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Rapid response team activation by patients can mitigate errors

From the June 1, 2006 issue

Many hospitals are familiar with the concept of rapid response teams (RRT), one of six initiatives that comprise the 18-month-long Institute for Healthcare Improvement's 100,000 Lives Campaign. The idea is simple: any healthcare worker can bypass the typical chain-of-command and call what is essentially a medical "SWAT team" to quickly assess the patient and intervene when life-saving care may be needed (1). Unlike the traditional "code" team, the RRT intervenes before the patient experiences a respiratory or cardiac arrest. The results have been impressive, with reductions in cardiac arrests, deaths, and length-of-stay (2).

Taking this intervention to a whole new level, The University of Pittsburgh Medical Center (UPMC) Shadyside, is perhaps the first hospital in the nation to invite patients and families to call for a RRT to address unresolved concerns about their safety and health (3,4,5). Upon admission, patients and family members are encouraged to pick up any phone in the hospital to report a Condition H (for "help") if they:

Fear something is seriously wrong with the patient and have expressed their concerns   without validation or recognition of its potential importance

  • Experience a communication failure
  • Become confused about the patient's care
  • Need to know where to voice concerns 
  • Feel something about the patient's condition is "just not right."

Condition H is available around-the-clock. The call goes to the hospital operator who pages the RRT. The team arrives at the patient's bedside within minutes, listens to the patient's or family member's concerns, assesses the patient, and responds with medical care or further investigation, as needed. According to Shadyside, RRT members are chosen based on their clinical skills as well as their ability to interact well with patients and families, as the whole effort can fail if a team member says, "This had better be good, because I was busy..."(4).     

Shadyside created Condition H after a staff member heard Sorrel King, a prominent patient safety advocate, tell the compelling story of medical errors that caused the death of her 18-month-old daughter, Josie, while receiving treatment for burns from a bathtub accident. Josie had been healing well, but she died 2 days before her planned discharge. Hospital staff failed to recognize that Josie had become seriously dehydrated, despite frequent pleas by Sorrel that her daughter was listless and extremely thirsty--and that something was very wrong (3-5). Inspired by Sorrel King's presentation, a Shadyside staff member contacted her and together they devised a plan that would allow patients and family members to bring their life-threatening concerns to the attention of an emergency medical team, similar to calling 911 for emergency help.

When staff at Shadyside first introduced the idea of Condition H, many feared that patients and families would make too many calls for non-urgent reasons, such as cold meals or uncomfortable pillows (4). But the results of a pilot test were very positive and the intervention was spread throughout the hospital. Placing a picture of Josie King on the cover of the patient brochure that describes Condition H (also called the Josie King Call Line), and showing patients a video about this tragedy, when time permits, also factors in as a deterrent to non-urgent calls. When patients see that the help line is named after a little girl who lost her life because of medical errors, they are less likely to use the line to complain about things like unsatisfactory hospital food and other minor annoyances (4).
   
Sorrel King has no doubt that access to a RRT would have saved her daughter's life, as the errors that caused her death were easily correctable.4 Likewise, we have no doubt that a patient- or family-activated RRT could have mitigated harm that has resulted from other life-threatening and deadly medication errors. Take one of the very errors that helped spark the modern patient safety movement--an overdose of cyclophosphamide administered to Betsy Lehman in 1994, which brought wide-spread public attention to medical errors. Betsy received an entire course of therapy each day for 4 consecutive days. Both Betsy and her husband repeatedly expressed that something was very wrong after the first dose, but their concerns were dismissed as expected toxicity of the chemotherapy. Sadly, on the day she was to be discharged, Betsy even phoned a friend and left a message: "I'm feeling very frightened, very upset. I don't know what's wrong, but something's wrong" (6). She died an hour later.

If Betsy or her husband had been given an opportunity to call a RRT when Betsy first experienced symptoms of the overdose, would she have survived? A different group of health practitioners whose primary role was to listen and be objective and responsive very well might have resulted in a better outcome if the error had been caught on day 1, when Betsy and her husband first expressed concerns.

Between July 2005 and March 2006, Shadyside received 20 calls, mostly from patients.5 All were all felt to be appropriately initiated, and the hospital considers each a learning experience (3). In fact, there is steadfast recognition that, although something interfered with communication between the patient, family, and staff, individuals should not be blamed. Condition H is considered an additional opportunity to step in before a tragedy occurs. On the other hand, Shadyside also believes that the program has caused staff to ramp up their communication with patients. Interviewed patients have expressed that they feel much safer knowing they can get immediate attention if they feel they need it (4).

UPMC is currently spreading Condition H to other facilities within its health system, and other hospitals around the country are also gearing up to empower patients to call a RRT. This intervention may truly be one of the most significant ways that healthcare providers can make patients an equal partner in their care and safety.   

References: 1) Institute for Healthcare Improvement. Rapid response teams: heading off medical crises at Baptist Memorial Hospital-Memphis. Accessed at: www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/
RapidResponseTeamsHeadingOffMedicalCrisesatBaptistMemorialHospitalin Memphis.htm
. 2) Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD. The 100,000 Lives Campaign: setting a goal and a deadline for improving health care quality. JAMA Jan 2006; 295(3):324-327. 3) ECRI. Hospital response team for patients addresses care breakdowns. The Risk Management Reporter 2006; 25(2):11-12. 4) Thomson American Health Consultants. Condition H phone line provides last chance to prevent serious errors. Healthcare Risk Management 2006; 28(2): 13-17. 5) Josie King Foundation. The Josie King Call Line. The Patient Safety Group. Accessed at: www.patientsafetygroup.org. 6) Lehrer S. Epilogue to: Explorers of the Body. 1979; Doubleday. Accessed at: http://stevenlehrer.com/explorers/epilogue.htm (at the time of this writing).

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