Clinical paperSuccessful implementation of a family and patient activated rapid response team in an adult level 1 trauma center☆
Introduction
When cardiac arrests occur in hospitalized patients, delays in treatment are associated with lower survival and poorer outcomes. Delays in treatment might be preventable as patients often show a physiological deterioration hours before cardiac or pulmonary arrest, with delays in activation of RRT having impacts on patient outcomes confirming the importance of time to therapy.1, 2 Seventy percent of patients show evidence of respiratory deterioration up to 8 h prior to cardiac arrest.3 In order to identify these “at-risk patients,” many hospitals have implemented rapid response teams (RRTs) as part of their involvement in the 100,000 Lives Campaign sponsored by the Institute for Healthcare Improvement (IHI).4
While it is clear that RRTs are important in the emergency response system of any hospital,1 there are some occasions when a healthcare provider is not available during the deterioration of the condition of a patient and so cannot activate the emergency response team. The opportunity for a non-healthcare provider, such as a patient's family member, being allowed to activate a RRT may address some of these occasions and allow assistance to be sought at an early stage. Family presence is a term describing the involvement of family members during the medical treatment of their loved one either as observers or as active participants. Prior to the development of cardiopulmonary resuscitation (CPR) in the late 1950s, family members were present at most deaths at home.5 Despite the influence of patient- and family-centered care concepts in the 1990s, family presence does not have universal acceptance in acute health care settings.6 Thus, family presence during CPR and invasive procedures has become a subject of attention in medical and nursing literature over the past 20 years.7
Common research themes involve the effects of family involvement in patient care on the potential disruption of care, feelings of discomfort being observed, and the potential for increased litigation. A substantial amount of research has followed, reporting positive results of family presence during CPR.8 Several national organizations have publicly acknowledged the benefits of family presence and adopted formal guidelines and practice statements, including the Emergency Nurses Association (ENA), the American Heart Association (AHA), and the American Association of Critical-Care Nurses (AACN).9
National Research Corporation (NRC) Picker's “Eight Dimensions of Patient-Centered Care” provided the conceptual framework for an approach that consciously accepts the patient's family's potential contributions in achieving improved care. The eight dimensions focus on (a) respect for patient values, preferences and expressed needs, (b) coordination and integration of care, (c) information, communication, and education, (d) physical comfort, emotional support, and alleviation of fear and anxiety, (e) involvement of family and friends, (f) transition and continuity, and (g) access to care. The involvement of family and friends dimension recognizes the central role of family members and close friends in the patients’ experience of illness. This dimension entails accommodation of family and friends, involving family in decision making, supporting the family as caregivers, and recognizing the needs of the family.10
Family presence as mentioned describes involvement of family members during the medical treatment of their loved one either as observers or active participants. For the purpose of this study, the definition of family published by the National Consensus Project for Quality Palliative Care was utilized: family is defined by the patient or in the case of minors or those without decision making capacity by their surrogates. Family may be related or unrelated to the patient. They are individuals who “provide support and with whom the patient has a significant relationship.”11
Taking into consideration these formal guidelines and research, Shands Jacksonville Medical Center (SJMC), a 696 bed level one trauma center, introduced and implemented a RRT with an additional mechanism for patients and family members to activate the team, if needed. This program enhancement was cooperatively adopted by the organization's medical staff with strong support of the University of Florida, College of Medicine, Jacksonville.
Section snippets
Methods
In conjunction with the University Health System Consortium's (UHC) Patient- and Family-Centered Care Implementation Collaborative, SJMC launched a pilot RRT in October 2006 followed by campus-wide implementation of RRT in July 2007. The program was enhanced in October 2007 to include implementation of patient and family activation of the RRT. The steps involved in initiating the project enhancement included a search of PubMed for literature reflecting patient or family activated RRTs. The
Results
RRTs were introduced in a small scale in October 2006 and campus-wide in July 2007, with the large-scale adoption of patient and family activation of the RRT in October 2007 (Table 2, which contains means and standard deviations for the measures that will be subsequently referred to). The average number of non-ICU codes differed for the three time periods (F = 15.75, p < 0.001). Based on Tukey pair-wise simultaneous 95% confidence intervals there was a significant difference between periods 1 and 2
Discussion
In June 2005, an International Conference on Medical Emergency Teams (ICMET) discussed the essential components of a rapid response system.1 Four key elements were identified: (1) a “crisis detection” mechanism, (2) a readily available response team, (3) a structure for resource support, and (4) a mechanism to evaluating crisis components and quality improvement. Medical Emergency Teams (MET) are usually physician-led (i.e. at the bedside) that prescribe therapy with full critical care
Conclusion
In searching the available literature (PubMed) we did not find any other programs where patient and family activation of RRT was implemented in a large academic, level 1 trauma hospital. Both RRT and family/patient RRT initiation has proven to be successful, coincident with a significant reduction of non-ICU hospital codes, reduced hospital mortality and reduced rescue failures at codes. This was all seen without an overload of false positive calls from patients or families. Each call from
Conflict of interest statement
There are no conflicts of interests expressed by any of the authors in relation to any component of this manuscript.
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“A Spanish translated version of the abstract of this article appears as Appendix in the online version at doi:10.1016/j.resuscitation.2010.06.020”.