College answer
A hospital-wide system to recognise and respond to the deteriorating patient is a requirement as set out in Standard 9 of the National Safety and Quality Healthcare Standards.
Implementation of RRS
- Engage all hospital staff and involve representation from all groups: hospital executive, senior nursing and medical, junior nursing and medical, allied health and ancillary staff and community representative
- Appoint “champions” from these groups to promote the system and to form the working party
- Review the literature and RRS models in other institutions and seek help from experts in the field
- Collect baseline data pre-implementation
- Determine appropriate RRS model for the hospital based on o Hospital case-mix o Hospital culture o Resources and funding
- Pre-existing system e.g.: cardiac arrest team
- Issues to consider
- Criteria for activation o Team composition o Home team involvement o ICU involvement o Projected number of calls
- Consequent effects on existing services as staff take up these additional responsibilities & service provision
- Education of users of system hospital-wide
- Team training for MET personnel including clinical skills, communication, teamwork and endof-life decision-making
- Source appropriate equipment / drugs for RRS calls and storage when not in use, with systems for checking & maintenance
- Establish system for data collection and audit
- Consider phased introduction of RRS or pilot project initially
- Data collection and audit from first day of implementation
- Review of data and benchmarking with other hospitals
- Feedback from RRS users and RRS team
- Modification of RRS as needed
- On-going education of staff and RRS team training
- Contribute to national database
Appropriate information not in the template was given credit.
An acceptable answer addressed the following points:
- The elements of the audit cycle
- The need to engage staff hospital-wide in the process
- Design of the system to suit hospital culture, case-mix, resources
- Team training and education
- Data collection and audit
Additional Examiners‟ Comments:
Many candidates lost marks for an answer that included relevant points but was clearly not at the level of a junior consultant.
Discussion
Clearly this issue has importance, as it has been dedicated the very second chapter of Oh's Manual ("Outreach"). On page 13 of the 7th edition, Welch and Subbe discuss the issue of "setting up an outreach service", a heading which seems relevant to this question. The "key steps in planning an RRS" seems like an important point-form table to reproduce here, with appropriate copyright-defensive paraphrasing (see below). Other major sources for this answer come from the helpful references made in Chapter 2, specifically to the (mainly British) series of RRS guidelines.
The "Standard 9" referred to in the college answer can be found in this horrific committee-spawned standards document. it is actually quite unhelpful if you are trying to build an RRS from scratch, and only outlines the hospital executives' expectations of such a service.
With luck a junior consultant would be able to express this sort of answer in writing within the space of 10 minutes.
- Planning the administration of RRS service
- Appointment of senior staff to develop the service
- Managerial and clincal staff
- Imperatve to include ward staff
- This forms the "working party"
- Planning and research by appointed committee members
- Epidemiology of critical illness in the hospital
- i.e. where is the service going to be required most: ED, recovery suite, in the wards
- Epidemiology of unexpected deaths in the hospital
- Source and timing of unplanned ICU admissions
- "what is the pattern of adverse events where harm can be attributed to the process of care?"
- Consider in this process the content of patient and family complaints, the results of root cause analysis and morbidity/mortality data
- Use these to design a system of criteria for triggering an RRS response, and a system of clearly defined referral/escalation protocols.
- Needs analysis of
- Patient mix
- Ward staff skill levels
- Proposed hours of service operation
- Expected demand based on hospital size and specialty services
- Availability of training facilities
- Equipment needs
- Funding
- Audit process planning
- Identify data for prospective collection
- "It is essential that robust data are collected", they said.
- Assess key practices against "specific, measurable standards"
- Have discrete goals for audit and evaluation:
- to identify areas where training is required
- to identify sources of systematic error
- to identify the changes in critical care workload
- Specific prospectively collected data may include:
- numbers of referrals
- Referral details (date, time, reason for referral)
- Patient details
- Significant problems identified
- Interventions performed
- Patient outcome
- Rapid Response Service design
- "At a minimum, the team should be capable of assessment, diagnosis, initiation of resuscitation, and rapid triage of the critically ill patient"
- The key word is "multiprofessional". You want a multiprofessional team.
- Composition of the team and skills of the members should represent the niche need identified by the planning committe.
- Some basic airway and vascular access skills are probably the expected minimum skill level
- A "pragmatic, staged implementation":
- Education of ward staff regarding the use of the trigger criteria
- Education of RRS members to compete their skill set
- System for update and recredentialling of RRS-relevant skills (eg. annual ALS course)
- Incremental spread of RRS, increasing the number of clinical areas covered, the number of team members, and the responsibilities of the team
- Regular scheduled audit and evaluation
- Nominate independent auditors
- Organise multidisciplinary audit meetings
- At a smaller level, organised regular RRS debrief sessions
- "Successful systems are based upon multiprofessional working, and effective communication education, data collection/audit, learning from errors, and planned improvement of whole systems of care."