The idea is simple: any patient or family member can bypass the typical chain-of-command and call what is essentially a medical "SWAT team" to quickly assess the patient and intervene when lifesaving care may be needed. A nurse or any other healthcare provider can also summon the team. Most teams include a highly trained critical care nurse and a respiratory therapist, and many teams include a physician or nurse practitioner. Unlike the traditional medical team that responds when a patient stops breathing or the heart stops beating (cardiac arrest), the RRT intervenes before these often fatal adverse outcomes occur. The goal of RRTs is to identify seriously ill patients, at-risk patients, and patients whose condition is deteriorating unexpectedly, and to trigger an urgent response by clinicians who have the skills and knowledge to deal with the emergency before the patient worsens or dies.
Almost a decade ago, the University of Pittsburgh Medical Center (UPMC) Shadyside was perhaps the first hospital in the nation to invite patients and families to call for a RRT to address unresolved concerns about their safety and health1. Upon admission, patients and family members were encouraged to pick up any phone in the hospital to report a Condition H (for "help") if they:
- Fear something is seriously wrong with the patient and have expressed their concerns without validation or recognition of its importance.
- Experience a communication failure with the healthcare team.
- Become confused about the patient's care.
- Need to know where to voice concerns about the patient's deteriorating clinical condition.
- Feel something about the patient's condition is "just not right."
Today, RRTs are widely used in hospitals. The general concept is sound—if we encourage all who observe the patient, including the family and patient himself, to call for help when needed, and if we send in a team of the right people with the right skills and knowledge at the right time, we should be able to rescue patients before their breathing or heart stops (cardiac arrest). The results of studies to determine whether these teams work have been mixed. For example, a 2010 study found that RRTs reduced the risk of cardiac arrest in adults by 34%. But the number of patients who died in the hospital was not significantly lower. With children, the study found that RRTs reduced the risk of cardiac arrest by 38% and the risk of death by 21%. A more recent analysis published in 2014 found that RRTs may reduce cardiac arrests by up to 50% and deaths during hospitalization by up to 33%. So, there is some evidence that allowing staff, patients, and families to summon a RRT can save lives.
Several tragic deaths about 15 years ago were compelling factors that led to patient- and family-initiated RRTs. The first was a tragic death of an 18-month-old child, Josie King, who had been hospitalized for treatment of burns from a bathtub accident. Josie had been healing well, but she died 2 days before she was supposed to go home. Hospital staff failed to recognize that Josie had become seriously dehydrated, despite frequent pleas by the child's mother, Sorrel, that her daughter was listless and extremely thirsty—and that something was very wrong. The child's mother was the first to notice her daughter's desperate thirst. When the child saw a drink, she would scream for it. And when bathing, she would suck frantically on the wet washcloth. She then developed a fever and diarrhea—another cause of serious dehydration. When she became listless and her eyes rolled back in her head, Sorrel frantically tried to get help for her child because she felt something was not right. But in the end, the young toddler died of a third-world illness—dehydration—in one of the best hospitals in the world, despite repeated attempts by her mother to draw attention to the problem.
The other tragic death involved a previously healthy 15-year-old boy, Lewis Blackman, who went into the hospital for an elective surgery and died 4 days later from excessive blood loss caused by a serious side effect of his pain medicine. His mother, Helen, reported that her son was pale and was experiencing excruciating pain in his abdomen, which she thought was unusual given that the surgical site was his chest. Lewis developed a high fever, low blood pressure, very pale and cold skin, and many other signs of internal bleeding and clinical deterioration. The boy's mother repeatedly insisted that her son be evaluated by a veteran doctor, rather than the new residents on duty over a weekend, because she knew something was very wrong with her son. But her repeated demands were never honored. Lewis died from internal bleeding caused by an ulcer, a known and serious side effect of the pain medicine, ketorolac, he was receiving.
Sorrel King and Helen Blackman have no doubt that access to a RRT could have saved their children, as the errors that caused their deaths were preventable and detectable. Likewise, we have no doubt that a patient- or family-activated RRT could have mitigated harm that has resulted from other life-threatening and deadly medication errors.
Allowing patients and families the ability to summon a RRT may be one of the most significant ways that healthcare providers can make patients an equal partner in their care and safety. Consider the following recommendations to best protect yourself and your family from accidental harm while hospitalized:
Educate yourself. Learn about the disease, medical tests, and the treatment plan for you or your hospitalized family member. Also learn what medicines are being administered, the prescribed doses, and when and how they are given. Write down important information. A patient or family member who knows what to expect can help recognize when something is not right.
Ask how to call a rapid response team (RRT). When admitted to a hospital, ask whether patients and families can call a RRT and under what conditions such a call would be appropriate. Be sure you and your family know how to summon a RRT.
Report what worries you. Report anything that worries you or does not seem right with you or your family member. Do not be afraid to speak up. Although doctors and nurses are highly trained regarding your medical condition, or your family member's condition, you know yourself and your family better than anyone on the medical team. Your observations are extremely important.
Ask questions. If you have questions about your care or family member's care, you need to ask. Also, if you do not understand the answer you get, you need to ask again.
Be persistent. Keep asking questions or voicing your concerns about your condition or care, or your family member's condition or care, until you get an answer that makes you comfortable.
Summon a RRT. If you feel no one is addressing your concerns, do not hesitate to summon a RRT using the directions provided upon admission. If the hospital does not offer a RRT, ask to speak to the doctor in charge (medical director), nurse in charge (nursing director), and the patient representative.
Speak up about the care provided. If you believe something is not being done correctly—perhaps a medicine or medicine dose does not seem right—do not be afraid to speak up. Healthcare professionals are human; they could make a mistake. Sadly, patients, families, and healthcare providers often live with regret because they did not follow through on a suspected problem. The lessons they want to share with all is to speak up and be persistent, even if there is just a hint of a potential safety issue.
1. Thomson American Health Consultants. Condition H phone line provides last chance to prevent serious errors. <em>Healthcare Risk Management.</em> 2006;28(2):13-17)