Rapid Response Method

(A) Each acute care hospital licensed by the Department, shall establish a Rapid Response Method (RRM) suitable for the hospital’s needs and resources, to enable health care staff members, patients and family members to directly request additional assistance from a specially- trained individual(s) when a patient’s condition appears to be deteriorating. The hospital shall ensure that the RRM is available 24 hours per day, seven days per week. (B) Policies and Procedures. A hospital shall develop and implement written policies and procedures for a RRM that encourage staff members, patients and family members to seek assistance when a patient’s condition appears to be deteriorating. These policies and procedures shall include at a minimum the following: (1) Description of the RRM including criteria and methods for activating the RRM by staff members, patient(s) and/or family members when a patient’s condition appears to be deteriorating. (2) Criteria for selection, training and evaluation of staff members who will be responsible for responding to a request for additional assistance. (3) Education of staff members, patient(s) and/or family members about the RRM including the means by which staff members, patients and family members may request additional assistance. (4) Requirement of written documentation for each instance of activation of the RRM, including assessment of patient and family member satisfaction with the RRM. (5) A mechanism for measuring the utility and effectiveness of the RRM, including but not limited to: (a) documentation of rates and effectiveness of utilization of the RRM by staff, patients and family members; and (b) measurement of rates of cardiopulmonary arrest, respiratory arrest and mortality before and after implementation of the RRM. (6) Documentation of actions taken to improve the RRM and to address underlying organizational issues raised by review mechanism(s) and data collected pursuant to 105 CMR 130.1600(B)(5). (C) The Department may issue guidelines updating or revising the minimum required policies and procedures in 105 CMR 130.1600(B).