Effect of an RRT on Resident Perceptions

Rapid response teams (RRTs) have been promoted by patient safety and quality‐improvement organizations as a strategy to reduce preventable in‐hospital deaths.[1] To date, critical analysis of RRTs has focused primarily on their impact on quality‐of‐care metrics.[2, 3, 4] Comparatively few studies have examined the cultural and educational impact of RRTs, particularly at academic medical centers, and those that do exist have focused almost exclusively on perceptions of nurses rather than resident physicians.[5, 6, 7, 8, 9, 10]

Although a prior study found that internal medicine and general surgery residents believed that RRTs improved patient safety, they were largely ambivalent about the RRT's impact on education and training.[11] To date, there has been no focused assessment of resident physician impressions of an RRT across years of training and medical specialty to inform the use of this multidisciplinary team as a component of their residency education.

We sought to determine whether resident physicians at a tertiary care academic medical center perceive educational benefit from collaboration with the RRT and whether they feel that the RRT adversely affects clinical autonomy.

METHODS

RESULTS

There were 246 responses to the survey of a possible 342, yielding a response rate of 72% (Table 2). Ten respondents stated that they had never cared for a patient where the RRT had been activated. Given their lack of exposure to the RRT, these respondents were excluded from the analysis, yielding a final sample size of 236. The demographic and clinical practice characteristics of respondents are shown in Table 1.

DISCUSSION

Most studies examining the educational and cultural impact of RRTs exist in the nursing literature. These studies demonstrate that medical and surgical nurses are often reluctant to call the RRT for fear of criticism by the patient's physician.[5, 8, 9, 10, 11, 12, 13] In contrast, our data demonstrate that resident physicians across all levels of training and specialties have a positive view of the RRT and its role in patient care. The data support our hypothesis that although most residents perceive educational benefit from their interactions with the RRT, this perception is greater for less‐experienced residents and for those residents who routinely provide care for critically ill patients and serve as code team leaders. In addition, a minority of residents, irrespective of years of training or medical specialty, felt that the RRT negatively impacted their clinical autonomy.

Our data have several important implications. First, although over half of the residents surveyed had not been exposed to RRTs during medical school, and despite having no formal training on the role of the RRT during residency, most residents identified their interactions with the RRT as potential learning opportunities. This finding differs from that of Benin and colleagues, who suggested that RRTs might negatively impact residents' educational development and decrease opportunities for high‐stakes clinical reasoning by allowing the clinical decision‐making process to be driven by the RRT staff rather than the resident.[5] One possible explanation for this discrepancy is the variable makeup of the RRT at different institutions. At our medical center, the RRT is comprised of a critical care nurse and respiratory therapist, whereas at other institutions, the RRT may be led by a resident, fellow, attending hospitalist, or intensivist, any of whom might supersede the primary resident once the RRT is engaged.

In our study, the perceived educational benefit of the RRT was most pronounced with interns. Interns likely derive incrementally greater benefit from each encounter with an acutely decompensating patient than do senior residents, whether the RRT is present or not. Observing the actions of seasoned nurses and respiratory therapists may demonstrate new tools for interns to use in their management of such situations; for example, the RRT may suggest different modes of oxygen delivery or new diagnostic tests. The RRT also likely helps interns navigate the hospital system by assisting with decisions around escalation of care and serving as a liaison to ICU staff.

Our data also have implications for resident perceptions of clinical autonomy. Interns, far less experienced caring for unstable patients than upper‐level residents, expressed more concern about the RRT stripping them of opportunities to do so and about feeling less prepared to handle clinically deteriorating patients. Part of this perception may be due to interns feeling less comfortable taking charge of a patient's care in the presence of an experienced critical care nurse and respiratory therapist, both for reasons related to clinical experience and to a cultural hierarchy that often places the intern at the bottom of the authority spectrum. In addition, when the RRT is called on an intern's patient, the senior resident may accompany the intern to the bedside and guide the intern on his or her approach to the situation; in some cases, the senior resident may take charge, leaving the intern feeling less autonomous.

If training sessions could be developed to address not only clinical decision making, but also multidisciplinary team interactions and roles in the acute care setting, this may mitigate interns' concerns. Such curricula could also enhance residents' experience in interprofessional care, an aspect of clinical training that has become increasingly important in the age of limited duty hours and higher volume, and higher acuity inpatient censuses. An RRT model, like a code blue model, could be used in simulation‐based training to increase both comfort with use of the RRT and efficiency of the RRTresidentnurse team. Although our study did not address specifically residents' perceptions of multidisciplinary teams, this could be a promising area for further study.

For surgical residents, additional factors are likely at play. Surgical residents spend significant time in the operating room, reducing time present at the bedside and hindering the ability to respond swiftly when an RRT is called on their patient. This could cause surgical residents to feel less involved in the care of that patientsupported by our finding that fewer surgical residents felt able to collaborate with the RRTand also to derive less educational benefit and clinical satisfaction from the experience. Differences between medical and surgical postgraduate training also likely play a role, manifest by varying clinical roles and duration of training, and as such it may not be appropriate to draw direct comparisons between respective postgraduate year levels. In addition, differences in patients' medical complexity, varying allegiance to the traditional hierarchy of medical providers, and degree of familiarity with the RRT itself may impact surgical residents' comfort with the RRT.

Limitations of our study include that it was conducted at a single site and addressed a specific population of residents at our tertiary academic center. Though we achieved an excellent response rate, our subspecialty sample sizes were too small to allow for individual comparisons among those groups. Conducting a larger study at multiple institutions where the makeup of the RRT differs could provide further insight into how different clinical environments and different RRT models impact resident perceptions. Finally, we allowed each respondent to interpret both educational benefit and clinical autonomy in the context of their own level of training and clinical practice rather than providing strict definitions of these terms. There is no standardized definition of autonomy in the context of resident clinical practice, and we did not measure direct educational outcomes. Our study design therefore allowed only for measurement of perceptions of these concepts. Measurement of actual educational value of the RRTfor example, through direct clinical observation or by incorporating the RRT experience into an entrustable professional activitywould provide more quantitative evidence of the RRT's utility for our resident population. Future study in this area would help to support the development and ongoing assessment of RRT‐based curricula moving forward.

CONCLUSION

Our data show that resident physicians have a strongly favorable opinion of the RRT at our institution. Future studies should aim to quantify the educational benefit of RRTs for residents and identify areas for curricular development to enhance resident education as RRTs become more pervasive.

Rapid response teams (RRTs) have been promoted by patient safety and quality‐improvement organizations as a strategy to reduce preventable in‐hospital deaths.[1] To date, critical analysis of RRTs has focused primarily on their impact on quality‐of‐care metrics.[2, 3, 4] Comparatively few studies have examined the cultural and educational impact of RRTs, particularly at academic medical centers, and those that do exist have focused almost exclusively on perceptions of nurses rather than resident physicians.[5, 6, 7, 8, 9, 10]

Although a prior study found that internal medicine and general surgery residents believed that RRTs improved patient safety, they were largely ambivalent about the RRT's impact on education and training.[11] To date, there has been no focused assessment of resident physician impressions of an RRT across years of training and medical specialty to inform the use of this multidisciplinary team as a component of their residency education.

We sought to determine whether resident physicians at a tertiary care academic medical center perceive educational benefit from collaboration with the RRT and whether they feel that the RRT adversely affects clinical autonomy.

METHODS

RESULTS

There were 246 responses to the survey of a possible 342, yielding a response rate of 72% (Table 2). Ten respondents stated that they had never cared for a patient where the RRT had been activated. Given their lack of exposure to the RRT, these respondents were excluded from the analysis, yielding a final sample size of 236. The demographic and clinical practice characteristics of respondents are shown in Table 1.

DISCUSSION

Most studies examining the educational and cultural impact of RRTs exist in the nursing literature. These studies demonstrate that medical and surgical nurses are often reluctant to call the RRT for fear of criticism by the patient's physician.[5, 8, 9, 10, 11, 12, 13] In contrast, our data demonstrate that resident physicians across all levels of training and specialties have a positive view of the RRT and its role in patient care. The data support our hypothesis that although most residents perceive educational benefit from their interactions with the RRT, this perception is greater for less‐experienced residents and for those residents who routinely provide care for critically ill patients and serve as code team leaders. In addition, a minority of residents, irrespective of years of training or medical specialty, felt that the RRT negatively impacted their clinical autonomy.

Our data have several important implications. First, although over half of the residents surveyed had not been exposed to RRTs during medical school, and despite having no formal training on the role of the RRT during residency, most residents identified their interactions with the RRT as potential learning opportunities. This finding differs from that of Benin and colleagues, who suggested that RRTs might negatively impact residents' educational development and decrease opportunities for high‐stakes clinical reasoning by allowing the clinical decision‐making process to be driven by the RRT staff rather than the resident.[5] One possible explanation for this discrepancy is the variable makeup of the RRT at different institutions. At our medical center, the RRT is comprised of a critical care nurse and respiratory therapist, whereas at other institutions, the RRT may be led by a resident, fellow, attending hospitalist, or intensivist, any of whom might supersede the primary resident once the RRT is engaged.

In our study, the perceived educational benefit of the RRT was most pronounced with interns. Interns likely derive incrementally greater benefit from each encounter with an acutely decompensating patient than do senior residents, whether the RRT is present or not. Observing the actions of seasoned nurses and respiratory therapists may demonstrate new tools for interns to use in their management of such situations; for example, the RRT may suggest different modes of oxygen delivery or new diagnostic tests. The RRT also likely helps interns navigate the hospital system by assisting with decisions around escalation of care and serving as a liaison to ICU staff.

Our data also have implications for resident perceptions of clinical autonomy. Interns, far less experienced caring for unstable patients than upper‐level residents, expressed more concern about the RRT stripping them of opportunities to do so and about feeling less prepared to handle clinically deteriorating patients. Part of this perception may be due to interns feeling less comfortable taking charge of a patient's care in the presence of an experienced critical care nurse and respiratory therapist, both for reasons related to clinical experience and to a cultural hierarchy that often places the intern at the bottom of the authority spectrum. In addition, when the RRT is called on an intern's patient, the senior resident may accompany the intern to the bedside and guide the intern on his or her approach to the situation; in some cases, the senior resident may take charge, leaving the intern feeling less autonomous.

If training sessions could be developed to address not only clinical decision making, but also multidisciplinary team interactions and roles in the acute care setting, this may mitigate interns' concerns. Such curricula could also enhance residents' experience in interprofessional care, an aspect of clinical training that has become increasingly important in the age of limited duty hours and higher volume, and higher acuity inpatient censuses. An RRT model, like a code blue model, could be used in simulation‐based training to increase both comfort with use of the RRT and efficiency of the RRTresidentnurse team. Although our study did not address specifically residents' perceptions of multidisciplinary teams, this could be a promising area for further study.

For surgical residents, additional factors are likely at play. Surgical residents spend significant time in the operating room, reducing time present at the bedside and hindering the ability to respond swiftly when an RRT is called on their patient. This could cause surgical residents to feel less involved in the care of that patientsupported by our finding that fewer surgical residents felt able to collaborate with the RRTand also to derive less educational benefit and clinical satisfaction from the experience. Differences between medical and surgical postgraduate training also likely play a role, manifest by varying clinical roles and duration of training, and as such it may not be appropriate to draw direct comparisons between respective postgraduate year levels. In addition, differences in patients' medical complexity, varying allegiance to the traditional hierarchy of medical providers, and degree of familiarity with the RRT itself may impact surgical residents' comfort with the RRT.

Limitations of our study include that it was conducted at a single site and addressed a specific population of residents at our tertiary academic center. Though we achieved an excellent response rate, our subspecialty sample sizes were too small to allow for individual comparisons among those groups. Conducting a larger study at multiple institutions where the makeup of the RRT differs could provide further insight into how different clinical environments and different RRT models impact resident perceptions. Finally, we allowed each respondent to interpret both educational benefit and clinical autonomy in the context of their own level of training and clinical practice rather than providing strict definitions of these terms. There is no standardized definition of autonomy in the context of resident clinical practice, and we did not measure direct educational outcomes. Our study design therefore allowed only for measurement of perceptions of these concepts. Measurement of actual educational value of the RRTfor example, through direct clinical observation or by incorporating the RRT experience into an entrustable professional activitywould provide more quantitative evidence of the RRT's utility for our resident population. Future study in this area would help to support the development and ongoing assessment of RRT‐based curricula moving forward.

CONCLUSION

Our data show that resident physicians have a strongly favorable opinion of the RRT at our institution. Future studies should aim to quantify the educational benefit of RRTs for residents and identify areas for curricular development to enhance resident education as RRTs become more pervasive.

Rapid response teams (RRTs) have been promoted by patient safety and quality‐improvement organizations as a strategy to reduce preventable in‐hospital deaths.[1] To date, critical analysis of RRTs has focused primarily on their impact on quality‐of‐care metrics.[2, 3, 4] Comparatively few studies have examined the cultural and educational impact of RRTs, particularly at academic medical centers, and those that do exist have focused almost exclusively on perceptions of nurses rather than resident physicians.[5, 6, 7, 8, 9, 10]

Although a prior study found that internal medicine and general surgery residents believed that RRTs improved patient safety, they were largely ambivalent about the RRT's impact on education and training.[11] To date, there has been no focused assessment of resident physician impressions of an RRT across years of training and medical specialty to inform the use of this multidisciplinary team as a component of their residency education.

We sought to determine whether resident physicians at a tertiary care academic medical center perceive educational benefit from collaboration with the RRT and whether they feel that the RRT adversely affects clinical autonomy.

METHODS

RESULTS

There were 246 responses to the survey of a possible 342, yielding a response rate of 72% (Table 2). Ten respondents stated that they had never cared for a patient where the RRT had been activated. Given their lack of exposure to the RRT, these respondents were excluded from the analysis, yielding a final sample size of 236. The demographic and clinical practice characteristics of respondents are shown in Table 1.

DISCUSSION

Most studies examining the educational and cultural impact of RRTs exist in the nursing literature. These studies demonstrate that medical and surgical nurses are often reluctant to call the RRT for fear of criticism by the patient's physician.[5, 8, 9, 10, 11, 12, 13] In contrast, our data demonstrate that resident physicians across all levels of training and specialties have a positive view of the RRT and its role in patient care. The data support our hypothesis that although most residents perceive educational benefit from their interactions with the RRT, this perception is greater for less‐experienced residents and for those residents who routinely provide care for critically ill patients and serve as code team leaders. In addition, a minority of residents, irrespective of years of training or medical specialty, felt that the RRT negatively impacted their clinical autonomy.

Our data have several important implications. First, although over half of the residents surveyed had not been exposed to RRTs during medical school, and despite having no formal training on the role of the RRT during residency, most residents identified their interactions with the RRT as potential learning opportunities. This finding differs from that of Benin and colleagues, who suggested that RRTs might negatively impact residents' educational development and decrease opportunities for high‐stakes clinical reasoning by allowing the clinical decision‐making process to be driven by the RRT staff rather than the resident.[5] One possible explanation for this discrepancy is the variable makeup of the RRT at different institutions. At our medical center, the RRT is comprised of a critical care nurse and respiratory therapist, whereas at other institutions, the RRT may be led by a resident, fellow, attending hospitalist, or intensivist, any of whom might supersede the primary resident once the RRT is engaged.

In our study, the perceived educational benefit of the RRT was most pronounced with interns. Interns likely derive incrementally greater benefit from each encounter with an acutely decompensating patient than do senior residents, whether the RRT is present or not. Observing the actions of seasoned nurses and respiratory therapists may demonstrate new tools for interns to use in their management of such situations; for example, the RRT may suggest different modes of oxygen delivery or new diagnostic tests. The RRT also likely helps interns navigate the hospital system by assisting with decisions around escalation of care and serving as a liaison to ICU staff.

Our data also have implications for resident perceptions of clinical autonomy. Interns, far less experienced caring for unstable patients than upper‐level residents, expressed more concern about the RRT stripping them of opportunities to do so and about feeling less prepared to handle clinically deteriorating patients. Part of this perception may be due to interns feeling less comfortable taking charge of a patient's care in the presence of an experienced critical care nurse and respiratory therapist, both for reasons related to clinical experience and to a cultural hierarchy that often places the intern at the bottom of the authority spectrum. In addition, when the RRT is called on an intern's patient, the senior resident may accompany the intern to the bedside and guide the intern on his or her approach to the situation; in some cases, the senior resident may take charge, leaving the intern feeling less autonomous.

If training sessions could be developed to address not only clinical decision making, but also multidisciplinary team interactions and roles in the acute care setting, this may mitigate interns' concerns. Such curricula could also enhance residents' experience in interprofessional care, an aspect of clinical training that has become increasingly important in the age of limited duty hours and higher volume, and higher acuity inpatient censuses. An RRT model, like a code blue model, could be used in simulation‐based training to increase both comfort with use of the RRT and efficiency of the RRTresidentnurse team. Although our study did not address specifically residents' perceptions of multidisciplinary teams, this could be a promising area for further study.

For surgical residents, additional factors are likely at play. Surgical residents spend significant time in the operating room, reducing time present at the bedside and hindering the ability to respond swiftly when an RRT is called on their patient. This could cause surgical residents to feel less involved in the care of that patientsupported by our finding that fewer surgical residents felt able to collaborate with the RRTand also to derive less educational benefit and clinical satisfaction from the experience. Differences between medical and surgical postgraduate training also likely play a role, manifest by varying clinical roles and duration of training, and as such it may not be appropriate to draw direct comparisons between respective postgraduate year levels. In addition, differences in patients' medical complexity, varying allegiance to the traditional hierarchy of medical providers, and degree of familiarity with the RRT itself may impact surgical residents' comfort with the RRT.

Limitations of our study include that it was conducted at a single site and addressed a specific population of residents at our tertiary academic center. Though we achieved an excellent response rate, our subspecialty sample sizes were too small to allow for individual comparisons among those groups. Conducting a larger study at multiple institutions where the makeup of the RRT differs could provide further insight into how different clinical environments and different RRT models impact resident perceptions. Finally, we allowed each respondent to interpret both educational benefit and clinical autonomy in the context of their own level of training and clinical practice rather than providing strict definitions of these terms. There is no standardized definition of autonomy in the context of resident clinical practice, and we did not measure direct educational outcomes. Our study design therefore allowed only for measurement of perceptions of these concepts. Measurement of actual educational value of the RRTfor example, through direct clinical observation or by incorporating the RRT experience into an entrustable professional activitywould provide more quantitative evidence of the RRT's utility for our resident population. Future study in this area would help to support the development and ongoing assessment of RRT‐based curricula moving forward.

CONCLUSION

Our data show that resident physicians have a strongly favorable opinion of the RRT at our institution. Future studies should aim to quantify the educational benefit of RRTs for residents and identify areas for curricular development to enhance resident education as RRTs become more pervasive.