The critical-assessment team, or CAT as it is known at Parrish Medical Center in Titusville, Fla., started in August 2005 as part of the VHA Rapid Adoption of the Rapid Response Program. The two main goals of the CAT team are to reduce mortality rates and reduce the number of code blues that happen outside the intensive-care unit.
CAT is called when a patient meets the criteria, or the nurse has a bad feeling (that gut feeling) that something is wrong and needs a little help to figure it out. Parrish Medical Center's CAT criteria are as follows:
- Heart rate: less than 40 or greater than 130.
- Systolic blood pressure: less than 90.
- Respiratory rate: less than eight or greater than 28.
- Pulse oximetry: Less than 90% despite oxygen.
- Urine output: Less than 50 cc in four hours.
- Change in level of consciousness or altered mental status.
- Nurse is concerned about the patient.
Once a patient meets the criteria, the registered nurse on the floor calls the ICU staff to come assess the patient. The patient is then stabilized and remains on the floor or is transferred to a higher level of care in the ICU.
In June 2008, we discovered that the number of code blues outside the ICU, which went to zero for several months, were now happening every month. Since August 2008, Parrish had experienced at least one code blue outside the ICU.
In order to determine why this was still happening, the ICU director took on a Green Belt Six Sigma project to look at the CAT process, study the data and implement performance improvement in the CAT process that would reduce the mortality rate and the number of code blue calls outside the ICU.
The Green Belt process showed that the top five reasons R.N. staff did not utilize CAT accounted for 71% of the staff not calling CAT for assistance. However, Parrish was still averaging 40 CAT calls per 1,000 in-patient discharges.
The Green Belt data showed us that 13 out of 26 (50%) code blues happened outside of the ICU. Even though nine of the 13 (69%) had a clinical indication to call CAT, they were not called. And of the nine patients who were a code blue on the floors, only one had a CAT team call. That meant only 11% of the code blues that were happening outside the ICU had CAT involvement.
Using this information, we looked at our process for calling CAT. The original process had been reactive—CAT was usually notified when the R.N. had a bad feeling or concern. We wanted a proactive approach to look at patients.
We used two IT programs to proactively look at our in-patient population every 15 minutes for clinical criteria that would indicate a call to CAT. The IT system automatically screens Parrish's information system every 15 minutes. A list of in-patients who have met one of the CAT clinical criteria in the past 24 hours is generated.
Now the in-patient list is reviewed four times a day at the bed board meeting with the nursing supervisor and unit charge nurses or clinical coordinators. The patient list is reviewed online from CAT screening data on a large wall-mounted monitor and together the R.N.s reassess the patients who have an indication for a call to CAT or meet the CAT criteria. When a patient shows indications, whether sudden or deteriorating that don't have a clinical reason behind them, CAT is deployed and the patient is stabilized in their room on the floor or transferred to a higher level of care in the ICU.
The result of using current data to identify in-patients in potential danger, and then stabilizing or moving the patient to a higher level of care has resulted in a 74% reduction in code blues outside of the ICU and a 33% reduction of inpatient mortalities, saving 69 lives.
The use of IT solutions to review patient data concurrently can help rapid-response teams have significant results in patient outcomes.
