Redesigning Quick Response in the Ambulatory Care Setting: Implementing a “Ramp Down” Approach

Purpose: The purpose of our contribution is to demonstrate the opportunity for improved patient care and nurse satisfaction by expediting clinical assessments and disposition during quick response (QR) calls.

Description: While rapid response teams (RRT) have been identified as best practice in hospital settings, there is a paucity in the literature regarding emergency medical response in ambulatory care patients, particularly in an outlying, stand-alone clinics with limited staff support (Rojas et al., 2017).

The quick response team (QRT) at this clinic is responsible for reporting to all QR calls within a 300,000 square foot building which encompasses approximately 50,000 square feet of medical space. This clinic is the largest outlying independent ambulatory care clinic within the local network with approximately 22,000 enrolled patients. The QRT consisted of two registered nurses (RN) and was responding in a “ramp up” model. This “ramp up” methodology is described as being nurse-led and does not include a provider responding simultaneously. In contrast, a “ramp down” approach consists of a provider concomitantly responding to all QR calls.

Growing frustration motivated a team of clinic nurses to evaluate nursing staff’s perception of the QRT process and perceived barriers. A layout analysis was completed and demonstrated multiple decision points resulting in time wasted in locating a provider. A similar circumstance was also found in the literature, where it was noted that “awaiting the physician arrival from the ICU further delayed necessary transitions to the ED” (Dechert et al., 2013). We found this “ramp up” phenomenon was also present in our outlying clinic setting where nurses were responding alone. Implementation of a “ramp down” approach in our clinic included executing a “doc of the day” plan where a provider is assigned to respond (with the RNs) to all QR calls for the day. Doc of the day was implemented in October 2019.

Evaluation and outcome: “Time spent” data was collected for all quick response calls 180 days prior (99 calls) and 180 post-implementations (54 calls) of doc of the day. The average time spent on QR calls was 48 minutes prior to “doc of the day” in comparison to 30 minutes post-implementation. Nursing staff surveys were also completed 180 days prior and 150 days post-implementation. In May 2019, 75% of surveyed primary care nurses reported frustration in finding a provider, and 57% of nurses indicated they would hesitate in initiating an intervention without a provider present. These values decreased by 58% and 27%, respectively.

Implementing a “ramp down” approach in responding to emergency situations in an ambulatory care clinic decreased the mean duration of QR calls by 18 minutes over a six-month period. The learning outcome and conclusion is that simultaneous provider response expedites the dispositioning of patients requiring evacuation to a higher level of care, decreasing the potential for poor patient outcomes. This “ramp down” approach and process improvement scenario may be implemented in other similar outpatient settings to improve efficiency, patient safety, and staff satisfaction.