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Patient-activated RRTs Catch On Around the U.S.

From: The Hospitalist, March 2008

A growing trend in U.S. hospitals that allows patients and their relatives or loved ones to activate a rapid response team (RRT) under certain conditions is winning acceptance from hospitalists nationwide

by Tom Giordano

A growing trend in U.S. hospitals that allows patients and their relatives or loved ones to activate a rapid response team (RRT) under certain conditions is winning acceptance from hospitalists nationwide.

The practice was started in May 2005 at the University of Pittsburgh Medical Center (UPMC) after an 18-month-old girl died from narcotic misuse, dehydration, and a breakdown in communication.

The child’s mother told hospital officials that if they had a patient-family initiated RRT, she believed her daughter would be alive today. An official with the hospital’s Center for Quality Improvement and Innovation (CQII) agreed, and a study of the practice was under way.

Within months, the UPMC decided to put the plan—called Condition H (for Help)—into practice. Sue Martin, RN, with the center’s CQII, calls Condition H “a corporate function that supports all of the [19] hospitals in our health system.”

Today there are some 20 hospitals in the U.S., besides those in the UPMC system, that have instituted a version of the plan. More will soon, having read or heard about the success UPMC says it’s having.

“When we first started doing it, people wondered why we would let the patient or visiting relatives activate the rapid response team, since they were nonprofessionals,” Martin says. “But after it was explained to them and they were told of its success, they accepted the concept.”

She says UPMC began getting inquiries—and still does—every month from hospitals and others in the medical community asking how the plan works. They ask if UPMC would teach them about Condition H, Martin says.

“We’ve been doing that ever since,” she says. “Look, things are not perfect in the health system, but we’re fixing them. And as we do, we need a community to help keep our patients safe.”

Just about the time UPMC began its patient-activated RRT in May 2005, the Greater Baltimore Medical Center (GBMC) followed suit.

Letters

CLARIFICATION OF THE COCKROFT-GAULT EQUATION

I applaud the recent article on dose adjustments in elderly patients (January 2008, p. 14). Physicians have not paid enough attention to this issue, resulting in undo expense and side effects in patients with renal insufficiency.

However, I would note that the version of the Cockroft-Gault Equation used by pharmaceutical companies in their studies and dosing recommendations uses ideal body weight (IBW) rather than actual weight. The equation as quoted in the article may result in an overestimation of the dose adjustment based on a drug company’s recommendation. This topic is covered in detail in other articles, but the Cockroft-Gault Equation using IBW follows:1,2

Creatine clearance (males) = (140 minus age) X (IBW) / (72) X (serum creatinine)

For women, the result is multiplied by 0.85 to account for reduced muscle mass.

References

  1. Rosborough TK, Shepherd MF, Couch PL. Selecting an equation to estimate glomerular filtration rate for use in renal dosage adjustment of drugs in electronic patient record systems. Pharmacotherapy. 2005;25:823-830.
  2. O’Mara NB. Calculating renal function. Pharmacist’s Letter/Prescriber’s Letter. 2005;21(7):210704.

Jeffrey Stalnaker, MD,
Hospitalist and Emergency Medicine,
Cape Canaveral Hospital,
Cocoa Beach, Fla.

“Our RRT covers both inpatients and outpatients, and includes a hospitalist,” says Michael Schwartzberg, media relations manager at GBMC.

“Our patient-activated RRT Code Help initiative was a natural outgrowth of the rapid response team,” he says. “While our RRT averages about 40 calls a month, to date there have been only several Code Help calls—but the initiative is still young.”

Schwartzberg says the purpose of Code Help is to reduce the number of “codes” outside intensive care units by initiating rapid diagnosis and interventions for patients with changing medical conditions.

“Code Help serves as a resource for patients as well as their families 24/7 in the event that they feel additional help is needed,” he says.

Schwartzberg says as GBMC continues to focus on ways to improve patient safety, “implementing Code Help is an integral component of our mission to provide medical care and service of the highest quality to each patient. Offering the Code Help program is a way to support that mission.”

Four months after UPMC implemented its Condition H program, St. Joseph Medical Center (SJMC) in Towson, Md., did likewise.

“During the past three months, our mortality (rate) is lower than it had been,” says Richard Boehler, MD, vice president of medical affairs and chief medical officer for SJMC. He spearheaded the RRT initiative. “Three months isn’t a trend or a pattern yet, but there aren’t that many things in my career that I have seen have such a profound impact. We’ve had a nice curve in terms of declining mortality.”

Dr. Boehler says the launch of an RRT at SJMC, comprising a critical care physician, an intensive care nurse, and a respiratory therapist, “is helping to prevent codes and mortality by intervening at the patient bedside or anywhere in the hospital where a patient’s condition is declining.”

Johns Hopkins Hospital (JHH) in Baltimore, Md., was planning to test a patient-activated system in its neuroscience unit this past fall but ran into a snag, according to Brad Winters, MD, assistant professor of anesthesiology and critical medicine at JHH.

“It got political when it was first proposed,” says Dr. Winters. “Some people had issues with it that had to be ironed out. It was modeled after (UPMC’s) program from which we created a brochure describing it in detail. But some of the feedback we got was negative.”

After much discussion and some revisions, “we ironed out the issues, and everyone is now on board with what we ended up with,” says Dr. Winters. “When the brochures come back from the printers now, they will tell families how the program works, why we have it, and how to use it. We intend to implement it not only in our neuroscience unit, but pediatrics.”

Dr. Winters says to a large degree the decision to implement the patient-activated RRT program “came from our attending conferences over the past couple of years. We considered the topic an important issue as we discussed it from a patient-care point of view.”

As far as he’s concerned, Dr. Winters says all hospitals “should consider such a policy since the families and loved ones of patients recognize subtle changes in the patient’s condition, while nurses, especially in pediatrics where moms and dads recognize those subtle changes quickly, may not.”

He says one of the initial concerns was that the program might be abused. “My take on it is that UPMC had it for a while and it was successful,” he says. “Nurses are very good, of course. But once in awhile the family picks up on something they miss, so it’s best to have as many eyes as possible involved. The more people we have observing a patient, the more likely that patient is to get good care.”

Back at UPMC, Martin says they’ve had no complaints about the program and Condition H is “spreading to every acute care hospital.” In the first nine months of 2005, Condition H was used 21 times “successfully,” she says. That’s about average use annually, she says.

But some hospitalists remain skeptical.

“In my opinion, having a patient or family call a code is the medical equivalent of having a patient tell the surgeon where to make an incision,” says Dr. Michael Rudolph, MD, a hospitalist for the past three years at Milford Hospital in Milford, Conn. “This ‘solution’ practiced [by UPMC] demonstrates a complete failure in communication between all the hospital staff and physicians and the patient and family.”

He suggests a more restrained, collaborative approach.

“A policy of the patient or family always having the ‘right’ to a face-to-face physician evaluation would do much more for patient care,” says Dr. Rudolph. “A family or patient demanding urgent evaluation is often appropriately concerned, anxious, or angry. This is an excellent time for the physician to review the case to make sure all is being done appropriately and to address the patient and family's medical and emotional needs.”

Dr. Rudolph also says allowing patients and families to call a code “will frequently result in the staff feeling that the patient cried wolf, which will invalidate the patient’s and family's concerns.” He asserts that while patient and family involvement in care “is critical to the healing process ... the physician has to set limits on how much of the care the patient and family can dictate.”

A hospitalist working in a hospital with a policy like UPMC’s “would lose significant ability to prioritize his/her work,” Dr. Rudolph continues. “There are so many unplanned interruptions that a hospitalist needs to learn to deal with on a routine basis that increasing the number of interruptions where dropping everything is necessary would lead to a sense of loss of control and an increased burn-out rate.”

He says it would also force hospitalists to second-guess their colleagues, “which will adversely affect team medicine in rapid fashion and may further increase wasteful, defensive medicine practices.”

But Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess Medical Center in Boston and a member of SHM’s board of directors, counters that patient-activated RRTs are a useful part of a team approach to care.

“I’m a strong believer in terms of ‘the patient knows best’,” says Dr. Li. “Ultimately, it’s a very good thing to allow patients to participate in their care. I would say the potential advantages (of a Condition H RRT policy) far outweigh any drawbacks.”

Dr. Li sees a potential upside not only for patients and their families, but for hospitalists.

“More than anybody, hospitalists oftentimes are leaders in rapid response teams, and if the policy becomes widespread, hospitals would require more resources for the hospitalist,” he says. That, he says, could lead to hiring more hospitalists.

There are those who theorize that while a Condition H policy might benefit patients, it may also be another source of confusion for families. These critics fear alienating some who believe it is the hospital’s job to be sure their family member is doing well, not theirs.

Dr. Li strongly disagrees. “We have a situation in this country where often the patient’s voice is not heard,” he says. “Anytime we can improve the opportunity for a patient to be heard, that’s good for the patient and good for our healthcare system.

Martin puts it another way.

“It’s the right thing to do,” she asserts. “Think about it: relatives and friends call 911 from home or wherever when there‘s an emergency. Condition H is similar to that. Why wouldn’t we let patients and family do that in the hospital?” TH

Tom Giordano is a journalist based in Connecticut.


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