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.

Contents

  1. TeamSTEPPSTM for Rapid Response Systems
  2. Overview
  3. Overview
  4. Why Should You Care?
  5. Does it Work?
  6. Does the RRS Work?
  7. NQF Safe Practices
  8. Joint Commission 2008 National Patient Safety Goal
  9. Implementation
  10. RRS Structure
  11. Activator(s)
  12. Responder(s)
  13. Activators & Responders
  14. Support: Quality Improvement & Administration
  15. Let's Watch the RRS in Action
  16. Teamwork & RRS
  17. Necessary Teamwork Skills
  18. Inter-Team Knowledge
  19. Inter-Team Knowledge (continued)
  20. Transition Support ("Boundary Spanning")
  21. Transition Support ("Boundary Spanning") (continued)
  22. Example of One RRS
  23. Example of One RRS (continued)
  24. Example of Another RRS
  25. Example of Another RRS (continued)
  26. Example of Another RRS (continued)
  27. Exercise I: Let's Identify Your RRS Structure
  28. Exercise I (continued): Let's Identify Your RRS Structure
  29. RRS Execution
  30. Detection
  31. Detection: STEP Assessment
  32. Where can Detection occur?
  33. RRS Activation
  34. RRS Activation: SBAR
  35. Response, Assessment & Stabilization
  36. Response, Assessment & Stabilization Huddle
  37. Response, Assessment & Stabilization CUS Words
  38. Patient Disposition
  39. Patient Disposition (continued)
  40. RRS Transition: I PASS the BATON
  41. RRS Evaluation
  42. Evaluation: Debriefs
  43. System Evaluation: Sensemaking
  44. System Evaluation: Sensemaking Tools
  45. Let's look back at our example
  46. Exercise II: RRS Execution
  47. Exercise III
  48. Scenario 1
  49. Scenario 2
  50. Scenario 3
  51. Scenario 4
  52. Scenario 5

TeamSTEPPS™ for Rapid Response Systems

TeamSTEPPSTM 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 triangle

Return to Top


Overview

  • What is the Rapid Response System?
    • The Rapid Response System (RRS) is the overarching structure that coordinates all teams involved in a rapid response call
  • What is TeamSTEPPS?
    • The Agency for Healthcare Research and Quality's curriculum and materials for teaching teamwork tools and strategies to healthcare professionals
    • This module of TeamSTEPPS is for RRS

Return to Top


Overview

  • What 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 Top


Why Should You Care?

  • People die unnecessarily every day in our hospitals
  • It is likely that each of you can provide an example of a patient who, in retrospect, should not have died during his or her hospitalization
  • There are often clear early warning signs of deterioration
  • Establishing a RRS is one of the Joint Commission's 2008 National Patient Safety Goals
  • Teamwork is critical to successful rapid response
  • The evidence suggests that RRS work!

Return to Top


Does it Work?

 BeforeAfter
No. of cardiac arrests6322
Deaths from cardiac arrest3716
No. of days in ICU post arrest16333
No. of days in hospital after arrest1363159
Inpatient deaths302222

Bellomo 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 Top


Does the RRS Work?

  • 50% reduction in non-ICU arrests
Buist 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 Top


NQF Safe Practices

  • In 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 care
  • In 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 Top


Joint Commission 2008 National Patient Safety Goal

  • Goal 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 worsening

Return to Top


Implementation

  • When implementing RRS, the Institute for Healthcare Improvement (IHI) recommends:
    • Engaging senior leadership
    • Identifying key staff for RRTs
    • Establishing alert criteria and a mechanism for calling the RRT
    • Educating staff about alert criteria and protocol
    • Using a structured documentation tool
    • Establishing feedback mechanisms
    • Measuring effectiveness
  • RRS can be customized to meet your institutions' needs and resources

Return to Top


RRS Structure

Image: 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 Top


Activator(s)

  • Activators can be:
    • Floor staff
    • A technician
    • The patient
    • A family member
    • Specialists
    • Anyone sensing the acute deterioration

Image: Activator is depicted as a penguin dressed in cavalry uniform sounding a bugle.

Return to Top


Responder(s)

  • Responders come to the bedside and assess the patient's situation
  • Responders 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 physician
    • Revising the treatment plan
  • Activators may become Responders and assist in stabilizing the patient

Image: Responders are depicted as two penguins in cavalry uniforms.

Return to Top


Activators & Responders

  • Activator(s) are responsible for calling the Responder(s) if a patient meets the calling criteria
  • Responders 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 Top


Support: Quality Improvement & Administration

  • The Quality Improvement (QI) Team supports Activators and Responders by reviewing RRS events and evaluating data for the purpose of improving RRS processes
  • The Administration Team of the RRS brings organizational resources, support, and leadership to the entire RRS and ensures that changes in processes are implemented if necessary

Image: QI Team is depicted as a penguin wearing a lab coat.

Return to Top


Let's Watch the RRS in Action

Image: Screen shot of TeamSTEPPS-RRS "failed opportunity" video vignette showing nurse, patient in bed, and visitor.

'Roll 'Em!' Play Video (icon: penguin film director)  
Let's Watch the RRS in Action (Flash video, 7 min., 18 sec.; 22.5 MB) (Download Flash)

Return to Top


Teamwork & RRS

  • The RRS has all these barriers to effective care:
    • Conflict
    • Lack of coordination
    • Distractions
    • Fatigue
    • Workload
    • Misinterpretation of cues
    • Lack of role clarity
    • Inconsistency in team membership
    • Lack of time
    • Lack of information sharing

Image: Two penguins wearing surgical scrub shirts flank a tower of ice blocks labeled as above.

Return to Top


Necessary Teamwork Skills

Image: 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 Top


Inter-Team Knowledge

  • Supports effective transitions in care between units
  • Is a prerequisite for transition support (or "boundary spanning")
  • Consists of understanding the roles and responsibilities of each team within the RRS

Return to Top


Inter-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 members
  • Activators must know the roles and responsibilities of Responders and vice versa

Image: 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 Top


Transition Support ("Boundary Spanning")

  • Requires inter-team knowledge
  • Combines monitoring transitions in care and providing backup behavior when needed
  • Provides role support
    • Example: Activator becoming Responder

Return to Top


Transition Support ("Boundary Spanning") (continued)

  • Manage data
  • Monitor transitions
  • Educate staff on situation and roles
  • Ensure data recording
  • Assist in role orientation

Image: 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 Top


Example of One RRS

  • Activators call Responders using a pager
  • Who are the Responders?
    • ICU Physician
    • ICU Charge Nurse
    • Nurse Practitioner (if available)
    • RRS coordinator
    • Transportation service
    • For Pediatric Unit, chaplain's office, security, and respiratory therapist are also included

Return to Top


Example of One RRS (continued)

  • Training
    • Includes direct teaching modules on rapid response and practice using Situation-Background-Assessment-Recommendation (SBAR)
    • Online training modules
    • Single-discipline training sessions
  • Data 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 Top


Example of Another RRS

  • Activators call Responders using an overhead page and a pager
    • Family members are considered Activators
  • Responders include:
    • Nursing staff
    • Respiratory care staff
    • ICU staff

Return to Top


Example of Another RRS (continued)

  • Training
    • In-class sessions
    • Simulation center
    • Interdisciplinary training in same location
  • Data collection
    • Event debriefing
    • Task-oriented checklist by roles

Return to Top


Example of Another RRS (continued)

Respiratory Therapist TasksCompleted?
1. Check the patient's pulse.Checked
2. Obtain vital signs.Not Checked
3. Place the pulse oximeter.Not Checked
4. Assess patient's IVs.Not Checked

Respiratory Therapist TasksCompleted?
1. Assess the airway.Not Checked
2. Count the respiratory rate.Not Checked
3. Assist ventilation.Not Checked
4. Check the patient's pupils.Not Checked

Return to Top


Exercise I: Let's Identify Your RRS Structure

Think about the four components of the RRS: Activators, Responders, QI and Administrative

  • Who are the Activators?
    • What are the alert criteria?
    • How are Responders called?
    • What do Activators do once
      Responders arrive?
  • Who are the Responders?
    • How many Responders arrive to a call?
    • What is each person's role?

 Exercise

Return to Top


Exercise I (continued): Let's Identify Your RRS Structure

  • What are the common challenges facing your RRS?
  • Are there challenges during:
    • Patient deterioration?
    • System activation?
    • Patient handoffs?
    • Patient treatment?
    • Evaluation of the response team?

Exercise

Return to Top


RRS Execution

Return to Top


Detection

(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
    • Huddle
    • STEP

'Roll 'Em!' Play Video (icon: penguin film director)


Detection (Flash video, 2 min., 25 sec.; 10 MB)

Return to Top


Detection: STEP Assessment

Graphic 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 activation
  • Is it time to activate the RRS?

Return to Top


Where can Detection occur?

  • Detection can occur from a variety of sources or concerns

Image: Activator penguin holding oversize magnifying glass observes others huddling around patient in bed.

Return to Top


RRS Activation

(Image: Line from box points to Responder penguins as Activator penguin sounds alarm with bugle. Text in box reads:)

  • Communication Tools/Strategies:
    • SBA


RRS Activation (Flash video, 32 sec.; 2.2 MB) (Download Flash)

Return to Top


RRS Activation: SBAR

  • SBAR provides a framework for team members to effectively communicate information to one another
  • Communicate 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 Top


Response, 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:
    • Leadership
    • Brief
    • Huddle
  • Tools/Strategies:
    • Communication
    • Check-back
    • Call Out
  • Tools/Strategies:
    • Mutual Support
    • Task Assistance
    • CUS

'Roll 'Em!' Play Video (icon: penguin film director)
Response, Assessment & Stabilization (Flash video, 2 min. 43 sec.; 11 MB) (Download Flash)

Return to Top


Response, Assessment & Stabilization Huddle

Problem solving

  • Hold ad hoc, "touch-base" meetings to regain situation awareness
  • Discuss critical issues and emerging events
  • Anticipate outcomes and likely contingencies
  • Assign resources
  • Express 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 Top


Response, 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 Top


Patient Disposition

(Image: Two penguins transferring a patient on a gurney.)

Communication Tools/Strategies

  • Handoffs
  • SBAR
  • I PASS the BATON

'Roll 'Em!' Play Video (icon: penguin film director)  
Patient Disposition (Flash video, 1 min., 17 sec.; 5.3 MB) (Download Flash)

Return to Top


Patient Disposition (continued)

Disposition can refer to a number of decisions, including:

  • Transferring the patient to another unit
  • A 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 care

Return to Top


RRS Transition: I PASS the BATON

Introduction:Introduce yourself and your role/job (include patient)
Patient:Identifiers, age, sex, location
Assessment:Present chief complaint, vital signs, symptoms, and diagnosis
Situation:Current status/circumstances, including code status, level of uncertainty, recent changes, and response to treatment
Safety:Critical lab values/reports, socio-economic factors, allergies, and alerts (falls, isolation, etc.)
THE
Background:Co-morbidities, previous episodes, current medications, and family history
Actions:What actions were taken or are required? Provide brief rationale
Timing:Level of urgency and explicit timing and prioritization of actions
Ownership:Who is responsible (nurse/doctor/team)? Include patient/family responsibilities
Next:What will happen next? Anticipated changes? What is the plan? Are there contingency plans?

Question, Clarify, and Confirm

Return to Top


RRS 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
    • Debriefs
    • Sensemaking
    • Checklist

 

'Roll 'Em!' Play Video (icon: penguin film director)

RRS Evaluation (Flash video, 1 min. 8 sec.; 4.5 MB)

Return to Top


Evaluation: Debriefs

  • Debriefs occur right after the event and are conducted by the Responders
  • Debriefs should address:
    • Roles
    • Responsibilities
    • Tasks
    • Emphasis on transitions in care
    • Achievement of patient stabilization

(Text Box/Example Checklist)

Topic
  • Communication clear?—checked
  • Roles and responsibilities understood?—checked
  • Situation awareness maintained?—checked
  • Workload distribution?—checked
  • Did we ask for or offer assistance?—checked
  • Were errors made or avoided?—checked
  • What went well, what should changes, what can improve?—checked

 

Return to Top


System Evaluation: Sensemaking

Sensemaking Review Sheet

  1. How did the Activators and Responders react to this situation?
  2. When looking at the "big picture," are there any patterns or trends?

Return to Top


System Evaluation: Sensemaking Tools

  • Proactive 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 Approach

  • What 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 Top


Let's look back at our example

'Roll 'Em!' Play Video (icon: penguin film director)
Let's Look Back at Our Example (Flash video, 8 min., 22 sec.; 35.6 MB) (Download Flash)

Return to Top


Exercise II: RRS Execution

Using the scenario provided, identify the five phases of the RRS and what tools and/or strategies were used during each phase

  • Detection
  • Activation
  • Response, Assessment, and Stabilization
  • Disposition
  • Evaluation

Exercise

Return to Top


Exercise III

Let's see if we can identify the tools needed or used in each example

  • Scenario 1
  • Scenario 2
  • Scenario 3
  • Scenario 4
  • Scenario 5

 

Exercise

Exercise

 

Return to Top


Scenario 1

The 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 Top


Scenario 2

The 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 Top


Scenario 3

A 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 Top


Scenario 4

The 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 Top


Scenario 5

A 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 Top
Return 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