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Don't have an ICU? You can still have an RRT
Smaller facilities look to their ED to fill staffing needs
The "traditional" model of a rapid response team (RRT), as outlined by the Boston-based Institute for Healthcare Improvement (IHI) and employed by a large number of hospitals, is often driven by (and mainly staffed by) the ICU or other staff with critical care experience, such as critical care nurses. But in a growing number of facilities, particularly smaller community hospitals, that role is now being filled by the emergency department (ED).
"The hospitals that I have talked with who utilize this model do so for several reasons — either the lack of an ICU unit, [insufficient] staffing, or for physician coverage of the rapid response team," notes Kathy D. Duncan, RN, expert faculty for RRTs at the IHI.
Duncan says this model, while used mostly in smaller hospitals, is not restricted to facilities that lack ICUs. "Sometimes they do have an ICU, but if it usually has only one or two patients, the nurses are cross-trained to be both ICU and ED nurses," she notes. By being cross-trained, they can alternate assignments from shift to shift, depending on need, she says. Also, no matter which unit is handling the rapid response team (RRT), a nurse in the other unit still might carry a beeper and serve as a backup.
Duncan adds that sometimes these nurses are cross-trained by the ED, while in other facilities the ED staff are the RRT. "Staffing often comes from that unit because they are there 24/7," Duncan explains.
In addition, if a physician is needed by the RRT, "the only guy in the building is often the ED doc," notes Duncan. "Most facilities will have a triage situation where the nurse and respiratory therapist will do the initial assessment, and if things look bad, they'll call the ED doc."
In facilities like these, she continues, the RRT may not be called that often — perhaps three or four times a month, she suggests — "but it's important to have someone available."
Large facilities different
In larger hospitals, says Duncan, this model is rarely used, and the ED and the RRT will not directly interface nearly enough. "I have heard from some folks in one Cincinnati facility that if the ED is holding patients for a longer period of time, and these are essentially med/surg patients waiting on a bed, there is some magic point in time — perhaps after two to four hours — after which they may call the rapid response team if the patient is deteriorating or if you need an extra set of hands," she notes.
It's extremely important, when the ED is the focal point of the RRT, that the department's manager be more knowledgeable about RRTs, says Duncan. "The manager needs to know all there is to know if they are providing coverage," she notes. "For example, in one small hospital in Cleveland, the ED manager and the ICU manager take turns on the RRT."
Running the show
Someone who definitely needs to know "all there is to know" is Patti Massmann, RN, director of nursing at Granite Falls (MN) Hospital, a small rural, critical access facility. Massmann oversees the RRT at Granite Falls, which went live in July 2006. While the team is run through emergency services, there is no manager for those services other than Massmann.
The structure was determined by the hospital's critical care team, says Massmann. "We had discussions regarding the framework of rapid response teams, looked at other facilities, reviewed IHI's recommendations [for setting up an RRT] and then made a model that made sense for us," she says.
Since Granite Falls has an ambulance service, says Massmann, "it made sense to use EMS staff since they are on call 24/7," she says. Half of the paramedics are also RNs and function as such within the hospital, she says. The rest of the team consists of the bedside nurse and the physician.
Anybody can make a call for the team, which comes through on the pagers that all team members carry, Massmann says. "The first criterion [for a call] is that you are worried — that something's just not right with the patient," she explains.
The primary benefit to the hospital is getting extra hands to the bedside fast when a patient is in critical condition, Massmann says.
In the past, says Massmann, these patients might have been put on the med/surg floor or in a monitored unit. "All of that is time-consuming," she says. "Now, we can get all the players to the bedside and, hopefully, keep the patient in the room and not have to move them to a higher level of care."
For more information, contact:
Kathy D. Duncan, RN, Expert Faculty for Rapid Response Teams, Institute for Healthcare Improvement, Marion, AR. Phone: (870) 739-3193.
Patti Massmann, RN, Director of Nursing, Granite Falls Hospital, 345 10th Ave., Granite Falls, MN 56241. Phone: (320) 564-6211.