Since last December, when the Institute for Healthcare Improvement launched the 100K Lives Campaign, you can barely open a healthcare journal without reading about various quality initiatives that are believed to reduce the number of patient deaths. As a result, many healthcare executives have begun to implement the recommended initiatives. In 1997, I was lucky enough to be introduced to one of these initiatives when Shadyside Hospital merged with UPMC Health System. As part of that merger, I had the pleasure of meeting two physician leaders from UPMC Presbyterian--Richard Simmons and Michael DeVita.
Several years earlier, Simmons and DeVita had begun to evolve their traditional cardiac-arrest team. Their proposed solution seemed so obvious it made me wonder why we had not thought of it earlier. Most nurses are trained to respond to a cardiac or respiratory arrest. Whether your organizations calls them a Code 99, a Code Blue or a Condition A, the team responds. What made Simmons and DeVita's work unique was the recommendation and supporting outcomes that demonstrated the value in not waiting for a patient's heart to stop beating or for them to stop breathing before responding. That is what Condition C (Critical) was all about. It seems a natural progression of thinking when you hear this solution out loud.
Condition C is a relatively simple concept but requires a dramatic cultural transformation to be successfully implemented. UPMC Shadyside, Pittsburgh, began the journey toward implementation of what has become known as Condition A for cardiac or respiratory arrest and Condition C for critically ill status. We clearly underestimated the processes that were necessary to make these programs successful.
In today's world, innovations are sometimes evaluated in light of the impact on workload alone, without concern for the impact on patient care. This was one of the first issues raised when the concept was introduced to our medical staff leaders. Their immediate response was: "We will not have time. Everyone will call them for simple issues. How can the intensivist manage all the patients in the ICU and take care of all these conditions?" This is a common response when first beginning this journey. Saving lives is what all of our healthcare professionals need to be focused on everyday. As it relates to workload, we have not found it to be an issue. If you would encounter more calls than your team could respond to, the answer is to stay committed and solve this problem. However, we average only two calls per day for our 521-bed campus.
In addition to your leadership message of holding steady to the course, an additional tactic useful in encouraging your organization to implement rapid-response teams is to just get them to try it. Pick one specific unit, design a team and introduce the concept of a multilevel rapid-response team. That provides a safe way to collectively learn and explore your outcomes.
There is also an emotional hook to rapid-response teams. Almost all hospital staff understands that when a patient is deteriorating, there may not be enough resources immediately available to provide care. Respiratory and EKG are often called to a specific location. At the end of these calls is a single nurse with an assignment much greater than the one patient who desperately needs his or her attention. The time wasted calling those individuals could be better served. Calling a Condition C once and getting the staff to respond as a team allows the nurse to focus on the patient.
My guess is that initially you will find that the number of calls received will be quite small. It takes some time and quite a bit of convincing to get healthcare workers to call a Condition C as they are accustomed to handling issues. It is the leaders' job to persuade them to call a rapid-response team when a patient is deteriorating. Nearly seven years after we implemented Condition C at UPMC Shadyside, I am still reminding people to consider calling a Condition C the next time.
We also encountered another interesting issue that was not anticipated. This was the historically uneven playing field between nurses and physicians. Physicians might tell a nurse, "You don't need to call a Condition C, I am right here." It took a lot of effort to convince the clinical staff that they had a right and responsibility to call a condition, even if a physician was present. While the physician may not need the additional responders, the nurse needs the ancillary team members. Calling a Condition C is about supporting the nurse as well as supporting the patient.
By addressing these issues over time, consistently, frequently and at all levels of the organization, we have seen the number of Condition C calls rise and the number of Condition A calls drop--this was our ultimate goal.
At the IHI's annual meeting in December 2004, Don Berwick launched the 100K Lives Campaign. On stage with Berwick was Sorrell King. King founded the Josie King Patient Safety Foundation following the unfortunate death of her young daughter at a hospital. King stood on stage with tears in her eyes and said to the audience, "Josie might be alive if I had been able to call one of those rapid-response teams." The simplicity of her comments was striking. It seemed so logical. In March, UPMC Shadyside contacted King and asked her if she would be willing to help us establish rapid-response teams. King was thrilled with our contact. She visited the hospital, spoke with employees and provided tremendous encouragement as we embarked on this new journey. For all the resistance felt at the introduction of the process, you can imagine the amount of feedback received when we introduced it, allowing families and patients to call a rapid-response team. By consistently and frequently talking about what mattered, we were able to move ahead with a pilot.
In closing, run as fast as you can toward developing rapid-response teams at multiple levels. If you are really daring, consider opening them up to patients and families. These programs save lives and demonstrate as healthcare leaders that we are deserving of the responsibility that has been bestowed upon us. Rapid-response teams move us toward creating healthcare systems of the future.
Tami Merryman is vice president of patient-care services at UPMC Shadyside Pittsburgh.
* Expect initial dissension; workers may fear a heavier workload.
* Just try it-a practice run provides a safe way to learn and explore possible outcomes.
* Once teams are established, convince healthcare workers to take advantage of the option.