At some point during hospitalization, many patients exceed the level of care that can be provided on the nursing units. At such times, they may not have yet met the criteria for transfer to the intensive care unit (ICU) or an ICU bed may not be immediately available. This uncertain phase of illness typically is not well managed as attending physicians may be occupied with other patients, often in clinics some distance from the hospital. As a result, unstable patients may progress to receive emergency care from "Code Blue" teams only after cardiopulmonary arrest. The Institute for Health Care Improvement (IHI) report suggests there may be substantial opportunity for quality improvement by arranging proactive delivery of an interim care through "Rapid Response Teams" (RRT). In accordance, we propose implementing an RRT to address these issues in the following ways.

1. Substantially shorten or eliminate the time to initial care of unstable patients by having staff with critical care experience attend to patients before they may reach the ICU. Alternatively, RRT staff may recognize the futility of resuscitation and focus care on assuring patient comfort.

2. For appropriate patients, the RRT would be empowered to expedite transfer to the ICU.

As a direct result of the team's triage and patient management functions, the effect of the RRT should be
evident as:

• a reduction in unexpected cardiopulmonary arrests, particularly outside the ICU;
• a decrease in the number of post-ICU discharges that "bounce back" to the ICU, improved outcomes for unstable patients, as they are currently treated by providers who may have
  insufficient experience managing unstable patients or who may be attempting this by telephone away from the patient's bedside; 
• minimized disruption of care provided within the ICU, as the RRT would prevent the need to have;
• ICU staff leave patients who need their uninterrupted attention;
• optimized utilization of PCMH resources by reducing length of stay and severity of illness.

The proposed RRT would be comprised of a physician trained in intensive care (intensivist), working with a nurse and a respiratory therapist with critical care experience. The RRT should carefully
coordinate care with the patient's primary team. It would orchestrate bed management with the ICU. Team services would be available throughout areas of the hospital where urgent care expertise & resources are not routinely available. In short, the team would do what is necessary to fill the current gap between general and intensive care. The program would be phased in as rapidly as supported by the recruitment of appropriate personnel.

The team would also:

• apply evidence-based "best practices";
• strive to minimize variability;
• develop a structured curriculum derived from best practices;
• play a leadership role in the education of residents, other trainees, and the clinical staff at large;
• and carefully study its impact on outcome and resource utilization.

The proposed site for implementation of the RRT will be Pitt County Memorial Hospital (PCMH), in partnership with Division of Pulmonary & Critical Care Medicine at Brody School of MedicineEast Carolina University. The hospital is a 750 bed tertiary center with a very active emergency department as well as medical & surgical critical care units. The hospital and the academic divisionare in a growth phase to expand critical care services.

Code Blue Team /Critical Care Services

Some critical functions of the RRT presently reside either with the Code Blue Team and/or critical care
services, especially the ECU MICU Service. These include:

• response to requests for consultation regarding patients whose condition may be declining sufficiently to warrant transfer to the ICU;
• response to acute cardiopulmonary events (arrests). In either case, MICU staff must leave the care of the most gravely ill patients at PCMH in favor of patients in outside the ICU, who may or may not be experiencing a life-threatening event. Design of the RRT must eliminate or substantially reduce MICU Service "distractions" arising outside the ICU. The RRT must be able to respond quickly (and some settings this is has been as quickly as 90 seconds) and in a manner to prevent out-of-ICU arrests.

Education

Teaching functions will be supported to the extent that they do not interfere with the primary goal of urgent patient care.

There already is a physician certified to coordinate the Fundamental Critical Care Support (FCCS)
course, sponsored by the Society of Critical Care Medicine (SCCM), on the Medical Staff. PCMH should
plan to provide this course locally. This will help fulfill PCMH's training role as well as provide a greater
pool from which to draw staff for RRT operation.

Data Collection & Research

Careful review of the literature advanced in support of RRT creation leads to the conclusion that it may be difficult, if not impossible, to demonstrate that, at PCMH, the team will reduce impatient mortality. RRT implementation has the potential to improve patient care and resource utilization in many important ways. An indispensable part of the team is inclusion of staff to properly collect those data that will document all the potential effects of the RRT (through clinical parameters as well as resource utilization).