Clinical Simulation Effective For Educating Rapid Response Systems

Deterioration in a patient’s condition is sometimes evident long before a code blue cardiac or pulmonary arrest is initiated. However, Nurses may fail to recognize these early warning signs and fail to seek help in a timely manner. Initializing Rapid Response Systems, or RSS, has been championed around the world as a life-saving mechanism against sudden, life threatening patient events. Here, Dr. Kim Baily PhD, MSN, RN, CNE, previous Simulation Coordinator for Los Angeles Harbor College and Director of Nursing for El Camino College, explores the literature that support the use of Clinical Simulation to improve learners’ knowledge and clinical judgment when concerning rapid response systems.

The introduction of Rapid Response Teams (RRT) at the beginning of this century first in Australia and then in the U.S. has helped to identify patients at risk. The goal of the Rapid Response Team is to intervene during periods of patient instability on general medical surgical floors and other non-ICU areas to help stabilize the patient or to transfer the patient to a higher level of care. As part of the Institute for Healthcare Improvement (IHI) 100,000 Lives Campaign, the IHI has challenged hospitals across the United States to reduce cardiac arrests and other sudden, life-threatening events in patients on general medical floors by implementing a system of RRTs.

Approximately 1500 hospitals are using or implementing RRTs. Some facilities also encourage family members to activate the RRT if they feel their family member is deteriorating. The effectiveness of Rapid Response Systems (RRS) is still up for debate. Research studies on the effectiveness of RRTs on reducing cardiopulmonary arrest and mortality are inconclusive.

There are manyfold reasons why comparative studies of RRS are difficult to quantify. Many hospitals do not collect data or if they do, they do not publish it. In addition, there are different types of RRTs with varying healthcare professionals/structures and in many cases there are no control groups for data comparison. In some teaching hospitals, physicians lead the team whilst in non-teaching hospitals the RRT team is more likely to be led by a registered nurse who has extensive ICU or ED experience. A recent meta-analysis by Solomon et al. supported the benefit of RRS with both in-hospital cardiopulmonary arrest (IHCPA) and overall hospital mortality rates (Solomon RS, Corwin GS, Barclay DC, Quddusi SF, Dannenberg MD.

Effectiveness of rapid response teams on rates of in-hospital cardiopulmonary arrest and mortality: A systematic review and meta-analysis. J Hosp Med. 2016;11(6):438-445). In another meta analysis by Chan et al, the authors concluded that the rate of cardiac arrest decreased however, overall mortality did not decrease with RRT intervention (Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Rapid response teams: a systematic review and meta-analysis. Archives of Internal Medicine 2010; 170(1): 18-26.)

Early Warning System (EWS) and Modified Early Warning Systems (MEWS)

Early Warning Systems are a set of guidelines that some hospitals use to help staff to identify patients with deteriorating conditions and to know when to notify a RRT. Specific changes in various physiological parameters are identified and scored and when a patient reaches a specific score, the staff is expected to initiate a rapid response. The parameters include respiratory rate, heart rate, systolic blood pressure, level of consciousness, temperature and hourly urine output (for previous 2 hours). These guidelines may be particularly useful for less experienced staff.

Disadvantages of EWS use include the possibility that staff may rely solely on EWS and, even though nurses perceive that a patient appears to be deteriorating, an RRT is not called because the patient does not reach the EWS criteria. If some form of an early warning system is going to be used, nurses should be encouraged to call an RRT if they are concerned about a patient even if the patient does not receive a high enough score to automatically trigger the RRT. Some facilities noted the addition of an automated MEWS tracking system to existing electronic healthcare systems was prohibitively expensive.

RRS Effectiveness

In those hospitals using a rapid response system (RRS), a delay in activation of the system has been shown to lead to adverse patient outcomes and increase hospital mortality. Possible reasons for nurses delaying activation include: lack of confidence, lack of education, lack of knowledge about activation, limited experience and fear of criticism from other healthcare professionals including the RRT members. Poor communication between clinical nurses and RRT members may also lead to slow activation and implementation of the system. The use of SBAR communication is an important component in the effectiveness of rapid response systems.

Healthcare Simulation & RRS Effectiveness

A recent paper by Lindey and Jenkins studied the impact of a novel educational intervention on nursing students’ clinical judgment regarding the management of patients experiencing rapid clinical deterioration and the function of the RRT. The study involved a randomized experimental design pretest/posttest. “The investigators developed an 11 item, multiple choice survey that was used to assess students’ pretest and posttest understanding of rapid response systems. Questions 1, 5, 6, 8, and 9 assessed knowledge concerning the purpose, function, and anticipated outcomes of rapid response systems. Questions 2, 3, 4, 7, and 10 assessed clinical judgment inactivating and participating in rapid response calls. Question 11 assessed the extent of participants’ exposure to rapid response calls prior to the study.” The study included seventy-nine final semester baccalaureate nursing students all of whom completed a pretest survey and an introduction to Code Blue in the form of a 90 minute Code Blue workshop.

The workshop included a 10 minute lecture on code blue plus 2 minutes calling for a rapid response team. All students were encouraged to call a rapid response if appropriate. The control group (n = 39) then completed a traditional Code Blue scenario and following the simulation, completed the posttest survey. The intervention group (n=40) received additional rapid response education which included a comparison of Code Blue instigation versus alerting an RRT. The group then completed an RRT nursing simulation, followed by administration of the posttest survey.

Independent t-test analysis revealed that nursing students who received the innovative education intervention had significantly higher posttest scores (M = 90.91, standard deviation [SD] = 8.73) than did the nursing students who had not received the intervention (M = 64.80, SD = 19.69), t(77) = 7.65, p < .001). The authors concluded that clinical simulation was effective in improving students’ knowledge and clinical judgment, specifically concerning rapid response systems (Lindey, P. & Jenkins, S. 2013. Nursing Students’ Clinical Judgment Regarding Rapid Response: The Influence of a Clinical Simulation Education Intervention. https://doi.org/10.1111/nuf.12002).

Suggestions for Simulation Scenarios

Convert existing medical simulation scenarios to focus on identifying patients with a deteriorating patient condition and when to call RRT. Set up the scenario so that the patient deteriorates but not to a state where a code should be called. Include a learning objective related to satisfactory reporting using SBAR communication. Examples of scenarios that lend themselves to RRT initiation:

1. Post operative bleeding
2. Change in respiratory status
3. Overdose of pain medication<

Suggestions for learning objectives for a RRT scenario

By the end of the nursing simulation, the learner will be able to:

1. Identify the signs and symptoms of a deteriorating patient who has postoperative bleeding by correctly identifying significant changes in vital signs and lab results.
2. Initiate a call for the RRT when the patient’s condition deteriorates in a timely manner.
3. Completes an effective SBAR to the RRT members

Rapid response systems support nursing staff by providing them with additional reinforcements for a patient whose condition is worsening but who is not sufficiently ill to warrant calling a code blue. Adequate training in the form of healthcare simulation can increase nursing staff understanding about use of the RRT and improve clinical judgement by training nurses to recognize early deteriorating changes in a patient’s condition.

Want to know more?
Read “Why We Do What We Do: The Evidence Behind Rapid Response Teams” on ClinicalCorrelations.org!