1. A FOUR-ARM - BEDSIDE FOCUSED RRS; PROCESS, IMPLEMENTATION AND OUTCOMES
Recognizing At-Risk Patients Earlier
and Improving Outcomes
Frank Sebat MD FCCM
Director Kritikus Foundation
RRS Conference Chicago May 2017
©KDMC STaRRS 2011

2. BEDSIDE FOCUSED RRS 4-ARM RRS
Despite broad implementation of RRSs to detect and intervene on at-risk ward patients:
Debate continues regarding degree of their benefit.
Even more uncertain is which RRS processes are most effective in improving patient outcomes.
The study at hand addresses some of these issues.

3. Conventional RRT Focused RRS vs Bedside FOCUSED EXPANDED 4-ARM RRS
Conventional RRT Focused RRS vs Bedside FOCUSED EXPANDED 4-ARM RRS. STUDY DESIGN: Frank Sebat MD, Maryanne Vandergrift RN MSN, Sid Childers BA MBA, Geoffrey Lighthall MD, PhD
A prospective before and after comparison of patient outcomes over five years in a 450-bed medical center (Keweah Delta Medical Center, Visalia Ca)
Control 28,914 patients were observed and treated with a conventional RRT focused RRS ( )
Intervention 39,802 patients were observed and treated with a restructured four-arm focused RRS (2011- Sept 2013).
During 2010, patients were not included while implementation of our test RRS occurred.
©KDMC STaRRS 2011

4. STUDY Metrics Before and after measures: Number of RRT/1000 discharges
Number of general ward cardiac arrest/1000 discharges
Unadjusted hospital mortality
Observed/Expected (O/E) hospital mortality

5. 4-ARM RRS
The RRT or efferent arm is the most visible component of a RRS… yet the afferent arm or bedside RN is key to the RRS for early recognition, prompt treatment and better patient outcomes!!!
©FRHG STaRRS Education
©KDMC STaRRS 2011 5

6. What does a beside focused 4-arm RRS look like?
4/24/2019
What does a beside focused 4-arm RRS look like? 6

7. What does a beside focused, 4-arm RRS, look like?
Expanded resources with:
80% resources focused on the afferent arms ability to recognize subtle physiologic changes to recognize early at- risk patients… Education, education education…Compliance!
Expand (all stakeholders) Administrative Arm empowered to implement PI.
Robust PI with automated near real time RRS and code blue data collection, with frequent analysis.
Standard RRT (CC RN, RRT, Stat LAB… X-ray ,EKG primary MD or intensivist PRN) after patient disposition, charged with post event debriefing with bedside staff.

8. 80% resources focused on the afferent arms ability to recognize early at-risk patients
Education, education education…compliance!
All new hires receive 50 min orientation to RRS and our early recognition tool the 10 Signs of Vitality
All staff over are required to go through a 1 hour computer based learning module.
During rollout all staff were required to have 1 ½ hr. class room/bedside interactive training including mock patient scenarios
Examination (30 min) on early recognition of at-risk patients

9. BEDSIDE FOCUSED 4-ARM RRS
Examples of Education and Tools

10. SHOCK IS A SYNDROME OF GLOBAL INADEQUATE TISSUE OXEGENATION manifested by 8 of the 10 SOV
Altered level of consciousness
Tachypnea, RR ≥ 20
SaO2 < 90%
Cool or mottled extremities, CAP refill >3 sec
Hypotension, BP < 90
Decreased urine output, 25 cc/hr, 300cc/12hr
Metabolic acidosis BE < -5 , LA > 2.0
Hypothermia, T < 36
Pain, HR and hyperthermia are not weighted but if abnormal require an assessment of all 10
©KDMC STaRRS 2011

11. 10 SOV Tool Early recognition of subtle physiologic changes
Abnormality of 1 requires assessment of all 10.
Presence of two weighted (below the red line) requires RRT activation
©FRHG STaRRS Education
©KDMC STaRRS 2011 11

12. TYPES OF SHOCK Hypovolemic Septic or Distributive Cardiogenic
Obstructive
Anaphylactic
©KDMC STaRRS 2011

13. TYPES OF SHOCK “Hypoxic or Respiratory” Shock
We added Hypoxic shock to conventional shock model and coupled it with the 10 SOV patient assessment and RRT activation tool .
WHY ? - This model lends itself to early recognition of subtle physiologic changes and propmpt standardized treatment:
10 SOV early recognition Shock criteria
AO-VIPPS Shock treatment algorithm
The above elements became the educational and compliance foundation for the 4-Arm “STaRRS” program - Shock Team and Rapid Response System
©KDMC STaRRS 2011

14. ©2011 STaRRS Education Presentation
Respiratory Failure
Acute Change in
Neurologic Status
Hypoxic
Hypovolemic
Septic/Distributive
Cardiogenic
Obstuctive
Anaphylactic S H O C K
Shock Cycle
Oxygen delivery
Death
Early organ ischemia
RRT
UNTREATED
100% FATAL
TOO LATE 
Multiorgan Failure
 Oxygen delivery
Further  Neurologic, Resp, CV function
RRT
©2011 STaRRS Education Presentation 14
©KDMC STaRRS 2011 14

15. TIME TO ALERT FROM SOV CRITERIA MET VS. MORTALITY OF PATIENTS IN SHOCK
(F Sebat et al, CCM, 2007, 35:11, ) 0%
10%
20%
30%
40%
Minutes
Minutes
> 90 Minutes
Time to Shock Alert
% Mortality
GOLDEN HOUR 15 15

16. 80% resources focused on the afferent arm’s ability to recognize early at-risk patients
Compliance, compliance, compliance… and more education and compliance:
Mandatory to call RRT if criteria met ( 2 of the 8 weighted 10 SOV) by Hospital policy.
Failure of to call RRT audited by PI when criteria met was rewarded by attendance to RRS university class.
Compliance with 10 SOV patient assessment tool was electronicky audited daily with reports sent to each units manger.
©KDMC STaRRS 2011

17. Compliance, compliance, compliance… and more education and compliance.
80% resources focused on the afferent arms ability to recognize early at-risk patients
Compliance, compliance, compliance… and more education and compliance.
All beside RN preform a beginning of shift 10-SOV assessment and PRN with any new abnormity of any VS
Daily computer generated reports regarding compliance with the above sent to each unit’s manager
Units with delayed RRT’s (more than 4 hr from when RRT criteria met and RRT called) or increase in code blues…i.e. failure to rescue received increase education.

18. Study results over 5 years
Table 2 Populations and demographics
Population
Control
Test /13
p value
Hospital admissions
28,914
39,802
Admissions/year
14,475
14,473
Mean Age (SD)
61.6 (18.5)
60.5 (18.8)
< .001
Male
45.74%
47.68%
<.001
Female
54.26%
52.32%
Caucasian
58.8%
53.8%
Hispanic
32.6%
36.5%
Other
4.4%
5.5%
Asian
1.9%
2.0% NS
African American
Unknown
0.4%
0.1%
American Indian
0.2%
Expected deaths (3M)
2.50%
(N=724)
3.16%
(N=1256)
P o p ul ati o n
Con trol
In te rv e nt io n
p v a l u e
Ti me Pe rio d
1/20 08 – 12/2 009
1/ – 9/
Ho spi tal ad mi ssi on s
28,9 14
3 9, 8 0 2
Ad mi ssi on s/y ea r
14,4 75
1 4, 4 7 3
Me an Ag e (S D)
61.6 (18. 5)
(1 8. 8)
<
Ma le
45.7 4% %
<
Fe ma le
54.2 6% %
Et hn icit y
Ca uc asi an
58.8 % %
Hi sp ani c
32.6 % %
Ot he r
4.4 %
5. 5 %
As ian
1.9 %
2. 0 %
N S
Afr ica n A me ric an
1. 9 %
Un kn ow n
0.4 %
0. 1 %
A me ric an In dia n
0.1 %
0. 2 %
Table 2 Populations and demographics
©KDMC STaRRS 2011

19. INITIAL CODE BLUE v. RRT ALERTS
2002
2003
2004
2005
2006
2007
2008
2009
2010
Jan-2011
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sept-11
Code Blues /1000 Discharges
4.8
6.17
5.85
6.66
5.5
5.34
4.81
4.29
3.38
3.36
2.55
5.90
0.81
2.36
1.68
1.69
RRTs /1000 Discharges
11.2
13.12
13.57 11
17.26
16.01
32.31
33.16
51.86
48.82
42.49
38.66
57.79
57.53

20. Study results over 5 years
Control
Intervention
p value
RRT calls/1000 discharges (total #)
10.2 (294)
48.8 (1943)
<.01
Cardiac arrests/1000 discharges
3.14 (91)
2.41 (95)
.04
Unadjusted hospital mortality
3.75% (1083)
3.22% (1282)
< .001
Observed/Expected mortality ratio
1.5
1.02
©KDMC STaRRS 2011

21. KEY POINTS: to Improving outcomes by a 4 –arm RRS focused on the Afferent arm
COMPLIANCE
Mandatory education and RRT activation criteria
Daily audits of RRTs/code blues for PI and compliance
RRS University
EDUCATION
RN 3 ½ hr of RRS/Shock model recognition and treatment
LVN 30 min VS parameters training
MD 30 min STaRRS training
Mock alerts and post RRT debriefing by RRT RN
Expanded patient assessment and RRT activation tool - 10 SOV
4 ARM RRS focused on:
Afferent arm development and training
Robust PI and Administrative arms for development of continuous system improvement and program compliance including the RRT arm
Increased number of pts recognized… Earlier recognition of pts within the Golden Hour… Prompt intervention… better outcomes
Next step…Automation!
©KDMC STaRRS 2011

22. Thank You for Attending
Don’t be shocked!
“It take a village”, a robust 4-arm RRS, to bring about needed changes to improve earlier recognition at-risk patients and prompt mobilization of the RRT… by the afferent arm
Thank You for Attending