A twist on the RRT positions nurses as leaders in responding to non-life-threatening situations.
- Medical emergencies occur in many medical settings, including psychiatric hospitals. Psychiatric nurses are expected to respond with the same quality care to the medical needs of all patients, and, when necessary, employees and visitors.
- The rapid response team is responsible for quickly responding to nonlife-threatening medical needs of patients, visitors, and employees and, through interdisciplinary collaboration, develop a plan of care.
By Jessica O. Hay, MSN, CPNP-AC; Allison J. Alberto, BSN, RN-BC; Kristin Lundsten MSN, RN, PMHN-BC; Nicole Nappe, BSN, RN; and Valerie Seney, MA, MSN, LMHC, RN-BC
Psychiatric nurses are trained to respond to individuals in psychiatric crises with resulting emotional and behavioral dysregulation, but what happens when inpatients need medical attention? In that situation, psychiatric nurses are expected to respond with the same quality care to meet the medical needs of all patients, and, when necessary, employees and visitors. One option to facilitate quality care is a rapid response team (RRT). Here we share our experience with developing, training, and implementing an RRT for responding to non-life-threatening medical events at a psychiatric hospital.
A unique situation
Emma Pendleton Bradley Hospital (Bradley) is unique in many ways. This freestanding psychiatric hospital in East Providence, RI, is about 15 minutes away from the closest tertiary hospital. In addition, it functions without advanced practice nurses or physicians for about 13 hours every day, as well as most weekends and holidays. Third-shift employees generally consist of RNs and milieu associates (MAs) with no advanced practice nurses or physicians on campus. The Joint Commission requires that hospitals provide the same level of care 24 hours a day, 7 days a week. Since nurses are the leaders in the hospital during much of second and third shift, medical code teams must be led by RNs to ensure Bradley is complying with Joint Commission requirements.
In 2008, a code blue system was created to respond to all patient, visitor, and employee medical concerns. To ensure prompt emergency medical care and transport to another care facility if needed, hospital leadership determined that the East Providence Emergency Medical System (EMS) would be used for all code blue activations. At that time, code blue was used for all medical concerns no matter the severity or acuity—everything from a small cut to reports of chest pain.
In 2011, in response to code blues being called incorrectly, one of the authors (Hay) completed a retrospective analysis to review the number of code blues activated for life-threatening events versus non-life-threatening events and to determine if an adjunct program, such as an RRT, would be appropriate for non-life-threatening medical emergencies. The analysis revealed that 18 code blue activations had been called for non-life-threatening situations. Hay shared this data with hospital leadership and obtained approval for the creation of a multidisciplinary committee to develop a nurse-led RRT.
RRT development and implementation
The purpose of the RRT is to quickly respond to non-life-threatening medical needs of patients, visitors, and employees and, through interdisciplinary collaboration, develop a plan of care. The goals of the team are to reduce the number of code blues activated for non-life-threatening events, reduce the use of EMS for non-emergent medical needs, and reduce the number of unplanned transfers to the emergency department 15 minutes away, while also improving patient care and safety and maintaining high-quality medical care.
For a year, the RRT development committee, which included a pediatric nurse practitioner, clinical nurse managers, MAs, and a representative from the quality and risk management department, worked to design and implement the rapid response system, rolling it out in two phases. The first phase comprised development, education, training (using the Lifespan Medical Simulation Center and high-fidelity mannequins), and implementation.
The second or ongoing phase, overseen by a medical code committee composed of a pediatric nurse practitioner, a clinical manager, and several clinical staff, provides oversight of medical codes, ongoing education and training, and continued quality improvement. This phase also includes continued training of lead RNs using the Lifespan Medical Simulation Center, reorganization and restructuring of quarterly mock medical codes, implementation of medical code response training with high-fidelity mannequins during nursing development day, and implementation of emergency management response in the Bradley residential group homes.
To ensure effectiveness, efficiency, and standardization of the medical response process, the RRT is modeled after the code blue team. The RRT comprises four to six RNs and MAs, who are trained in cardiopulmonary resuscitation and use of an automated external defibrillator. Resuscitation interventions used by hospital staff are limited to basic life support.
The RN who acts as the leader of the RRT team assesses the ill or injured individual’s medical needs, ensures vital signs are obtained, provides appropriate nursing care, and reviews the patient’s medical history. This lead RN, who also has the authority to convert the RRT to a code blue as needed, shares pertinent information with the pediatric team, the attending, or the physician on call, using the acronym ISBAR (Identify, Situation, Background, Assessment, Recommendation) to formulate an appropriate plan of care and determine whether transportation to a higher level of care is required. Should a transfer be indicated, the lead RN is responsible for the hand-off of care and updating clinicians. (See Leader training.)
Implementation of the RRT at Bradley has been a huge success. In 2012, the year before implementation, the hospital had 18 code blue activations, all for non-life-threatening emergencies. In 2013, we had three code blue activations and seven RRT activations, and 2014 saw four code blue activations and nine RRT activations. Bradley has experienced a greater than 150% reduction in non-life-threatening code blue activations, and the number of unplanned transfers has been reduced by more than 65%.
Jessica O. Hay is a pediatric nurse practitioner at Bradley Hospital in East Providence, Rhode Island. Allison J. Alberto is a clinical staff nurse at Bradley Hospital in East Providence, Rhode Island. Kristin Lundsten is the director of nursing at Newport County Community Mental Health Center in Middletown, Rhode Island. Nicole Nappe is a clinical nurse manager in the children’s inpatient unit at Bradley Hospital. Valerie Seney is the director of nursing in the behavioral health unit at Newport Hospital in Newport, Rhode Island.
Puskar K, Smith HD, Herisko C, Urda B. Medical emergencies in psychiatric hospitals. Issues Ment Health Nurs. 2011;32(10):649-53.