Rapid Response Team Policies for Acute Patients in Riyadh Military Hospital and the UK - Essay Example

? Critical Review and Critique on Rapid Response Team Policies for Acute Patients in Riyadh Military Hospital and UK Total Number of Words: 4,002 Table of Contents I. Introduction ………………………………………………………………………… 3 II. Literature Review ………………………………………………………………….. 4 a. Main Purpose of Rapid Response Team …………………………………… 4 b. Differences between the ICU Rapid Response Team Policies in Riyadh Military Hospital and UK …………………………………………. 5 b.1 Early Signs of Patient Deterioration …………………………….. 5 b.2 Strategy Used in Activating the Rapid Response Time and Time Spent to Activate Response ……………………………….. 8 b.3 Time taken to Transfer Patients from Ward to ICU and Emergency Cases wherein the Hospital has No Available Bed …. 9 b.5 Application of the SBAR (Situation, Background, Assessment, and Recommendations) when Treating Acute Patients …………………………………………………… 10 b.6 Clinical Issue related to DNR (do not resuscitate) in case the Patient is Suffering from Physical Deterioration ………………... 12 III. Conclusion and Recommendations ………………………………………………... 13 References …………………………………………………………………………………. 17 Appendix I – Summary of Signs and Symptoms wherein the Rapid Response Team should be Deployed ........................................................................................ 22 Introduction To avoid a sudden cardiac arrest or death, healthcare professionals should not delay the provision of life support and other related health care needs of the patients (Williams et al. 2011; Hillman et al. 2005). Published back in 2007 in an article entitled “Safer Care for the Acutely Ill Patient”, the National Patient Safety Agency (2007) reported that 576 out of the 1,804 hospital deaths were due to diagnostic errors, unrecognized patient deterioration that were left untreated, and problems with resuscitation after a sudden cardiac arrest. Based on the most recent accident and emergency report coming from the Hospital Episodes Statistics (HES) in England, the number of patients admitted for accident and emergency between April 2009 to March 2010 was 15.6 million (NHS 2011). In Scotland alone, the NHS reported that the number of admitted patients who were given accident and emergency services last December 2011 was 129,100 (NHS 2012). As a common knowledge, accident and emergency cases includes not only life-threatening scenarios but also some minor injuries which could be easily treated by the health care professionals. Because of the daily inflows of emergency cases received by each of the local hospitals each day, the standard waiting time in UK before the patient could receive health care intervention was 4 hours (NHS 2012). Considering the average waiting hours before each patient could receive health care intervention, this study will focus on discussing clinical strategies used in UK and Riyadh Military Hospital (RMH) to ensure that its health care professionals are able to deliver quality care and treatment to each patient on a timely basis. In relation to the significance of rapid response team in saving the lives of the patients who were admitted in emergency department, this study will compare and contrast the rapid response team policies for acute patients in UK and the Riyadh Military Hospital. Established on December 1978, Riyadh Military Hospital (RMH) also known as the “Riyadh Armed Forces Hospital” is a tertiary healthcare facility in Riyadh City in Saudi Arabia (RMH 2012). To enable the readers gain better understanding with regards to the effectiveness and differences between the ICU rapid response team in both countries, this report will first discuss the main purpose of rapid response team. As part of critically reviewing the effectiveness of rapid response team in RMH and UK, this report will compare and contrast the ICU rapid response team policies for the following clinical situations: (1) early signs of patient deterioration; (2) strategy used in activating the rapid response time and time spent to activate response; (3) time taken to transfer patients from ward to ICU; (4) emergency cases wherein the hospital has no available bed; (5) application of the SBAR (situation, background, assessment, and recommendation) when treating acute patients in both countries; and (6) clinical issue related to DNR (do not resuscitate) in case the patient suffering from physical deterioration. Main Purpose of Rapid Response Team In UK, the main purpose of Rapid Response to Acute Illness (RRAI) is “to support clinical teams in the reduction of harm and mortality associated with the acutely deteriorating patient” (1000 Lives o FYWYDAU n.d., p. 5). In general, early intervention from the rapid response team could save the lives of patients who show sudden changes in their breathing patterns or a sudden drop in their heart rate (AHRQ, 2012; Thomas et al. 2007). To reduce the risk of avoidable patients’ death, the study of Dacey et al. (2007) strongly concludes that immediate deployment of rapid response team at the first sign of patient deterioration (i.e. cardiac or respiratory failure) is necessary. There are quite a lot of emergency cases wherein patients who were admitted in ward could experience signs of deterioration. To prevent worsening of the patients’ health condition, rapid response teams were established to perform immediate life-saving measures either at the patient’s bed-side or even before the patients can be admitted to an ICU (AARC.org 2012). To avoid the risk of patient coma, the standard emergency care procedure includes ensuring that the patient’s airway, breathing, and circulation (ABC) is properly secured and well-maintained (Posner et al. 2007). This explains why a rapid response team is usually composed of respiratory therapist, a physician, physician’s assistant, pharmacist and critical care or ICU nurses (AARC.org 2012). Differences between the ICU Rapid Response Team Policies in Riyadh Military Hospital and UK Early Signs of Patient Deterioration Detecting early signs of patient deterioration is necessary to reduce the risk of mortality rate caused by airway obstruction or cardiac arrest (Luettel, Beaumont and Healey, 2007). For instance, obstruction in the patient’s normal airway functioning is considered a life-threatening scenario since the lack of oxygen that flows in the blood that flows through the human body can lead to end-organ damage, hypoxia, hypoxemia, and high mortality rates (Eddleston et al. 2006; Levy 2005). Given that the patient shows signs and symptoms of airway obstruction, the rapid response team should immediately establish the patient’s airway as part of the initial care management (Mayo-Smith 1993). Airway management is not limited to the obstruction of the patient’s airway. In some cases, other medical indications that requires airway management includes: cardiac and/or respiratory arrest, failure to protect the patient’s airway, inadequate oxygenation or ventilation, care of the critically ill or acute patients who has multi-system disease or injuries, and control of airway during surgical procedures which requires general anaesthesia (Kabrhel et al. 2007). Therefore, the bedside nurses in UK and RMH both are obliged to pay close attention not only to the patients’ breathing pattern but also the patients’ heart rate, respiratory rate, blood pressure, oxygen saturation, temperature, significant changes in the patients’ mental status, urine output, chest pain, seizure, and uncontrolled pain during the assessment stage (AHRQ 2012; Smith and Roberts 2011, p. 140). (See Appendix I – Summary of Signs and Symptoms wherein the Rapid Response Team should be Deployed on page 22) According to Lawson and Peate (2009, p. 91), the early warning score (EWS) is a tool that is commonly used in hospitals “to assist in the early detection of critical illness”. In line with this, Smith and Roberts (2011, p. 138) identified several variation of such scoring tool as: (1) patients at risk score; (2) modified EWS or EWS; and (3) national EWS (NEWS) system. Regardless of the kind of scoring tool used in each hospital, admission officer or bedside nurses are required to record and document the patients’ vital signs and the results of their physiological observation on EWS scoring sheet. As part of the standard clinical procedure when assessing the patients, gathered clinical information will serve as the baseline when assessing the health progress and deterioration of the patients. Similar to most of the clinical practices in UK, admission officer and/or bedside nurses in RMH makes it a practice to use EWS as a monitoring and assessment tool. To ensure the accuracy of EWS record, Smith and Roberts (2011, p. 140) strongly recommends that only nurses with proper training should be allowed to perform and record observation findings on the patients’ physiological changes. Aside from specifying exact date and time of physical observations and recording initials of nurses who performed the observation, nurses assigned to assess the patients should also determine the frequency of observation (i.e. minimum of 12 hourly, 4 hourly, 1 hourly or every 30 minutes) depending on the physical health condition of the patient (Grainger and Kapila 2010). Using the most current EWS record, bedside nurses are expected to identify patients who may be at risk of physical deterioration. Thus, allowing the bedside nurses to collaborate with other clinical staff to determine whether or not there is a need to call the attention of the rapid response team. There are other strategic ways in which the nurses at RMH are performing early identification of patients who are at risk of deterioration. Among these strategies include: (1) designating qualified nurses to receive notification from the ICU transfers to medical or surgical ward(s); and (2) designating qualified nurses to make routine rounds in medical or surgical wards to assist and provide necessary support to bedside nurses who are paying close attention to signs of patient deterioration. Designating highly qualified nurses to receive notification from the ICU transfers to medical or surgical ward(s) and/or designating qualified nurses to make routine rounds in medical or surgical wards to assist and provide necessary support to bedside nurses could somehow increase the chance wherein the designated nurse could effectively focus on monitoring the patients’ vital signs and other related physiological observations. As compared to encouraging the bedside nurses to master the use of EWS system, the implementation of these two strategies can be very costly on the part of the RMH administration. Aside from reducing the accountability and responsibility of bedside nurses when assessing and monitoring the early signs of patient deterioration, these strategies could only promote work redundancies. Strategy Used in Activating the Rapid Response Time and Time Spent to Activate Response Within the hospital setting, there are cases wherein the primary physician or GP is out of reach. In case the bedside nurse is in doubt of the patient’s health situation or in case advice or assistance is needed, Halter et al. (2009) mentioned that it is an option to call the attention of the rapid response team for some assistance. Although the average response time from call to arrival is between 2 to 10 minutes from the time the call was made, the time spent to activate response should be at most 5 minutes or less (Halter et al. 2009). To prevent further deterioration or risk of losing the lives of non-ICU/ED inpatients, criteria used in the activation of rapid response team in RMH is based on the early signs of deterioration. In general, the results shown in the most current EWS record is one of the bases for activating the rapid response team. For example, patients showing signs and symptoms related to a potential arrest will be given the colour code “blue”. Since blue code is the top priority of the rapid response team, the bedside nurses is obliged to immediately call the team for early interventions (Thomas et al. 2007). To reduce harm from deterioration, Patient Safety First (2008) suggest that the rapid response team should identify deterioration by recording physiological observations, identify appropriate level of care, and track and trigger system followed by responding to deterioration through graded response strategy, escalation protocol, and the use of communication tools like SBAR. Similar to the clinical practice in UK, immediate activation of the rapid response team in RMH can be made on a 24/7 basis. Based on EWS report, the bedside nurse will make the final judgment with regards to the degree of patient deterioration (Mackintosh, Rainey and Sandall 2012). Halter et al. (2009) explained that activation of the rapid response team can be made by encouraging the bedside nurse to notify the house manager to contact the rapid response team via telephone call or pager. As soon as the rapid response team receives the call or message from the pager, the team members together with the bedside nurse could re-assess the patients’ health condition before deciding on the patient’s care and treatment plan and/or assist the bedside nurse when there is a need to transfer the patient to the ICU. Given that the rapid response team and the bedside nurse decided that there is no need to contact a physician, the team should carry out existing orders in order to stabilize the patient’s health condition. As soon as the patient is stabilized, the team members should contact the bedside nurse within the next couple of hours in order to check on the patient’s health condition. In case there is a need for a physician, the team members and the bedside nurse should contact responsible physician. In case the physician is available, the nurse should report assessment, receive, and carry out new orders. In case the physician is not available, the nurse should contact a resident (Halter et al. 2009). Time taken to Transfer Patients from Ward to ICU and Emergency Cases wherein the Hospital has No Available Bed Internal transfer is referring to the process of “transferring a patient from a ward to other departments for the purpose of clinical care, diagnosis or dependency and/or bed availability” (Brennan 2009, p. 4). In UK hospitals, patient transfer between 2200 to 0700 hours is strictly prohibited unless there is a significant clinical reason for the transfer (p. 6). To ensure patients’ safety, the transfer policy in UK requires all registered nurses to communicate the intended patient care to the receiving ward (p. 7) and record the name of the patient, age, referring team, accepting team, real time of ordered transfer, and to- and point-of-destination on the hospital information system aside from being prepared to receive the patient from the ward (pp. 5 – 6). The average time taken to transfer a patient from ward to ICU varies depending on the availability of beds in the ICU. In case demand for ICU beds exceeds the number of available beds, the ICU consultant is expected to discuss with the senior nurses and specialist teams about the transfer and necessary transfer arrangement of less ill patient to the ICU of another hospital (Intensive Care Society 2012). Although this strategy can cause inconvenience to other patients, transferring less ill patients to the ICU of another hospital will enable the nurses admit critically ill patient who are not fit to travel to another hospital. Application of the SBAR (Situation, Background, Assessment, and Recommendation) when Treating Acute Patients SBAR (Situation, Background, Assessment, and Recommendation) is a type of communication tool or a standard communicating framework which is often used to enhance the communication and teamwork among each of the healthcare professionals (Institute for Healthcare Improvement 2012; Guise and Lowe 2006). Basically, SBAR is commonly applied when treating or caring for acute patients because it allows “timely, accurate, complete, unambiguous” communication which can be easily understood by the receiver (Joint Commission on Accreditation of Healthcare Organizations 2006). Considering the fact that the actual design of the SBAR communication framework is simple and “easy-to-remember” (Leonard, Bonacum and Graham 2012), several studies concludes that the application of SBAR in nursing profession can effectively reduce the risk of human errors (Beckett and Kipnis 2009; Guise and Lowe 2006). Within the hospital settings, unlimited human errors can occur due to lack of teamwork or poor communication among the healthcare professionals (Guise and Lowe 2006). As a result of weak or delayed communication among the staff, patient’s safety often suffers. In general, the local hospitals in UK are utilizing the SBAR communication framework when treating acute patients. Using the four (4) standardized prompt questions in SBAR communication framework, the healthcare professionals in UK-based hospitals could easily share a concise and more focused patient assessment information (NHS 2012). In UK hospitals, registered nurses are encouraged to make use of SBAR communication framework when discussing urgent or non-urgent case of inpatients or outpatients with a physician and/or allied health professionals like the respiratory therapists or the physiotherapists (NHS 2012). When transferring the patients to and from the progressive care unit, intensive care unit, and/or cardiac laboratories, the research study of Wentworth et al. (2012) strongly encourages the need to develop a standardised electronic communication tool using the SBAR communication framework. Either communicating over the phone or on a written document such as a printed tool card or a visual prompt note, the same communication framework can be used when communicating changes in the shift report with co-nurses. Despite the healthcare advantages of using the SBAR communication framework, registered nurses and physicians who are currently employed at RMH are not using the SBAR communication tool. To improve the healthcare professionals’ communication in RMH, the patient’s primary provider should be contacted to inform them about the importance of using the SBAR communication framework when discussing the patients’ current health condition. By doing so, nurses and physicians who are working at RMH can effectively reduce the risk of human errors. Clinical Issue related to DNR (do not resuscitate) in case the Patient is Suffering from Physical Deterioration Ethical theories such as the law of autonomy, informed consent, non-maleficence, beneficence, and justice serve as a guide for nurses on how to care and treat the patients (Bailey 2007). Before allowing the patients to make their personal decisions with regards to their preferred care and treatment, healthcare professionals should inform the patients about the healthcare intervention process, advantages and disadvantages of their optional treatment(s), physical assessment, and care plan (DOH 2001b, p. 1). In case the patient is unconscious at the time of treatment, healthcare professionals in UK and RMH are obliged to follow the guidelines stipulated in the following Department of Health documents: (1) Reference Guide to Consent for Examination or Treatment (2001); and (2) Mental Capacity Act (2005). Under the Mental Capacity Act (2005), it was mentioned that healthcare practitioners should avoid making unwise decisions on behalf of the patients and that any decisions made should be for the benefit or the best interests of the patients. For this reason, it is part of the clinical practice that healthcare professionals should not restrict the patients from their right or basic freedom to decide for themselves. As a universally accepted healthcare ethics, healthcare professionals including the nurses should respect the patients’ decision for their own preferred treatment and care. In case the patient has issued an early notice of do not attempt resuscitation (DNAR) or do not resuscitate (DNR) order, healthcare professionals and nurses should respect and grant the patients’ requests provided that the healthcare professionals are confident that the patient is in the right frame of mind at the time he/she has made the DNR order (DOH 2001b, p. 3). Even though the rapid response team in RMH includes all hospital outpatients and inpatients with or without DNR or DNAR status, bedside nurses should inform or remind the team whether or not the patient has issued an advance DNR order at the time when the patient is already showing early signs of deterioration. Although patients with advanced DNAR order will not be coded, this group of patients could still receive health benefits from the simple clinical intervention(s) which will be provided by the team. By doing so, the healthcare professionals will be able to satisfy both the ethical principles of autonomy and justice. As part of the legal and ethical healthcare practice in UK and RMH, it is a standard operating procedure for healthcare professionals to follow the rules behind ‘informed consent’ prior to the delivery of any treatment, physical assessment or investigation, and the provision of personal care for the patient (NHS 2006; p. 8; DOH 2001a, p. 2; DOH 2001b; p. 1). Furthermore, healthcare professionals should also avoid assuming that the patient will no longer be able to communicate or make any decisions for himself/herself (DOH 2001b, p. 9). In case the patient or patient’s family members have decided to accept DNAR order, nurses should keep it a practice to obtain a signed advance DNAR order either directly from the patient or from the patients’ family members in case the patient is no longer capable of signing a contract. Conclusion and Recommendations Registered nurses play a significant role not only in terms of detecting the early signs of patient deterioration but also when it comes to the need to activate the rapid response team. To improve the ability of the registered nurses in detecting the early signs of patient deterioration and activating the rapid response team, this study strongly suggest the need to improve the nurses’ responses to the rapid response team by improving their knowledge and skills on how to activate the rapid response team, encourage them to work in autonomy, use their intuition in making judgment, and solve clinical problems collaborately (Williams et al. 2011). In general, detecting the early signs of patient deterioration is necessary to reduce the risk of mortality rate caused by airway obstruction or cardiac arrest (Luettel, Beaumont and Healey, 2007). Due to the complexity of the hospital system (i.e. shifting schedule, work rotation, etc.), Luettel, Beaumont and Healey (2007, p. 26) reported that existing policies in UK with regards to the process of detecting and recognizing early signs of patient deterioration seems to be too “difficult to follow”. For example, respiratory rate is considered an important indicator of patient deterioration. Due to work overload, lack of sufficient skills training, and increased dependence over the use of electronic devices, there will always be risks wherein this particular vital sign is left unrecorded on the patients’ observation charts (Smith and Roberts 2011; Kennedy 2007). To avoid the delivery of suboptimal and untimely care intervention to the patients, it is necessary to improve the hospital system on rapid response team and encourage the bedside nurses to spend quality time measuring and documenting respiratory rate on the patients’ observational charts. Immediate healthcare intervention to the early signs of patient deterioration is necessary to reduce the risk of mortality rate caused by airway obstruction or cardiac arrest. For this reason, Halter et al. (2009) strongly recommends that the time spent to activate the rapid response team should not be more than 5 minutes. To encourage immediate activation of the rapid response team, the bedside nurse should immediately notify the house manager to contact the rapid response team via telephone call or pager in case signs of patient deterioration were evident. To avoid human errors on patient’s medication and treatment, registered nurses who are working in a hospital should make use of the SBAR (Situation, Background, Assessment, and Recommendation) communication framework in order to enhance the communication among the healthcare professionals. Even though the SBAR communication framework is effective in terms of reducing the risk of communication errors, a lot of registered nurses who are inexperienced in using this particular communication framework could feel less confident when it comes to giving out recommendations. For this reason, this study strongly recommends the need to provide either educational training or team support and encouragement to registered nurses when implementing the use of this particular communication tool (NHS 2012; Haig, Sutton and Whittington 2006). Unlike the registered nurses and physicians in UK, registered nurses and physicians who are currently employed at RMH are not taking advantage of the SBAR communication tool. For this reason, this study strongly recommends the need to contact the patient’s primary provider to educate them about the importance of using the SBAR communication framework when discussing the patients’ current health condition. By doing so, nurses and physicians who are currently working at the RMH can effectively reduce the risk of untimely treatment or medication errors caused by miscommunication. Registered nurses should keep in mind that ethical theories related to the law of autonomy, informed consent, non-maleficence, beneficence, and justice should serve as a guide when caring and treating the patients (Bailey 2007). In general, violation of the healthcare ethics could make the healthcare professionals held liable for medical malpractice or professional negligence (Carr 2009; Robbins and Birminghams 2005). To avoid facing legal charges coming from the patients’ family members, healthcare professionals should always make it a practice to inform and seek consent from the patient before conducting physical assessment for early signs of patient deterioration. 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(2011). Nurses’ Perceptions of How Rapid Response Teams Affect the Nurse, Team, and System. Journal of Nursing Care Quality 26(3), pp. 265-272. Appendix I – Summary of Signs and Symptoms wherein the Rapid Response Team should be Deployed Rapid Response System Calling Criteria Staff members may can the team if one of the following criteria is met: Heart rate above 140/min or less than 40/min. Respiratory rate more than 28/min or less than 8/min. Systolic blood pressure greater than 180 mmHg or less than 90 mmHg. Oxygen saturation less than 90% despite supplementation. Acute changes in mental status. Urine output less than 50cc over 4 hours. Staff member has significant concern about the patient’s condition. Additional criteria used at some institutions: Chest pain unrelieved by nitroglycerin. Threatened airway. Seizure. Uncontrolled pain. Source: AHRQ, 2012 Read More