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Jt Comm J Qual Patient Saf. Author manuscript; available in PMC 2015 July 01. Published in final edited form as: Jt Comm J Qual Patient Saf. 2015 ; 41(4): 186–183.
The Deployment of Rapid Response Teams in U.S. Hospitals Deonni P. Stolldorf, PhD, RN and Tennessee Valley Healthcare System; Vanderbilt School of Nursing Cheryl B. Jones, PhD, RN, FAAN The University of North Carolina at Chapel Hill School of Nursing
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Abstract
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The Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health system (1999), highlighted the need for improvements in the quality of health care, advocating for improvements in patient safety, preventing avoidable harm, and providing the necessary care to patients who could benefit from it. Rapid Response Teams (RRTs) are one crucial aspect of a hospital's RRS, providing hospitals with a mechanism to respond and care for patients experiencing an avoidable medical crisis. RRTs became imbedded in US hospitals following the launch of the 100 000 Lives Campaign in 2004 by the Institute for Healthcare Improvement and the introduction of RRTs as one of six initiatives to improve the quality of patient care. RRT adoption also provides hospitals the opportunity to meet a Joint Commission requirement for hospitals to implement a mechanism that enabled staff members to obtain help from experts when their patient's condition is worsening. Despite the proliferation of RRTs in hospitals, descriptive reports of these teams across groups of hospitals have been relatively few and provided limited descriptive information on RRTs. Therefore, using data we collected as part of a larger mixed-methods study of RRTs to examine their sustainability, we describe RRTs in a group of hospitals that were part of a collaborative to facilitate RRT adoption and implementation.
Background and Rationale
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Several Institute of Medicine (IOM) reports1,2 have highlighted the need for improvements in the quality of health care in the US: safer systems of care that avoid harm or injury to patients and address the needs of patients. Rapid Response Systems (RRS) are one strategy that has been used to address this need and provide safer care environments.3 An RRS is a coordinated and organizational-wide approach to care for patients in crisis by getting the right resources and services to the patient as quickly as possible to prevent adverse patient outcomes.4,5 Rapid response teams (RRTs) is a crucial aspect of an organization's RRS.4 RRTs are expert clinicians who provide additional care for patients on acute care units who are experiencing unexpected, sudden changes in their conditions.6 The goal of these teams is to prevent
Deonni P Stolldorf 1310 24th Ave South Nashville TN 37212 615-873-7971 [email protected]@va.gov. Competing interests The authors declare no competing interests related to the development and submission for publication of the manuscript.
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avoidable patient progression to cardiopulmonary arrest.7,8,9 RRTs are predominantly activated by health care providers when predetermined objective or subjective criteria are met. 10–12 Depending on organizational policies, patients and families may also activate RRTs. RRTs have the potential to improve both patient and broader organizational outcomes. Patient outcomes reported include reduced hospital stay,13 unanticipated ICU admissions,1415 and non-ICU cardiorespiratory arrest.16 Broader organizational outcomes reported include quality of care,17 nurse satisfaction,18 staff collaboration,19 and patient safety.20-23
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In the first consensus report on METs, DeVita and colleagues4 described an RRS and provided guidance on the implementation of an RRS. In the report, the authors called for the standardization and classification of institutional RRS', and they argued for the reporting of the deployment of these systems in institutions and, in particular, the characteristics of the various components (i.e., “afferent” and “efferent”, process improvement, and governance or administrative structure). Yet, despite their call for more descriptive information on RRS components, few studies have reported such information. Some studies have reported on some aspects of the RRS: variations in RRS effectiveness (i.e., adult and pediatric non-ICU cardiorespiratory arrest and total hospital mortality) and implementation (team composition, activation criteria, and implementation processes);3 failure of the afferent limb of an RRS;5 RRT calling criteria; 23,24 team composition;25,26 and, RRT implementation processes.12,27,28 But most studies were limited to either single institutions or non-U.S. hospitals. Recently, Wakeam and colleagues 29 offered some descriptive information of RRTs in their sample of hospitals (n=7). Yet, despite the spread of RRTs in U.S. hospitals, detailed descriptive data on RRTs that goes beyond individual hospital reports are mostly lacking. Donaldson et al.26 provide some descriptive information on the activation of and composition of RRTs in nine multihospital organizations. However, because hospitals provided only limited data, the authors could not provide a detailed report of the RRT programs in the nine participating organizations. The researchers did observed differences in RRT composition between teaching and non-teaching hospitals. Specifically, compared to non-teaching hospitals, most teaching hospitals included physicians on their teams. This distinction, however, is not clear in the literature. For example, some teaching hospitals were reported to have intensive care unit (ICU) nurses and respiratory therapists11,30, 31 and some non-teaching hospitals reported having a physician on the team.32, 33
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The availability of descriptive information on RRT programs is important for several reasons. First, it could guide future RRT quality improvement efforts by providing guidance to leaders whose organizations wish to either implement full-scale RRT programs, or modify their existing RRT programs to allow for a better fit with existing hospital processes. Second, it responds to the call by DeVita and colleagues4 for the reporting of the characteristics of the various components of the RRS. Third, it could shed light on if the standardization of RRTs and to some degree RRS' have been achieved in hospitals.
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Therefore, the purpose of this paper is to describe the RRT programs among a group of hospital members of a statewide RRT collaborative and to describe differences in RRT programs between academic health centers and community hospitals. The RRS structure, as proposed by DeVita et al. is used to frame the report, by conceptualizing a hospital's RRT program as in integral part of the RRS.
Methods Design A cross-sectional study design deploying a survey methodology was used to examine the components of RRTs in hospitals. The survey was part of a larger mixed-methods study examining RRT sustainability. The survey was specifically developed for this study by the research team to gather hospitals' self-reported data.
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Setting and Sample This study's sample consisted of all hospitals that participated in a RRT Collaborative (RRTC) in a southeastern U.S. state (n=56). The RRTC was a 9-month statewide collaborative conducted in 2006 and 2007 to successfully establish, implement, measure, evaluate, and sustain RRTs at 50 acute care hospitals. The RRTC was one of nine RRT initiatives funded nationwide by the Robert Wood Johnson Foundation. Hospitals that participated in the collaborative had access to resources, such as a RRT Toolkit with implementation guidelines, training, support, and data and outcome measurement services. Variables and Instrument
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A 40- item survey was developed for this study. Variables included in the survey were categorized as organizational characteristics (e.g., hospital type), RRT characteristics (e.g., RRT composition), and RRT-related outcomes (e.g., in-hospital mortality rate). Prior to its administration, the survey was evaluated for content validity, clarity, and interpretability via a panel of experts. Panel members, including the leader of the state-wide RRTC, faculty content experts, Chief Nurse Officers from non-RRTC hospitals, and survey experts from a local, university-affiliated research institute, were asked to review and provide feedback on the survey and its content. Based on expert review, the survey was modified to include two additional questions related to the characteristics of RRTs. Also, RRT outcome questions were modified to more accurately reflect the measures used by the RRTC to measure RRT effectiveness. Screening questions were also added to ensure that only targeted hospitals completed the survey.
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Data Collection and Analysis After receiving Institutional Review Board approval, the RRT survey was administered as a web-based survey, using the electronic software program Qualtrics™. The sample of hospitals was accessed with the assistance of a representative who led the state-wide collaborative and who served as a key contact and study advisor. The representative sent a pre-notification email to all RRTC participants introducing the researcher to hospital leaders and alerting them to the study. This representative also provided contact information for all hospitals in the study sample to the researcher, which was used for contacting key hospital Jt Comm J Qual Patient Saf. Author manuscript; available in PMC 2015 July 01.
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leaders and distributing all study-related correspondence (i.e., invitations to participate, consent information, and thank-you cards) to prospective participants. Throughout the research process, the representative served as a resource, was kept informed of the study's progress, and served as a “sounding board” when problems arose.
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The survey was administered using a modified version of the Tailored Design Method. 34 The researcher first sent a recruitment letter with an electronic survey link by email to all hospitals in the RRTC. This letter was sent to the appropriate administrator (CNO, Chief Executive Officer [CEO], or Chief Operating Officer [COO]) at each hospital to invite them to participate in the study. A follow-up email was sent to thank those who had responded to the survey and to remind others that the opportunity to participate in the survey was still available. Two weeks after the initial recruitment letter was emailed a hard copy of the recruitment letter, consent form, a hard copy of the survey, and the link to the electronic survey were mailed to the respective hospital administrators who had not completed the electronic survey. This correspondence reminded them of the study and invited them to complete it. Sending both a hard copy and a link to the electronic survey gave hospital administrators the option to complete via the method of their choosing. A final contact was made by phone one week after the hard copies were mailed to again note the importance of the study and invite prospective participants to complete the survey. The electronic survey remained activated for four weeks from the date of the initial recruitment letters.
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Descriptive data analysis was conducted using the Statistical Package for the Social Sciences (SPSS) version 19.0.2 (Armonk, NY). An exploratory correlation analysis was conducted to determine the relationship between RRT characteristics and hospital size and type. Because of the predominantly nominal nature of the data, Point-Biseral and Cramer's V correlation analyses were used.
Results Sample Characteristics
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Thirty-three of the 56 hospitals invited to participate in the survey responded; 32 surveys were completed on-line and one survey was returned as a paper copy by mail. Two hospitals were excluded from the analysis. One was excluded because no questions were answered, other than general organizational characteristics. The other hospital had not implemented an RRT. Therefore, the final sample of hospitals was 31, for a response rate of 58%. Twentyseven hospital administrators completed the survey, and 4 were completed by others assigned by an administrator. Of those completing the survey, six were CNOs, two were COOs, and the remainder was completed by various others, including directors, nurse managers, patient safety officers, and quality experts. Organizational Characteristics The 31 participating organizations included academic health centers (AHC)(19%), community hospitals (CHs) (71%), corporate health systems (CHS)(6%), and one critical access hospital (CAH)(3%). Hospital size varied from 24 to 870 licensed and staffed bed (M = 295), with half of the hospitals being less than 150 beds. Only limited descriptive details
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on hospital size are provided to protect the identity of both the small and large hospitals that participated in the survey. To allow for a comparison of RRT characteristics between teaching and non-teaching hospitals, two hospitals initially classified as corporate healthcare systems were, based on further examination of each hospital, classified as an AHC (n=1) and a CH (n=1). The one critical access hospital was classified as a CH. RRS Characteristics
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Afferent Component—The afferent component of the RRS addresses event detection and a trigger mechanism to get help for a patient with an un-met clinical need.4 In terms of triggering a RRT call, all 31 hospitals reported that RRTs could be activated by registered nurses (RNs); in 30 hospitals (99%) other hospital staff members (e.g., respiratory therapists [RTs], licensed practical nurses [LPNs]), or unit secretaries) could also activate RRTs; in 19 hospitals (62%) families could activate RRTs; and in 17 hospitals (55%) patients could activate RRTs. In slightly over half of the hospitals (52%), RRTs could be activated by RNs, other hospital staff, and families and patients. In twelve hospitals (39%), RRTs could be activated by only RNs and other hospital staff. Efferent Component—The efferent component of the RRS is the “crisis response” (p. 404) and includes the response team (i.e., RRT, MET, or CCO) or other specialized resources (e.g., cardiac arrest, trauma, or stroke teams)35. Of the 31 hospitals that participated in the study, the number of RRTs and the size of the RRT (i.e., number of staff members) varied across organizations (see Table 1). The team leader of RRTs also differed. The majority (n = 22, 71%) had nurse-led teams. All participating hospitals reported providing RRT coverage on all shifts.
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The composition of the RRT varied across hospitals (see Table 1). Most teams had Intensive Care Unit (ICU) RNs and RTs as part of the team. Nine hospitals (29%) included a hospitalist as part of the team and 7 hospitals (23%) reported the presence of a dedicated RRT nurse. Nineteen hospitals (61%) reported the presence of an RRT oversight committee (defined as group of individuals that implemented and continue to monitor the RRT program). Most hospitals reported engaging in RRT follow-up activities (see Table 1). Ten hospitals (32%) conducted debriefing sessions following RRT calls, and thirteen hospitals (42%) reassessed patients within 24 hours following an RRT call. However, only seven hospitals (23%) included both debriefing sessions and reassessing patients within 24 hours following an RRT call.
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Process Improvement and Administrative Oversight Components—Evaluative, patient safety and feedback activities are included in the process improvement component, whereas the oversight component encompasses the administrative and governance functions of the RRS. Hospitals in the study sample had incorporated some activities within each of these two components. In terms of the process improvement component, 19 (61%) hospitals enabled staff on acute care units to evaluate the RRT. In 18 (58%) hospitals RRT members (RRTM) received feedback on their performance from their leaders. In 21 (68%) of the hospitals, organizational leaders shared RRT program outcomes (e.g., the number of calls, Jt Comm J Qual Patient Saf. Author manuscript; available in PMC 2015 July 01.
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the number of unanticipated ICU admissions, cardiac arrest rates outside of ICU, in-hospital mortality rate) with staff members (see Table 2). Only 12 (39%) hospitals conducted all three evaluation activities; 18 (58%) hospitals conducted at least two of the evaluation activities; and only 5(16%) of hospitals conducted only one of the three evaluation activities. Organizational and RRT Characteristics
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Several RRT characteristics were compared by hospital type and size.(Figure 1) A higher percentage of AHCs had two or more RRTs in the organization than CHs (43% vs. 8%) and the composition of the team also differed by organizational type (see Figure 1). Also, AHCs did not report including hospitalists on their RRT, whereas 38% of CHs included a hospitalist in their RRT. A higher percentage of AHCs (43%) had a dedicated RRT nurse role when compared to CHs (17%). Except for reassessing patients within 24 hours following a RRT call, more AHCs conducted RRT related activities than CHs (see Figure 1). Specifically, five AHCs (71%) conducted debriefing sessions following RRT calls, provided staff members the opportunity to evaluate the RRT, and shared RRT outcomes with staff members. In contrast, only 5 (21%) of CHs conducted debriefing sessions, 14 (58%) provided staff members the opportunity to evaluate the RRT, and 16 CHs (67%) shared RRT outcomes with staff members.
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When comparing RRT characteristics by hospital size, some patterns emerged. Large hospitals (i.e., greater than 500 licensed and staffed beds) were more likely to have more than one RRT, have an ICU or ED physician on the team, and have a dedicated RRT nurse role in the organization. Except for debriefing sessions, conducting RRT related activities were comparable between medium-sized and large hospitals, but were markedly different between small and large hospitals (see Figure 1). The percentage of small, medium-sized, and large hospitals with an RRT oversight committee was comparable.
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Correlation analyses were conducted to examine the relationship between RRT characteristics and hospital type and size. Statistically significant positive relationships were observed (see Table 3). Specifically, strong, positive correlations were observed between the number of teams and hospital type (r=.392, p = .029) and size (r =.431, p = .016) and hospital size and the use of MD-led teams (Cramer's V = .443, p = .048) and the use of a dedicated RRT (Cramer's V = .462, p = .037). Strong, positive correlations were also observed between the use of debriefing sessions following RRT calls and hospital size (Cramer's V = .453, p = .012) and hospital type (Cramer's V = .515, p = .016). No significant correlations were observed between the use of a dedicated RRT model and the number of or type of post-RRT activities. Collinearity was observed between hospital type and size (Cramer's V= .839, p < .001). RRT Outcomes The survey also included questions on outcomes associated with RRTs and respondents' perception of how patient outcomes had changed since RRTs made the transition from the initial pilot program to permanent status in the organization. Participants were asked to report RRT outcomes for 1 year prior to the survey date, and the number of RRT calls in the month prior to the survey date.
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Unfortunately, over 50% of hospitals in the sample did not provide any patient outcomes data. Specific reasons for the lack of response to these items are unknown, but speculation is that hospitals may have been hesitant to report these data because they are sensitive and/or difficult to retrieve. Also, despite requesting patient outcomes data using metrics gathered through the RRTC, hospital administrators who reported patient outcomes data inconsistently, making it difficult to compare RRT outcomes. For example, some hospital administrators reported RRT outcomes as percentages, some reported them as numerical values, and some reported them as a simple increase or decrease. However, 17 hospitals reported the number of RRT calls in the year prior to the survey. Table 4 presents the number of RRT calls per bed by hospital size and type.
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This study found, variations in the organizational characteristics and the RRS' deployed by the hospitals that participated in a state-wide RRT collaborative. Hospitals varied by size and type, with most hospitals being small (i.e., less than 150 licensed and staffed beds), community-based hospitals. While all hospitals had developed a RRS, variations existed and robustness was lacking in each of the four components of many of the hospitals' RRS'. As part of the afferent limb, all hospitals incorporated a trigger mechanism to activate a team of care providers to meet the unmet needs of patients. Yet, in 39% of hospitals only RNs and other hospital staff could activate RRTs. Family and patient activation had, therefore, not yet been fully taken up by participating hospitals at the time of this survey.
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Variations in the efferent limb of the RRS, such as the type of team (RN-led versus MDled), team composition, and number of teams, suggest hospital administrators adopted RRT models that best fit with the needs of the organization and the resources available. This finding may be a reflection of flexibility that is crucial for the effective implementation of RRT programs. Institution-specific barriers, as suggested by Wakeam et al., 29 may also have been the driving force behind the structure of these teams.
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All hospitals in the study provided RRT coverage for 24 hours a day, 7 days a week, compared to only 85% of hospitals in the study by Donaldson et al.25 The majority of hospitals selected to use RN-led teams (71%) that included an ICU RN and/or an ED RN, whereas only two (29%) hospitals included an ICU or ED physician in their teams. This finding is in contrast to the findings by Donaldson et al.25 who found that most teaching hospitals included a physician on their teams, but aligns with what has been reported in the literature.11, 30, 32 Only 22% of hospitals used a dedicated RRT nurse to respond to calls. Limited organizational resources and lack of funding might have been important drivers in the selection of a less resource intensive RRT model versus the resource intensive dedicated RRT model. Because RRT calls can be sporadic, to offset the cost of using a dedicated RRT model the dedicated RRT RN must be assigned additional responsibilities. Clarifying what these additional responsibilities needed to be might have been challenging for administrators.
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Yet, dedicated RRT nurses can be important RRT champions who can help to increase the visibility of RRTs in the organization and generate end-user buy-in to calling the RRT. 32 Also, the use of existing ICU or ED nurses to respond to RRT calls may compromise quality of care and patient safety. When these nurses respond to a RRT call but also have a patient assignment, an increase patient-to-nurse ratios results which has been linked with adverse patient outcomes, nurse burnout, and job satisfaction.39, 40 Therefore, as hospital administrators continue to monitor and change their RRT programs, careful consideration must be given to the RRT model that was or will be instituted.
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This study also found that key aspects of the RRS components of safety/process improvement and administrative structure were lacking in hospitals. Only twelve (39%) hospitals included all three RRT evaluation activities namely, staff members had the opportunity to evaluate the RRT, RRTMs received feedback on their performance, and RRT outcomes were shared with staff members. Also, although DeVita et al.4 strongly recommended that there be an RRS coordinator to oversee the RRT program, only 19 hospitals (61%) have an RRT oversight committee in place to oversee RRT activities and 18 (58%) hospitals had a supervisor formally assigned to the RRT program.
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The lack of robust evaluation processes and a RRT coordinator or supervisor to oversee the program could potentially hinder quality improvement efforts related to the RRS. Given that RRT members play an important role in end-users future calling behavior,20, 26 end-users must be given the opportunity to evaluate their RRT call experiences. Evaluation of RRT members' performance must be an integral part of RRT evaluation processes. Sharing RRT outcomes with staff and demonstrating the effectiveness of the RRT program may also facilitate future calling behavior. A RRT program supervisor, who is responsible for coordinating and overseeing RRT program activities, and who can facilitate quality improvement initiatives, could help to strengthen an organization's RRS and facilitate its responsiveness to organizational changes and needs.
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This study also found that teaching hospitals, compared to non-teaching hospitals, were more likely to have a higher number of teams who could respond to RRT calls, use a MDled team and dedicated RRT model, and conduct debriefing sessions following RRT calls. Although these statistically significant findings were also observed in large hospitals, large hospitals were strongly correlated with teaching hospitals, indicating collinearity. Reasons for these statistically significant findings in teaching hospitals are likely due to the increased availability of resources in large, teaching hospitals. Although teaching hospitals were more likely to have a dedicated RRT model, no correlation was found between the use of a dedicated RRT nurse and the number of or type of evaluation activities conducted following RRT calls. Because hospital administrators could choose whether or not to respond to each question in the electronic survey, the lack of hospital administrators to report patient outcomes data does not necessarily mean that their hospitals did not collect these data. Some hospital administrators reported perceived benefits of RRT implementation; however, some reported no perceived changes in outcomes (i.e., acute care inpatient mortality rate, unplanned ICU transfers, codes outside of the ICU, and the number of codes per 1000 discharges). These
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findings are similar to the inconsistencies in RRT outcomes that have been reported in the literature, with some studies noting improvements in patient outcomes14 versus others that report no improvements.17 The perceptions regarding the efficacy of RRTs were similarly mixed in the current study. Study Limitations and Recommendations for Future Research
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There are several study limitations that are worth noting. First, the use of self-administered web-based surveys has both advantages (i.e., low cost of administration, speed and accuracy of data collection)36 and disadvantages (i.e., non-response and response bias).37, 38 Efforts to mitigate these limitations included providing clear instructions and the use of frequent reminders to complete the survey, ensuring participants of the confidentiality of their responses, and carefully wording the survey questions to avoid leading respondents to answer in particular ways.37, 38 While random selection of hospitals and a larger sample size may have reduced the risk of non-response bias, this study did enable the rapid collection of information for leaders in those hospitals that participated in the RRTC. In turn, they can use this study's findings to refine the RRTs in their organizations. Future studies on RRTs should include larger sample sizes and randomization to allow for the broader generalization of study findings.
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A response rate of 58% achieved in this study compares well with other RRT studies that used a survey methodology.41 Measures were built into the study methods to achieve a good response rate namely, working closely with the state's hospital association to personalize mailings, including skip patters in the electronic survey, providing electronic indication of survey progress, thoroughly pre-testing the survey, and enabling respondents to report problems. A comparison of responder and non-responder hospitals showed no statistically significant differences in the # of beds between responders (Median = 242; 25th - 75th IQR =101-529) and non-responders (Median = 143; 25th – 75th IQR = 101 – 529) (z = 1.75, p=. 081).
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Although another limitation of the study is the completion of the survey by only one respondent administrator, mechanisms were built into the survey to allow the CNO or CEO, who received the initial study invitation and link to the electronic survey, to select a person familiar with the RRT program to respond to the invitation and complete the survey. In 74% of the hospitals, these administrators selected someone else to complete the survey (i.e., directors, nurse managers, patient safety officers, and quality experts). In subsequent case studies with some of these hospitals, the researcher found that the survey responders were responsible for providing overview of the RRT program. However, although it is likely, it remains unclear if the person who completed the survey for each of the hospitals that participated in the survey was involved with or oversaw the RRT program. Social desirability of responses may also have biased the findings; however, to reduce this risk, steps were taken to ensure the anonymity and confidentiality of responses. A comparison of RRT-related patient outcomes across organizations was not possible because of inconsistencies in the reporting of these outcomes, and the large amount of missing data. Future studies could address this limitation by including patient outcomes as a study variable and gathering the raw data to calculate the variable consistently across all Jt Comm J Qual Patient Saf. Author manuscript; available in PMC 2015 July 01.
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participating hospitals. This would remove the potential error introduced when even common outcome metrics are used, based on organizational calculations.
Conclusions
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This article provides a detailed description of the results of a web-based survey administered to gather descriptive data on hospitals and their RRTs. Organizational characteristics, RRT characteristics and RRT call rates of a sample of hospitals are reported. Hospitals were heterogeneous in their characteristics and the RRTs they implemented. Hospitals have been successful in addressing the afferent and efferent limbs of their RRS', but improvements are necessary in the areas of safety/process improvement and administrative oversight. The Joint Commission requirement, for a system such as RRTs to be in place, may have been the impetus for hospitals to implement RRTs. This requirement may, in future, need to also include requiring RRT-related quality improvement initiatives and the presence of an RRT oversight committee. Individual hospital policies may also need to be enacted to ensure that safety/process improvement and oversight processes are integrated in RRT programs and the necessary funds made available to support these activities. Without these requirements and policies, RRT programs and RRS' may never reach their full capacity in organizations.
Acknowledgements The authors wish to acknowledge the contributions of Drs. Donna Havens, David A. Hofmann, Dr. Barbara A. Mark, and Dr. Bryan Weiner, in the conceptualization and development of the dissertation research project, which is reflected in some of the content presented in this manuscript. The authors also wish to acknowledge that the material is based upon work supported by the Office of Academic Affiliations, Department of Veterans Affairs, VA National Quality Scholars Program and with use of facilities at VA Tennessee Valley Healthcare System, Nashville, Tennessee.
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Grant Support Partial funding for the project was provided by the National Institute of Nursing Research Grant Number 5 T32 NR 008856.
APPENDIX A RAPID RESPONSE TEAM SURVEY
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Author Manuscript Author Manuscript Author Manuscript References Author Manuscript
1. Institute of Medicine. To err is human: building a safer health system. National Academy Press; Washington, DC: 1999. 2. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century.. National Academy Press; Washington, DC: 2001. 3. Winters BD, et al. Rapid-response systems as a patient safety strategy. Ann Intern Med. 2013; 158(5 Pt 2):417–25. [PubMed: 23460099] 4. DeVita MA, et al. Findings of the first consensus conference on Medical Emergency Teams. Crit Care Med. 2006; 34(9):2463–78. [PubMed: 16878033] 5. Trinkle RM, Flabouris A. Documenting rapid response system afferent limb failure and associated patient outcomes. Resuscitation. 2011; 82(7):810–4. [PubMed: 21497982]
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6. Arashin KA. Using the synergy model to guide the practice of rapid response teams. Dimens Crit Care Nurs. 2010; 29(3):120–4. [PubMed: 20395727] 7. Barbetti J, Lee G. Medical emergency team: a review of the literature. Nurs Crit Care. 2008; 13(2): 80–5. [PubMed: 18289186] 8. Duncan KD. RRTs and electronic code documentation: advancing in-hospital resuscitation practices. Nurs Manage. 2005; 36(12):18–22. [PubMed: 16344688] 9. Odell M, Victor C, Oliver D. Nurses’ role in detecting deterioration in ward patients: systematic literature review. J Adv Nurs. 2009; 65(10):1992–2006. [PubMed: 20568317] 10. Durkin SE. Implementing a Rapid Response Team. AJN. 2006; 106(10):50–3. [PubMed: 17016094] 11. Scott SS, Elliott S. Implementation of a rapid response team: a success story. Crit Care Nurs. 2009; 29(3):66–74. 12. Tolchin S, et al. Eliminating preventable death at Ascension health. Jt Comm J Qual Patient Saf. 2007; 33(3):145–54. [PubMed: 17425236] 13. Bellomo R, et al. Prospective controlled trial of effect on medical emergency team on postoperative morbidity and mortality rates. Crit Care Med. 2004; 32(4):916–21. [PubMed: 15071378] 14. Salamonson Y, et al. The evolutionary process of medical emergency team (MET) implementation: Reduction in unanticipated ICU transfers. Resuscitation. 2001; 49(2):135–41. [PubMed: 11382518] 15. Garretson S, et al. Rapid response teams: a proactive strategy for improving patient care. Nurs Stand. 2006; 21(9):35–40. [PubMed: 17137279] 16. Chan PS, et al. Rapid response teams. A systematic review and meta-analysis. Arch Internal Med. 2010; 170(1):18–26. [PubMed: 20065195] 17. Berwick DM, et al. The 100,000 Lives campaign: setting a goal and a deadline for improving health care quality. JAMA. 2006; 295(3):324–7. [PubMed: 16418469] 18. Metcalf R, et al. Rapid Response Team Approach to Staff Satisfaction. Orthop Nurs. 2008; 27(5): 266–71. [PubMed: 18832984] 19. Williams DJ, et al. Woodard EK. Nurses’ perceptions of how rapid response teams affect the nurse, the team, and the system. J Nurs Care Qual. 2011; 26(3):265–72. [PubMed: 21248644] 20. Braithwaite RS, et al. Use of medical emergency team (MET) responses to detect medical errors. Qual Saf Health Care. 2004; 13(4):255–9. [PubMed: 15289627] 21. Chen J, et al. The Merit Study Investigators of the Simpson Centre and the ANZICS Clinical Trials Group. The relationship between early emergency team calls and serious adverse events. Crit Care Med. 2009; 37(1):148–53. [PubMed: 19050625] 22. Iyengar, A.; Baxter, A.; Forster, AJ. [Feb 6, 2014] Using Medical Emergency Teams to detect preventable adverse events.. Crit Care. Jul 30. 2009 http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2750180/ 23. Bell MB, et al. Prevalence and sensitivity of MET-criteria in a Scandinavian University Hospital. Resuscitation. 2006; 70(1):66–73. [PubMed: 16757089] 24. Boniatti MM, et al. Prognostic value of the calling criteria in patients receiving a medical emergency team review. Resuscitation. 2010; 81(6):667–70. [PubMed: 20227811] 25. Donaldson N, et al. Leading successful rapid response teams. A multisite implementation evaluation. JONA. 2009; 39(4):176–81. 26. Jones DA, DeVita MD, Bellomo R. Rapid-response teams. N Engl J Med. 2011; 365(2):139–46. [PubMed: 21751906] 27. The Quality letter for healthcare leaders. Buying time, saving lives: hospital rapid response teams find ways to reduce mortality outside the ICU. Qual Lett Healthc Lead. Dec; 2004 16(12):2–9. 28. Morse KJ, et al. Rapid response teams: reducers of death. Nursing. 2007; 37(Suppl Critical):2, 4, 6. [PubMed: 17440330] 29. Wakeam E, et al. Barriers and strategies for effective patient rescue: A qualitative study of outliers. Jt Comm J Qual Patient Saf. 2014; 40(11):503–13.
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30. Chan PS, et al. Hospital-wide code rates and mortality before and after implementation of a rapid response team. JAMA. 2008; 300(21):2506–13. [PubMed: 19050194] 31. Jolley J, et al. Rapid response teams: do they make a difference? Dimens Crit Care Nurs. 2007; 26(6):253–60. [PubMed: 18090145] 32. Halvorsen L, et al. Building a rapid response team. Adv Crit Care. 2007; 18(2):129–140. 33. Jamieson E, Ferrell C, Rutledge DN. Medical emergency team implementation: experiences of a mentor hospital. Med Surg Nurs. 2008; 17(5):312–23. 34. Dillman, DA.; Smyth, JD.; Christina, LM. Internet, Phone, Mail, and Mixed-Mode Surveys. Wiley & Sons; Hoboken, NJ: 2014. 35. Sakai T, DeVita MA. Rapid response system. J Anesth. 2009; 23(3):403–8. [PubMed: 19685122] 36. Fleming CM, Bowden C. Web-based surveys as an alternative to traditional mail methods. Environ Manage. 2009; 90(1):284–92. 37. Polit, DF.; Beck, CT. Nursing research: principles and methods. Lippincott Williams & Wilkins; Philadelphia, PA: 2004. 38. Lewis-Beck, MS.; Bryman, A.; Liao, TF. The SAGE Encyclopedia of Social Science Research Methods. Sage; Thousand Oaks, CA: 2007. 39. Aiken LH, et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002; 288(16):1987–1993. [PubMed: 12387650] 40. Kane RL, et al. The association of registered nurse staffing levels and patient outcomes. Med Care. 2007; 45(12):1195–1204. [PubMed: 18007170] 41. Davies O, et al. Barriers to activation of a rapid response team. Resuscitation. 2014; 85(11):1557– 61. [PubMed: 25108061]
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Figure 1.
Comparison of RRT Characteristics by Hospital Type and Size
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Table 1
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Rapid Response Team Characteristics, Composition, and Follow-up Activities N (%) Number of teams 1
26 (84)
≥ 2
5 (16)
Persons on team 1 – 3
21 (68)
4-5
10 (32)
Team leader RN-led
22 (71)
MD-led
3 (10)
Co-led by RN and MD
6 (20)
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RRT composition ICU or ED Physician
3 (10)
ICU or ED RN
29 (94)
Hospitalist
9 (29)
Respiratory Therapist
28 (90)
Nursing House Supervisor/Clinical Coordinator
13 (42)
Dedicated RRT nurse who rounds on patients, units
6 (19)
Dedicated RRT nurse (not necessarily an ICU nurse)
1 (3)
RRT follow-up activities
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RRT debriefing
10 (32)
Patient reassessed within 24 hours
13 (42)
RRT debriefing and reassess within 24 hours
7 (23)
RRT debriefing only
3 (10)
Patient reassessed within 24 hours only
6 (19)
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Table 2
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RRT Evaluation and Oversight N (%) RRT evaluation activities Staff evaluates RRT
19 (61)
RRTM performance feedback
18 (58)
RRT outcomes are shared
21 (68)
All three above evaluation activities
12 (39)
Staff evaluates RRT and RRTM performance feedback
12 (39)
Staff evaluates RRT and RRT outcomes are shared
14 (45)
RRTM performance feedback and RRT outcomes are shared
18 (58)
Staff evaluates RRT only RRT member performance feedback only
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RRT outcomes are shared only RRT oversight committee
5 (16) 0 (0) 0 (0) 19 (61)
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Table 3
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Correlations between RRT Characteristics and Hospital Type and Size a
Variable
N (%)
Hospital Type d*
b
c
Hospital Size d*
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Number of teams
31(100)
Number of persons on team
31 (100)
Number of post-RRT activities
31(100)
Debriefing
10(32)
Reassessed ≤ 24hrs
13(42)
-
-
Staff evaluates RRT
19(61)
-
-
RRT outcomes shared
21 (68)
-
-
RRTM performance
18(58)
-
-
Dedicated RRT
7 (23)
-
RRT Oversight
19(61)
-
-
Team Leader
31(100)
-
-
RN-Led
22 (71)
-
MD-Led
3 (10)
-
Co-Led MD/RN
6 (20)
-
.392
(p = .029)
.431
-
-
.453
e*
(p=.016)
e*
(p=.012)
.515
e*
(p=.016)
.462
(p=0.037)
.443
e*
(p=.048) -
Note. (-) = not significant at the .05 level. a
total percentage value may be greater than 100 because of rounding
b
teaching and non-teaching
c
small (0 – 150), medium = (151 – 500), and large (= ≥ 501)
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d
Point-Biseral correlations:
e Cramer's V correlations *
significant at the .05 level
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Table 4
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RRT Calls by Hospital Size and Type RRT calls/bed Hospital Size 0 – 150
0.44
151-500
1.18
≥ 501
1.10
Hospital Type Academic Health Center
1.03
Community Hospital
0.85
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Jt Comm J Qual Patient Saf. Author manuscript; available in PMC 2015 July 01. Published in final edited form as: Jt Comm J Qual Patient Saf. 2015 ; 41(4): 186–183.
The Deployment of Rapid Response Teams in U.S. Hospitals Deonni P. Stolldorf, PhD, RN and Tennessee Valley Healthcare System; Vanderbilt School of Nursing Cheryl B. Jones, PhD, RN, FAAN The University of North Carolina at Chapel Hill School of Nursing
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Abstract
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The Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health system (1999), highlighted the need for improvements in the quality of health care, advocating for improvements in patient safety, preventing avoidable harm, and providing the necessary care to patients who could benefit from it. Rapid Response Teams (RRTs) are one crucial aspect of a hospital's RRS, providing hospitals with a mechanism to respond and care for patients experiencing an avoidable medical crisis. RRTs became imbedded in US hospitals following the launch of the 100 000 Lives Campaign in 2004 by the Institute for Healthcare Improvement and the introduction of RRTs as one of six initiatives to improve the quality of patient care. RRT adoption also provides hospitals the opportunity to meet a Joint Commission requirement for hospitals to implement a mechanism that enabled staff members to obtain help from experts when their patient's condition is worsening. Despite the proliferation of RRTs in hospitals, descriptive reports of these teams across groups of hospitals have been relatively few and provided limited descriptive information on RRTs. Therefore, using data we collected as part of a larger mixed-methods study of RRTs to examine their sustainability, we describe RRTs in a group of hospitals that were part of a collaborative to facilitate RRT adoption and implementation.
Background and Rationale
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Several Institute of Medicine (IOM) reports1,2 have highlighted the need for improvements in the quality of health care in the US: safer systems of care that avoid harm or injury to patients and address the needs of patients. Rapid Response Systems (RRS) are one strategy that has been used to address this need and provide safer care environments.3 An RRS is a coordinated and organizational-wide approach to care for patients in crisis by getting the right resources and services to the patient as quickly as possible to prevent adverse patient outcomes.4,5 Rapid response teams (RRTs) is a crucial aspect of an organization's RRS.4 RRTs are expert clinicians who provide additional care for patients on acute care units who are experiencing unexpected, sudden changes in their conditions.6 The goal of these teams is to prevent
Deonni P Stolldorf 1310 24th Ave South Nashville TN 37212 615-873-7971 [email protected]@va.gov. Competing interests The authors declare no competing interests related to the development and submission for publication of the manuscript.
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avoidable patient progression to cardiopulmonary arrest.7,8,9 RRTs are predominantly activated by health care providers when predetermined objective or subjective criteria are met. 10–12 Depending on organizational policies, patients and families may also activate RRTs. RRTs have the potential to improve both patient and broader organizational outcomes. Patient outcomes reported include reduced hospital stay,13 unanticipated ICU admissions,1415 and non-ICU cardiorespiratory arrest.16 Broader organizational outcomes reported include quality of care,17 nurse satisfaction,18 staff collaboration,19 and patient safety.20-23
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In the first consensus report on METs, DeVita and colleagues4 described an RRS and provided guidance on the implementation of an RRS. In the report, the authors called for the standardization and classification of institutional RRS', and they argued for the reporting of the deployment of these systems in institutions and, in particular, the characteristics of the various components (i.e., “afferent” and “efferent”, process improvement, and governance or administrative structure). Yet, despite their call for more descriptive information on RRS components, few studies have reported such information. Some studies have reported on some aspects of the RRS: variations in RRS effectiveness (i.e., adult and pediatric non-ICU cardiorespiratory arrest and total hospital mortality) and implementation (team composition, activation criteria, and implementation processes);3 failure of the afferent limb of an RRS;5 RRT calling criteria; 23,24 team composition;25,26 and, RRT implementation processes.12,27,28 But most studies were limited to either single institutions or non-U.S. hospitals. Recently, Wakeam and colleagues 29 offered some descriptive information of RRTs in their sample of hospitals (n=7). Yet, despite the spread of RRTs in U.S. hospitals, detailed descriptive data on RRTs that goes beyond individual hospital reports are mostly lacking. Donaldson et al.26 provide some descriptive information on the activation of and composition of RRTs in nine multihospital organizations. However, because hospitals provided only limited data, the authors could not provide a detailed report of the RRT programs in the nine participating organizations. The researchers did observed differences in RRT composition between teaching and non-teaching hospitals. Specifically, compared to non-teaching hospitals, most teaching hospitals included physicians on their teams. This distinction, however, is not clear in the literature. For example, some teaching hospitals were reported to have intensive care unit (ICU) nurses and respiratory therapists11,30, 31 and some non-teaching hospitals reported having a physician on the team.32, 33
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The availability of descriptive information on RRT programs is important for several reasons. First, it could guide future RRT quality improvement efforts by providing guidance to leaders whose organizations wish to either implement full-scale RRT programs, or modify their existing RRT programs to allow for a better fit with existing hospital processes. Second, it responds to the call by DeVita and colleagues4 for the reporting of the characteristics of the various components of the RRS. Third, it could shed light on if the standardization of RRTs and to some degree RRS' have been achieved in hospitals.
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Therefore, the purpose of this paper is to describe the RRT programs among a group of hospital members of a statewide RRT collaborative and to describe differences in RRT programs between academic health centers and community hospitals. The RRS structure, as proposed by DeVita et al. is used to frame the report, by conceptualizing a hospital's RRT program as in integral part of the RRS.
Methods Design A cross-sectional study design deploying a survey methodology was used to examine the components of RRTs in hospitals. The survey was part of a larger mixed-methods study examining RRT sustainability. The survey was specifically developed for this study by the research team to gather hospitals' self-reported data.
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Setting and Sample This study's sample consisted of all hospitals that participated in a RRT Collaborative (RRTC) in a southeastern U.S. state (n=56). The RRTC was a 9-month statewide collaborative conducted in 2006 and 2007 to successfully establish, implement, measure, evaluate, and sustain RRTs at 50 acute care hospitals. The RRTC was one of nine RRT initiatives funded nationwide by the Robert Wood Johnson Foundation. Hospitals that participated in the collaborative had access to resources, such as a RRT Toolkit with implementation guidelines, training, support, and data and outcome measurement services. Variables and Instrument
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A 40- item survey was developed for this study. Variables included in the survey were categorized as organizational characteristics (e.g., hospital type), RRT characteristics (e.g., RRT composition), and RRT-related outcomes (e.g., in-hospital mortality rate). Prior to its administration, the survey was evaluated for content validity, clarity, and interpretability via a panel of experts. Panel members, including the leader of the state-wide RRTC, faculty content experts, Chief Nurse Officers from non-RRTC hospitals, and survey experts from a local, university-affiliated research institute, were asked to review and provide feedback on the survey and its content. Based on expert review, the survey was modified to include two additional questions related to the characteristics of RRTs. Also, RRT outcome questions were modified to more accurately reflect the measures used by the RRTC to measure RRT effectiveness. Screening questions were also added to ensure that only targeted hospitals completed the survey.
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Data Collection and Analysis After receiving Institutional Review Board approval, the RRT survey was administered as a web-based survey, using the electronic software program Qualtrics™. The sample of hospitals was accessed with the assistance of a representative who led the state-wide collaborative and who served as a key contact and study advisor. The representative sent a pre-notification email to all RRTC participants introducing the researcher to hospital leaders and alerting them to the study. This representative also provided contact information for all hospitals in the study sample to the researcher, which was used for contacting key hospital Jt Comm J Qual Patient Saf. Author manuscript; available in PMC 2015 July 01.
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leaders and distributing all study-related correspondence (i.e., invitations to participate, consent information, and thank-you cards) to prospective participants. Throughout the research process, the representative served as a resource, was kept informed of the study's progress, and served as a “sounding board” when problems arose.
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The survey was administered using a modified version of the Tailored Design Method. 34 The researcher first sent a recruitment letter with an electronic survey link by email to all hospitals in the RRTC. This letter was sent to the appropriate administrator (CNO, Chief Executive Officer [CEO], or Chief Operating Officer [COO]) at each hospital to invite them to participate in the study. A follow-up email was sent to thank those who had responded to the survey and to remind others that the opportunity to participate in the survey was still available. Two weeks after the initial recruitment letter was emailed a hard copy of the recruitment letter, consent form, a hard copy of the survey, and the link to the electronic survey were mailed to the respective hospital administrators who had not completed the electronic survey. This correspondence reminded them of the study and invited them to complete it. Sending both a hard copy and a link to the electronic survey gave hospital administrators the option to complete via the method of their choosing. A final contact was made by phone one week after the hard copies were mailed to again note the importance of the study and invite prospective participants to complete the survey. The electronic survey remained activated for four weeks from the date of the initial recruitment letters.
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Descriptive data analysis was conducted using the Statistical Package for the Social Sciences (SPSS) version 19.0.2 (Armonk, NY). An exploratory correlation analysis was conducted to determine the relationship between RRT characteristics and hospital size and type. Because of the predominantly nominal nature of the data, Point-Biseral and Cramer's V correlation analyses were used.
Results Sample Characteristics
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Thirty-three of the 56 hospitals invited to participate in the survey responded; 32 surveys were completed on-line and one survey was returned as a paper copy by mail. Two hospitals were excluded from the analysis. One was excluded because no questions were answered, other than general organizational characteristics. The other hospital had not implemented an RRT. Therefore, the final sample of hospitals was 31, for a response rate of 58%. Twentyseven hospital administrators completed the survey, and 4 were completed by others assigned by an administrator. Of those completing the survey, six were CNOs, two were COOs, and the remainder was completed by various others, including directors, nurse managers, patient safety officers, and quality experts. Organizational Characteristics The 31 participating organizations included academic health centers (AHC)(19%), community hospitals (CHs) (71%), corporate health systems (CHS)(6%), and one critical access hospital (CAH)(3%). Hospital size varied from 24 to 870 licensed and staffed bed (M = 295), with half of the hospitals being less than 150 beds. Only limited descriptive details
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on hospital size are provided to protect the identity of both the small and large hospitals that participated in the survey. To allow for a comparison of RRT characteristics between teaching and non-teaching hospitals, two hospitals initially classified as corporate healthcare systems were, based on further examination of each hospital, classified as an AHC (n=1) and a CH (n=1). The one critical access hospital was classified as a CH. RRS Characteristics
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Afferent Component—The afferent component of the RRS addresses event detection and a trigger mechanism to get help for a patient with an un-met clinical need.4 In terms of triggering a RRT call, all 31 hospitals reported that RRTs could be activated by registered nurses (RNs); in 30 hospitals (99%) other hospital staff members (e.g., respiratory therapists [RTs], licensed practical nurses [LPNs]), or unit secretaries) could also activate RRTs; in 19 hospitals (62%) families could activate RRTs; and in 17 hospitals (55%) patients could activate RRTs. In slightly over half of the hospitals (52%), RRTs could be activated by RNs, other hospital staff, and families and patients. In twelve hospitals (39%), RRTs could be activated by only RNs and other hospital staff. Efferent Component—The efferent component of the RRS is the “crisis response” (p. 404) and includes the response team (i.e., RRT, MET, or CCO) or other specialized resources (e.g., cardiac arrest, trauma, or stroke teams)35. Of the 31 hospitals that participated in the study, the number of RRTs and the size of the RRT (i.e., number of staff members) varied across organizations (see Table 1). The team leader of RRTs also differed. The majority (n = 22, 71%) had nurse-led teams. All participating hospitals reported providing RRT coverage on all shifts.
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The composition of the RRT varied across hospitals (see Table 1). Most teams had Intensive Care Unit (ICU) RNs and RTs as part of the team. Nine hospitals (29%) included a hospitalist as part of the team and 7 hospitals (23%) reported the presence of a dedicated RRT nurse. Nineteen hospitals (61%) reported the presence of an RRT oversight committee (defined as group of individuals that implemented and continue to monitor the RRT program). Most hospitals reported engaging in RRT follow-up activities (see Table 1). Ten hospitals (32%) conducted debriefing sessions following RRT calls, and thirteen hospitals (42%) reassessed patients within 24 hours following an RRT call. However, only seven hospitals (23%) included both debriefing sessions and reassessing patients within 24 hours following an RRT call.
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Process Improvement and Administrative Oversight Components—Evaluative, patient safety and feedback activities are included in the process improvement component, whereas the oversight component encompasses the administrative and governance functions of the RRS. Hospitals in the study sample had incorporated some activities within each of these two components. In terms of the process improvement component, 19 (61%) hospitals enabled staff on acute care units to evaluate the RRT. In 18 (58%) hospitals RRT members (RRTM) received feedback on their performance from their leaders. In 21 (68%) of the hospitals, organizational leaders shared RRT program outcomes (e.g., the number of calls, Jt Comm J Qual Patient Saf. Author manuscript; available in PMC 2015 July 01.
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the number of unanticipated ICU admissions, cardiac arrest rates outside of ICU, in-hospital mortality rate) with staff members (see Table 2). Only 12 (39%) hospitals conducted all three evaluation activities; 18 (58%) hospitals conducted at least two of the evaluation activities; and only 5(16%) of hospitals conducted only one of the three evaluation activities. Organizational and RRT Characteristics
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Several RRT characteristics were compared by hospital type and size.(Figure 1) A higher percentage of AHCs had two or more RRTs in the organization than CHs (43% vs. 8%) and the composition of the team also differed by organizational type (see Figure 1). Also, AHCs did not report including hospitalists on their RRT, whereas 38% of CHs included a hospitalist in their RRT. A higher percentage of AHCs (43%) had a dedicated RRT nurse role when compared to CHs (17%). Except for reassessing patients within 24 hours following a RRT call, more AHCs conducted RRT related activities than CHs (see Figure 1). Specifically, five AHCs (71%) conducted debriefing sessions following RRT calls, provided staff members the opportunity to evaluate the RRT, and shared RRT outcomes with staff members. In contrast, only 5 (21%) of CHs conducted debriefing sessions, 14 (58%) provided staff members the opportunity to evaluate the RRT, and 16 CHs (67%) shared RRT outcomes with staff members.
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When comparing RRT characteristics by hospital size, some patterns emerged. Large hospitals (i.e., greater than 500 licensed and staffed beds) were more likely to have more than one RRT, have an ICU or ED physician on the team, and have a dedicated RRT nurse role in the organization. Except for debriefing sessions, conducting RRT related activities were comparable between medium-sized and large hospitals, but were markedly different between small and large hospitals (see Figure 1). The percentage of small, medium-sized, and large hospitals with an RRT oversight committee was comparable.
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Correlation analyses were conducted to examine the relationship between RRT characteristics and hospital type and size. Statistically significant positive relationships were observed (see Table 3). Specifically, strong, positive correlations were observed between the number of teams and hospital type (r=.392, p = .029) and size (r =.431, p = .016) and hospital size and the use of MD-led teams (Cramer's V = .443, p = .048) and the use of a dedicated RRT (Cramer's V = .462, p = .037). Strong, positive correlations were also observed between the use of debriefing sessions following RRT calls and hospital size (Cramer's V = .453, p = .012) and hospital type (Cramer's V = .515, p = .016). No significant correlations were observed between the use of a dedicated RRT model and the number of or type of post-RRT activities. Collinearity was observed between hospital type and size (Cramer's V= .839, p < .001). RRT Outcomes The survey also included questions on outcomes associated with RRTs and respondents' perception of how patient outcomes had changed since RRTs made the transition from the initial pilot program to permanent status in the organization. Participants were asked to report RRT outcomes for 1 year prior to the survey date, and the number of RRT calls in the month prior to the survey date.
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Unfortunately, over 50% of hospitals in the sample did not provide any patient outcomes data. Specific reasons for the lack of response to these items are unknown, but speculation is that hospitals may have been hesitant to report these data because they are sensitive and/or difficult to retrieve. Also, despite requesting patient outcomes data using metrics gathered through the RRTC, hospital administrators who reported patient outcomes data inconsistently, making it difficult to compare RRT outcomes. For example, some hospital administrators reported RRT outcomes as percentages, some reported them as numerical values, and some reported them as a simple increase or decrease. However, 17 hospitals reported the number of RRT calls in the year prior to the survey. Table 4 presents the number of RRT calls per bed by hospital size and type.
Discussion Author Manuscript
This study found, variations in the organizational characteristics and the RRS' deployed by the hospitals that participated in a state-wide RRT collaborative. Hospitals varied by size and type, with most hospitals being small (i.e., less than 150 licensed and staffed beds), community-based hospitals. While all hospitals had developed a RRS, variations existed and robustness was lacking in each of the four components of many of the hospitals' RRS'. As part of the afferent limb, all hospitals incorporated a trigger mechanism to activate a team of care providers to meet the unmet needs of patients. Yet, in 39% of hospitals only RNs and other hospital staff could activate RRTs. Family and patient activation had, therefore, not yet been fully taken up by participating hospitals at the time of this survey.
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Variations in the efferent limb of the RRS, such as the type of team (RN-led versus MDled), team composition, and number of teams, suggest hospital administrators adopted RRT models that best fit with the needs of the organization and the resources available. This finding may be a reflection of flexibility that is crucial for the effective implementation of RRT programs. Institution-specific barriers, as suggested by Wakeam et al., 29 may also have been the driving force behind the structure of these teams.
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All hospitals in the study provided RRT coverage for 24 hours a day, 7 days a week, compared to only 85% of hospitals in the study by Donaldson et al.25 The majority of hospitals selected to use RN-led teams (71%) that included an ICU RN and/or an ED RN, whereas only two (29%) hospitals included an ICU or ED physician in their teams. This finding is in contrast to the findings by Donaldson et al.25 who found that most teaching hospitals included a physician on their teams, but aligns with what has been reported in the literature.11, 30, 32 Only 22% of hospitals used a dedicated RRT nurse to respond to calls. Limited organizational resources and lack of funding might have been important drivers in the selection of a less resource intensive RRT model versus the resource intensive dedicated RRT model. Because RRT calls can be sporadic, to offset the cost of using a dedicated RRT model the dedicated RRT RN must be assigned additional responsibilities. Clarifying what these additional responsibilities needed to be might have been challenging for administrators.
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Yet, dedicated RRT nurses can be important RRT champions who can help to increase the visibility of RRTs in the organization and generate end-user buy-in to calling the RRT. 32 Also, the use of existing ICU or ED nurses to respond to RRT calls may compromise quality of care and patient safety. When these nurses respond to a RRT call but also have a patient assignment, an increase patient-to-nurse ratios results which has been linked with adverse patient outcomes, nurse burnout, and job satisfaction.39, 40 Therefore, as hospital administrators continue to monitor and change their RRT programs, careful consideration must be given to the RRT model that was or will be instituted.
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This study also found that key aspects of the RRS components of safety/process improvement and administrative structure were lacking in hospitals. Only twelve (39%) hospitals included all three RRT evaluation activities namely, staff members had the opportunity to evaluate the RRT, RRTMs received feedback on their performance, and RRT outcomes were shared with staff members. Also, although DeVita et al.4 strongly recommended that there be an RRS coordinator to oversee the RRT program, only 19 hospitals (61%) have an RRT oversight committee in place to oversee RRT activities and 18 (58%) hospitals had a supervisor formally assigned to the RRT program.
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The lack of robust evaluation processes and a RRT coordinator or supervisor to oversee the program could potentially hinder quality improvement efforts related to the RRS. Given that RRT members play an important role in end-users future calling behavior,20, 26 end-users must be given the opportunity to evaluate their RRT call experiences. Evaluation of RRT members' performance must be an integral part of RRT evaluation processes. Sharing RRT outcomes with staff and demonstrating the effectiveness of the RRT program may also facilitate future calling behavior. A RRT program supervisor, who is responsible for coordinating and overseeing RRT program activities, and who can facilitate quality improvement initiatives, could help to strengthen an organization's RRS and facilitate its responsiveness to organizational changes and needs.
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This study also found that teaching hospitals, compared to non-teaching hospitals, were more likely to have a higher number of teams who could respond to RRT calls, use a MDled team and dedicated RRT model, and conduct debriefing sessions following RRT calls. Although these statistically significant findings were also observed in large hospitals, large hospitals were strongly correlated with teaching hospitals, indicating collinearity. Reasons for these statistically significant findings in teaching hospitals are likely due to the increased availability of resources in large, teaching hospitals. Although teaching hospitals were more likely to have a dedicated RRT model, no correlation was found between the use of a dedicated RRT nurse and the number of or type of evaluation activities conducted following RRT calls. Because hospital administrators could choose whether or not to respond to each question in the electronic survey, the lack of hospital administrators to report patient outcomes data does not necessarily mean that their hospitals did not collect these data. Some hospital administrators reported perceived benefits of RRT implementation; however, some reported no perceived changes in outcomes (i.e., acute care inpatient mortality rate, unplanned ICU transfers, codes outside of the ICU, and the number of codes per 1000 discharges). These
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findings are similar to the inconsistencies in RRT outcomes that have been reported in the literature, with some studies noting improvements in patient outcomes14 versus others that report no improvements.17 The perceptions regarding the efficacy of RRTs were similarly mixed in the current study. Study Limitations and Recommendations for Future Research
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There are several study limitations that are worth noting. First, the use of self-administered web-based surveys has both advantages (i.e., low cost of administration, speed and accuracy of data collection)36 and disadvantages (i.e., non-response and response bias).37, 38 Efforts to mitigate these limitations included providing clear instructions and the use of frequent reminders to complete the survey, ensuring participants of the confidentiality of their responses, and carefully wording the survey questions to avoid leading respondents to answer in particular ways.37, 38 While random selection of hospitals and a larger sample size may have reduced the risk of non-response bias, this study did enable the rapid collection of information for leaders in those hospitals that participated in the RRTC. In turn, they can use this study's findings to refine the RRTs in their organizations. Future studies on RRTs should include larger sample sizes and randomization to allow for the broader generalization of study findings.
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A response rate of 58% achieved in this study compares well with other RRT studies that used a survey methodology.41 Measures were built into the study methods to achieve a good response rate namely, working closely with the state's hospital association to personalize mailings, including skip patters in the electronic survey, providing electronic indication of survey progress, thoroughly pre-testing the survey, and enabling respondents to report problems. A comparison of responder and non-responder hospitals showed no statistically significant differences in the # of beds between responders (Median = 242; 25th - 75th IQR =101-529) and non-responders (Median = 143; 25th – 75th IQR = 101 – 529) (z = 1.75, p=. 081).
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Although another limitation of the study is the completion of the survey by only one respondent administrator, mechanisms were built into the survey to allow the CNO or CEO, who received the initial study invitation and link to the electronic survey, to select a person familiar with the RRT program to respond to the invitation and complete the survey. In 74% of the hospitals, these administrators selected someone else to complete the survey (i.e., directors, nurse managers, patient safety officers, and quality experts). In subsequent case studies with some of these hospitals, the researcher found that the survey responders were responsible for providing overview of the RRT program. However, although it is likely, it remains unclear if the person who completed the survey for each of the hospitals that participated in the survey was involved with or oversaw the RRT program. Social desirability of responses may also have biased the findings; however, to reduce this risk, steps were taken to ensure the anonymity and confidentiality of responses. A comparison of RRT-related patient outcomes across organizations was not possible because of inconsistencies in the reporting of these outcomes, and the large amount of missing data. Future studies could address this limitation by including patient outcomes as a study variable and gathering the raw data to calculate the variable consistently across all Jt Comm J Qual Patient Saf. Author manuscript; available in PMC 2015 July 01.
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participating hospitals. This would remove the potential error introduced when even common outcome metrics are used, based on organizational calculations.
Conclusions
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This article provides a detailed description of the results of a web-based survey administered to gather descriptive data on hospitals and their RRTs. Organizational characteristics, RRT characteristics and RRT call rates of a sample of hospitals are reported. Hospitals were heterogeneous in their characteristics and the RRTs they implemented. Hospitals have been successful in addressing the afferent and efferent limbs of their RRS', but improvements are necessary in the areas of safety/process improvement and administrative oversight. The Joint Commission requirement, for a system such as RRTs to be in place, may have been the impetus for hospitals to implement RRTs. This requirement may, in future, need to also include requiring RRT-related quality improvement initiatives and the presence of an RRT oversight committee. Individual hospital policies may also need to be enacted to ensure that safety/process improvement and oversight processes are integrated in RRT programs and the necessary funds made available to support these activities. Without these requirements and policies, RRT programs and RRS' may never reach their full capacity in organizations.
Acknowledgements The authors wish to acknowledge the contributions of Drs. Donna Havens, David A. Hofmann, Dr. Barbara A. Mark, and Dr. Bryan Weiner, in the conceptualization and development of the dissertation research project, which is reflected in some of the content presented in this manuscript. The authors also wish to acknowledge that the material is based upon work supported by the Office of Academic Affiliations, Department of Veterans Affairs, VA National Quality Scholars Program and with use of facilities at VA Tennessee Valley Healthcare System, Nashville, Tennessee.
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Grant Support Partial funding for the project was provided by the National Institute of Nursing Research Grant Number 5 T32 NR 008856.
APPENDIX A RAPID RESPONSE TEAM SURVEY
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30. Chan PS, et al. Hospital-wide code rates and mortality before and after implementation of a rapid response team. JAMA. 2008; 300(21):2506–13. [PubMed: 19050194] 31. Jolley J, et al. Rapid response teams: do they make a difference? Dimens Crit Care Nurs. 2007; 26(6):253–60. [PubMed: 18090145] 32. Halvorsen L, et al. Building a rapid response team. Adv Crit Care. 2007; 18(2):129–140. 33. Jamieson E, Ferrell C, Rutledge DN. Medical emergency team implementation: experiences of a mentor hospital. Med Surg Nurs. 2008; 17(5):312–23. 34. Dillman, DA.; Smyth, JD.; Christina, LM. Internet, Phone, Mail, and Mixed-Mode Surveys. Wiley & Sons; Hoboken, NJ: 2014. 35. Sakai T, DeVita MA. Rapid response system. J Anesth. 2009; 23(3):403–8. [PubMed: 19685122] 36. Fleming CM, Bowden C. Web-based surveys as an alternative to traditional mail methods. Environ Manage. 2009; 90(1):284–92. 37. Polit, DF.; Beck, CT. Nursing research: principles and methods. Lippincott Williams & Wilkins; Philadelphia, PA: 2004. 38. Lewis-Beck, MS.; Bryman, A.; Liao, TF. The SAGE Encyclopedia of Social Science Research Methods. Sage; Thousand Oaks, CA: 2007. 39. Aiken LH, et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002; 288(16):1987–1993. [PubMed: 12387650] 40. Kane RL, et al. The association of registered nurse staffing levels and patient outcomes. Med Care. 2007; 45(12):1195–1204. [PubMed: 18007170] 41. Davies O, et al. Barriers to activation of a rapid response team. Resuscitation. 2014; 85(11):1557– 61. [PubMed: 25108061]
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Figure 1.
Comparison of RRT Characteristics by Hospital Type and Size
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Table 1
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Rapid Response Team Characteristics, Composition, and Follow-up Activities N (%) Number of teams 1
26 (84)
≥ 2
5 (16)
Persons on team 1 – 3
21 (68)
4-5
10 (32)
Team leader RN-led
22 (71)
MD-led
3 (10)
Co-led by RN and MD
6 (20)
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RRT composition ICU or ED Physician
3 (10)
ICU or ED RN
29 (94)
Hospitalist
9 (29)
Respiratory Therapist
28 (90)
Nursing House Supervisor/Clinical Coordinator
13 (42)
Dedicated RRT nurse who rounds on patients, units
6 (19)
Dedicated RRT nurse (not necessarily an ICU nurse)
1 (3)
RRT follow-up activities
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RRT debriefing
10 (32)
Patient reassessed within 24 hours
13 (42)
RRT debriefing and reassess within 24 hours
7 (23)
RRT debriefing only
3 (10)
Patient reassessed within 24 hours only
6 (19)
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Table 2
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RRT Evaluation and Oversight N (%) RRT evaluation activities Staff evaluates RRT
19 (61)
RRTM performance feedback
18 (58)
RRT outcomes are shared
21 (68)
All three above evaluation activities
12 (39)
Staff evaluates RRT and RRTM performance feedback
12 (39)
Staff evaluates RRT and RRT outcomes are shared
14 (45)
RRTM performance feedback and RRT outcomes are shared
18 (58)
Staff evaluates RRT only RRT member performance feedback only
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RRT outcomes are shared only RRT oversight committee
5 (16) 0 (0) 0 (0) 19 (61)
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Table 3
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Correlations between RRT Characteristics and Hospital Type and Size a
Variable
N (%)
Hospital Type d*
b
c
Hospital Size d*
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Number of teams
31(100)
Number of persons on team
31 (100)
Number of post-RRT activities
31(100)
Debriefing
10(32)
Reassessed ≤ 24hrs
13(42)
-
-
Staff evaluates RRT
19(61)
-
-
RRT outcomes shared
21 (68)
-
-
RRTM performance
18(58)
-
-
Dedicated RRT
7 (23)
-
RRT Oversight
19(61)
-
-
Team Leader
31(100)
-
-
RN-Led
22 (71)
-
MD-Led
3 (10)
-
Co-Led MD/RN
6 (20)
-
.392
(p = .029)
.431
-
-
.453
e*
(p=.016)
e*
(p=.012)
.515
e*
(p=.016)
.462
(p=0.037)
.443
e*
(p=.048) -
Note. (-) = not significant at the .05 level. a
total percentage value may be greater than 100 because of rounding
b
teaching and non-teaching
c
small (0 – 150), medium = (151 – 500), and large (= ≥ 501)
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d
Point-Biseral correlations:
e Cramer's V correlations *
significant at the .05 level
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Table 4
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RRT Calls by Hospital Size and Type RRT calls/bed Hospital Size 0 – 150
0.44
151-500
1.18
≥ 501
1.10
Hospital Type Academic Health Center
1.03
Community Hospital
0.85
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