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CE_Nov REV 6/30/11 12:45 PM Page 18 According to the Institute of Medicine (IOM), assessment is "an important mechanism for the detection of errors and the prevention of adverse events." Studies have shown that errors typically result from problems within the system (e.g. acute-care hospitals or nursing homes) where people work. In its publication To Err is Human, the IOM endorses the systems approach to understanding and reducing errors and notes that failure in large systems, such as hospitals and their various patient care units, are mostly due to unanticipated events or factors occurring within multiple parts of the system. Direct-care registered nurses, typically, do not control the system. The corporation controls the system. It determines budgetary priorities, expenditures, and cost containment schemes based on its philosophy, mission, and vision. An overt violation of safety standards set by a state, e.g. safe staffing ratios or interfering with the RN ability to perform ongoing patient assessment for early detection of a change in the patient status, can cause devastating errors resulting in sentinel events. Duty and Right to Advocate in the Exclusive Interest of the Patient rns have a duty to recognize circumstances that cause harm to their patients and activities and decisions that in their professional judgment are against the interest of their patients. RNs have the right to advocate in the exclusive interest of their patients and must be able to do so without fear of retaliation or reprisal. Direct-care RNs are inseparably linked to patient safety. Safe staffing standards, based on the patient's acuity, allow the directcare RN to observe the subtle changes in the patient condition and recognize the early signs and symptoms of the beginning of a patient's decline. These can only be detectible through the directcare RN physical presence and her/his ability to directly observe changes in the patient's physical and cognitive status. This Rapid Response Team approach has not been scientifically validated; it is based on assumptions and so called "best practices" also known as "just-in-time" nursing and medicine. It blatantly disregards scientific studies finding that the association of RN staffing levels with the rescue of patients with life-threatening conditions suggests that RNs contribute importantly to surveillance, early detection, and timely intervention that save lives. RNs should always advocate for the appropriate placement of the patient, where the patient is cared for on a unit that can provide safe, therapeutic, and effective patient care delivered in a competent manner. Rapid Response Teams Do not Cut Hospital Heart Attacks and Death Rates in the december 2008 edition of the Journal of the American Medical Association (JAMA) titled: "Hospital-wide Code Rates and Mortality Before and After Implementation of Rapid Response Teams," Chan PS, et al reported that Rapid Response Teams set up to spot patients at risk of having cardiac or respiratory arrests in the United States hospitals do not save lives and may not be a good use of resources. The researchers stated that hospitals have widely adopted this practice with little evidence to suggest they help save lives. The researchers further noted that another phenomenon has surfaced, namely, the secondary effect of the team may have resulted in an increase in patients and families issuing "Do Not Resuscitate" 18 N AT I O N A L N U R S E or DNR orders that prohibits hospital staff from taking life-saving measures. In the September 2010 edition of the Journal of the American Medical Association (JAMA) titled: "Rethinking Rapid Response Teams," Litvak and Pronovost concluded that "For the majority of patients whose condition deteriorates while receiving inadequate care in an improper unit, efforts should be made to ensure they receive adequate care in the proper unit, to move away from taking credit for rescuing patients who experience triage errors, to focus on patient flow, and to provide the patient with the right care at the right time, not more and not less." According to Litvak and Pronovost, underlying inadequate care is that patients have been admitted or transferred to a unit unable to provide an appropriate level of care, where sufficient nurse, physician, and monitoring resources are available. A triage error (patient misplacement), or an inability (or unwillingness because of cost containment/profit motive) to place the patient in the preferred unit, subjects patients to an unreasonable risk of suffering complications, preventable harm, and even death. Researchers should seek to identify and mitigate risks borne by patients admitted to the incorrect hospital unit. In the September 2010 issue of the Journal of the American Medical Association, researchers concluded that underlying inadequate care is that patients have been admitted to a unit that provides inadequate care. The philosophy of RRTs is premised on the idea that current care is inadequate; therefore, introducing ICU-level care will benefit the patient. In response to the study, Dr. Gregg C. Fonarow, director of the Ahmanson-UCLA Cardiomyopathy Center at the University of California, Los Angeles said, "This latest study failed to show reductions in hospital-wide code rates or mortality with a rapid response team." The September 2010 issue of Johns Hopkins Medicine News wrote, "The success of a rapid response team is determined through what Pronovost calls 'perverse accounting.'" They are judged, he says, by counting the number of people saved or identified to be sent back to the ICU. "Imagine if we sent everyone from the ICU to the parking lot instead of to the floor," Pronovost says. "The rapid response teams would look like they're doing wonders because they would have to come in and save all of those patients. It's not a rapid response team issue. It's sending them to the proper level of care. It's a silly science where you take credit for your own bad decisions." Conclusion: It seems perverse to measure the success of RRTs by counting the number of saved lives that were put at risk by triage errors, driven by ineffective management of patient flow, hospital restructuring, and market-driven budget constraints. Furthermore, the Rapid Response Team, as intended, is an attempt to circumvent the ratios mandates and other specialty-specific safe staffing standards. It is redundant, causing further fragmentation and confusion surrounding needed levels of patient care and should be abolished for misleading the public. Unlike the ratio solution, there is no empirical evidence validating the beneficial effects of the Rapid Response Team scheme on the mortality rate in U.S. hospitals. On the contrary, studies show that Rapid Response Teams set up to spot patients at risk for cardiac or respiratory arrest in U.S. hospitals do not save lives. W W W. N A T I O N A L N U R S E S U N I T E D . O R G JUNE 2011