National Nurses United

Nurse Practice 6/11/06 9:08 AM Page 18 Nursing Practice Submitted by Hedy Dumpel, RN, JD and the Joint Nursing Practice Commission Safety Dance Are Rapid Response Teams just another scheme to ignore ratios and deskill the role of direct-care RNs? T his article examines the proliferation of the use of Rapid Response Teams (RRT), a team of critical care experts established to bring critical care expertise to the patient's bedside. These teams are arguably another corporate "penny wise, pound foolish" scheme to countermand the "failure to rescue" criticism directed towards the hospital industry. The deployment of RRTs has created a false sense of security among RNs and patients alike. Management consultants, pushing their "safety" schemes, state that there are various systemic factors that contribute to the variability of the safety of patients in health care today: (1) failure in planning patient care (including patient assessments, treatments, identifying and implementing goals); (2) failure to communicate (patient to direct-care RN, shift/transfer report from RN to RN; and RN to MD reports); and (3) failure to recognize deteriorating patient conditions. According to these consultants, the RRT stands to impact this "failure to rescue" state of affairs by identifying unstable patients and those patients likely to suffer cardiac or respiratory arrest, or some other deadly outcome. The goal is to respond to a "spark" (subjective patient complaints, sign and symptoms) before it becomes a "forest fire" (cardiac or respiratory arrests). Where is the logic? Who has the responsibility and accountability to identify and recognize the patient's deteriorating condition? Answer: the direct-care RN assigned to the patient, not the rapid response team. Who has the responsibility to initiate competent interventions? The answer again is the direct-care RN assigned to the patient, not the RRT. In order to be able to assess and intervene in a timely manner, there must, first, be a sufficient number of direct-care RNs with current demonstrated competency present and available. What is confusing is that the RRT is touted as the stabilizer of a pre-"forest fire" condition and not the 18 REGISTERED NURSE identifier of deteriorating conditions. Proponents of rapid response teams have instituted something called the "100,000 Lives Campaign," claiming that more than 2,700 hospitals have joined nationwide. The requirement is that when patients' vital signs get close to what is sometimes called a "flat line" or "near miss," then stat page the STAR or similar type of team. But here's a question: Why wait? There seem to be three stages of deterioration: (1) a subtle decline in the patient's vital sign and status; (2) STAR or RRT level of deterioration creating a "near miss" situation; and (3) patient crashed, requiring full resuscitation/Code Blue or ending up in a "failure to rescue" situation. This raises another question. Why is there a need for an intermediary team? In many instances hospitals "break" the ratios when the team is deployed. Members of the rapid response team may be assigned to provide meals/break relief and are instantaneously pulled off, or a 1:1 ICU patient may be instantly reclassified as a 1:2 to accommodate the rapid response team. Traditionally, all direct-care RNs had the required, validated competency to take care of patients who were admitted to heterogeneous units. Units would have a designated charge nurse and/or Clinical Nurse Specialist (CNS), an expert, who would be available to W W W. C A L N U R S E S . O R G assist with assessments, provide consultation, and perform sophisticated and complex interventions to stabilize the patient. Or who, in collaboration with the direct-care RN, can make a determination that the patient be transferred to a critical care unit with richer ratios and more sophisticated equipment and technology. Every opportunity was used to do teaching. The goal was to strive for expertise in a designated area of clinical specialty. Today, hospital units have become "combo" units, where patients are housed in nonICU/CCU "tele" box, "medical monitoring," or centrally monitored beds when, in reality, their condition requires a higher level and intensity of care with a richer direct-care RNto-patient ratio. Couple this with a feeble attempt to substitute the expertise and role of the CNS and charge nurse with that of the rapid response team under direr and lifethreatening situations, and you have a recipe for disaster. Plus, it drives fragmentation of care through deskilling (dumbing down) of the role of the direct-care RN by concentrating specialized knowledge at the RRT level only. All direct-care RNs should have the skill and knowledge of how to recognize early alteration in the patient's physical and cognitive condition. This requires a vibrant education/in-service department, and a JUNE 2006

• Cover