/Targets:
· Improve patient outcomes by facilitating early transfer to the MICU, thereby reducing adverse events.
· Increase nursing staff satisfaction by bringing critical care expertise to general care units, thus supporting the general care staff nurse.
· Expected patient outcomes include: earlier treatment and possibly averting the need for transfer to MICU, but, if necessary, earlier transfer to MICU. Anticipated nursing outcomes include: facilitation of communication, rapport-building, skills acquisition, and professional growth and development.
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Process Improvements:An Early Nursing Intervention Team (ENIT) is a program that goes above and beyond the RRT concept. In addition to responding to calls from general care units concerning a patient’s clinical deterioration, the ENIT program includes twice daily rounding on all general care units by an experienced MICU nurse. Implementation of the ENIT program required the following changes:
· Initiated twice daily rounding on all general care units, including educating staff about the ENIT program and addressing any patient/clinical issues to include the Situation Background Assessment Recommendation (SBAR) concept.
· Developed system of paging/calling ENIT nurse at the floor nurse’s first concern for a patient.
· Established activation criteria for ENIT calls.
· Obtained budgetary approval to increase registered nurse staffing complement in the MICU to accommodate the ENIT program, thus ensuring that the ENIT nurse is able to round twice daily on ten inpatient units.
· Provided pre-implementation education to all nursing staff.
· Communicated the concept and purpose of the ENIT program to all medical staff.
· Implemented weekly planning meetings prior to ENIT program inception.
· Continued regular meetings to provide feedback about the ENIT program and share lessons learned.
· Established regular meetings with key medical staff and the Chief of Medicine.
· Established follow-up call to general care units to track progress of patients seen by the ENIT nurse.
Nursing staff education included the following processes and procedures:
· Role of the floor nurse vs. the role of the ENIT nurse.
· Use of SBAR tool.
· Activation criteria.
· Activation process.
Procedure: floor nurse actions:
· Recognize clinical instability.· Collaborate with floor charge nurse.
· Notify provider.
· Call ENIT nurse.
· Collaborate with ENIT nurse.
· Documentation.
· Ensure family notification if appropriate.
Procedure: ENIT nurse actions (including rounding twice daily):
· Assess patient.
· Stabilize patient.
· Assist staff with communication.
· Educate and support staff.
· Assist with transfer to MICU if needed.
· Documentation.
· Follow-up telephone call.
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What Are the Most Effective Strategies and Why?
The key to success is the twice daily rounding. This established a rapport between the MICU staff and the general care staff. As a result, the floor staff do not hesitate to call the ENIT nurse when they are concerned about a patient. Using the MICU charge nurse in the ENIT role has also been an integral part of the success. The MICU charge nurse is in the best position to facilitate optimum patient flow in and out of the MICU because he or she is aware of potential transfers out of the unit, potential transfers into the unit from the emergency department and the floors, and can prioritize this flow. Finally, yet importantly, having enthusiastic support from top leadership in the institution has also been a factor in Rochester General Hospital’s success. The MICU was able to increase the budgeted full-time equivalents to provide the necessary staffing to free the MICU charge nurse of a patient assignment.Lessons Learned:
· Ensure communication to all involved staff: nursing and medical staff at all levels―from the staff nurse to the off-shift nursing supervisors to the chief nursing officer―from the first-year resident and mid-level providers to the attending physicians.· Involve all key stakeholders from the onset and follow up with them as needed.
· Feedback through both formal and informal routes has led to changes in the program and to hospital-wide implementation.
· Develop teams that are a good fit for your institution―nurse-led teams are a successful model at Rochester General, but may not be the best model for other institutions (sometimes a very creative approach can work; persevere when criticized).
· Advertise your success; use exemplars.
· Continue to grow and develop the general care staff toward the goal of increasing independence from the critical care staff.
· Prepare for an influx of experienced nurses from general care units ready to transfer to the MICU.
· Avoid turf wars; promote collegiality.
· Provide regular oversight through regular meetings with the ENIT nurse team to ensure consistent program implementation.
· Twice daily rounding has led to side benefits of increased collegiality and recruitment of a experienced general care nurse to the MICU.
· The intensive care unit staff vacancy rate has dropped dramatically from a high of 36% in early 2004 to 13% in early 2006.
The only problem encountered was early resistance to the program by the medical house staff due to the increase in workload associated with writing transfer orders and notes. While Rochester General had communicated the proposed program to the attending physicians, there was inadequate communication with the medical resident staff. The facility overcame the issue by:
· meeting with house staff annually and educating them to the necessity of patient transfers to the MICU for nursing care;
· meeting with the Chief of Medicine and the Director of Residency program quarterly; and
· accepting patients in the MICU to be covered by the “floor” residents rather than the MICU residents.
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Techniques for Sustaining the Results:Communication is the key. Rochester General has celebrated its success every step of the way―at the unit level to the executive management level. An ENIT planning committee continues to meet twice monthly to report on the progress of the program and to identify concerns, opportunities for improvement, and even expansion of the program. A communication sheet is completed each shift by the ENIT nurse to note any issues encountered on ENIT rounds.
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Outcomes:There has been a 43% reduction in codes on general care units in the first year of the ENIT program compared to the same timeframe in the previous year. There were 44 codes from June 2004 to May 2005, compared to just 25 codes from June 2005 to May 2006. Other patient data currently being analyzed include survival to discharge, length of stay, and time to transfer to ICU following ENIT.
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Quality Improvement Contact:Vicky Orto, M.S., R.N., C.N.A.A., B.C.
Director, Medical-Surgical Nursing
o Telephone: (585) 922-4073
o E-mail:
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