Abstract
Background and Objectives
Rapid response teams (RRT) are multidisciplinary teams activated to assess patients outside of the Intensive Care Unit (ICU) and require a shared framework for approaching a deteriorating patient. In this project, we aimed to improve the understanding of RRT protocols through the development and implementation of the RRT Huddle Checklist.
Methods
This quality improvement project took place from 2019 to 2022. A multidisciplinary workgroup conducted a current state analysis and defined the ideal RRT process. To improve the RRT process, we developed and implemented an RRT Huddle Checklist based on the SBAR framework, standardized education, and created a process for regular feedback. The primary aim was to improve understanding of RRT protocols among participants. RRT duration was used as a balancing measure.
Results
A total of 301 stakeholders completed surveys, including 127 nurses, 101 residents, 45 RRT nurses, 10 Hospital Medicine faculty and fellows, and 18 PICU fellows. After implementation of the RRT Huddle Checklist, the proportion of respondents who agreed with knowing RRT protocols increased from 69% in 2020 to 75% in 2022, with no increase in RRT duration.
Conclusions
The implementation of the RRT Huddle Checklist resulted in an increased proportion of key stakeholders that understood RRT protocols without increasing the duration of RRTs. The RRT Huddle Checklist tool utilizes a widely known, validated framework that can be adapted at other institutions to standardize the RRT process and promote ongoing just-in-time education.
Introduction
Rapid response teams (RRT) are medical response teams designed to rapidly assess and treat deteriorating patients outside of the intensive care unit (ICU). Reported efficacy of pediatric RRTs is variable. Some groups have described a reduction in cardiac arrests and overall mortality after implementation of RRTs,1–3 while others report no association between RRTs and reduction in in-hospital mortality. 4 Despite these mixed results, recent Society of Critical Care Medicine guidelines recommend the use of RRT systems to recognize and respond to clinically deteriorating patients outside of the intensive care setting and quality improvement (QI) initiatives to track them. 5 Elements of a successful RRT system include interprofessional trust and collaboration, clear protocols, feedback, continuous evaluation, and multidisciplinary training. 6 Additionally, knowledge and understanding of these processes and protocols are essential.
A standardized communication process may be one strategy by which to ensure a reliable RRT process. Efficient communication of essential information by the primary team allows responding team members to rapidly understand and assess the decompensating patient. Handoff processes, such as sign out of critical patients, have utilized validated communication tools, such as IPASS and SBAR to facilitate accurate and streamlined information sharing in acute scenarios.7,8 The I-PASS mnemonic stands for “Illness severity, Patient summary, Action list, Situation awareness and contingency planning, Synthesis by receiver” and provides a standardized framework to follow for a patient handoff process, such as during sign-out. 7 The SBAR mnemonic stands for “Situation, Background, Assessment, Recommendation” and is utilized as a communication framework to standardize how information is relayed between team members. 8 These handoff tools with easy-to-recall mnemonics are intended to standardize communication between care team members.
In order to improve the overall RRT system within our institution, we developed a standardized communication process tool to improve expectations and knowledge surrounding the RRT process and ensure communication of essential information to RRT members. Here we present the development and implementation of an RRT Huddle Checklist. To understand the impact of our checklist and education intervention, we measured the provider knowledge of the RRT protocol pre- and post-intervention.
Methods
Context
This QI project took place from 2019 to 2022 at an academic pediatric medical center with over 300 beds. The pediatric RRT is a multidisciplinary team that can be activated by a patient's care team, including their primary medical team, bedside nurse, or family member to assess a deteriorating patient. The RRT can be activated every day at any time of the day or night. At our institution, the RRT is comprised of a PICU fellow, PICU RRT nurse, pediatric senior resident, Pediatric Hospital Medicine (PHM) faculty and/or fellow, and respiratory therapist. Additional members expected at an RRT include the first contact provider and the patient's bedside nurse or unit charge nurse. All patients admitted to the general care floors can be evaluated by the RRT. This includes patients cared for by all medical and surgical services (general and subspecialty) outside of an ICU, regardless of location (ie, general care or moderate care units). The three most common reasons for activating an RRT within our institution are respiratory distress or decompensation, altered mental status, and hemodynamic instability. During the study period (2019-2022), there were a total of 1861 pediatric RRT events.
Our primary objective of this project was to improve the RRT processes by increasing the provider-level understanding of RRT protocols. This study was deemed not regulated by the institutional review board (HUM00168619).
Current State Analysis
To improve RRT processes within our institution, a multidisciplinary workgroup was created in 2019 composed of pediatric residents, pediatric chief resident, PHM faculty, PICU fellows, PICU faculty, RRT PICU nurses, and nursing from two general care units. To understand the current state, our workgroup team members observed the process of RRT team events throughout the hospital and received key stakeholder input through surveys and focus groups. The methodology and findings of the focus groups with key stakeholders are described separately. 9 Understanding of barriers and facilitators to calling RRTs was obtained via these surveys from pediatric and internal medicine-pediatric residents, PICU fellows, bedside nurses from general and moderate care units from 2019-2020. The survey was modified from the validated RRT Facilitators and Barriers Survey to reflect the RRT process at our institution.10,11 The survey was administered utilizing Qualtrics software, an online survey platform and tool that allows for survey creation, distribution, analysis, and storage of survey results. Survey responses were anonymous, and participants were not required to answer questions. Respondents rated their agreement with each statement using a 5-point Likert Scale (strongly disagree, somewhat disagree, neither agree nor disagree, somewhat agree, strongly agree).
Using the information obtained from process observation, surveys, and focus groups, the workgroup developed a process map depicting the current workflow (Figure 1A) and ideal state (Figure 1B), and an Ishikawa diagram which identified root causes of the problems of inefficient workflow and redundant communication during RRTs (Figure 2). The Ishikawa diagram is utilized to show the causal factors that are organized into major sections that contribute to a final problem.
Current process map (A) and ideal state of RRT process (B).
Ishikawa diagram.
Interventions
Based on key drivers identified in the current state analysis, the following interventions were developed: (1) creation of an RRT Huddle Checklist utilizing the SBAR framework, 8 (2) development of ongoing educational processes for key stakeholder groups using the RRT Huddle Checklist, and (3) utilization of the multidisciplinary group for ongoing key stakeholder feedback (Figure 3). The Key Driver Diagram displayed in Figure 3 outlines the global and SMART aim of the project as well as organizes the potential changes to implement to work towards the defined aim. The “SMART” aim mnemonic stands for “Specific, Measurable, Achievable, Relevant, and Time-Bound” to ensure our goals were attainable within a reasonable time period. Additionally, the interventions are color coded to display their status of “potential, active, or adopted”. Iterative Plan Do Study Act (PDSA) cycles were used to refine intervention components. PDSA cycles are an integral element of quality improvement methodology and allow for implementation of the planned intervention with planned reassessments at specific time intervals and modifications based on conclusions from the intervention or implementation. Interventions were piloted on one general care unit with weekly PDSA cycles to assess effectiveness, followed by a stepwise implementation to other units in collaboration with unit-based nursing leadership and provider services. Interventions occurred from 2021 to 2022.
Key driver diagram with SMART (specific measurable achievable relevant time-bound) aims.
Intervention: Rapid Response Team (RRT) Huddle Checklist
The RRT Huddle checklist was created using the SBAR framework, 8 which, in conjunction with high reliability training, 12 is utilized across our institution to standardize handoff processes. The RRT Huddle Checklist is a laminated two-page document (one sheet; front and back) that is brought to every RRT. The front page outlines the process for the primary team beginning at the time the RRT is activated (Figure 4). At the top of the page, response time is defined as within 10 min of RRT activation, with the plan for the huddle to last no more than 5 min. The tool outlines the huddle process as defined by our ideal state determination with a reminder that the huddle is to occur outside of the patient room and all members should be present to begin. The opening statement comes from the bedside RN and indicates the patient is safe to proceed with the RRT huddle outside of the patient room. If this is not the case, it is clearly stated that a Code Blue should be activated instead to bring a larger team more promptly to bedside. Following this, the huddle prioritizes team member introductions. The checklist outlines the SBAR presentation and is color coded to the individual expected to present each section, with recommendations for how long that section should take. The checklist is divided into two columns with the left column including processes that should occur outside the patient room, and the right column including processes that should occur once the team enters the patient room. The back of the RRT Huddle Checklist includes additional information institutionally pertinent to RRTs.
RRT huddle checklist.
Intervention: Continuing Education
Nursing education surrounding the RRT Huddle Checklist was provided by nursing leadership representatives from the RRT workgroup during morning, unit-based, daily management system huddles. Resident education was shared at a resident conference with regular follow up via email and annual lectures about RRTs. Incoming first year Pediatric and combined Internal Medicine/Pediatric residents received simulation-based education during orientation to learn about RRT activation and practice utilizing the RRT Huddle Checklist communication tool. Finally, the wording and structure of the checklist itself was intended to provide just-in-time, recurring education about the SBAR structure and key components for information transfer at an RRT huddle.
Intervention: Regular Feedback to Key Stakeholders
The multidisciplinary RRT workgroup met every 1-2 weeks for the duration of the development and implementation of the RRT Huddle Checklist to share and incorporate feedback to refine the RRT checklist, education process, and education materials. Examples of feedback incorporated from iterative PDSA cycles included color coding team members’ roles and responsibilities, clarifying the expectation that the RRT huddle be completed within 5 min, prompt involvement of the patient and/or their caregivers, identifying that the ideal location of the RRT huddle should occur outside the patient's room, and including the cardiac ICU fellow for RRTs activated for cardiology patients.
Measures
Our primary outcome measure was knowledge of the overall RRT protocol, with the goal to increase reported knowledge to ≥75% among stakeholders. Stakeholder understanding of the activation criteria and their own role and others’ roles during RRTs served as process measures. Key stakeholders were surveyed in 2022 following complete implementation of the checklist using the same 2020 baseline survey questionnaire with additional questions about the RRT Huddle Checklist.
Current state analysis and discussion with key stakeholders revealed a significant concern that implementation of this checklist process would lead to a delay in patient care, thus RRT duration was selected as a balancing measure. RRT duration was defined as the time between RRT activation via page and either (1) the time that the RRT team departed from the patient's room if the disposition was to stay in their current location or (2) the time that the RRT team transferred and admitted the patient to the ICU. The start and end times and all performed interventions were documented by the PICU RRT nurse in the patient's chart upon completion of the RRT event.
Statistical Analysis
Categorical variables and survey responses are reported as the frequency and proportion. Survey responses were included if a respondent answered any question and survey responses were not mandatory. Statistical analysis was completed using Wilcoxon rank-sum test to compare the 5-point Likert scale responses to survey questions in 2020 pre-intervention to 2022 post- implementation of RRT Huddle Checklist. Results were considered significantly different if P < .05. Statistical analysis was completed utilizing Stata Statistical Software (Version 18, StataCorp, College Station, TX). For analysis of the balancing measure, RRT duration, an XbarS Statistical Process Control (SPC) chart was analyzed using QIMacros (KnowWare International, Inc., Denver, CO).
Results
Survey Respondent Demographics
Overall survey response rates were 49% in 2020 (pre-intervention) and 33% in 2022 (post-intervention) and are shown in Table 1. The majority of survey respondents were bedside nurses (42.2%; 127/301), followed by resident physicians (33.5%; 101/301). Resident physician responses were broken down by Post Graduate Year (PGY) with PGY-1 reflecting intern year or first year of residency. Most respondents had personally activated fewer than 10 RRTs, decreasing from 82% in 2020 to 66% in 2022. Very few respondents (2.5%) reported never participating in an RRT.
Survey Respondent Demographics.
Number of RRTs personally activated by respondent. Asked resident physicians in 2020. Asked resident physicians, bedside nurses, and PHM Faculty/Fellows in 2022.
Number of RRTs activated on a patient cared for by respondent. Asked of resident physicians, bedside nurses, PICU Fellows in 2020 and resident physicians, bedside nurses, and PHM Faculty/Fellows in 2022.
Primary Outcome: Knowledge of RRT Protocols, Including Education and the RRT Huddle Checklist
The proportion of respondents who reported understanding RRT protocols increased from 69% in 2020 to 75% in 2022 (Table 2; P = .25). In 2020, 17% of respondents agreed that they received regular RRT continuing education, and this improved to 27% in 2022 (P = .002). Significant improvement from 2020 to 2022 was noted for bedside nurses’ (5% to 20%; P < .001) and PICU fellows’ (0% to 60%; P = .04) agreement with receiving regular education about the RRT process (Table 3).
Facilitators and Barriers to Activating Rapid Response Team Events.
Only Resident Physicians and Bedside Nurses asked this question in 2020.
PICU RRT Nurses were not asked this question in 2020.
Only PICU Fellows and RRT Nurses were asked this question in 2020.
Wilcoxon rank-sum test to compare 2020 and 2022 data utilizing 5-point Likert scale responses.
Survey Response Analysis by Role.
Wilcoxon Ranked Sum test.
Only asked of members that activate an RRT (Residents and Bedside Nurses in 2020 and added PHM Fellow/Faculty in 2022).
Only PICU fellows and RRT nurses were asked this question in 2020.
PHM Faculty and Fellows were not surveyed in 2020.
Exact P-value.
Following the implementation of the RRT Huddle Checklist tool, 87% of respondents reported knowledge of the checklist (Table 4). Similarly, 67% of respondents reported having utilized the checklist in 2022. Among those who utilized the checklist in 2022, 85% felt that it clarified roles, 87% thought it improved communication, 46% reported that it helped deliver more timely and appropriate care, and 71% agreed that it helped with shared decision-making. However, while 21% felt that the checklist hindered care, most (70%) of respondents reported that the checklist should continue to be utilized.
Survey Responses About RRT Checklist.
Process Outcomes: Understanding of RRT Activation and Team Member Roles During RRT
Knowledge surrounding when to call an RRT increased from 85% in 2020 to 99% in 2022 (P < .001), while understanding of one's own role during the RRT increased from 83% in 2020 to 86% in 2022 (P = .006). There was an improvement in team members knowing “what to do during an RRT”, increasing from 91% in 2020 to 97% in 2022, albeit not significant (P = .06).
Balancing Measure: RRT Duration
There was no significant change in RRT duration following the implementation of the checklist between August and October 2021 as demonstrated by lack of special cause variation (Figure 5).
Average RRT duration Xbar statistical process control (SPC) chart.
Discussion
In this single-site, hospital-wide QI project at an academic children's hospital, we present our multidisciplinary approach to improving the knowledge of the RRT process. Utilizing a structured QI approach, we developed and implemented a RRT Huddle Checklist to standardize and teach the RRT process, as well as clarify team members’ roles and responsibilities after an RRT has been activated for a patient. We achieved our primary aim and demonstrated that the implementation of an RRT Checklist improved knowledge of RRT protocols to 75% post-implementation. Additionally, we demonstrated an improvement in respondents knowing their role, and over half of the respondents felt that the checklist tool helped with shared decision making. Despite stakeholder concerns that the standardization of the process with a checklist would hinder timely care for patients, we found no significant change in our balancing measure of RRT duration.
We developed and piloted the RRT Huddle Checklist in a stepwise manner across our hospital, which allowed for frequent PDSA cycle reassessments, gathering specific feedback, and making prompt updates to optimize both the checklist and education efforts. Through these interventions, we noted improvement in team members’ agreement with understanding appropriate RRT activation and knowledge of team members’ roles during RRT huddles. Other published communication checklist tools, for example, in the post-operative handoff process,13,14 have emphasized the role of the checklist tool serving as a framework for all team members to be cognizant of and follow together. Results from our focus groups described the importance of a standardized RRT workflow based on the four stages “1: Trigger, 2: Team arrival and information sharing, 3: Intervention, and 4: Disposition and follow-up” so these became the scaffold of our RRT Huddle Checklist. 9 Another recently published qualitative study exploring RRT members’ perspectives on safe and effective information transfer during an RRT event identified eight themes that providers felt influence RRT quality, efficacy, and efficiency. 15 These themes included summary statement or recap, closed-loop communication, interpersonal communication, preparation, duration, emotional validation, contingency planning, and role definition. Although the results of the latter study were not known to our team during the development of the RRT Huddle Checklist, almost all the themes are incorporated into our handoff tool.
While one-fifth of key stakeholders felt the RRT Huddle Checklist hindered care, we found no increase in the balancing measure, duration of RRT huddles, following incorporation of the checklist into the RRT process. This stakeholder perception may stem from the historical process of immediately entering the patient's room to assess and intervene for patients, as opposed to the current process of huddling outside of the room as an RRT team. Another possible reason for the perception of the RRT Huddle Checklist hindering care may stem from the concern that the patient is not safe to wait the total of 15 min from time of RRT activation to completion of RRT Huddle prior to assessment. Through our updated RRT Activation Criteria and continuing education sessions, consistent messaging emphasizes that if a patient cannot wait 15 min for provider assessment, then a Code Blue event should be activated instead of an RRT. The first question of the RRT Huddle Checklist ensures that it is safe to proceed with a huddle and gives providers the flexibility to deviate should a patient's condition require more rapid attention. It also prompts just-in-time training so that providers learn when to call the Code Blue Team instead in future situations. In this manner, the RRT Checklist serves as a visual aid for organizing communication, as well as a “just-in-time” educational tool providing frequent training on the process and expectations. Finally, in addition to the objective assessment that timely care was not hindered, a majority of respondents felt that the checklist should continue to be used and noted multiple communication benefits.
Previously described checklists for RRTs exist for clinical assessment 16 and debriefing. 17 To our knowledge, there are no published examples of a communication checklist tool to standardize the process of RRT huddles called for evaluation of deteriorating pediatric patients. Through surveys and focus groups, the concept of a communication checklist as an intervention to improve the process of RRTs was identified. 9 Importantly, we utilized the RRT checklist as a framework for both initial and ongoing education about the process of RRTs and how to communicate during deteriorating patient events. This process of continued education is particularly useful as the RRT team roles vary daily and may be especially important at academic institutions, which may have high turnover of many trainees in several specialties.
Our study had several limitations. First, there was low survey response rates across stakeholder groups. Second, the implementation of the RRT Huddle Checklist was undertaken as part of a larger, multidisciplinary approach to improving RRTs at our institution. As such, other interventions were implemented during this period, including improved and more consistent education for most stakeholders about the RRT activation criteria and process, which may have impacted the results. However, the RRT Huddle checklist supported and reinforced these existing efforts. Third, we were unable to prospectively track ongoing usage of the RRT Huddle Checklist. Assessment of ongoing usage through annual re-surveying, therefore, is reliant on team members recollection of RRT checklist usage, which is subject to recall bias. However, the intention of the RRT checklist was ultimately to support a standardized process of communication and a shared mental model of RRT processes, and we demonstrate that this primary aim was achieved whether or not the physical checklist aid continued to be utilized. Further work through auditing of RRTs is needed to understand sustainability of the RRT Huddle Checklist and its utilization. Anecdotally, it is now standard for RRT huddles to be completed outside the room consistent with our newly defined ideal state, suggesting that there has been a positive process change with our education and implementation of this RRT Huddle Checklist tool. Fourth, this quality improvement project was a single-site study undertaken at an academic pediatric hospital and may not be generalizable to other clinical settings. Although clinical environments may be different, the need for a standardized communication tool and process for RRTs has been identified by multiple recent qualitative studies, and here we provide the methodology, development, and incorporation of this tool into our hospital's processes. Additionally, for those institutions with similar processes, our tool can be utilized as a framework for adaptation. For those considering the implementation of such a tool, we recommend a staged approach with a multi-disciplinary team, which allows for key stakeholder perspectives through the development and implementation of the tool.
Conclusions
Utilization of a communication checklist tool, such as the RRT Huddle Checklist, provides a framework for ongoing education surrounding the RRT process and procedure and promotes shared decision-making among multidisciplinary team members during RRTs without delaying care provided. The effectiveness of an RRT system can only be improved if there is a clear foundation and shared understanding of processes and procedures among the multi-disciplinary team.
Footnotes
Abbreviations
Acknowledgments
The authors thank Tiffany Fields for her support of this project in the development of our RRT data dashboard, Katherine Bates, MD for her assistance with SPC chart interpretation and review, and Carly Schmidt, MD for assistance with statistical analysis planning. Finally, we thank the entire C.S. Mott Rapid Response Team Workgroup and unit-based nursing educators for their support on this project.
Authors’ Contributions
MCP conceptualized the study, designed quality improvement interventions, developed the surveys, coordinated data collection, analyzed the data, and drafted the initial manuscript. EFC conceptualized the study, designed quality improvement interventions, validated data, supervised data analysis, and critically reviewed and revised the manuscript. SB, DB, and DO designed quality improvement interventions and assisted with implementation of interventions. LG, KBP, RS, and CS conceptualized the study and designed quality improvement interventions and implemented interventions, and critically reviewed and revised the manuscript. AKC conceptualized the study, designed quality improvement interventions, validated data, completed SPC data analysis and interpretation, supervised data analysis, and critically reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
Authors’ Information
KBP was affiliated with the Division of Pediatric Critical Care Medicine at University of Michigan at the time of the study. She is now affiliated with the Division of Pediatric Critical Care Medicine at the Louisiana State University School of Medicine. LG was affiliated with the Department of Pediatrics at University of Michigan at the time of the study. She is now affiliated with the Division of Pediatric Critical Care Medicine at the Johns Hopkins University School of Medicine.
Consent to Participate
Survey participants voluntarily responded, and survey responses were anonymous.
Consent for Publication
Not applicable.
Data Availability
Data may be made available upon written request to corresponding author.
Declaration of Conflicting Interest
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical Considerations
This quality improvement study was deemed not regulated by the University of Michigan institutional review board (HUM00168619).
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
