J Nichols final 4-12-16final

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Runninghead:RAPIDRESPONSETEAMS
Rapid Response Teams: Improving Patient Outcomes on Surgery and Medical Units
A Research Proposal
Submitted in Partial Fulfillment of the Requirements for
Nur6403 Non-Thesis Project
For the Master of Science in Nursing Administration
And Emergency Management at
Arkansas Tech University
Graduate Department of Nursing
By
James Nichols, B.S.N.
Spring 2016

RAPID RESPONSE TEAMS 2
Table of Contents
Introduction…………………….………………………………... 4
Significance of Problem to Nursing Profession…………….……..5
Statement of Purpose………………………………………….…..6
Theoretical Framework/Model………………………………….…6
Research Question………………………………………………....6
Review of Literature…………………………………………….... 8
Methodology…………………………………………………........12
Conclusion……………………………………………………….. 16
References…………………………………………………………18
Appendix A (Activation Protocol for RRT) ……………………...23
Appendix B (RRT Form) ………………………………………...24
Appendix C (RRT Feedback Form)………………………………25
Appendix D (RRT Ref Card for Badge & RRT Sign)……………26

Abstract
Rapid response teams (RRTs) made up of highly skilled nurse specialists are being implemented
in the United States in an effort to lead to more positive hospital patient outcomes in cases of
patient health downturn events. The implementation of such a unit in a Magnet certified urban
hospital will definitively allow for the determination of the effectiveness of these teams in regard
to shorter patient hospital stays, reduction in patients requiring increased level of care and
increased level of patient functionality at discharge. The purpose of this project is to determine if
implementing a RRT at a Magnet designated urban hospital will improve patient outcomes in a
medical surgical environment. This study will use the Iowa Model of Evidence Based Practice to
Promote Health Care combined with Abdallah’s Theory of Nursing focusing on 21 nursing
problems as a framework to develop practice guidelines incorporating a decision algorithm for
when it will be appropriate for the RN to activate the RRT.

Rapid Response Teams: Improving Patient Outcomes on Surgery and Medical Units
Introduction
Healthcare organizations around the United States (U. S.) are experiencing an
overwhelming increase in the acuity of the patients they treat with the combined issues of a
shortage of both registered nurses (RN) and skilled experienced technical staff. One initiative
used by health care organizations to increase patient safety, patient outcomes and to offset RN
staffing ratios that are low, is the implementation of a Rapid Response Team (RRT). The RRT
is a team of nurses usually an advanced practice nurse, a critical care nurse with trauma
experience, and a respiratory therapist on call by both staff and the patient’s family to respond
to a patient health downturn (Kapu, Lee, & Wheeler, 2014). A patient health downturn is a
reduction in the patients’ health condition that requires the immediate intervention of nursing
staff. The overall effectiveness of the RRT remains in question after several years of intensive
studies.
While RRTs have been credited with reduction in fatalities from cardiac events at the
same time admissions to intensive care units have increased due to RRT interventions. The
RN’s primary focus in patient safety is to become “an around the clock surveillance system in
hospitals for early detection and prompt intervention when patient’s conditions deteriorate”
(Aiken, 2002, p. 290). The RN is to identify and intervene in a timely manner if the patient
deteriorates physically or is in danger of death (Parker, 2014). The Institute for Healthcare
Improvements as part of its “100,000 Lives” Campaign in 2004 recommended RRTs to provide
floor nurses the resources needed to respond to patient downturns in their physical conditions
(Berrois, Caple, Elmer, Jensen, Kashyap, O’Horo, & Velagapudi, 2014). RRTs are based on the

concept that by having specialized teams of nurses providing interventions at the first
indication of a physical downturn negative patient events can be prevented (Berg et al., 2010).
Subsequent research has shown only a reduction in cardiac arrest after implementation of the
rapid response teams with only limited improvements in the categories of hospital mortality
and lowering the percentage of patients requiring an increase in level of care (Byrden &
McNeill, 2013).
RRTs have shown to reduce the average length of stay and increase hospital discharges
while increasing intensive care unit admissions (Evans, 2013). Despite predictions of cost
savings the actual cost of implementing a RRT has been estimated to be $23.00 per day for a
patient. However an increase in the number of intensive care unit admissions, may reduce the
overall cost to a hospital because of the increased reimbursement rates used by insurance and
government agencies for intensive care patients compared with patients on the medical surgical
units (Adang, Schoonhoven, Simmes, & Van der Hoven, 2014; Evans, 2013). The increased
admission rates to intensive care units combined with the increased daily reimbursement rate
for transferred patients, could increase hospital revenue if the change in level of care is not
determined to be the fault of hospital staff. Despite the fact that the U. S. health care system is
the most costly in the world, the U. S. still has between 50 and 100 thousand patient deaths
each year in a hospital setting (Evans, 2013). This statistic emphasizes the inefficiencies of the
current system (Evans, 2013).
Significance of the Problem to Nursing Practice
Between 44,000 and 98,000 hospital patients die each year because of medical errors or
oversights (Evans, 2013). RRTs are one intervention used to try to lower these numbers (Evans,

2013). The increasing acuity of patients on surgical and medical floors combined with the
continuing staffing limits make the safeguarding of patients a more challenging issue as time
goes by. The use of RRTs and other innovative techniques will be necessary in the future to
compensate for the lack of man power and increasing workload (Evans, 2013).
By staffing RRTs primarily with RNs and respiratory technicians the role and
responsibility of the allied health professions is broadened and expanded. Also, the use of RN’s
in the consulting role allows for more open and free communication between peers this free
exchange of ideas facilitates the problem solving process increasing patient safety while adding
to the job satisfaction of nurses (Kaput, Lee, & Wheeler, 2014).
Statement of Purpose
The purpose of this project is to determine if implementing a RRT at a Magnet designated
urban hospital will improve patient outcomes in a medical surgical environment.
Research Question
Will the implementation of a RRT on medical surgical units at a Magnet designated
urban hospital improve patient outcomes for at risk patients as measured by shorter patient
hospital stays, reduction in patients requiring increased level of care and increased level of
patient functionality at discharge?
Theoretical Framework/Model
This study will use the Iowa Model of Evidence Based Practice to Promote Health Care
combined with Abdallah’s Theory of Nursing focusing on 21 nursing problems as a framework

and to develop practice guidelines incorporating a decision algorithm for when it will be
appropriate for the RN to activate the RRT (George, 2012).
The Iowa Model of Evidence Based Practice explores each stage of health care delivery
from the overall infrastructure to the provider and to the patient (Dontje, 2007). When a patient
suffers a downturn in health the RN is limited by the inability to consult freely with experts and
request assistance in providing optimal care until the situation becomes critical. By using the
Iowa model this study will compare an intervention using the RRT and the current system of
calling a code white only in a critical patient situation. A code white is when a patient is in a
critical health state and the nurse activates the protocol which summons the house manager, a
respiratory therapist, a medical doctor from the emergency department, a cardiac intensive care
nurse, a pharmacist and all available nurses on the floor. By comparing patient outcomes for at
risk patients as measured by shorter patient hospital stays, reduction in patients requiring
increased level of care and increased level of patient functionality at discharge of the RRT group
(intervention group) to the code white group (control group) the outcome of the implementation
of a RRT group in a Magnet certified hospital can be assessed.
The theory that is most applicable to the use of RRT teams in the Medical Surgical units
is Admiral Abdallah’s Theory of Nursing focusing on 21 nursing problems which include every
aspect of the patient nurse interaction (George, 2012). Abdallah’s theory focuses on the health of
the patient in detail breaking down the different aspects of care into 21 nursing problems
spanning every aspect of the patient experience from physiological to psychological to spiritual
and environmental (George, 2012). Admiral Abdallah’s Theory of Nursing’s comprehensive
view is similar to the Iowa Model’s detailed and comprehensive definition of the broad

responsibilities of nursing in patient care which make the two theories appropriate in the study of
RRT’s.
The following nursing problems according to Admiral Abdallah’s list of 21 nursing
problems are specific to this situation:
Problem 3. To insure safety through the prevention of accident, injury and other trauma and
through prevention of the spread of infection.
Problem 5. Maintain supply of oxygen to the body cells. Provide respiratory therapy by the RRT
if needed.
Problem 8. Maintain electrolyte and fluid balance. Initiation of fluid bolus or blood
administration if needed by the RRT.
Problem 9. To recognize the physiological responses of the body to diseases condition. To watch
for changes in skin color, mental status and other signs of change by both the primary care RN
and later the RRT.
Problem 10. To facilitate and maintain the regulatory mechanism and functions. Monitoring both
the vital signs and the patient’s mental status by both the primary care RN and later by the RRT.
The Iowa theory relates to this project by investigating whether a RRT could improve the
results of patients on the medical surgical units who are taking a downturn preventing increases
in the level of care, shortening the length of patient’s stay and improving the patient’s level of
functionality at discharge as defined by goals 3, 5, 8, 9 and 10 of Admiral Abdallah’s 21 nursing
problems.

Review of Literature
The purpose of the review of literature is to present current research on the effectiveness
of RRTs in relation to improved patient outcomes and lower patient mortality rates. Between 50
and 98 thousand patients die from avoidable incidents while hospitalized each year (Evans,
2014). A literature review was performed in February of 2016 using these databases: PubMed,
CINAHL, Cochrane, Google Scholar, Ovid, and Ebsco in conjunction with the key terms RRT
and patient mortality. The following review of literature presents current research studies on
clinical outcomes and implementation of RRTs.
Clinical Outcomes
In a study by Evans (2013) utilizing a 300 bed non-urban hospital as a setting, the
researcher reviewed five years of data to determine the effects of implementation of a RRT on
patient mortality, patient cardiac arrest, length of patient stay and per patient cost (Evans, 2014).
Evans (2014) found that the increased cost per patient of implementation of the RRT cost the
hospital $23.00 for each patient in the facility each day, the increased cost was largely because of
the need for dedicated RRT nurses salary because these nurses were not based in one unit and
their services could not increase the census and thus billable hours overall. Evans (2013) also
found that the length of stay increased by an average of 0.40 days, a statistically lower number of
deaths occurred after the implementation of the RRT and total discharges increased while
admissions to the intensive care units increased (Evans, 2014). Similarly, Adang et al. (2014)
found increases of $21 for each patient in the hospital each day to implement a RRT.
Bryden and McNeill (2013) in a systematic review of 43 studies found a correlation
existed between the skill level of the members of the RRT and positive patient outcomes. Berg,

Jain, Nallmouthu, and Sasson (2010) conducted a systematic review and meta-analysis of 18
studies covering 1.3 million hospital admissions also found evidence lacking only finding a
reduction in cardiac arrest outside the intensive care units (ICU) with no corresponding increase
in survival of these same patients. Pham, Pfoh, Sydney, Weavers and Winters’ (2013) systematic
review of 44 studies of rapid response systems found that while rates of cardiac arrest were
lowered overall hospital mortality was not improved by the implementation of a Rapid Response
System. Also, Fikkers, Mintjes, Schoonhoven, Simmes and Van der Hoven (2012) found in a
study of patients before and after RRT implementation at a university medical center a 50
percent reduction in cardiac arrest and unexpected deaths.
RRT’s have shown various improvements in areas of decreased patient codes, of
decreased variability in recording patient downturns, of increased recognition of patient’s
downturns and increased RN initiation of escalation of patient’s level of care in three hospitals.
Avis, Foy, Grant, and Foy (2016) reported a decrease in patient codes two years after the
implementation of a RRT. Mackintosh, Rainey, and Sandall (2012) found that the use of RRTs
reduced variability in recording and recognizing a patient’s downturn, increased RNs initiating
procedures to escalate the level of care of patients and in the process increased patient safety and
positive patient outcomes. Bonafeide, Keren, Locailio, Viany, and Weinrich (2014) in a
quantitative study, with the sample of 1810 patients, found that a RRT intervention was 62%
effective in preventing escalation in the level of care.
Implementation of RRT
Avis et al. (2016) detailed the criteria for activation of the RRT which included heart rate
greater than 125 or less than 45, oxygen saturation less than 90%, systolic blood pressure greater
than 180, seizure, chest pain, change in mental status, postpartum hemorrhage, unplanned

spontaneous delivery, vaginal bleeding before delivery, patient non responsive to treatment and
concern of staff (See Appendix A). In educating staff about the RRT the hospital used video to
review the purpose, activation procedure and expectations of outcomes of the RRT with staff
(Johnson, 2009). Kapu et al. (2016) determined that the addition of the acute care nurse
practioner to the RRT increased efficiency by allowing facilitation of transfers and more
treatment option.
Several studies have focused on barriers to quick activation of RRTs. Bonafeide et al.
(2014) found that three barriers to quick activation of the RRT were lack of self-efficacy by the
RN, perception of hierarchy, and negative expectation of outcomes. One solution suggested by
Elliot and Scott (2014) detailed documentation forms and feedback forms to be used by RRTs
and activating staff which allowed for review of activation procedures and reduction of barriers
to activation (See Appendix B & C). Johansen, Lennes, Howell, Hsu, and Stevens (2012) found a
correlation between a primary team focused implementation and care provider’s willingness to
activate the RRT suggesting that the active participation of the medical surgical unit nurse
primarily responsible for the patient in the intervention is key to quick activation of the RRT.
Parker (2014) in a study found that nurses who utilize analytical decision making versus intuitive
decision making were twice as likely to activate the RRT suggesting hospitals focusing on
evidence based practice will be more successful in timely activation of the RRT’s.
Overall the literature has mixed reviews of RRT’s except for the lowering of cardiac
related deaths. While the lowering in cardiac deaths alone would prove the value of the RRT
research has shown an increase in nurse satisfaction with the implementation of the RRT’s. The
literature does address research studies on the implementation in the hospital setting, there are no
specific studies focusing solely on implementation of RRTs on a hospital medical surgical unit.

Utilizing current research studies and evidence based best practices to implement RRTs in the
medical surgical unit would potentially change the outcomes for patients and offer additional
support for nurses utilizing RRTs.
Methodology
The purpose of this project is to determine if implementing a RRT at a Magnet
designated urban hospital will improve patient outcomes in a medical surgical environment.
Setting
In order to establish the desirability of a RRT, the implementation of a RRT will be
undertaken at a Magnet certified urban hospital. The medical surgical floors will be the primary
focus of the study expanding to other units at a later date.
Target population
The target population will be medical surgical patients of a Magnet urban hospital who
face a patient health downturn.
Data Collection
Data will be collected using rapid response team records (see Appendix B) and feedback
to RRT forms (see Appendix C). The rapid response team record will be completed both by the
activating nurse with as much information filled out as possible before the team arrives and by
the designated team member during the event. The duplication of identical information will
allow for comparison and be an effective measure of the communications between the activating
personal and team members. The use of an identical instrument will allow for quicker and more
accurate communication under stress situations. The feedback to the RRT form serves many
purposes facilitating the after action reporting process, enhancing the quality control,
encouraging the improvement effort and providing information for comparison-analysis

purposes. Also, information on transfers to the ICU units from general surgery for two years
before the implementation of the RRT will need to be secured at the beginning of the survey. In
addition, all information regarding activation of code whites for the same two year period
including the medical records of all the individual records will need to be secured and all
identifying information for the patients will need to be removed from the data.
Implementation
The RRT will consist of a respiratory therapist (RT), an advanced practical nurse (APN)
and a trauma certified RN with several years of experience in a cardiac intensive care unit
(CICU). While operating as a seamless team of equals the APN will take the lead in
interventions and verbalize the orders; also, the APN will be able to rapidly implement
medication orders and transfer orders for patients (Kapu et al. 2016). The cardiac intensive care
RN will focus on advanced life support issues. The respiratory therapist will provide airway
management and pulmonary management support. The RRT members will need to undergo an
intensive training program and will need to observe an active RRT for six weeks to ensure they
understand the operations of a properly functioning RRT (Johnson, 2009). A great deal of effort
needs to be taken to allow for self-selection of teams. The group of candidates should be
selected, finalist should be put through a mock training event for two days and at the end of the
event all candidates should bid on who they want as team mates. This self-selection process
should allow for the optimal probability for an effective and coherent team formation. Also, a
deselection process should exist so that if two team members wish to deselect the third team
member this will be allowed (Northouse, 2016). As professionals it should be assumed that only
for professional reasons would a member be deselected (Loy, 2003).

A proper communication system connecting the RRT with the switchboard, units, call
number, physicians, MDs, intensive care units, pharmacist and all other resources needed will
need to be implemented and thoroughly tested. A text based system would be preferable as the
security of a visual system versus a verbal system will help to protect patient privacy and Health
Portability and Privacy Act (HIPPA) compliance (Haddow, 2009; Fearn-Banks, 2010). This will
also provide for more detailed and accurate information. The one exception would be during the
actual code when hands free speaker technology would be essential. The system will need to be
tested for redundancy and effectiveness even in the direst circumstances such as a natural
disaster (Haddow, 2009; Fearn-Banks, 2010).
A documentation system will be used to document the activating nurse’s view of the
RRT, the RRT member’s activities on each call, the outcome of each patient and the view of the
attending MD or charge nurse for the unit involved regarding the effectiveness of each call (See
Appendix B & C).
An educational session will include all hospital employees. The education session will
emphasize the contact number, when to call for the RRT (see Appendix A) and the expectations
of the RRT program (Johnson, 2009). The systems would need to utilize multiple approaches to
learning in order to maximize the effectiveness and retention of information for individuals with
different learning preferences and education levels (Roberts, 2005). A video with actual mock
codes and events would be optimal with multiple platforms for viewing for the healthcare team
via online access, at unit level meetings and organization level meetings, and audio pod-cast
technology (Johnson, 2009). Simple signs using visual cues and colors should be placed
throughout the hospital and each room promoting the RRT and the number to call. A card with
the RRT number and activation protocol should be produced and should be below each

employees ID for quick reference (see Appendix A & D). A yearly refresher course regarding
RRT activation should be included for each employee.
When the RRT is activated continuity of care is interrupted when new providers are
added to the patients care team. The primary care team according to an article by Berrios et al.
(2014) should remain actively engaged in the continued care of the patient working in
conjunction with the RRT when the RRT is activated, this ensures that the patient’s and families’
wishes are given the proper weight in any treatment. One on one educational events with the
RRT members and unit level staff would be beneficial in building a team “spirit de corp”
between the two groups and help to reinforce the essential nature of the medical surgical nurse in
the RRT intervention.
When time permits a safety huddle should be held immediately after the event and
include all personnel available. The safety huddle will allow for an open discussion of what went
correctly, what could have been done better, equipment needs, concepts for improvement,
needed training and will allow for psychological closure with a healing moment for those
involved. In the case of a patient death or critical change in patients’ health status called a
sentinel event a debrief chaired by the chief nursing officer with all involved parties needs to be
held to quickly determine what changes need to be made to improve patient safety and unit
efficiency (Roberts, 2005).
The data of all information will be compared such as the information involved in each
code white, the information involved in each patient transfer from the floor to a higher level of
care such as intensive care and any other pertinent information such as safety issues needs to be
copied and stored in an area so that two years of data is protected for comparison with the first
two years of operational outcome information for the RRT. In addition to the outcome measures

of shorter patient hospital stays, reduction in patients requiring increased level of care and
increased level of patient functionality at discharge additional review of, changes in patient
mortality rates, changes in patient morbidity rates and the change in cost of operations must be
undertaken in this study. A cost benefit analysis should also be done.
Ethics-
The hospital institutional review board (IRB) of the implementing hospital will approve
this project before implementation as data will be collected to measure the outcomes. Patient
confidentiality and privacy will be protected by removing all identifiable information from any
data used in this study.
The RRT implementation will also have to be approved by the Magnet hospital’s nursing
congress which as part of the shared governance tenet of Magnet hospital approves every change
in nursing care implemented at a Magnet hospital. Also, the medical board and executive board
of the Magnet hospital would have to approve the plan.
Conclusion
With increased patient acuity, lower staffing ratios, an aging population and limited
reimbursement for patient complications preventing patient injury and status downturns is
essential to the viability of the Magnet designated urban hospital and the long term health of the
community at large. Due to the lack of conclusive evidence and the individual differences in the
hospitals, RRT make ups, activation protocols and other factors a comparison of the same
hospitals’ medical surgical units before and after the implementation of a RRT using best
evidence based practice would be beneficial in determining whether a RRT is the correct way to
maximize the patient safety and patient outcomes at a Magnet designated urban hospital.

The literature supports a corresponding decrease in cardiac mortality and morbidity with a
corresponding reduction in hospital length of stay and increase in admissions to the intensive
care unit resulting from the implementation of a RRT (Evans, 2013). Implementation of the RRT
in the Magnet hospital environment may also lead to decreases in mortality/morbidity and
increases in patient functionality at discharge if best evidence practice is implemented in the
creation and operation of the RRT. The empowerment achieved by the use of RN’s in the
resource and support role of RRT team member will help to broaden the scope of practice of
RN’s and increase the job satisfaction levels of nurses on medical surgical units. Also, RRT will
increase the effectiveness of communications between the medical surgical RNs and emergency
response teams when a patient intervention is required by a patient health downturn event (Kaput
et al., 2014).
Future research should cover the effectiveness of interactions and communications of the
RRT, the medical surgical nursing staff and the medical doctors in interventions resulting from
patient health downturn events. Research should also focus on how to optimize communication
in these highly stressful and time critical events.

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Proposed Activation Protocol for RRT (Appendix A)
Respiratory Distress (Breaths / Minute) Less than 10 or Greater than 30
Change in Mental Status Sudden decrease in Level of Consciousness
Tachycardia (Beats/Minute) Greater than 130
Bradycardia (Beats/Minute) Less than 40
Blood Pressure SBP Less than 90 or greater than 180
Chest Pain Complaint non traumatic chest pain
Seizures Sudden or extended or prolonged
Pulse ox (SPO2) Less than 92%
Color change
Agitation
Limb weakness or smile droop
Nurse intuition

Documentation of RRT (Appendix B)
(Elliot & Scott, 2014)

Feed back to RRT (Appendix C)
Thank you for calling the RRT
The RRT is here for you. If there is anything we can do to improve our response, we need and
welcome your input
Please take a few minutes to answer our questions below
Did the team arrive promptly?
Yes No
Was the RN/RT efficient and respectful?
Yes No
Did you feel the patients’ needs were addressed appropriately?
Yes No
Did you feel supported by the RRT?
Yes No
Would you call the RRT?
Yes No
(Elliot & Scott, 2014)

Sign and Info Card for Badge (Appendix D)
CALL RRT – RAPID RESPONSE TEAM 9111
OR 552-9111
• If Family or Staff see a patient in distress, pain or suffering any of the below symptoms call
• Respiratory Distress (Breaths / Minute) Less than 10 or Greater than 30
• Change in Mental Status Sudden decrease in Level of Consciousness
• Tachycardia (Beats/Minute) Greater than 130
• Bradycardia (Beats/Minute) Less than 40
• Blood Pressure SBP Less than 90 or greater than 180
• Chest Pain Complaint non traumatic chest pain
• Seizures Sudden or extended or prolonged
• Pulse ox (SPO2) Less than 92%
• Color change
• Agitation
• Limb weakness or smile droop
• Nurse intuition
CALL RRT – RAPID RESPONSE TEAM 9111 OR 552-
9111
• If Family or Staff see a patient in distress, pain
or suffering any of the below symptoms.
• Respiratory Distress
• Change in Mental Status
• Tachycardia (Beats/Minute)
• Bradycardia (Beats/Minute)
• Chest Pain
• Seizures
• Color change
• Agitation
• Limb weakness or smile drop

J Nichols final 4-12-16final

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