Supported by the Institute for Healthcare Improvement
The new "rapid responder"
As rapid response team members, pharmacists set appropriate
dosing levels, make medications available, and determine if
medications contributed to patient deterioration.
By Frank A. Federico, RPh
he successful implemen-
T
tation of the Institute for
Healthcare Improve-
ment’s 5 Million Lives
Campaign interventions
depends on a multidisci-
plinary approach and
support from hospital
leadership. Each suggest-
ed intervention for pro-
tecting patients from incidents of medical harm
shouldn’t be considered in isolation; components of
each intervention may be improved by work in anoth-
er area.
Medication reconciliation is one of the most com-
mon 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 administra-
tion of insulin, a high-alert medication, should be
linked to the work of the team that’s focused on
glycemic control—likewise protocols for anticoagula-
tion management should be linked to deep vein
thrombosis prophylaxis, opioid therapy, and under-
standing patient deterioration.
Pharmacists can play a key role in ensuring reliable
medication management processes. Their role contin-
ues to evolve. Responsibilities have traditionally
included review of medication orders and drug distri-
bution. Over time, pharmacists have become an inte-
gral part of the healthcare team by being available to
answer staff questions while in patient care units, par-
ticipating in treatment decisions as part of multidisci-
plinary rounds, and leading medication safety initia-
6 Pharmacy Solutions, November 2008
tives. 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.
Emerging model
Composition of the rapid response team varies based
on available resources in the hospital. This team typi-
cally has some combination of a critical care nurse, res-
piratory 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 pharma-
cists are involved on code teams.3 In this role, pharma-
cists determine appropriate and safe medication dos-
ing and prepare medications for administration. An
extension of this program is the participation of phar-
macists in rapid response teams.
The goal of the team is to bring critical care exper-
tise to the patient bedside (or wherever it’s needed),
particularly for patients at risk for cardiac or respirato-
ry 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 mor-
bidity and mortality when rapid response teams are
implemented.4-6
As team members, pharmacists contribute by deter-
mining appropriate medication dosing, making needed
medications available, and helping to determine if
medications contributed to patient deterioration. While
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the team focuses on stabilizing the patient, the pharma-
cist 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 situa-
tions, 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 res-
piratory depression due to oversedation. After the
patient’s medication needs are met, the pharmacist
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may leave the team to continue stabilizing the patient
unless the problem is medication related.
As with many improvement programs, implement-
ing 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 review-
ing its opioid administration policy, the hospital staff
determined a need to develop a dosing and monitor-
ing 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
Pharmacy Solutions, November 2008 7
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, deter-
mine the specific role that they’ll play during an emer-
gency. Johns Hopkins Children’s Center in Baltimore
conducted simulated cardiac arrests or medical emer-
gencies to learn how the team performs. During these
simulations, the team discovered that nurses are over-
burdened 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 phar-
macy residency programs may choose to add residents
to code teams and rapid response teams.
To ensure that pharmacists can effectively con-
tribute, they should be involved in the necessary orien-
tation and training of all rapid response team partici-
pants. Hamot Medical Center in Erie, Pa., developed a
program in which pharmacists participate in educa-
tional 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 partici-
pate in rapid response team efforts? Begin by under-
standing how often medication-related patient deteri-
oration contributes to rapid response team calls.
8 Pharmacy Solutions, November 2008
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 associ-
ated 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 mem-
bers 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 signifi-
cant contributions to rapid response team calls, they
may not be needed in each scenario. When possible,
include them on the team. Alternatively, some hospi-
tals 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. ■
REFERENCES
1. Leape LL, et al. Pharmacist participation on physician
rounds and adverse drug events in the intensive care
unit. JAMA. 1999;282(3):267-270.
2. Kaushal R, et al. Unit-based clinical pharmacists’ preven-
tion of serious medication errors in pediatric inpatients.
Am J Health Syst Pharm. 2008;65(13):1254-1260.
3. Bond CA, Raehl CL, Franke T. Clinical pharmacy services
and hospital mortality rates. Pharmacotherapy. 1999;
19(5):556-564.
4. Folli HL, Poole RL, Benitz WE, Russo JC. Medication error
prevention by clinical pharmacists in two children’s hospi-
tals. Pediatrics. 1987;79(5):718-722.
5. DeVita MA, et al. Use of medical emergency team
responses to reduce hospital cardiopulmonary arrests.
Qual Saf Health Care. 2004;13(4):251-254.
6. Sharek PJ, et al. Effect of a rapid response team on hospi-
tal-wide mortality and code rates outside the ICU in a chil-
dren’s hospital. JAMA. 2007;298(19):2267-2274.
Frank A. Federico is content director, Institute for Healthcare
Improvement, Cambridge, Mass.
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