TeamSTEPPS Rapid Response Systems Module: Classroom Slides TeamSTEPPS is a teamwork system developed jointly by the Department of Defense (DoD)and the Agency for Healthcare Research and Quality (AHRQ) to improve institutional collaboration and communication relating to patient safety. TeamSTEPPS® Rapid Response Systems ModuleClassroom SlidesContentsTeamSTEPPSTM for Rapid Response SystemsOverviewOverviewWhy Should You Care?Does it Work?Does the RRS Work?NQF Safe PracticesJoint Commission 2008 National Patient Safety GoalImplementationRRS StructureActivator(s)Responder(s)Activators & RespondersSupport: Quality Improvement & AdministrationLet's Watch the RRS in ActionTeamwork & RRSNecessary Teamwork SkillsInter-Team KnowledgeInter-Team Knowledge (continued)Transition Support ("Boundary Spanning")Transition Support ("Boundary Spanning") (continued)Example of One RRSExample of One RRS (continued)Example of Another RRSExample of Another RRS (continued)Example of Another RRS (continued)Exercise I: Let's Identify Your RRS StructureExercise I (continued): Let's Identify Your RRS StructureRRS ExecutionDetectionDetection: STEP AssessmentWhere can Detection occur?RRS ActivationRRS Activation: SBARResponse, Assessment & StabilizationResponse, Assessment & Stabilization HuddleResponse, Assessment & Stabilization CUS WordsPatient DispositionPatient Disposition (continued)RRS Transition: I PASS the BATONRRS EvaluationEvaluation: DebriefsSystem Evaluation: SensemakingSystem Evaluation: Sensemaking ToolsLet's look back at our exampleExercise II: RRS ExecutionExercise IIIScenario 1Scenario 2Scenario 3Scenario 4Scenario 5TeamSTEPPS™ for Rapid Response SystemsTeamSTEPPSTM for Rapid Response Systems (cover page).Decorative Image: TeamSTEPPSTM logo image, abbreviated title, and full title (Team Strategies & Tools to Enhance Performance & Patient Safety)Decorative Image: TeamSkills triangleReturn to TopOverviewWhat is the Rapid Response System? The Rapid Response System (RRS) is the overarching structure that coordinates all teams involved in a rapid response callWhat is TeamSTEPPS? The Agency for Healthcare Research and Quality's curriculum and materials for teaching teamwork tools and strategies to healthcare professionalsThis module of TeamSTEPPS is for RRSReturn to TopOverviewWhat is the Rapid Response Team? RRS has several parts, one of them being the Rapid Response Team (RRT)A RRT – known by some as the Medical Emergency Team – is a team of clinicians who bring critical care expertise to the patient's bedside or wherever it is needed (IHI, 2007)Return to TopWhy Should You Care?People die unnecessarily every day in our hospitalsIt is likely that each of you can provide an example of a patient who, in retrospect, should not have died during his or her hospitalizationThere are often clear early warning signs of deteriorationEstablishing a RRS is one of the Joint Commission's 2008 National Patient Safety GoalsTeamwork is critical to successful rapid responseThe evidence suggests that RRS work!Return to TopDoes it Work? BeforeAfterNo. of cardiac arrests6322Deaths from cardiac arrest3716No. of days in ICU post arrest16333No. of days in hospital after arrest1363159Inpatient deaths302222Bellomo R, Goldsmith D, Uchino S, et al. A prospective before-and-after trial of a medical emergency team. Medical Journal of Australia. 2003;179(6):283-287.Return to TopDoes the RRS Work?50% reduction in non-ICU arrestsBuist MD, Moore GE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study. BMJ. 2002;324:387-390.Reduced post-operative emergency ICU transfers (58%)and deaths (37%)Bellomo R, Goldsmith D, Uchino S, et al. Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med. 2004;32:916-921.Reduction in arrest prior to ICU transfer (4% vs. 30%)Goldhill DR, Worthington L, Mulcahy A, Tarling M, Sumner A. The patient-at-risk team: identifying and managing seriously ill ward patients. Anesthesia. 1999;54(9):853-860.17% decrease in the incidence of cardiopulmonary arrests(6.5 vs. 5.4 per 1000 admissions)DeVita MA, Braithwaite RS, Mahidhara R, Stuart S, Foraida M, Simmons RL. Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Qual Saf Health Care. 2004;13(4):251-254.Return to TopNQF Safe PracticesIn 2003, the National Quality Forum (NQF) identified the RRS as a chief example of a team intervention serving the safe practice element of Team Training and Team Interventions RRSs are viewed as an ideal example of safe practices in teamwork meeting the objective of establishing a proactive systemic approach to team-based careIn 2006, the NQF updated their Safe Practices recommendations NQF continues to endorse RRSs and concludes that annually organizations should formally evaluate the opportunity for using rapid response systems to address the issues of deteriorating patients (NQF, 2006)Return to TopJoint Commission 2008 National Patient Safety GoalGoal 16: Improve recognition and response to changes in a patient's condition 16A. The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient's condition appears to be worseningReturn to TopImplementationWhen implementing RRS, the Institute for Healthcare Improvement (IHI) recommends: Engaging senior leadershipIdentifying key staff for RRTsEstablishing alert criteria and a mechanism for calling the RRTEducating staff about alert criteria and protocolUsing a structured documentation toolEstablishing feedback mechanismsMeasuring effectivenessRRS can be customized to meet your institutions' needs and resourcesReturn to TopRRS StructureImage: RRS Structure graphic with one Activator penguin dressed in cavalry uniform sounding a bugle, two Responder Penguins in cavalry uniforms, one QI Penguin wearing a lab coat, and one Administration Penguin holding a clipboard and wearing a lab coat. All five are standing on blocks, with the Activator and Responder penguins on a block labeled 'Clinical Treatment', and the QI and Administration penguins on a block labeled 'Support Mechanisms'. A Feedback loop circles through each block, connecting all the penguins.Return to TopActivator(s)Activators can be: Floor staffA technicianThe patientA family memberSpecialistsAnyone sensing the acute deteriorationImage: Activator is depicted as a penguin dressed in cavalry uniform sounding a bugle.Return to TopResponder(s)Responders come to the bedside and assess the patient's situationResponders determine patient disposition, which could include: Transferring the patient to another critical care unit (e.g., ICU or CCU)A handoff back to the primary nurse/primary physicianRevising the treatment planActivators may become Responders and assist in stabilizing the patientImage: Responders are depicted as two penguins in cavalry uniforms.Return to TopActivators & RespondersActivator(s) are responsible for calling the Responder(s) if a patient meets the calling criteriaResponders must reinforce the Activator(s) for calling:"Why did you call?" vs. "Thank you for calling. What is the situation?"Remember: There are no "bad calls"!Return to TopSupport: Quality Improvement & AdministrationThe Quality Improvement (QI) Team supports Activators and Responders by reviewing RRS events and evaluating data for the purpose of improving RRS processesThe Administration Team of the RRS brings organizational resources, support, and leadership to the entire RRS and ensures that changes in processes are implemented if necessaryImage: QI Team is depicted as a penguin wearing a lab coat.Return to TopLet's Watch the RRS in ActionImage: Screen shot of TeamSTEPPS-RRS "failed opportunity" video vignette showing nurse, patient in bed, and visitor. Let's Watch the RRS in Action (Flash video, 7 min., 18 sec.; 22.5 MB) (Download Flash)Return to TopTeamwork & RRSThe RRS has all these barriers to effective care: ConflictLack of coordinationDistractionsFatigueWorkloadMisinterpretation of cuesLack of role clarityInconsistency in team membershipLack of timeLack of information sharingImage: Two penguins wearing surgical scrub shirts flank a tower of ice blocks labeled as above.Return to TopNecessary Teamwork SkillsImage: Large TeamSkills Triangle Logo. The logo is a triangle that has 4 blocks inside a circle entitled Patient Care Team. The words knowledge, attitudes, and performance appear in each point of the triangle and point through the Patient Care Team circle to the Skills blocks entitled Leadership, Communication, Situation Monitoring, and Mutual Support.Return to TopInter-Team KnowledgeSupports effective transitions in care between unitsIs a prerequisite for transition support (or "boundary spanning")Consists of understanding the roles and responsibilities of each team within the RRSReturn to TopInter-Team Knowledge (continued)In the RRS, inter-team knowledge means all RRS members possess a shared understanding of the roles and responsibilities of all other membersActivators must know the roles and responsibilities of Responders and vice versaImage: A block made up of four pieces labeled Activators, Responders, Quality Improvement, and Administration. Teamwork is connecting all of the blocks. Above the Activator section, an Activator penguin is thinking, "Responders need... ICU requires..." Above the Responders section, two responder penguins are thinking, "Activator needs...ICU requires... Administration requires... Patient needs..."Return to TopTransition Support ("Boundary Spanning")Requires inter-team knowledgeCombines monitoring transitions in care and providing backup behavior when neededProvides role support Example: Activator becoming ResponderReturn to TopTransition Support ("Boundary Spanning") (continued)Manage dataMonitor transitionsEducate staff on situation and rolesEnsure data recordingAssist in role orientationImage: A block made up of four pieces labeled Activators, Responders, Quality Improvement, and Administration. A penguin with a patient is shown in the middle of the block.Return to TopExample of One RRSActivators call Responders using a pagerWho are the Responders? ICU PhysicianICU Charge NurseNurse Practitioner (if available)RRS coordinatorTransportation serviceFor Pediatric Unit, chaplain's office, security, and respiratory therapist are also includedReturn to TopExample of One RRS (continued)Training Includes direct teaching modules on rapid response and practice using Situation-Background-Assessment-Recommendation (SBAR)Online training modulesSingle-discipline training sessionsData Collection includes reporting: Who called the response team and what criteria were used?Who responded and in what timeframe?What was done for the patient?What are the top 5 diagnoses seen in the RRS?Return to TopExample of Another RRSActivators call Responders using an overhead page and a pager Family members are considered ActivatorsResponders include: Nursing staffRespiratory care staffICU staffReturn to TopExample of Another RRS (continued)Training In-class sessionsSimulation centerInterdisciplinary training in same locationData collection Event debriefingTask-oriented checklist by rolesReturn to TopExample of Another RRS (continued)Respiratory Therapist TasksCompleted?1. Check the patient's pulse.Checked2. Obtain vital signs.Not Checked3. Place the pulse oximeter.Not Checked4. Assess patient's IVs.Not CheckedRespiratory Therapist TasksCompleted?1. Assess the airway.Not Checked2. Count the respiratory rate.Not Checked3. Assist ventilation.Not Checked4. Check the patient's pupils.Not CheckedReturn to TopExercise I: Let's Identify Your RRS StructureThink about the four components of the RRS: Activators, Responders, QI and AdministrativeWho are the Activators? What are the alert criteria?How are Responders called?What do Activators do onceResponders arrive?Who are the Responders? How many Responders arrive to a call?What is each person's role? Return to TopExercise I (continued): Let's Identify Your RRS StructureWhat are the common challenges facing your RRS?Are there challenges during: Patient deterioration?System activation?Patient handoffs?Patient treatment?Evaluation of the response team?Return to TopRRS ExecutionReturn to TopDetection(Slide shows three boxes, from left to right: First box)Activator sees signs of acute deterioration before actual deterioration Detection(Arrow points from first box to second box: Second box)Situation Monitoring Detection(Line connects second box to third box)Tools/Strategies HuddleSTEPDetection (Flash video, 2 min., 25 sec.; 10 MB)Return to TopDetection: STEP AssessmentGraphic displays meaning of the components of the STEP assessment: Status of the Patient, Team Members, Environment, and Progress towards the goal.Two boxes point toward the top element of the STEP diagram (Status of the Patient):Use your institution's detection criteria for RRS activationIs it time to activate the RRS?Return to TopWhere can Detection occur?Detection can occur from a variety of sources or concernsImage: Activator penguin holding oversize magnifying glass observes others huddling around patient in bed.Return to TopRRS Activation(Image: Line from box points to Responder penguins as Activator penguin sounds alarm with bugle. Text in box reads:)Communication Tools/Strategies: SBARRS Activation (Flash video, 32 sec.; 2.2 MB) (Download Flash)Return to TopRRS Activation: SBARSBAR provides a framework for team members to effectively communicate information to one anotherCommunicate the following information: Situation—What is going on with the patient?Background—What is the clinical background or context?Assessment—What do I think the problem is?Recommendation/Request—What would I recommend/request?Remember to introduce yourself...Return to TopResponse, Assessment & Stabilization(First text box reads:)Responders analyze patient condition; attempt to stabilize Response, Assessment & Stabilization(Points to second text box, which reads: )Leadership, Situation Monitoring, Mutual Support, Communication, & Inter-Team Knowledge Response, Assessment & Stabilization(Points to three text boxes)Tools/Strategies: LeadershipBriefHuddleTools/Strategies: CommunicationCheck-backCall OutTools/Strategies: Mutual SupportTask AssistanceCUSResponse, Assessment & Stabilization (Flash video, 2 min. 43 sec.; 11 MB) (Download Flash)Return to TopResponse, Assessment & Stabilization HuddleProblem solvingHold ad hoc, "touch-base" meetings to regain situation awarenessDiscuss critical issues and emerging eventsAnticipate outcomes and likely contingenciesAssign resourcesExpress concerns(Photo of medical staff in an operating room.)Devise contingencies for sending the patient to the ICU or other ancillary units.(Photo of patient and health care professional in a hospital room.)Devise contingencies for a handoff back to the general care area (i.e., keeping the patient in current location).Return to TopResponse, Assessment & Stabilization CUS Words(Image: 3-part illustration of CUS Words concept using penguins as demonstrators.)C—I am Concerned!U—I am Uncomfortable!S—This is a Safety Issue (STOP!)Return to TopPatient Disposition(Image: Two penguins transferring a patient on a gurney.)Communication Tools/StrategiesHandoffsSBARI PASS the BATON Patient Disposition (Flash video, 1 min., 17 sec.; 5.3 MB) (Download Flash)Return to TopPatient Disposition (continued)Disposition can refer to a number of decisions, including:Transferring the patient to another unitA handoff back to the primary nurse/primary physician (i.e., patient stays in same location)A handoff to a specialized team (cardiac team, code team, stroke team, etc)A revised plan of careReturn to TopRRS Transition: I PASS the BATONIntroduction:Introduce yourself and your role/job (include patient)Patient:Identifiers, age, sex, locationAssessment:Present chief complaint, vital signs, symptoms, and diagnosisSituation:Current status/circumstances, including code status, level of uncertainty, recent changes, and response to treatmentSafety:Critical lab values/reports, socio-economic factors, allergies, and alerts (falls, isolation, etc.)THEBackground:Co-morbidities, previous episodes, current medications, and family historyActions:What actions were taken or are required? Provide brief rationaleTiming:Level of urgency and explicit timing and prioritization of actionsOwnership:Who is responsible (nurse/doctor/team)? Include patient/family responsibilitiesNext:What will happen next? Anticipated changes? What is the plan? Are there contingency plans?Question, Clarify, and ConfirmReturn to TopRRS Evaluation(First text box:)Activators, Responders, Admin & QI Components evaluate performance and assess data for process improvement Evaluation(Points to second text box:)Leadership, Sensemaking & Communication Evaluation(Points to third text box:)Tools/Strategies DebriefsSensemakingChecklist RRS Evaluation (Flash video, 1 min. 8 sec.; 4.5 MB)Return to TopEvaluation: DebriefsDebriefs occur right after the event and are conducted by the RespondersDebriefs should address: RolesResponsibilitiesTasksEmphasis on transitions in careAchievement of patient stabilization(Text Box/Example Checklist)TopicCommunication clear?—checkedRoles and responsibilities understood?—checkedSituation awareness maintained?—checkedWorkload distribution?—checkedDid we ask for or offer assistance?—checkedWere errors made or avoided?—checkedWhat went well, what should changes, what can improve?—checked Return to TopSystem Evaluation: SensemakingSensemaking Review SheetHow did the Activators and Responders react to this situation?When looking at the "big picture," are there any patterns or trends?Return to TopSystem Evaluation: Sensemaking ToolsProactive approaches Failure Modes and Effects Analysis (FMEA)Probabilistic Risk Assessment (PRA)Reactive approaches Root Cause Analysis (RCA)(Text box at right describes the integrated approaches.)Integrated Sensemaking ApproachWhat can go wrong?What are the consequences?How do things go wrong?How likely are they?What went wrong?Why did it go wrong?Return to TopLet's look back at our exampleLet's Look Back at Our Example (Flash video, 8 min., 22 sec.; 35.6 MB) (Download Flash)Return to TopExercise II: RRS ExecutionUsing the scenario provided, identify the five phases of the RRS and what tools and/or strategies were used during each phaseDetectionActivationResponse, Assessment, and StabilizationDispositionEvaluationReturn to TopExercise IIILet's see if we can identify the tools needed or used in each exampleScenario 1Scenario 2Scenario 3Scenario 4Scenario 5 Exercise Return to TopScenario 1The nurse called the RRT to a patient who exhibited a reduced respiratory rate. The team was paged via overhead page. Within several minutes, team members arrived at the patient's room; however, the respiratory therapist did not arrive. After a second overhead page and other calls, the respiratory therapist arrived, stating that he could not arrive sooner due to duties in the ICU. This critical team member did not ascribe importance to the rapid response call and failed to provide a critical skill during a rapid response event. As a result, there was a delay in the assessment of the patient's airway and intervention pending arrival of the response respiratory therapist.Return to TopScenario 2The RRT was called for a patient who had a risk of respiratory failure. The patient was intubated and transferred to a higher level of care. Response team members and the nurse who called the team completed a Call Evaluation Form. The response team members noted that some supplies, such as nonrebreather masks and an intubation kit, were not readily available on the floor, which resulted in a delay. This delay could have impacted the patient, and it also affected the team members' ability to return to their patient assignments. The patient's nurse noted on the form that the response team seemed agitated by the lack of supplies and the delay. The evaluation forms were sent via interdepartmental mail to the quality department as indicated on the form. The forms were not collated or reviewed for several weeks. The analyst responsible felt that most of the reports prepared in the past were not used by or of interest to management. Several times the agenda item for RRS updates had been removed from the Quality Council's meeting agenda due to an expectation that the "Rapid Response System is running fine."Return to TopScenario 3A family member noticed the patient seemed lethargic and confused. The family member alerted the nurse about these concerns. The nurse assured the family member that she would check on the patient. An hour later, the family member reminded the nurse, who then assessed the patient. The nurse checked the patient's vital signs. She did not note any specific change in clinical status, though she agreed that the patient seemed lethargic. At the family member's urging, the nurse contacted the physician, but the conversation focused on the family member's insistence that the nurse call the physician rather than conveying a specific description of the patient's condition. Based on the unclear assessment, the physician did not have specific instructions. The physician recommended additional monitoring.Another nurse on the floor suggested calling the RRT, which she heard had helped with this type of situation on another floor. The first nurse missed the training about the new RRS, which was not discussed in staff meetings. Based on her colleague's recommendation, the nurse called the RRT via the operator. The overhead page stated the unit where assistance was needed but not the patient's room number. The operator forgot to take down all of the usual information because he missed lunch and was distracted. The team arrived on the floor but had to wait to be directed to the appropriate room. Once there, the RRT received a brief overview from the nurse, who left the room shortly afterward. The responders conducted an assessment of the patient and identified that the patient was overmedicated.Return to TopScenario 4The RRT was called to the outpatient (OP) area for a report of a patient with a seizure. The usual or expected set of supplies was not available for the team in the OP area. The RRT arrived and assessed the patient. As part of the assessment, the team ordered a stat lab. The lab technician working with the OP area had not heard of the RRS and refused to facilitate a stat lab because he was unfamiliar with having this need in an OP area. The RRT members were frustrated but did not challenge the lab technician. The patient was taken to the Emergency Department.Return to TopScenario 5A night nurse noted that a patient who had been on the unit for 2 days seemed more tired than usual. Although the patient was usually responsive and animated, she did not seem as responsive during the evening shift. After checking on her twice, the nurse noted that the patient seemed weak and confused. The nurse called the physician at 3 a.m. and described the patient's general status change as being "not quite right" but did not provide a detailed report or recommendation. The physician, frustrated, did not ask probing questions about the patient. The physician noted that it was 3 a.m., mentioned that perhaps the patient was tired, and instructed the nurse to monitor the patient. The next morning, the physician came in to do rounds and could not find a complete update from the previous evening. Upon assessing the patient, the physician ordered a stat MRI to rule out stroke.The nurse experienced anxiety due to deterioration of patient status and inability to communicate with the physician. The physician was frustrated by not clearly receiving all of the relevant patient information during the first physician-nurse communication. The patient's stroke remained unidentified during evening shift.Return to TopReturn to Index Current as of November 2008 Internet Citation: TeamSTEPPS Rapid Response Systems Module: Classroom Slides. November 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/rrs/rrs_slides/rrsslides.html
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