Chapter
Simulation and RRS

Hsiang-Chin Hsu M.D., MSc.
徐 祥清National Cheng Kung
University, Tainan, Taiwan

Introduction
Rapid Response System is a tool implemented in hospitals designed
to identify and respond to patients with early signs of clinicaldeterioration in non-intensive care units. RRS can encourage andempower the ward staff to recognize potential dangerous status andrequest for help for their patients. It is a logical solution to provide
patients safety and to prevent medical deterioration from progressing
and degenerating into irreversible cardiopulmonary arrest in hospital.
Additionally, RRS could also reduce hospital mortality and unanticipated
ICU admission, then keep ICU open for other patients and improveturnover of patients flow. Therefore, early recognition and timely
treatment for patients with high risks of deterioration can significantly
improve patient outcomes.
However, the activation relies on medical, nursing, and other staff
working in general wards. With large and increasing proportions of
hospitalized patients more elderly and co-morbidities, it is more
important to reinforce the abilities including regular monitoring andinterpretation of vital sign, timely administration of treatments,
requesting for additional professional help, and activation of RRS.
Besides, team function is also important in general wards. Different frommedical and nursing assessment and treatment, team training focuses onorganizational skills. General principles for team training include using
life-like situations, emphasizing objectives on team function, anddebriefing with focus on organization. Therefore, scenarios are needed
to be designed with clear objectives for team management andnon-technical skills.

Learning Objectives
These objectives can be based one of the three components of affective
limbs that we mentioned above or combined more than one component.
It can be slightly different in every institution based on differentactivation criteria, materials, and resources deficiency.

I.

Activation of RRS

Before setting up the learning objectives, the first thing is to realize
when and how RRS is activated. The activation can be divided into threecomponents: (1) the selection/diagnostic/triggering criteria; (2) human
and/or technologic monitoring; and (3) a mechanism for triggeringresponse. Each component’s response will determine the fluency of RRS
startup, the cascade of response, and then influencing the patient safety.
Specifically, the activation is named as afferent limb. Respectively, theefferent limb is believed to be responders, such as Medical Emergency
Teams (METs) or Rapid Response Teams (RRTs) according to different
hospitals’ organization or system. Each component of the afferent limb
and the efferent limb could be a challenge to each hospital’s system
based on different hospital culture, materials, and personal resources.
On the aspect of the afferent limb, RRS is responsible for monitoring
the patient, detecting any change or deterioration and then triggering aresponse, such as the efferent limb of an RRS. Failure or delay ofactivation may induce irreversible clinical outcome, such as
cardiopulmonary arrest, unanticipated intensive care unit (ICU)
admission and morbidity. Usually the afferent limb can be happened ingeneral wards or chronic care unit in hospital, rehabilitation department
or any health care institutions. The learning objectives for those who arefrom such units could focus on the criteria, patients’ monitoring,first-line treatment (The first 5 minutes), and triggering.
The first 5 minutes (Table) is a protocol meaning "the first 5 minutes
to be done before medical emergent team (MET) arrives at the site". It isbriefly shown what to do in 5 minutes from grasping the abnormal
situation of the patient and actually starting up the RRS until the teamarrives. This is also written in acronym ABCDE to make it easier toremember. The above actions in the first 5 minutes are needed to be
trained frequently by simulation and instructors also provide feedback
and debrief according to the first 5 minutes concept or guideline ofinstitutions.

Table: The guideline of the first 5 minutes in RRS
AirwayAssistance
Activate code teamAnnunciateacquire data
Attend patient
AccessAssistAirway maintenanceContact ward nurses
Call and trigger the code teamInform where, who, what is the code
activation
Information of the caseFirst-line treatment before RRS arrive
IV line preparedness
Follow the team leadership

BreathingBedBackboard
Blood glucose

Provide oxygen devices
Prepare the resuscitation environment
Backboard for CPR
Check blood sugar for conscious disturbancepatients

Circulation
CPR
Crash cart
Connect
Clear the room
Communicate

Check pulse
Start CPR for pulseless patient
Prepare resuscitation cart
Prepare IV fluid and medication
Prepare ward environment
Inform code team of current condition

Defibrillate
Document

Defibrillation for Vf and pulseless VT
Record resuscitation process

Explain (S-BAR)
Situation
Background
Assessment
Recommendation

The cause of reason of RRS activation
Past history
The assessment of current condition
The request of current treatment

On the aspect of the efferent limb, the learning objectives are tobring the response team to the bedsides or to the scene efficiently. Inmany hospitals, the response team has existing specific activation
criteria clearly for specific situation, such as sepsis team, stroke team,and so on. However, there are still some crisis events that did not fit
perfectly into certain activation criteria for each team. For the teams thatdeal with specific situation or teams that handle all situation, thelearning objectives is to response to activation promptly, establish
leadership, clear communication and collect all resources as soon aspossible. Regular review of the frequency of activating indication canallow efferent limb to optimize the care response for.

II.

Teamwork using non-technical skills

The situation of RRS usually involves the both afferent and efferent
limbs and relies on medical, nursing, and other staff working in generalwards. An inter-professional and collaborative strategy is necessary toobserved and debriefed during scenario. Through involving members ofdifferent healthcare professions in the design process, potential issuesaround the inter-professional objectives can be easily be performed andpredicted only using scenario training. Besides, to simulate relation withdifferent professions provide both realism of the scenario and the some
sort of communication between team members maximizing
non-technical skills.

Design Scenarios
Simulation with high fidelity simulator is a good tool for staff tofrequently practice the assessment of potential critical patients, thedecision of activation of RRS, and function as an effective teamwork. The
first step in development of the scenario is to create the definedobjectives of every scenario clearly. A scenario may have 2-4 primaryobjectives that are essential to teach. With too much objectives, thescenarios become over-inclusive and make the educational planunachievable. Based on objectives, several components are needed to
be built for completing scenarios.
I.

FrameworkFramework of simulation is the most important structure needed to
be defined clearly before education. The three themes identified aspreparedness, activation, and reflection.
The theme “preparedness” refers to the activities that areundertaken to ensure that the simulation session has the potential to
run effectively and thoroughly. Among RRS, medical, nursing, and otherstaff collaborative work as a team and the objectives are needed to beclearly defined for maximizing learning experiences. The setting
objectives are better to be broader, not too narrow. Based on theobjectives, learners can be confident to and willingness to participate in
the next theme “activation”. The theme “activation” is the scenario, theessential part in the education program. The learners are expected to bethemselves to deal with the situation represented in the scenario.
Among the RRS scenario, learners are trained to be able to activate RRS
earlier. So, the scenario is better not too complicated for beginners. In
the theme “reflection”, instructors can debrief according to the learners’
activities in scenario based on the objectives.

II.

Equipment and Environment

After deciding the scenario framework, the physical fidelity (realsituation setting), which includes manikin, environment, and clinicalequipment, is based on the degree of fidelity in the scenario. The choiceof the manikin depends on the learning objectives. High fidelity manikin
may represent the complicated situation of patients’ condition in RRS
activation. High fidelity manikin could also provide too much informationof patient medical condition to distract participants from learning
objectives.
For the environment, a simulation center is convenient and efficient
but may not be as realistic as performing a scenario in the participants’natural working space that we named in situ simulation.
The equipment used in the scenario is better to be same or similar
as what participants used in their regular clinical practice. Different
equipment will make participants confused and take time to adapt in thesimulation process, and may also cause frustration and learning
difficulties. For example, real-life defibrillation and intravenous pumps
are usually used in general wards which are high valued as realism byparticipants. Ensuring a complete list of all equipment and supplies
needs for the scenario is essential.
III.

Moulage

The scenario of RRS activation is mostly in the general wards. The
standard dressing of patients and intravenous line setting can provide
the realism. The use of photographs and video can also be effective as
more complicated scenarios.
IV.

Confederate

Confederates are important in scenario for RRS. In real situation, theactivation of RRS involves members of different healthcare professions.
Confederate are useful in divulging important information as well as
physical characteristics that are difficult to simulate. Therefore, withconfederate, simulation can enhance the scenario’s realism and learning
objectives. It also can be confusing and fluctuating participants if theconfederate distract from the scenarios. It is better to provideconfederate specific scripts.
V.

Adjuncts

Laboratory results, diagnostic imaging, ECGs, patient charges, andnursing flow sheets can be powerful adjuncts for helping participants toinvolve in the scenario. The more complex scenario needs more detailed
adjuncts for realism of the scenario. We may collect such adjuncts fromreal patients. Be sure to remove any patient identification from theadjunct we collect. When using real-life scenarios, privacy must beensured. The name given to the manikin in the scenario should notreflect the actual patient’s name.

Debriefing
Debriefing after scenario should focus on the criteria, patients’monitoring, the concept of “First 5 minutes”, and triggering. In addition,
we need to consider the background of different students in thecurriculum design. According to different units characteristics, possible
complications or potential deterioration should require more attention
and repetitive training. For example, in such unit with elderly patientswith difficult swallowing function, and respiratory complication (i.e.;such accidental food aspiration or increased sputum impaction) could
happen anytime. These situations require close monitoring, first-linetreatment and activation of RRS if necessary. Besides, regular review ofthe frequency of activating criteria can also provide us learning
objectives in different units, respectively. Even though, the following
principles of debriefing will necessarily be covered: the team’s goals, roleassignment, leadership, and communication. We should focus on not
only the timely decision of RRS activation, the initiation of first treatment,
but also the team function.

SummaryThe education of ward staff and those involving in RRS is necessary.
With all kinds of education methods, the capabilities of RRS can bestrengthened, including technical skills and non-technical skills.
Simulation education with scenarios designed with clear objectives is an
important method for team management and non-technical skills. Basedon the clear objectives, trainers can focus on non-technical skill
performance in scenarios and debriefing setting.