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Residents finding their place on rapid response teams

While teams may reduce the rates of codes and mortality, housestaff are still finding out where they fit in

From the March ACP Observer, copyright 2006 by the American College of Physicians.

By Yasmine Iqbal

At Seattle's Virginia Mason Medical Center earlier this year, a nurse took a second look at the monitor of an elderly patient with bacterial pneumonia and lung disease: His oxygen saturation had suddenly dropped. Third-year resident Megan E. Briggs, ACP Associate Member, was among the first to respond to the nurse's call for help.

If the call had come two years ago, Dr. Briggs and the nurse may have been the only ones at the patient's bedside, particularly because the patient seemed to rally quickly. Instead, they were joined by the center's new rapid response team members, consisting of a hospitalist, a respiratory therapist and a senior nurse from the critical care unit.

"Together, we determined that this patient might be sicker than we thought, even though his oxygen saturation level had come back to normal," said Dr. Briggs. The patient was transferred to the ICU and given a BiPAP mask and further tests. Results the next morning showed he had the flu.

Dr. Briggs is convinced the rapid response team had a big impact. "Without the team, we probably wouldn't have transferred the patient or tested for influenza, and we might have ended up intubating him," she said. "As it turned out, he did fine."

Rapid response teams—also known as medical emergency teams—are increasingly cropping up in hospitals nationwide. Designed to respond to acute situations before they become critical, the teams are made up of different members of hospital staff.

Residents are often core team members. But as different hospitals experiment with a variety of team models, residents are serving new roles. Sometimes they remain the physician of record, but in other models they may be directly supervised or at least checking in with attending physicians. As the new team model continues to evolve in an effort to reduce patient mortality and complications, residents' roles on those teams are also a work in progress.

A fast rise

Virginia Mason is just one of many hospitals nationwide that either have a team in place or plan to develop one shortly.

Pioneered several years ago in Australia, rapid response teams are getting a big push in the U.S. from Boston's Institute for Healthcare Improvement (IHI). The IHI has made rapid response teams one of the six quality "planks" in its highly visible "100,000 Lives" patient safety campaign. According to the IHI Web site, such teams are already in place in about 100 American hospitals—with half of the 3,000 hospitals that have signed up for the IHI campaign planning to implement one.

The goal of these teams is to respond to subtle warning signs—usually detected by an astute nurse or resident—that patients often display before a life-threatening event. In the past, such concerns may have been dismissed, but a rapid response system now allows the nurse to summon a designated team to the bedside when a patient's condition deteriorates in specific ways. (See "What should trigger a rapid response?")

By establishing teams, hospitals hope to treat patient problems before they become codes. The IHI Web site, for instance, reports that Baptist Memorial Hospital in Memphis, Tenn., experienced a 28% drop in code rates after putting together a team.

And in a 2004 study, authors from the University of Pittsburgh Medical Center—which first formed a rapid response team in 1988—reported that the mean monthly incidence of cardiopulmonary arrests had dropped by 17% between 1999 and 2000, suggesting that 21 lives each year were saved.

"There's no doubt in my mind that these teams save lives," said Michael A. DeVita, FACP, associate professor of critical care medicine and internal medicine at the University of Pittsburgh Medical Center Presbyterian Hospital. "They provide one-stop shopping for any clinician who is worried about a patient."

Where do residents fit in?

The question for residents, however, is: Where do they fit in? When a team was first assembled at Virginia Mason in 2004, for example, residents weren't initially part of the team roster. That quickly became a hot topic at housestaff meetings.

"Acute resuscitation is a huge part of our educational experience, and we felt that we were missing out," said Dr. Briggs. "Fortunately, this institution is committed to its residents, and only a few months went by before it was decided that we should be included."

While on the team, however, the Virginia Mason residents are under the supervision of the team hospitalist, a situation some residents may perceive as cutting in on their autonomy, said Michael E. Westley, MD, Virginia Mason's associate program director of internal medicine.

"We believe you can't have great learning without great care," he said. "For us, that means that residents should have close supervision during acute situations."

He recalled a recent incident where the resident on a rapid response team made an incomplete assessment of a patient's gastrointestinal bleed. "Fortunately, a faculty physician was right there to catch the mistake," Dr. Westley said. "The resident received a high-value learning experience, but the patient was still taken care of."

As for Dr. Briggs, "I don't feel they take away my autonomy—-if something critical is happening to my patient." She finds that the senior team physicians often make helpful suggestions and rarely take over the patient's care. And "having them there makes you feel like you're not getting hung out to dry."

But some residents maintain that they should be the go-to physician in team situations—a role they play at many hospitals. Inga Lennes, MD, a third-year internal medicine resident at Boston's Beth Israel Deaconess Medical Center, pointed out that residents there take a more central team role. Teams at Beth Israel were first put in place last fall and consist of a resident, the bedside nurse, a senior nurse and a respiratory technician.

"An ICU physician might actually take longer to get up to speed on that particular case," said Dr. Lennes, who underscored the importance of residents' familiarity with a patient when a rapid response call comes in. "What's important is the quick evaluation and the change in management, if needed." Amanda Pressman, MD, a fellow third-year internal medicine resident at Beth Israel, agreed. "I'm not sure that having an intensivist immediately at the bedside is any better for patient safety."

"Studies suggest that you get the same bang for your buck, whether or not you put a senior physician on the team," said Michael D. Howell, MD, an intensive care specialist who helped put the hospital's team system together. "It's not who you send, it's what you do when you get there."

And, he added, "there's always tension between resident autonomy and the supervised care of patients—always has been, always will be. We feel our model does a good job of balancing those demands."

Senior physicians at Beth Israel do get involved: Residents on the teams must follow a "golden hour rule" and call the attending within an hour to either have him or her come to the bedside or, if the situation has resolved, discuss the case.

At Boston's Brigham and Women's Hospital, resident team members use a care-escalation algorithm to inform the attending physician even sooner. The hospital began a team pilot project in December 2005, with teams consisting of a respiratory therapist and a critical care nurse, as well as interns and residents.

To ensure that they are proceeding correctly, team residents have to call the attending within 30 minutes—if not sooner—if a situation is not resolved. They also need to discuss the patient's situation with an intensivist or cardiologist within 60 minutes.

"We need to advise residents that it's OK to ask for help early," said Jeffrey M. Rothschild, ACP Member, an assistant professor of medicine at Brigham and Women's.

And at University of Pittsburgh Medical Center Presbyterian Hospital—where residents are currently on the teams' periphery—efforts are now underway to give them a much larger role, Dr. DeVita said.

"When we first implemented the teams in December 2000, we did have some pushback from residents," he said. "They felt their right to practice and learn was being taken away." The residents asked to be more involved—and the hospital is now designing a two-week elective that will focus exclusively on rapid response teams.

"The residents will have a required rotation," Dr. DeVita said. "They'll get to perform in a supervised atmosphere and will participate in our 'antecedents to crisis' chart reviews to learn how systems fail and how they can support patients."

Benefits and downsides

Whether they respond as primary physicians or in a more supervised setting, residents agree they can learn a lot from being a team member.

"Learning to discern a really sick patient from a not-so-sick patient is one of the main skills you're supposed to develop as a resident," said Dr. Lennes. "We do get some of this training during our critical care rotations, but being on a rapid response team really teaches you to recognize the patient who is declining right in front of you."

Dr. Lennes has also found that teamwork strengthens her communication skills. "You learn to listen to the nurses and ask a lot of questions to really find out what's happening." She and Dr. Pressman are now surveying second- and third-year residents to determine how comfortable they are handling rapid response criteria and how often they would call an attending for help. They'll use survey results to design Web-based educational modules, with information for residents on how to handle each "trigger" and tips for attendings on how to use team efforts in teaching.

But rapid response teams aren't without kinks—or controversy. In a study published in the June 18, 2005, issue of The Lancet, for example, Australian researchers compared findings from 23 hospitals (12 had rapid response teams; 11 did not), and concluded that "[t]he MET [medical emergency team] system greatly increases emergency team calling, but does not substantially affect the incidence of cardiac arrest, unplanned ICU admissions, or unexpected death."

A slot on a rapid response team also increases residents' workload. According to Dr. Briggs, repeated calls "can really break up the admissions that you're doing." But these interruptions are offset doing fewer codes. "As a second-year resident, I got called to a code almost every night," she said. "As a third-year, I get a [rapid response] call every night, but there are very few codes."

Residents report some snafus related to the rapid response teams that have to be ironed out. Those include:

  • False alarms. Some team calls turn out to be unnecessary—an equipment problem, for example. "For some residents, this is the first experience they've had with rapid response teams, so they conclude that they're useless," said Dr. Lennes. That impression quickly fades, she added, when they realize the team's advantages. As nurses become more familiar with rapid response team trigger criteria, she added, there have been fewer false alarms.

    And according to Dr. Briggs, "I've never been in a situation where the person who activated the team was told 'you shouldn't have called.' We feel that it's better to be overcautious than sorry."

  • Extra paperwork. At Beth Israel, the details of every call must be documented, which creates additional paperwork. In most cases, however, the documentation should be done anyway. "An event note used to be the best practice," said Dr. Pressman, "but now it's mandatory."

  • Cultural barriers. Barriers to teamwork in a hospital are probably the biggest obstacles to assembling an effective rapid response team. The authors of the 2004 University of Pittsburgh study, for example, wrote that nurses originally were reluctant to activate the team and bypass the residents. Creating and distributing objective criteria for when a team should be called helped remove that barrier.

These hurdles are just more elements of an evolving model, with issues that must still be worked out. One person who has witnessed different team approaches is Mark L. Zeidel, FACP, chair of Beth Israel's department of medicine, who held the same title at the University of Pittsburgh when that center first implemented teams.

As for residents' much greater role on the teams at Beth Israel, "I was concerned about how residents were going to handle these situations, but so far, we haven't seen one call where they didn't respond fully and appropriately," he said. "I came from a different model, but so far, this one seems to be working just fine."

Yasmine Iqbal is a freelance health and science writer in Philadelphia.

The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.

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What should trigger a rapid response?

Hospitals have adopted different criteria for summoning a rapid response team. Here are the triggers used to call the team at Virginia Mason Medical Center in Seattle:

  • Any caregiver worried about the patient
  • Acute change in heart rate of less than 40 or more than 130 beats per minute
  • Acute change in systolic blood pressure to less than 90 mmHg
  • Acute change in respiration rate less than 8 or more than 30 breaths per minute
  • Acute change in pulse oxygen saturation to less than 90%, despite 02 (added non-rebreather mask)
  • Acute change in conscious state (added seizure or signs of a stroke)
  • Acute change in urine output to less than 50 ml in 4 hours

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