The successful implementation of the Institute for Healthcare Improvement's 5 Million Lives Campaign interventions depends on a multidisciplinary approach and support from hospital leadership. Each suggested intervention for protecting patients from incidents of medical harm shouldn't be considered in isolation; components of each intervention may be improved by work in another area.
Medication reconciliation is one of the most common healthcare interventions to prevent adverse drug events and harm, and to some extent medications play a role in almost all of the Campaign's interventions. For example, the protocols developed for administration of insulin, a high-alert medication, should be linked to the work of the team that's focused on glycemic control-likewise protocols for anticoagulation management should be linked to deep vein thrombosis prophylaxis, opioid therapy, and understanding patient deterioration.
Pharmacists can play a key role in ensuring reliable medication management processes. Their role continues to evolve. Responsibilities have traditionally included review of medication orders and drug distribution. Over time, pharmacists have become an integral part of the healthcare team by being available to answer staff questions while in patient care units, participating in treatment decisions as part of multidisciplinary rounds, and leading medication safety initiatives. Studies report that these activities result in a decrease in medication errors and adverse events.1,2 As part of this evolution, pharmacists are also being included in rapid response teams.
Composition of the rapid response team varies based on available resources in the hospital. This team typically has some combination of a critical care nurse, respiratory therapist, hospitalist, physician assistant, and resident or fellow. Some teams may consist of only a single critical care nurse.
An emerging model includes pharmacists. Research demonstrates a reduction in mortality when pharmacists are involved on code teams.3 In this role, pharmacists determine appropriate and safe medication dosing and prepare medications for administration. An extension of this program is the participation of pharmacists in rapid response teams.
The goal of the team is to bring critical care expertise to the patient bedside (or wherever it's needed), particularly for patients at risk for cardiac or respiratory arrest-two high-mortality conditions. There are often observable signs of patient deterioration, and early recognition and prompt treatment can reduce death rates in hospitalized patients. The team can be called on to respond at the first sign of trouble. Data from several studies indicate an improvement in morbidity and mortality when rapid response teams are implemented.4-6
As team members, pharmacists contribute by determining appropriate medication dosing, making needed medications available, and helping to determine if medications contributed to patient deterioration. While the team focuses on stabilizing the patient, the pharmacist reviews the medication administration record to identify any potential medication-related causes.
To expedite medication administration during a team response, pharmacists can rapidly review orders and ensure appropriate preparation. In some situations, needed medications aren't found in the unit. In these instances, the pharmacist can quickly acquisition these medications from pharmacy supplies.
Cases in point
At Long Beach Memorial and Children's Hospital in California, pharmacists are an integral part of the rapid response team. The team relies on the pharmacist's familiarity with dosing and medications, especially for patients with conditions such as hypertension and arrhythmias. Pharmacists identify and recommend doses of reversal agents for patients experiencing respiratory depression due to oversedation. After the patient's medication needs are met, the pharmacist may leave the team to continue stabilizing the patient unless the problem is medication related.
As with many improvement programs, implementing a rapid response team uncovers other systems defects. The evaluation of a deteriorating patient's medication treatment regimen may reveal instances where inappropriate medication use or dosing may be contributing to the patient's condition. For example, Robert Wood Johnson University Hospital Hamilton in New Jersey added a clinical pharmacist (PharmD) to the rapid response team after the hospital identified a repeated use of naloxone with team calls. After reviewing its opioid administration policy, the hospital staff determined a need to develop a dosing and monitoring protocol.
In pediatric situations, pharmacists are particularly important in ensuring appropriate medication dosing and preparation. Many of the commercially available medications used aren't available in pediatric dosage forms and concentrations. A pharmacist on the team can help expedite obtaining the dose from the pharmacy or provide calculations to prepare the dose in the unit.
To engage pharmacists in rapid response teams, determine the specific role that they'll play during an emergency. Johns Hopkins Children's Center in Baltimore conducted simulated cardiac arrests or medical emergencies to learn how the team performs. During these simulations, the team discovered that nurses are overburdened during a crisis. Adding a pharmacist to the team helped improve the efficiency and effectiveness of nurses, allowing them to continue to focus on patient needs while the pharmacist prepares medications. The team also developed a first responder curriculum that provides descriptions of roles during an emergency.
There may be situations when pharmacists may not be able to participate in every rapid response team call because of staffing availability or other critical events that require their expertise. At Missouri Baptist Medical Center in St. Louis, the pharmacist is notified by beeper that the rapid response team has been called. The pharmacist is prepared to assist during the call if needed and to ensure that necessary medications reach the patient quickly.
Many variations of pharmacist involvement in rapid response teams exist. Howard County General Hospital in Columbia, Md., has a model in which pharmacists and ICU nurses determine the contents of the kits used by the rapid response team. Hospitals that have pharmacy residency programs may choose to add residents to code teams and rapid response teams.
To ensure that pharmacists can effectively contribute, they should be involved in the necessary orientation and training of all rapid response team participants. Hamot Medical Center in Erie, Pa., developed a program in which pharmacists participate in educational in-services provided for each nursing unit's staff. During the educational programs, common clinical scenarios are examined and basic treatments are reviewed. Hamot requires that all pharmacists who participate in rapid response teams are certified in advanced cardiac life support or pass a certification test. When the team is called, the pharmacist responds with the crash cart, which is stocked with potentially necessary medications.
At your facility
How can pharmacists in your organization participate in rapid response team efforts? Begin by understanding how often medication-related patient deterioration contributes to rapid response team calls. Review each incident. If medications contributed to the deterioration of the patient, review medication ordering and administration policies. For example, opioids have been identified as frequent contributors to patient harm. Oversedation may occur as the result of improper dosing, administration errors, or because the patient may be in a high-risk group. Clinicians must also be aware of the most common harm associated with insulin and hypoglycemia, particularly as efforts to establish glycemic control increase. They can also help develop the appropriate protocols to ensure proper medication selection, correct dosing, and adequate monitoring to minimize adverse drug events and actions to take if a patient experiences harm.
The extended role of pharmacists as valuable members of the rapid response team does have staffing implications; first and foremost, the more traditional clinical duties and drug distribution responsibilities must be fulfilled. Although pharmacists make significant contributions to rapid response team calls, they may not be needed in each scenario. When possible, include them on the team. Alternatively, some hospitals equip pharmacists with a beeper so they're aware of a rapid response team call and can respond when needed. In some cases, the alert may only serve to ensure that medications are available as needed. In other cases, the pharmacist may provide a consult on medication dosing or contributing factors to patient deterioration via telephone to the rest of the team. Each organization must determine how to develop and staff its rapid response team in a way that best fits its needs and capabilities.