Teaming Up to Prevent 'Crashes'
Tuesday, September 4, 2007
Imagine making an emergency call not for help getting to the hospital but after you've already arrived there. That's what Ray Clement and his wife did last year at the University of Pittsburgh Medical Center's Shadyside Hospital, where he had gone with a suspected blood clot. When Clement thought his doctor had abandoned him in a crisis, he sounded the alarm.
Within five minutes, four hospital workers were at his bedside, including the doctor he thought had disappeared.
Clement's call went out to a crisis team of the kind that growing numbers of medical centers are providing. The "rapid response team" (RRT) is designed to identify patients before they crash, or "code," in respiratory or cardiac distress. Though staff members typically call for the team, some hospitals -- in a controversial step -- now permit patients and their families to activate the system if they feel a patient is failing or not getting needed medical attention.
"Families know these patients better than anybody else," said Kathy Duncan, a faculty expert on RRTs at the Institute for Healthcare Improvement, a nonprofit organization focused on patient safety initiatives. "It's a natural progression of the culture of safety in the hospital. Everybody has a resource to call for help with the patient."
The 20 or so U.S. hospitals where patients can call an RRT include St. Joseph Medical Center in Towson and Franklin Square Hospital Center in Baltimore. The Greater Baltimore Medical Center began its program, called Code Help, in July, and Johns Hopkins Hospital is planning to test a patient-activated system on its neuroscience unit this fall.
Families and patients are encouraged to call the teams if something seems seriously amiss or if they feel the patient's assigned doctor or nurse is not providing the medical answers they need.
"We're letting the patient and family really become partners in their health," said Tami Merryman, vice president of the Center for Quality Improvement and Innovation at the Pittsburgh medical center, which IHI says was the first to implement patient-initiated RRTs, in 2005.
More broadly, the rapid response system is part of a national initiative to reduce preventable deaths, spurred by a 2000 Institute of Medicine report on medical errors. While it's now up to hospitals to decide whether to have such teams, a December vote by the Joint Commission, a nonprofit that accredits hospitals, could mandate them in all medical centers.
Ray Clement's decision to call a rapid response team is an example of one kind of case the system is designed to address.
The 50-year-old from South Park, Pa., went to the emergency room at Shadyside in January 2006 when he had arm pain after having a stent replaced. On an earlier occasion, similar pain had signaled a clot.
He was admitted to the hospital, given a sonogram and a blood thinner as a precaution, then told to wait. Over the next hour or more, a nurse repeatedly paged the emergency room doctor who had admitted him, telling Clement each time that the doctor had not yet had a chance to read the sonogram. Finally, Clement was told the doctor had gone home.
"I thought, 'This is horrible,' " said Clement. " 'I can't make a move until I hear from this guy. Should I even be on blood thinners? And he's gone home.' "
Earlier, his wife had noticed information about the RRT -- called "Condition H for 'Help' " -- in the hospital's patient rights brochure, and the two decided to call the team.
"I was nervous and completely frustrated," Clement said, "and mad when I heard the doctor went home."
Once the team arrived, said Clement, they "wanted to get to the bottom of things." Clement learned he indeed had a blood clot and was treated accordingly.
The rapid response team is "probably one of the best changes I've seen in medical attention," said Clement, who began frequenting hospitals as a teenager with Hodgkin's disease and who has also needed treatment for long-term problems stemming from his chemotherapy. "The system they have in place is extremely efficient."
Thanks -- and Resentment
The composition of rapid response teams differs by hospital. Many are staffed by nurses, respiratory therapists and doctors. A few include patient advocates and social workers. In some hospitals, patients can call a team directly; in others, they must take their request to the floor nurse; the nurse cannot refuse to call.
Initially, staff members often resist the idea of letting patients and families mobilize the team, fearing they will be overwhelmed by frivolous requests. Merryman, who spearheaded the Condition H initiative at Shadyside, said she heard comments such as, "You can't trust they won't call for bedpans." In fact, patients seem to use the system sparingly, hospital administrators say.
Some hospital workers also worry that patients may view the teams as a sign that the medical staff is trying to shirk its responsibility or shift it to them. "It's a major concern that family members might think, 'Why do we need to do that?' " said Brad Winters, who is considering changing Hopkins's adult patient rapid response system, which he runs, to one that lets patients initiate a call.
Even after such systems are implemented, not all staff members are necessarily on board. Neena Reddy, a house physician at Shadyside who is part of a patient-initiated RRT, says she has received incredulous calls from doctors, asking her to check if a Condition H call from a patient of theirs had really been necessary.
The theory behind permitting family-initiated calls is that family members -- because they know the patient so well -- often recognize problems or atypical behavior before doctors do. They may be the first to notice that Grandma seems disoriented or less talkative than usual, which may indicate a medical decline. Once called, the team examines the patient and decides whether a higher level of care is needed.
Often, says Reddy, a patient's problem is one of communication with medical staff rather than an issue of care itself.
Reddy's first Condition H call came from a woman with a history of anemia who came to the hospital complaining of dizziness. Tests showed that her blood count was low and she needed a transfusion, but she was terrified and felt that her doctor was trying to intimidate her into a procedure she did not want.
Reddy talked with the woman and learned that the patient believed a past transfusion had led to renal failure and kidney dialysis, "the worst experience of her life," and she was frightened that it would happen again.
"She said, 'Can you promise me nothing bad will happen?' " said Reddy.
"I said, 'No. But the fainting spells you are having are very real.' "
After hearing this, the patient decided to undergo the transfusion. "She had the chance to make a choice for herself," said Reddy. "Before, she was making the decision under duress."
Reddy has found that clarifying patient concerns can sometimes make all the difference. "Sometimes they have anxiety you don't know about."
How Much Impact?
St. Joseph Medical Center in Towson started patient-initiated RRTs about a year ago, after a case involving family feedback. A patient's husband felt uncomfortable that his wife had been moved out of the intensive care unit, although he could not pinpoint why. So he asked the staff to take another look at his wife. This additional evaluation showed that she needed emergency heart surgery.
"He had picked up that there was a change," said St. Joseph's chief medical officer, Richard Boehler. "For us, the story was gripping. Here was a family member who had intervened. We don't know what the outcome would have been otherwise."
Despite such anecdotes, measuring the value of rapid response systems is difficult. A few published studies show a drop in mortality and codes outside the ICU, according to a literature review in the May issue of Critical Care Medicine, but whether other initiatives may also contribute to these decreases is not clear.
"Overall, rapid response systems seem to have some benefit," said Winters, the lead author on the study. "At the same time, the benefit is not tremendously strong and the quality of the studies is not the best."
Still, some statistics are encouraging. Since its rapid response system was implemented two years ago, St. Joseph has seen death rates drop 15 percent and the number of "codes" fall from 15 a month to between six and eight a month, according to Boehler. Franklin Square Hospital Center also has seen a decrease in mortality and code calls outside intensive care since it began RRTs, according to Pat Norstrand, the center's senior director of quality risk and safety.
At Shadyside, which has 486 beds, Condition H has been used 72 times since its hospital-wide inception in July 2005. Pain management issues have accounted for most calls. In 62 percent of the cases, patient calls have averted a medical error, said Merryman, who reviews each call.
Presbyterian Hospital, another unit of the Pittsburgh medical center, has seen a 17 percent decrease in deaths within the year RRTs were implemented, according to Michael DeVita, a professor of critical care medicine at the University of Pittsburgh School of Medicine.
Hospitals are also trying other approaches to improve patient safety. The Johns Hopkins Children's Center, for example, is teaching parents signs of deterioration to watch for when their children are discharged from the intensive care unit, said Elizabeth Hunt, who runs the pediatric RRT program.
Sorrel King, a patient advocate whom many hospital administrators credit with originating the idea of patient-initiated RRTs, wishes one had been in place in 2001 when her daughter Josie died at Hopkins from dehydration. King said nurses repeatedly insisted that the child was fine, even though King felt that something was wrong. ("Hopkins accepts full responsibility for this child's death," said Katerina Pesheva, a spokeswoman for the Johns Hopkins Children's Center.)
Had there been a crisis team to call, King is convinced Josie would be alive today.
"Of the patient families I've talked to, the complaints come to one single thread: 'They didn't listen to me,' " King said. "A fresh set of eyes could evaluate the situation." ?
Shirley S. Wang has a doctorate in clinical psychology. Comments:firstname.lastname@example.org.