From The President’s Desk… Fall/Winter 2024

 

Rapid Response Teams: 

The Case of Failure to Rescue
by
Christine Dorman, DNP, APRN, ACNP-BC, CCRN Vantage Point Legal Nurse Consulting, LLC

(Sources for this article are included in the Side Bar.)

Introduction
The development of cardiac arrest (code blue) teams has been well-established and commonplace in the United States (US) and international hospitals. However, studies have shown that the survival rate of adults experiencing cardiopulmonary deterioration that led to in-hospital deaths remains significantly high in the US (5).

Furthermore, prior research revealed that early warning signs (EWS) are often precursors to clinical deterioration that can lead to cardiac arrest. These studies demonstrated that patients typically experience signs and symptoms of clinical deterioration 6 to 8 hours prior to a code event (2). Likewise, the studies highlighted how EWS tools were utilized as a single scoring system embedded into the electronic medical record (EMR) to identify at-risk patients. This divulged fewer associated in-hospital cardiac arrests due to the combination of EWS tools and a clinician’s judgment when the rapid response system was activated (8).

Background
Can delaying or not activating the rapid response team (RRT) lead to failure to rescue (FTR) patients? To answer this question, it’s important to explore the history of RRTs and their emerging role in addressing FTR events in hospitals.

Rapid response teams: Rapid response systems (RRS) or RRTs were first introduced in Australia and adopted in the US in 2002 as a patient safety intervention (6). The concept of an RRT is to treat patients who demonstrate imminent signs of clinical decompensation. RRT is defined as a multidisciplinary group of hospital personnel who are deployed to respond promptly to acutely deteriorating patients outside of the intensive care units (ICU) (5).

Failure to rescue: FTRs are patient safety issues that arise from delay in recognition or response to an in-hospital complication(s). FTRs have been deemed a metric tool utilized by hospitals to access morbidity and mortality or simply put, an indicator of failed surveillance (7).

Development: Survival rates after in-hospital cardiac arrest is estimated between 7-26% (5). The culmination of these cardiac arrests, adverse events, and FTRs ultimately led to the development of RRTs (5).

Since 2004, RRTs have been widely adopted by hospital systems nationally and internationally, largely as part of the 100,000 Lives Campaign conducted by the Institute of Health (IHI).  Consequential, The Joint Commission (TJC) mandated that all hospitals in the US establish a RRS as a part of the 2008 National Patient Safety Goal initiative. Additionally, in 2015 the American Heart Association (AHA) included RRS as a part of their guidelines for cardiopulmonary resuscitation and emergency cardiovascular care (8). Hence, the Agency for Healthcare Research and Quality (AHRQ) and TJC have endorsed both RRTs as patient safety practice and quality initiatives to reduce FTRs (1,5).

Team Composition
The team composition of RRTs will vary from institution to institution. Nevertheless, they exist to deploy the appropriate staffing resources to assess individual patients experiencing clinical deterioration. The main goal of the RRT is to intervene early to prevent further patient decline, cardiopulmonary arrest, and/or death. Early intervention ensures that proper triage, medical decision making, evaluation, testing (labs and/or imaging), medications, and care coordination is implemented in a timely fashion (2).

Typical makeup of RRT team members include physicians (hospitalist or intensivist) or licensed independent providers such as an advance practiced registered nurse (APRN) or physician assistant (PA), ICU nurse, respiratory therapists, and pharmacists (2).

Rapid Response Criteria
Patient monitoring and trends occur in a variety of formats. It ranges from surveillance of a patient’s heart rate, blood pressure, respiratory rate, pulse oximetry, capnography, urinary output, level of consciousness, and pain assessment. Any alteration in these monitoring trends is considered an EWS to prompt an RRT.

Preliminary research showed that delay or not activating an RRT in patients who meet the criteria can result in prolonged hospitalization and increased mortality (7). Any staff member can activate an RRT if there is a patient concern or if the criteria are met. In some hospitals family members are allowed to activate an RRT (7).

The most common criteria for activation of RRTs include:

• Airway compromise (threatened airway, pulse oximetry less than 90% despite oxygen supplementation);
• Acute change in respiratory rate (rate less than 8 per minute or greater than 28 per minute);
• Acute change in heart rate or cardiac status (rate less than 40 per minute or greater than 140 per minute);
• Chest pain unrelieved by nitroglycerin;
• Acute change in blood pressure (systolic pressure less than 90 mm Hg or greater than 180 mm Hg);
• Acute mental status change (unresponsiveness, seizures, hypoglycemia);
• Change in urinary output (less than 50 mL over 4 hours or no output); and
• Uncontrolled pain (2).

Effectiveness of Rapid Response Teams
Early publications reported substantial improvement in clinical outcomes. However subsequent studies remain controversial. Despite the controversy surrounding the benefits of RRTs, they exist nonetheless to address the potential benefits of early rescue therapy utilization, fostering quality care, and a culture of patient safety. RRTs are also a proposed standard of care (SOC) and safety practice endorsed by TJC and the IHI Quality to address FTRs (2,4).

Barriers to Implementation
Various factors affect barriers to effective RRT implementation. They include:

• A lack of understanding or recognition of the patient’s condition and deterioration;
• Nursing education;
• Limited nursing experience;
• Alarm fatigue;
• A lack of confidence in assessment skills;
• A lack of leadership support;
• A lack of staff buy-in due to poor organizational culture;
• Time of day;
• Poor staff workflow; and
• The burden of now caring for a more critically ill patient (5, 6).

Case Scenario
Mrs. MB is a 69-year-old female with a past medical history of asthma, hypertension, and hyperlipidemia who presented to the emergency room with a two-day complaint of difficulty breathing, cough, and wheezing. She is admitted to the telemetry unit for asthma exacerbation. Mrs. MB informs her nurse that she’s feeling a little anxious, shorter of breath, and requested medication to calm down. Over the next 24 hours she developed worsening hypoxia, tachycardia, and tachypnea. The next morning, Mrs. MB is found unresponsive with agonal respirations. Arterial blood gas revealed evidence of hypercarbia and hypoxemia. She’s immediately transferred to the ICU and intubated upon arrival.

The Role of the Legal Nurse Consultant
The duties of RRT respondents involve quick assessment and stabilization of acutely ill patients. A stepwise RRT approach is utilized in nearly all healthcare systems. This stepwise approach regarding responsibilities and proper monitoring is outlined in their facility’s policies and procedures. Many organizations incorporate trends and screening tools such as an EWS or modified early warning signs (MEWS) which are integrated into the electronic medical record (EMR). These are key factors that LNCs should recognize as they are indicative of a patient’s clinical deterioration (6,8,9).

Common Nursing and Medical Malpractice Litigation Themes

Duty:  If a licensed provider or hospital employee fails to activate an RRT when a patient exhibits signs of deterioration may be viewed as a deviation in the SOC.

Breach: Nursing staff and healthcare providers have a duty to monitor patients and respond in a timely manner to those displaying a clinical change in condition. Failure to respond or activate RRTs may be viewed as a breach of duty.

Causation: If a hospital employee or healthcare provider’s delay or failure to activate RRT resulted in an adverse event or preventable patient outcome. This may help to establish causation.

Damages: Refers to the actual harm or injury sustained by the patient due to a medical professional’s negligence that results in hardship, loss of income, pain, disability, or suffering.

Some common nursing malpractice themes associated with potential rescue failures include but are not limited to:

• Failure to recognize signs of clinical deterioration;
• Failure to report a change in patient condition;
• Failure to monitor or document monitoring;
• Failure to communicate pertinent information;
• Delay or failure to activate RRT;
• Failure to follow institutional policies and procedures; and
• Inappropriate communication or documentation (3).

Some potential medical malpractice claims include but not limited to:

• Delay or failure to respond to an RRT;
• Failure to treat in a timely manner;
• Failure to provide correct treatment; and
• Failure to document RRT event (3).

Legal Nurse Consultant’s Case Scenario Review
In the above clinical scenario, the LNC’s medical record review discovered the following:

• The nurse missed the EWS or MEWS;
• The nurse failed to recognize a change in this patient’s condition;
• The nurse failed to activate an RRT;
• The nurse failed to communicate change in the patient’s condition to the provider; and
• The nurse failed to follow institutional policies and procedures

Summary
In conclusion, while research has shown some controversy on the effectiveness of RRTs and FTRs, it has addressed the importance of identifying preventable adverse outcomes that jeopardizes patient safety and quality care. Together these structured and standardized criteria help to reduce and/or eliminate adverse patient outcomes for non-ICU patients with treatable events.

RRTs have been cited as a National Patient Safety Goal by the TJC and AHRQ. It is has become the de facto SOC in hospitals throughout the US and worldwide. Prompt recognition and interventions are highly dependent on the staff’s skill set, competency, and experience. Reduced vigilance, lack of a multi-disciplinary team approach, and failure to initiate or follow RRT policies to reduce adverse events can predispose hospitals and their staff to potential liability.

(Sources for this article are included in the Side Bar.)

Author: Christine Dorman, DNP, APRN, ACNP-BC, CCRN
Greater Orlando AALNC Chapter, Director at Large
Owner: Vantage Point Legal Nurse Consulting
Website: https://vplnc.com
Email: christinedorman@vplnc.com
Contact: 800-368-7410 

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CHAPTER MEMBER HIGHLIGHT

CRYSTAL CRAWFORD, BSN, RN, RNC-LR, C-EFM

Crystal is an accomplished Registered Nurse with over 23 years of experience at the bedside.  She has dedicated her entire career to maternal and newborn health in the areas of Labor & Delivery, High-Risk Antepartum, Mother/Infant and the Neonatal Intensive Care Unit.  Since 2018, Crystal has assumed the role of managing the Neonatal Resuscitation Program at her current facility as well as practicing as an instructor and instructor mentor, contributing significantly to the professional development of healthcare practitioners in emergency newborn care. Her commitment to excellence is underscored by certifications in electronic fetal monitoring and low-risk neonatal nursing, reflecting her unwavering dedication to maintaining the highest standards of patient care. In addition to her clinical accomplishments, Crystal has cultivated a distinguished reputation as a legal nurse consultant and a sought-after nurse expert witness. Actively engaged with the American Association of Legal Nurse Consultants, she not only upholds professional standards but also serves as a Special Interest Group (SIG) chair, demonstrating leadership and commitment to advancing the field.

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ABOUT THE GREATER ORLANDO CHAPTER OF AALNC

The American Association of Legal Nurse Consultants (AALNC) was founded in 1989, as a not for profit membership organization dedicated to the professional enhancement and growth of registered nurses practicing in the specialty of legal nurse consulting. Chapter development quickly followed. The Orlando community was rich with nurses already practicing in the field of legal nursing. This group of committed professionals quickly became members of the new national organization and recognized the need for a local chapter. The Greater Orlando Chapter of AALNC, founded in 1989, was the second chapter formed under the new national organization. The Chapter was begun in support of AALNC’s mission, by providing networking opportunities, mentoring and support to nurses through professional development and education – a mission that is continued to this day.