|Year : 2016 | Volume
| Issue : 1 | Page : 41-45
Experience gained by emergency medicine residents as members of the rapid response team
Elizabeth Vessio1, Meaghen Finan2, Donald Jeanmonod1, Vamsi Balakrishnan1, Danielle Cross-Belser1, Jeffrey Melanson1, Rebecca Jeanmonod1
1 Department of Emergency Medicine, St. Luke's University Health Network, Bethlehem, PA, USA
2 Department of Critical Care, Mt. Sinai Medical Center, New York, USA
|Date of Submission||17-Feb-2016|
|Date of Acceptance||09-Apr-2016|
|Date of Web Publication||2-Jun-2016|
St. Luke's University Health Network, 801 Ostrum St, Bethlehem, PA 18015
Source of Support: None, Conflict of Interest: None
Objectives: Rapid response teams (RRTs) are multidisciplinary teams designed to respond to unstable patients within the hospital. Given the acuity of these patient encounters, this offers an opportunity to expose emergency medicine (EM) residents to a high concentration of experiences that are important for their training. This study was a retrospective observational study quantifying the value to an EM resident performing primary airway assessments while participating on the RRT.
Methods: The study site is a community trauma center that hosts an EM residency. All RRT logs from 2008 to 2013 were reviewed by trained data abstractors. Abstractors recorded interventions performed by EM residents, which we a priori identified as endotracheal intubation, ordering of noninvasive positive pressure ventilation (NIPPV), placement of central vascular access, placement of intraosseous access, and/or ordering of resuscitative medications. Data were entered into a standardized Excel spreadsheet where abstractors chose from a closed list of possibilities and were analyzed with descriptive statistics.
Results: One thousand nine hundred and eighty-four encounters were reviewed. 53.9% of patients had advancement in their level of care. 29.2% of rapid responses resulted in patient intubation and 17.8% of patients required initiation of NIPPV. In addition, 1.6% of patients required immediate placement of a central line and 0.4% required placement of intraosseous access. EM residents involved in the RRT ordered resuscitative medications in 17.2% of encounters.
Conclusions: EM resident involvement on RRTs provides them exposure to a number of critical encounters and advanced procedures that are essential for their EM training.
The following core competencies are addressed in this article: This article addresses the ACGME milestones pertaining to patient care as well as procedural skills.
Keywords: Airway, experiential learning, rapid response, resident education, resuscitation
|How to cite this article:|
Vessio E, Finan M, Jeanmonod D, Balakrishnan V, Cross-Belser D, Melanson J, Jeanmonod R. Experience gained by emergency medicine residents as members of the rapid response team. Int J Acad Med 2016;2:41-5
|How to cite this URL:|
Vessio E, Finan M, Jeanmonod D, Balakrishnan V, Cross-Belser D, Melanson J, Jeanmonod R. Experience gained by emergency medicine residents as members of the rapid response team. Int J Acad Med [serial online] 2016 [cited 2023 Jan 31];2:41-5. Available from: https://www.ijam-web.org/text.asp?2016/2/1/41/183336
| Introduction|| |
Rapid response teams (RRTs) quickly evaluate deteriorating patients. Between 3% and 17% of hospital, inpatients will have an unexpected adverse event, and early recognition of this deterioration may improve in-hospital mortality and reduce transfers to the Intensive Care Unit (ICU) from inpatient units. The institute for healthcare improvement has encouraged hospitals to form RRTs to reduce in-hospital morbidity and mortality. The majority of RRT data analysis has focused on differences in patient outcomes as a result of the institution of an RRT. Whether or not these teams actually accomplish this goal is unclear with conflicting data., Nevertheless, the theoretical benefits of having a team trained specifically to intervene on medically unstable inpatients are obvious.
RRT members may include some combination of physicians, nurses, respiratory therapists, mid-level providers, and other staff responsible for patient management decisions and disposition following the event. Although individual team members may vary and optimal team membership is uncertain, there is a suggestion that having a physician on an RRT may improve outcomes. One study evaluating differences in RRT staffing showed that there was no difference in patient mortality or progression to cardiopulmonary arrest when the team was staffed by an ICU attending compared to a senior resident. There is also support for competency of emergency medicine (EM) residents as members of hospital cardiac arrest teams. One study showed no difference in survival outcomes after cardiac arrest when the team was led with a hospitalist versus an EM resident.
EM was developed as a field specializing in initial evaluation, management, and disposition of patients with acute complaints. EM physicians are routinely part of emergency medical service and first responder teams in which they contribute expertise in emergent situations. In spite of this, most RRTs do not involve an EM physician.
An important part of EM resident education is learning how to quickly assess a deteriorating patient and becoming comfortable performing critical care medicine. Therefore, including an EM resident on RRTs seems to be a natural extension of his/her daily responsibilities. One survey-based study of residents' perception of the RRT showed that the majority of residents (78%) thought the RRT improved their learning experience, especially in specialties dealing with critical patients regularly. The educational benefit for EM residents serving as part of the RRT has not been previously evaluated.
We sought to quantify the educational experience gained by EM residents by participating in an assigned role on an RRT longitudinally in a single community-academic medical center.
| Methods|| |
This is a retrospective cohort of all RRT activation records in a single hospital from July 2008 to January 2014. The study was approved by the Institutional Review Board.
Study site and population
This study was conducted in a 480-bed community-based Level 1 trauma center that hosts an EM residency with forty total residents. The hospital sees 25,000 total admissions (both inpatient and observation) annually. Rapid response data sheets were filled out at the time of the event, and electronic medical records were reviewed for all patients listed as having undergone a rapid response during July 2008 through January 2014.
Data abstractor training
A single investigator trained all data abstractors in chart review and data collection. This included 2 h of one-on-one tutorial on both data gathering from the rapid response data sheets and the electronic medical record as well as data entry into a standardized Excel spreadsheet. In addition, all data abstractors were given a digital tutorial with screenshots for their personal use to maintain their understanding of the data collection procedure. All datasheets were reviewed by the training investigator for completeness and accuracy.
Emergency medicine resident airway training requirements and qualifications
EM residents in their 2nd and 3rd year of residency training are responsible for airway management as members of the RRT. They carry a pager to alert them to RRT activation and carry an RRT “tacklebox” that contains endotracheal tubes, laryngoscopes, video-assist laryngoscopes, laryngeal mask airways, bougies, and standard intubation induction agents (etomidate, succinylcholine, vecuronium). To become eligible for this position, each resident must successfully complete the 35 required intubations for Accreditation Council for Graduate Medical Education EM residency graduation standards, take a difficult airway course, pass a difficult airway simulation-based test, and complete a 2-week anesthesia rotation. Other members of the RRT include a respiratory therapist, an ICU nurse, an internal medicine resident, and a critical care resident.
Study protocol and measurements
During the RRT activation, a duplicate run sheet is completed by the EM resident which includes the resident name, call time, patient name and demographic information, the reason for RRT activation, interventions carried out by the resident as well as medications administered or ordered, airway attempts, airway success, and patient outcome. One copy of the sheet is placed on the patient chart, and the other is stored in a rapid response binder in the Emergency Department (ED).
Data abstractors logged all rapid response data sheet information and reviewed the inpatient electronic medical record to determine patient disposition following the event and the service responsible for the patient. Data were collected over 66 months (July 2008 to January 2014). July 2008 was the start date of data collection as this was the 1st month that EM residents were included on the hospital RRT.
Descriptive statistics were used to assess demographic factors and interventions. Data were analyzed using MedCalc (©1993–2013, Ostend, Belgium) and VassarStats: Website for Statistical Computation (vassarstats.net, author Richard Lowry, PhD, Professor of Psychology Emeritus, Vassar College, Poughkeepsie, NY, ©1998–2013).
| Results|| |
During the study, 1984 rapid response sheets were filed, which averages to about one activation daily. Of the 1886 sheets that contained patient demographic data, the mean age was 68.8 ± 16.9 years, with 47.2% female patients. Sixty-nine percent were on medical services, 17.5% were on surgical, or obstetrical services and the remainder were psychiatric, pediatric, or outpatient care areas.
Change in level of care
Data regarding change in level of care were collected on 1982 patients. Six hundred forty patients (32.3%) required transfer to the ICU, 79 (4%) were transferred to a step-down unit, 12 (0.6%) required operative intervention, 4 (0.2%) went to the cardiac catheterization lab, and 133 (6.7%) died. In 914 patients (46.1%), there was no change in status or assignment. The remainder went to a procedural suite.
Procedures performed and resuscitative medications administered
Procedural and medication information was collected on 1971 patients. Five hundred seventy-six (29.2%) patients were intubated, and 350 (17.8%) patients were placed on noninvasive positive pressure ventilation. Central lines were placed in 31 patients (1.6%), and intraosseous access was performed on 8 patients (0.4%). Resuscitative medications were administered to 339 patients (17.2%).
| Discussion|| |
In an academic hospital, there is a three-pronged mission: Education, research, and patient care/service. A successful hospital must consider the financial implications of altering any aspect of its service model. Therefore, we must consider the educational, financial, and patient care consequences of senior EM residents leaving their scheduled ED shifts to respond to RRT activations.
Our study demonstrates that being part of an RRT offers significant educational benefits to EM residents, allowing an opportunity for them to supplement their resuscitative skill sets. RRT activations involve a preselected group of sicker patients of high acuity. The majority of RRT activations occur for patients that are already admitted to the hospital, and our data show that 32.3% of them require ICU level care following RRT activation. Comparatively, in the ED, more than 75% of patients are discharged, and only about 1.5% of patients require ICU care. As RRT members, residents have the potential to gain more experience with primary assessment of critically ill patients than they might have had while on an ED shift that inevitably has a large range of patient acuities. In addition to gaining experience with the primary and secondary survey, the residents have many opportunities for intubation, central line placement, and experience with administration of resuscitative medications as well as management and direction of a patient care team.
Time spent managing a rapid response on the floor is time taken away from managing patients awaiting care in the ED. Educationally, this may be a sound trade-off for junior residents working in the ED who are not eligible to respond to the RRT activation. Having a senior leave, the department may give more junior residents the opportunity to see a greater number or sicker patients than they otherwise might have. This may also give them the opportunity to assist in more senior level ED tasks, like managing patient flow, or may help them work on higher order tasks such as efficiency and multi-tasking.
Obviously, having a resident leave the ED during shift results in fewer providers available to see patients, and would, therefore, have some impact on departmental efficiency and productivity. We feel that, in most institutions, this would be a minor issue. As previously stated, RRT activations occur approximately once daily at our hospital. The resuscitation tends to be fast-paced, and the majority of RRT activations last less than an hour. Residents usually return to their shifts within 20–30 min. According to one productivity study, residents in their 2nd and 3rd year of residency typically see between 1.28 and 1.4 patients an hour. The impact of a senior resident seeing one less patient in a day as a result of responding to an RRT activation should be easily absorbed by attending physician presence. During an unexpected ED surge with minimal staffing for instance, during an overnight period, this may be more problematic, but this is the case with any surge situation.
Our study did not assess for differences in patient outcome as a result of having an EM resident responsible for airway management compared to a provider in another discipline. We do, however, recognize the importance of assuring the best patient care. Previously mentioned studies at other institutions have demonstrated no significant difference in patient outcome with resident-led cardiac arrest and RRT versus attending physician-led teams., Data from a prior study at our institution demonstrated that inclusion of an EM resident on the RRT reduced the rate of progression to cardiac arrest by 29% for in-hospital rapid responses, but further outcomes-based studies are warranted.
The optimal role for an EM resident on an RRT is not clear. At our institution, they are assigned the task of airway management, but the resident frequently also assumes the role of team leader. This may occur because the EM resident is more comfortable running resuscitations than the other providers on the RRT. Ideally, the provider assigned to airway management should not also be team leader, and this begs the question of multidisciplinary RRT training with a goal of role adherence. Whether an EM resident is best suited to airway management versus team leader is beyond the scope of our study.
Our study is limited by its retrospective design. As in all retrospective studies, we could only assess what data were recorded. Although the RRT paperwork is standardized with prescribed areas for details regarding airway management and patient demographics, several sheets were nevertheless incomplete, resulting in an inability to fully assess every event. It is possible and even likely that some resuscitative interventions were not recorded, and therefore it is likely that our study underestimates the resuscitative experience of EM residents.
Our study did not assess for patient outcomes as a factor of having EM resident presence on the RRT. This is an important consideration in designing an RRT and warrants further investigation.
This study was limited to one institution and may not be generalizable to other hospitals. Larger hospitals with more frequent rapid response activations and more ED patients may not be able to support the loss of a resident from the department. A multicenter analysis may show further support of the benefits gained by EM residents as members of an RRT and give insight on how to best incorporate residents as part of the team.
| Conclusions|| |
EM residents are well-suited to be RRT members. As a member of that team, they gain exposure to considerable resuscitative experience.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jones D, Bellomo R, DeVita MA. Effectiveness of the medical emergency team: The importance of dose. Crit Care 2009;13:313.
Maharaj R, Raffaele I, Wendon J. Rapid response systems: A systematic review and meta-analysis. Crit Care 2015;19:254.
Hillman K, Chen J, Cretikos M, Bellomo R, Brown D, Doig G, et al.
Introduction of the medical emergency team (MET) system: A cluster-randomised controlled trial. Lancet 2005;365:2091-7.
Massey D, Aitken LM, Chaboyer W. Literature review: Do rapid response systems reduce the incidence of major adverse events in the deteriorating ward patient? J Clin Nurs 2010;19:3260-73.
Morris DS, Schweickert W, Holena D, Handzel R, Sims C, Pascual JL, et al.
Differences in outcomes between ICU attending and senior resident physician led medical emergency team responses. Resuscitation 2012;83:1434-7.
Adams BD, Zeiler K, Jackson WO, Hughes B. Emergency medicine residents effectively direct inhospital cardiac arrest teams. Am J Emerg Med 2005;23:304-10.
American College of Emergency Physicians. Definition of Emergency Medicine. Available from: https://www.acep.org/Clinical---Practice-Management/Definition-of-Emergency-Medicine. [Last accessed on 2016 Jan 05].
Butcher BW, Quist CE, Harrison JD, Ranji SR. The effect of a rapid response team on resident perceptions of education and autonomy. J Hosp Med 2015;10:8-12.
Cobb T, Jeanmonod D, Jeanmonod R. The impact of working with medical students on resident productivity in the emergency department. West J Emerg Med 2013;14:585-9.
Davis J, Watts D, Brown A, Prestosh J, Stotzfus J. Rate of cardiopulmonary arrest before and after implementing rapid response teams using emergency medicine residents. Acad Emerg Med 2009;16 4 Suppl 1:s181.