Ambulatory Rapid Response: A Nurse-Driven Innovation for Improvement of Emergency Management in the Outpatient Environment

Background: In 2018, our facility opened a new 260,000 square-foot state-of-the-art ambulatory care facility. This new facility put many complex care specialists and advanced technology under one roof supporting a comprehensive, coordinated, and multidisciplinary approach to patient care. While this patient- and family-centered approach to care dramatically improved the patient experience, the relocation of multiple clinics to this large facility created new unique challenges. Many of the clinics moving to the new facility had historically been located on hospital campuses, affording clinicians easier access to higher levels of care. The sheer size of the building, and its location next to a major city thoroughfare, also led to public misconception the new facility might offer emergency services. Nurses and providers in the ambulatory environment are sometimes less confident managing emergencies, due to perceived lack of resources or skills, and fewer opportunities to reinforce competencies. Lack of confidence combined with an extended emergency response time has the potential to lead to poor patient outcomes, cause significant caregiver distress, and impact clinic flow. There is paucity in the literature about the use of a dedicated emergency response team in an ambulatory environment. Due to the higher level of patient complexity, unclear processes to mobilize resources across clinics, and the potential for acute patients arriving at the new facility expecting emergency services, a proposal was made to develop an onsite ambulatory rapid response team (ARRT).

Objective: The goals of the ARRT included early recognition and stabilization of decompensating patients, increasing clinician’s confidence in their ability to safely provide care for a patient or visitor in an emergency, improving mobilization of resources, and standardizing emergency equipment and medications across all ambulatory clinics.

Methods: A thorough assessment of current state emergency response in the clinics was conducted. A 12-question ambulatory emergency response survey was used to gather data about staff’s perception of management of emergencies, as well as general confidence level in escalation of care. Less than 40% of staff respondents indicated they felt confident managing emergencies in their current clinic environment, supporting the need for improved emergency response processes. Nurses, respiratory therapists, and advanced practice providers, staffed in the new building, were invited to join the ARRT. Pediatric advanced life support training was required to participate. Initial training included high-fidelity simulation and hands-on trauma basics, focusing on crisis resource management and communication techniques. Ongoing competencies and training were developed to reinforce assessment and intervention skills.

Results: Since implementation, the ARRT has received an average of one care escalation each week. Each call resulted in quick assessment, stabilization, and transfer to a higher level of care. Feedback has been obtained after each call, via survey, from members of the patient care team and the ARRT. The survey responses received to date have been overwhelmingly positive and have contributed to continuous improvement of team processes. In order to assess the effectiveness of the ARRT, staff will be re-surveyed at 6 and 12 months, using the ambulatory emergency response survey.