Implementation and Impact of a Rapid Response Team in a Children’s Hospital

Pediatric intraoperative cardiopulmonary arrests: A survey to evaluate if Medical Emergency Teams are utilized in pediatric operating rooms

BACKGROUND

Studies have shown that standardized code teams may improve outcomes following cardiac arrests. Pediatric intra-operative cardiac arrests are rare events and are associated with a mortality rate of 18%. There is limited data available regarding use Medical Emergency Team (MET) response to pediatric intra-operative cardiac arrest. The purpose of this study was to identify the use of MET in response to pediatric intraoperative cardiac arrest as an exploratory step in establishing evidence-based standardized practice across the hospital for training and management of this rare event.

METHODS

An anonymous electronic survey was created and sent to two populations: The Pediatric Anesthesia Leadership Council, a section of the Society for Pediatric Anesthesia, and the Pediatric Resuscitation Quality Collaborative, a multinational collaborative group, which works to improve resuscitation care in children. Standard summary and descriptive statistics were used for survey responses.

RESULTS

The overall response rate was 41%. The majority of respondents worked in a university affiliated, free-standing children's hospital. Ninety-five percent of respondents had a dedicated pediatric MET at their hospital. In 60% of responses from Pediatric Resuscitation Quality Collaborative and 18% of Pediatric Anesthesia Leadership Council hospitals, the MET responds to pediatric intra-operative cardiac arrest; however, the majority of times MET involvement is requested rather than automatic. The MET was found to be activated intraoperatively for situations other than cardiac arrest such as, massive transfusion events, need for extra staff, and for specialty expertise. In 65% of institutions, simulation-based training for cardiac arrest is supported but lacking pediatric intra-operative focus.

CONCLUSIONS

This survey revealed heterogeneity in the composition and response of the medical response teams responding to pediatric intra-operative cardiac arrests. Improved collaboration and cross training among MET, anesthesia, and operating room nursing may improve outcomes of pediatric intra-operative code events.

Nursing Surveillance for Deterioration in Pediatric Patients: An Integrative Review

PROBLEM

Adverse events occur in up to 19% of pediatric hospitalized patients, often associated with delays in recognition or treatment. While early detection is recognized as a primary determinant of recovery from deterioration, most research has focused on profiling patient risk and testing interventions, and less on factors that impact surveillance efficacy. This integrative review explored actions and factors that influence the quality of pediatric nursing surveillance.

ELIGIBILITY CRITERIA

Original research on nursing surveillance, escalation of care, or cardiopulmonary deterioration in hospitalized pediatric patients in non-critical environments, published in English in peer reviewed journals.

SAMPLE

Twenty-four studies from a literature search within the databases of CINAHL, PubMed, and Web of Science were evaluated and synthesized using a socio-technical systems theory framework. Study quality was assessed using The Mixed Methods Appraisal Tool.

RESULTS

Assessment, documentation, decision-making, intervening and communicating were identified as activities associated with surveillance of deterioration. Factors that influenced nurses' detection of deterioration were patient acuity, nurse education, experience, expertise and confidence, staffing, standardized assessment and communication tools, availability of emergency services, team composition and opportunities for multidisciplinary care planning.

CONCLUSIONS

Research provides insight into some aspects of nursing surveillance but does not adequately explore factors that affect clinical data interpretation and synthesis, and role integration between nurse and parents, and nurse and other clinicians on surveillance of clinical stability.

IMPLICATIONS

Research is needed to enhance understanding of the contextual factors that impact nursing surveillance to inform intervention design to support nurses' timely recognition and mitigation of clinical deterioration.

Development and Validation of the Pediatric Resuscitation and Escalation of Care Self-Efficacy Scale

OBJECTIVES

To validate a scale to assess pediatric providers' resuscitation and escalation of care self-efficacy and assess which provider characteristics and experiences may contribute to self-efficacy.

METHODS

Cross-sectional cohort study performed at an academic children's hospital. Pediatric nurses, respiratory therapists, and residents completed the Generalized Self-Efficacy Scale (GSES) and Pediatric Resuscitation Self-Efficacy Scale (PRSES) as well as a survey assessing their experiences with pediatric escalation of care.

RESULTS

Four hundred participants completed the GSES and PRSES. A total of 338 completed the survey, including 262 nurses, 51 respiratory therapists, and 25 residents. Cronbach α for the PRSES was 0.905. A factor analysis revealed 2 factors within the scale, with items grouped on the basis of expertise required. Multiple logistic regression analyses controlling for GSES score, number of code blue events participated, number of code blue events activated, number of rapid response team events participated, number of rapid response team response events called, performance on a knowledge assessment of appropriate escalation of care, and years of experience demonstrated that PRSES performance was significantly associated with GSES scores and number of escalation of care events (code blue and rapid response) previously participated in (R ² = 0.29, P < .001).

CONCLUSIONS

The PRSES can be used to assess pediatric providers' pediatric resuscitation self-efficacy and could be used to evaluate pediatric escalation of care interventions. Pediatric resuscitation self-efficacy is significantly associated with number of previous escalation of care experiences. In future studies, researchers should focus on assessing the impact of increased exposures to escalation of care, potentially via mock codes, to accelerate the acquisition of resuscitation self-efficacy.

Bias in Before-After Studies: Narrative Overview for Anesthesiologists

Before-after study designs are effective research tools and in some cases, have changed practice. These designs, however, are inherently susceptible to bias (ie, systematic errors) that are sometimes subtle but can invalidate their conclusions. This overview provides examples of before-after studies relevant to anesthesiologists to illustrate potential sources of bias, including selection/assignment, history, regression to the mean, test-retest, maturation, observer, retrospective, Hawthorne, instrumentation, attrition, and reporting/publication bias. Mitigating strategies include using a control group, blinding, matching before and after cohorts, minimizing the time lag between cohorts, using prospective data collection with consistent measuring/reporting criteria, time series data collection, and/or alternative study designs, when possible. Improved reporting with enforcement of the Enhancing Quality and Transparency of Health Research (EQUATOR) checklists will serve to increase transparency and aid in interpretation. By highlighting the potential types of bias and strategies to improve transparency and mitigate flaws, this overview aims to better equip anesthesiologists in designing and/or critically appraising before-after studies.

Validity and effectiveness of paediatric early warning systems and track and trigger tools for identifying and reducing clinical deterioration in hospitalised children: a systematic review

OBJECTIVE

To assess (1) how well validated existing paediatric track and trigger tools (PTTT) are for predicting adverse outcomes in hospitalised children, and (2) how effective broader paediatric early warning systems are at reducing adverse outcomes in hospitalised children.

DESIGN

Systematic review.

DATA SOURCES

British Nursing Index, Cumulative Index of Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effectiveness, EMBASE, Health Management Information Centre, Medline, Medline in Process, Scopus and Web of Knowledge searched through May 2018.

ELIGIBILITY CRITERIA

We included (1) papers reporting on the development or validation of a PTTT or (2) the implementation of a broader early warning system in paediatric units (age 0-18 years), where adverse outcome metrics were reported. Several study designs were considered.

DATA EXTRACTION AND SYNTHESIS

Data extraction was conducted by two independent reviewers using template forms. Studies were quality assessed using a modified Downs and Black rating scale.

RESULTS

36 validation studies and 30 effectiveness studies were included, with 27 unique PTTT identified. Validation studies were largely retrospective case-control studies or chart reviews, while effectiveness studies were predominantly uncontrolled before-after studies. Metrics of adverse outcomes varied considerably. Some PTTT demonstrated good diagnostic accuracy in retrospective case-control studies (primarily for predicting paediatric intensive care unit transfers), but positive predictive value was consistently low, suggesting potential for alarm fatigue. A small number of effectiveness studies reported significant decreases in mortality, arrests or code calls, but were limited by methodological concerns. Overall, there was limited evidence of paediatric early warning system interventions leading to reductions in deterioration.

CONCLUSION

There are several fundamental methodological limitations in the PTTT literature, and the predominance of single-site studies carried out in specialist centres greatly limits generalisability. With limited evidence of effectiveness, calls to make PTTT mandatory across all paediatric units are not supported by the evidence base.

PROSPERO REGISTRATION NUMBER

CRD42015015326.

Rapid response systems for paediatrics: Suggestions for optimal organization and training

Resuscitation and cardiac arrest events in the paediatric population are rare occurrences. Improving outcomes from such events continues to be a difficult challenge. Rapid response systems and teams have been integrated into many hospitals in an effort to facilitate early identification and management of patients at risk for clinical deterioration. Optimizing education in the form of team training is a major component of successful team performance. Simulation-based team training, is a key educational supplement for existing standardized resuscitation courses. This position statement describes the evidence supporting rapid response systems and teams as well as simulation-based team training and provides recommendations for implementation in hospital care for paediatric patients.

A mixed methods evaluation of paediatric trainee preparedness to manage cardiopulmonary arrests

Paediatric cardiopulmonary arrest (CPA) survival rates are strongly linked to the training of the doctors responding to the event. This study sought to characterise the level of experience in managing CPAs among paediatric trainees and to investigate the nontechnical (NTS) required to effectively lead a paediatric CPA team. A mixed-methods research design was used. For the quantitative phase, a questionnaire was developed to assess training, confidence, and experiences related to CPA management. During the qualitative phase, 17 paediatric trainees participated in a series of critical incident technique (CIT) interviews to explore the NTS used during the management of paediatric CPAs. A total of 56 of 131 (37.1% response rate) trainees responded to the preparedness questionnaire. A total of 48.2% of respondents expressed low confidence in their skill as a team leader during the management of a CPA. The CIT interviews highlighted deficiencies in specific NTS (identifying options, prioritising, and identifying and utilising resources).

CONCLUSION

Our results indicate that there is a desire for more training in CPA management among paediatric trainees, in particular as a team leader, which includes a focus on key NTS. What is Known • Levels of preparedness to be a paediatric cardiopulmonary arrests team member/leader are generally lower than desirable. • The importance of nontechnical skills to the effective performance of adult cardiopulmonary arrests teams has been identified. What is New • Levels of preparedness to be a cardiopulmonary arrests team member were higher than reported in US studies. • There is a need for greater training in cardiopulmonary arrest management which includes a focus on key nontechnical skills to include identifying options, prioritising, identifying and utilising resources.

Association of Pediatric Medical Emergency Teams With Hospital Mortality

BACKGROUND

Implementation of medical emergency teams has been identified as a potential strategy to reduce hospital deaths, because these teams respond to patients with acute physiological decline in an effort to prevent in-hospital cardiac arrest. However, prior studies of the association between medical emergency teams and hospital mortality have been limited and typically have not accounted for preimplementation mortality trends.

METHODS

Within the Pediatric Health Information System for freestanding pediatric hospitals, annual risk-adjusted mortality rates were calculated for sites between 2000 and 2015. A random slopes interrupted time series analysis then examined whether implementation of a medical emergency team was associated with lower-than-expected mortality rates based on preimplementation trends.

RESULTS

Across 38 pediatric hospitals, mean annual hospital admission volume was 15 854 (range, 6684-33 024), and there were a total of 1 659 059 hospitalizations preimplementation and 4 392 392 hospitalizations postimplementation. Before medical emergency team implementation, hospital mortality decreased by 6.0% annually (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.92-0.96) across all hospitals. After medical emergency team implementation, hospital mortality continued to decrease by 6% annually (OR, 0.94; 95% CI, 0.93-0.95), with no deepening of the mortality slope (ie, not lower OR) in comparison with the preimplementation trend, for the overall cohort (P=0.98) or when analyzed separately within each of the 38 study hospitals. Five years after medical emergency team implementation across study sites, there was no difference between predicted (hospital mean of 6.18 deaths per 1000 admissions based on preimplementation trends) and actual mortality rates (hospital mean of 6.48 deaths per 1000 admissions; P=0.57).

CONCLUSIONS

Implementation of medical emergency teams in a large sample of pediatric hospitals in the United States was not associated with a reduction in hospital mortality beyond existing preimplementation trends.

The Simulation-Based Assessment of Pediatric Rapid Response Teams

OBJECTIVE

To create scenarios of simulated decompensating pediatric patients to train pediatric rapid response teams (RRTs) and to determine whether the scenario scores provide a valid assessment of RRT performance with the hypothesis that RRTs led by intensivists-in-training would be better prepared to manage the scenarios than teams led by nurse practitioners.

STUDY DESIGN

A set of 10 simulated scenarios was designed for the training and assessment of pediatric RRTs. Pediatric RRTs, comprising a pediatric intensive care unit (PICU) registered nurse and respiratory therapist, led by a PICU intensivist-in-training or a pediatric nurse practitioner, managed 7 simulated acutely decompensating patients. Two raters evaluated the scenario performances and psychometric analyses of the scenarios were performed.

RESULTS

The teams readily managed scenarios such as supraventricular tachycardia and opioid overdose but had difficulty with more complicated scenarios such as aortic coarctation or head injury. The management of any particular scenario was reasonably predictive of overall team performance. The teams led by the PICU intensivists-in-training outperformed the teams led by the pediatric nurse practitioners.

CONCLUSIONS

Simulation provides a method for RRTs to develop decision-making skills in managing decompensating pediatric patients. The multiple scenario assessment provided a moderately reliable team score. The greater scores achieved by PICU intensivist-in-training-led teams provides some evidence to support the validity of the assessment.

Electronic approaches to making sense of the text in the adverse event reporting system

INTRODUCTION

Health care organizations working to eliminate preventable harm and to improve patient safety must have robust programs to collect and to analyze data on adverse events in order to use the information to affect improvement. Such adverse event reporting systems are based on frontline personnel reporting issues that arise in the course of their daily work. Limitations in how existing software systems handle these reports mean that use of this potentially rich information is resource intensive and prone to variable results.

AIM

The aim of this study was to develop an electronic approach to processing the text in medical event reports that would be reliable enough to be used to improve patient safety.

METHODS

At Connecticut Children's Medical Center, staff manually enter reports of adverse events into a web-based software tool. We evaluated the ability of 2 electronic methods-rule-based query and semi-supervised machine learning-to identify specific types of events ("use cases") versus a reference standard. Rule-based query was tested on 5 use cases and machine learning on a subset of 2 using 9164 events reported from February 2012-January 2014.

RESULTS

Machine learning found 93% of the weight-based errors and 92% of the errors in patient-identification. Rule-based query had accuracy of 99% or greater, high precision, and high recall for all use cases.

CONCLUSIONS

Electronic approaches to streamlining the use of adverse event reports are feasible to automate and valuable for categorizing this important data for use in improving patient safety.

Frequency of medical emergency team activation prior to pediatric cardiopulmonary resuscitation

BACKGROUND

Medical Emergency Teams (METs) are designed to respond to signs of clinical decline in order to prevent cardiopulmonary arrest and reduce mortality. The frequency of MET activation prior to pediatric cardiopulmonary resuscitation (CPR) is unknown.

METHODS

Within the Get With The Guidelines-Resuscitation Registry (GWTG-R), we identified children with bradycardia or cardiac arrest requiring CPR on the general inpatient or telemetry floors from 2007 to 2013. We examined the frequency with which CPR outside the ICU was preceded by a MET evaluation. In cases where MET evaluation did not occur, we examined the frequency of severely abnormal vital signs at least 1hour prior to CPR that could have prompted a MET evaluation but did not.

RESULTS

Of 215 children from 23 hospitals requiring CPR, 48 (22.3%) had a preceding MET evaluation. Children with MET evaluation prior to CPR were older (6.8±6.5 vs. 3.1±4.7 years of age, p<0.001) and were more likely to have metabolic/electrolyte abnormalities (18.8% vs. 5.4%, p=0.006), sepsis (16.7% vs. 4.8%, p=0.01), or malignancy (22.9% vs. 5.4%, p<0.001). Among patients who did not have a MET called and with information on vital signs, 55/141 (39.0%) had at least one abnormal vital sign that could have triggered a MET.

CONCLUSION

The majority of pediatric patients requiring CPR for bradycardia or cardiac arrest do not have a preceding MET evaluation despite a significant number meeting criteria that could have triggered the MET. This suggests opportunities to more efficiently use MET teams in routine care.

Paediatric early warning systems for detecting and responding to clinical deterioration in children: a systematic review

OBJECTIVE

To systematically review the available evidence on paediatric early warning systems (PEWS) for use in acute paediatric healthcare settings for the detection of, and timely response to, clinical deterioration in children.

METHOD

The electronic databases PubMed, MEDLINE, CINAHL, EMBASE and Cochrane were searched systematically from inception up to August 2016. Eligible studies had to refer to PEWS, inclusive of rapid response systems and teams. Outcomes had to be specific to the identification of and/or response to clinical deterioration in children (including neonates) in paediatric hospital settings (including emergency departments). 2 review authors independently completed the screening and selection process, the quality appraisal of the retrieved evidence and data extraction; with a third reviewer resolving any discrepancies, as required. Results were narratively synthesised.

RESULTS

From a total screening of 2742 papers, 90 papers, of varied designs, were identified as eligible for inclusion in the review. Findings revealed that PEWS are extensively used internationally in paediatric inpatient hospital settings. However, robust empirical evidence on which PEWS is most effective was limited. The studies examined did however highlight some evidence of positive directional trends in improving clinical and process-based outcomes for clinically deteriorating children. Favourable outcomes were also identified for enhanced multidisciplinary team work, communication and confidence in recognising, reporting and making decisions about child clinical deterioration.

CONCLUSIONS

Despite many studies reporting on the complexity and multifaceted nature of PEWS, no evidence was sourced which examined PEWS as a complex healthcare intervention. Future research needs to investigate PEWS as a complex multifaceted sociotechnical system that is embedded in a wider safety culture influenced by many organisational and human factors. PEWS should be embraced as a part of a larger multifaceted safety framework that will develop and grow over time with strong governance and leadership, targeted training, ongoing support and continuous improvement.

Rapid response systems: a systematic review and meta-analysis

INTRODUCTION

Although rapid response system teams have been widely adopted by many health systems, their effectiveness in reducing hospital mortality is uncertain. We conducted a meta-analysis to examine the impact of rapid response teams on hospital mortality and cardiopulmonary arrest.

METHOD

We conducted a systematic review of studies published from January 1, 1990, through 31 December 2013, using PubMed, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and the Cochrane Library. We included studies that reported data on the primary outcomes of ICU and in-hospital mortality or cardiopulmonary arrests.

RESULTS

Twenty-nine eligible studies were identified. The studies were analysed in groups based on adult and paediatric trials that were further sub-grouped on methodological design. There were 5 studies that were considered either cluster randomized control trial, controlled before after or interrupted time series. The remaining studies were before and after studies without a contemporaneous control. The implementation of RRS has been associated with an overall reduction in hospital mortality in both the adult (RR 0.87, 95 % CI 0.81-0.95, p<0.001) and paediatric (RR=0.82 95 % CI 0.76-0.89) in-patient population. There was substantial heterogeneity in both populations. The rapid response system team was also associated with a reduction in cardiopulmonary arrests in adults (RR 0.65, 95 % CI 0.61-0.70, p<0.001) and paediatric (RR=0.64 95 % CI 0.55-0.74) patients.

CONCLUSION

Rapid response systems were associated with a reduction in hospital mortality and cardiopulmonary arrest. Meta-regression did not identify the presence of a physician in the rapid response system to be significantly associated with a mortality reduction.

Evaluating processes of care and outcomes of children in hospital (EPOCH): study protocol for a randomized controlled trial

Background

The prevention of near and actual cardiopulmonary arrest in hospitalized children is a patient safety imperative. Prevention is contingent upon the timely identification, referral and treatment of children who are deteriorating clinically. We designed and validated a documentation-based system of care to permit identification and referral as well as facilitate provision of timely treatment. We called it the Bedside Paediatric Early Warning System (BedsidePEWS). Here we describe the rationale for the design, intervention and outcomes of the study entitled Evaluating Processes and Outcomes of Children in Hospital (EPOCH).

Methods/Design

EPOCH is a cluster-randomized trial of the BedsidePEWS. The unit of randomization is the participating hospital. Eligible hospitals have a Pediatric Intensive Care Unit (PICU), are anticipated to have organizational stability throughout the study, are not using a severity of illness score in hospital wards and are willing to be randomized. Patients are >37 weeks gestational age and <18 years and are hospitalized in inpatient ward areas during all or part of their hospital admission.

Randomization is to either BedsidePEWS or control (no severity of illness score) in a 1:1 ratio within two strata (<200, ≥200 hospital beds). All-cause hospital mortality is the selected primary outcome. It is objective, independent of do-not-resuscitate status and can be reliably measured. The secondary outcomes include (1) clinical outcomes: clinical deterioration, severity of illness at and during ICU admission, and potentially preventable cardiac arrest; (2) processes of care outcomes: immediate calls for assistance, hospital and ICU readmission, and perceptions of healthcare professionals; and (3) resource utilization: ICU days and use of ICU therapies.

Discussion

Following funding by the Canadian Institutes of Health Research and local ethical approvals, site enrollment started in 2010 and was closed in February 2014. Patient enrollment is anticipated to be complete in July 2015. The results of EPOCH will strengthen the scientific basis for local, regional, provincial and national decision-making and for the recommendations of national and international bodies. If negative, the costs of hospital-wide implementation can be avoided. If positive, EPOCH will have provided a scientific justification for the major system-level changes required for implementation.

Trial registration: NCT01260831 ClinicalTrials.gov date: 14 December 2010.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0712-3) contains supplementary material, which is available to authorized users.

Characteristics and outcomes of pediatric rapid response teams before and after mandatory triggering by an elevated Pediatric Early Warning System (PEWS) score

BACKGROUND

The Pediatric Early Warning System (PEWS) was created to identify unstable patients before their deterioration. Rapid response teams (RRTs) were developed to assist with management of such patients. In 2009, our institution mandated the activation of RRTs if a PEWS score was elevated (ie, ≥5).

OBJECTIVES

The goal of this study was to examine changes in characteristics of RRT calls before and after the implementation of a mandatory hospital policy requiring RRT activation due to an elevated PEWS score.

METHODS

This study was a retrospective database review, with RRT data from June 2007 to December 2010 examined. A total of 44 RRTs were recorded before mandatory triggering and 69 RRTs afterward in the study period (P = .32).

RESULTS

Compared with the premandatory group, the mandatory triggering group found that tachycardia was a more frequent trigger for RRTs, with an increase of 26.1% (P = .004). RRTs triggered by a change in mental status/agitation decreased by 22.9% (P = .009). An increase of 15.1% of RRTs required no interventions with mandatory triggering. Nighttime RRTs increased by17.5% (P = .07). There was a trend toward decreased PICU transfers in the mandatory triggering group, with no significant change in code blue calls.

CONCLUSIONS

A hospital policy of mandating RRT activation based on PEWS scores increased nighttime calls and altered the primary reasons for RRT activation in our center, with no evidence of improvements in patient care. These findings should be interpreted with caution given the relatively rare outcomes the policy is intended to prevent; however, our findings highlight the difficulties inherent in evaluating methods to improve pediatric patient safety.

Clinical profile of children requiring early unplanned admission to the PICU

OBJECTIVE

The goal of this study was to describe the frequency, characteristics, and outcomes of children who require early unplanned admission to the PICU within 24 hours of hospitalization from the emergency department.

METHODS

This study was a retrospective audit of 24 months of prospectively collected medical emergency team records at a tertiary pediatric hospital in Canada. Our review identified 39 hospitalized children who had an activation that resulted in unplanned admission to the PICU within 24 hours of admission from the ED.

RESULTS

Forty-six percent of the study subjects were infants aged < 1 year, and 64% were male. Respiratory complaints were the most common reason for hospitalization (59%). Preexisting medical conditions (51%), abnormal respiratory rates (46%), abnormal heart rates (33%), abnormal blood gas values (49%), high supplemental oxygen requirement (23%), and treatment with nebulized medications (46%), intravenous fluids (33%), and antibiotics (33%) were common. The median time to medical emergency team activation was 9.4 hours (interquartile range: 4.4-14.5). Nearly one-half (49%) of the patients required a significant intervention after admission to the PICU, with a mean length of stay of 3.4 days and a mortality rate of 50/%.

CONCLUSIONS

Male subjects, infants aged < 1 year, and children with respiratory complaints accounted for a large proportion of children requiring early unplanned admission to the PICU within 24 hours of hospitalization from the ED. Further studies are required to determine which factors are associated with deterioration after hospitalization.

Prevalence, characteristics, and opinions of pediatric rapid response teams in the United States

OBJECTIVE

Rapid response teams (RRTs) have been proposed as patient safety initiatives for hospitalized children. The aim of this study was to determine the prevalence, characteristics, and opinions of RRTs in hospitals with PICUs in the United States.

METHODS

This study was conducted as a cross-sectional survey of PICU physicians in adult and children's hospitals that care for children. One survey was sent to the PICU medical director in each hospital. The primary outcome was the presence of an RRT. Other outcomes included RRT characteristics and beliefs regarding their impact on patient safety.

RESULTS

The survey response rate was 64% (134 of 210). Of the responding institutions, 79% (103) had an RRT; most of these teams were implemented in the last 5 years. Family activation was present in 69%, and automatic triggers existed in 34% of cases. RRTs included a median of 3 members and were composed of physicians in 77%, nurses in 100%, and respiratory therapists in 89% of institutions. Respondents with RRTs were more likely to agree that RRTs improve patient safety than respondents without RRTs (76% vs 52%) and more likely to disagree that they are not worth the money invested (82% vs 63%).

CONCLUSIONS

Although the evidence and opinions on the benefit of RRTs are mixed, the majority of US hospitals with PICUs have implemented RRTs. These systems demonstrate variability in activation mechanisms and team composition. Hospitals may be empirically adopting these initiatives without knowledge of the specific characteristics that are optimal for patient outcomes.

Beyond statistical prediction: qualitative evaluation of the mechanisms by which pediatric early warning scores impact patient safety

BACKGROUND

Early warning scores (EWSs) assign points to clinical observations and generate scores to help clinicians identify deteriorating patients. Despite marginal predictive accuracy in retrospective datasets and a paucity of studies prospectively evaluating their clinical effectiveness, pediatric EWSs are commonly used.

OBJECTIVE

To identify mechanisms beyond their statistical ability to predict deterioration by which physicians and nurses use EWSs to support their decision making.

DESIGN

Qualitative study.

SETTING

A children's hospital with a rapid response system.

PARTICIPANTS

Physicians and nurses who recently cared for patients with false-positive and false-negative EWSs (score failures).

INTERVENTION

Semistructured interviews.

MEASUREMENTS

Themes identified through grounded theory analysis.

RESULTS

Four themes emerged among the 57 subjects interviewed: (1) The EWS facilitates safety by alerting physicians and nurses to concerning changes and prompting them to think critically about deterioration. (2) The EWS provides less-experienced nurses with vital sign reference ranges. (3) The EWS serves as evidence that empowers nurses to overcome barriers to escalating care. (4) In stable patients, those with baseline abnormal physiology, and those experiencing neurologic deterioration, the EWS may not be helpful.

CONCLUSIONS

Although pediatric EWSs have marginal performance when applied to datasets, clinicians who recently experienced score failures still considered them valuable to identify deterioration and transcend hierarchical barriers. Combining an EWS with a clinician's judgment may result in a system better equipped to respond to deterioration than retrospective data analyses alone would suggest. Future research should seek to evaluate the clinical effectiveness of EWSs in real-world settings.

Impact of an intensivist-led multidisciplinary extended rapid response team on hospital-wide cardiopulmonary arrests and mortality

OBJECTIVE

The effectiveness of rapid response teams remains controversial. However, many studied rapid response teams were not intensivist-led, had limited involvement beyond the initial activations, and did not provide post-ICU follow-up. The objective of this study was to examine the impact of implementing an intensivist-led multidisciplinary extended rapid response team on hospital-wide cardiopulmonary arrests and mortality.

DESIGN

This was a pre-post rapid response team implementation study.

SETTING

: Tertiary care academic center in Saudi Arabia.

PATIENTS

A total of 98,391 patients in the 2-yr pre-rapid response team and 157,804 patients in the 3-yr post-rapid response team implementation were evaluated.

INTERVENTION

The rapid response team was activated by any health care provider based on pre-defined criteria and a four-member intensivist-led multidisciplinary rapid response team responded to provide the necessary management and disposition. The rapid response team function was extended to provide follow-up until clinical stabilization. In addition, the rapid response team provided a mandatory post-ICU follow-up for a minimum of 48 hrs.

MEASUREMENTS AND MAIN RESULTS

The primary outcomes were cardiopulmonary arrests and mortality. After rapid response team implementation, non-ICU cardiopulmonary arrests decreased from 1.4 to 0.9 per 1,000 hospital admissions (relative risk, 0.68; 95% confidence interval, 0.53-0.86; p = 0.001) and total hospital mortality decreased from 22.5 to 20.2 per 1,000 hospital admissions (relative risk, 0.90; 95% confidence interval, 0.85-0.95; p < 0.0001). For patients who required admission to the ICU, there was a significant reduction in the Acute Physiology and Chronic Health Evaluation II scores after rapid response team implementation from 29.3 ± 9.3 to 26.9 ± 8.5 (p < 0.0001), with reduction in hospital mortality from 57.4% to 48.7% (relative risk, 0.85; 95% confidence interval, 0.78-0.92; p < 0.0001). Do-not-resuscitate orders for ward referrals increased from 0.7 to 1.7 per 1,000 hospital admissions (relative risk, 2.58; 95% confidence interval, 1.95-3.42; p < 0.0001) and decreased for patients admitted to ICU from the wards from 30.5% to 26.1% (relative risk, 0.86; 95% confidence interval, 0.74-0.99; p = 0.03). Additionally, ICU readmission rate decreased from 18.6 to 14.3 per 100 ICU alive discharges (relative risk, 0.77; 95% confidence interval, 0.66-0.89; p < 0.0001) and post-ICU hospital mortality from 18.2% to 14.8% (relative risk, 0.85; 95% confidence interval, 0.72-0.99; p = 0.04).

CONCLUSION

The implementation of rapid response team was effective in reducing cardiopulmonary arrests and total hospital mortality for ward patients, improving the outcomes of patients who needed ICU admission and reduced readmissions and mortality of patients who were discharged from the ICU.

The Cardiac Children's Hospital Early Warning Score (C-CHEWS)

Inpatient pediatric cardiovascular patients have higher rates of cardiopulmonary arrests than other hospitalized children. Pediatric early warning scoring tools have helped to provide early identification and treatment to hospitalized children experiencing deterioration thus preventing arrests from occurring. However, the tools have rarely been used and have not been validated in the pediatric cardiac population. This paper describes the modification of a pediatric early warning scoring system for cardiovascular patients, the implementation of the tool, and its companion escalation of care algorithm on an inpatient pediatric cardiovascular unit.

Rapid-response systems as a patient safety strategy: a systematic review

Rapid-response systems (RRSs) are a popular intervention in U.S. hospitals and are supported by accreditors and quality improvement organizations. The purpose of this review is to evaluate the effectiveness and implementation of these systems in acute care settings. A literature search was performed between 1 January 2000 through 30 October 2012 using PubMed, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials. Studies published in any language evaluating outcome changes that occurred after implementing an RRS and differences between groups using and not using an RRS (effectiveness) or describing methods used by RRSs (implementation) were reviewed. A single reviewer (checked by a second reviewer) abstracted data and rated study quality and strength of evidence. Moderate-strength evidence from a high-quality meta-analysis of 18 studies and 26 lower-quality before-and-after studies published after that meta-analysis showed that RRSs are associated with reduced rates of cardiorespiratory arrest outside of the intensive care unit and reduced mortality. Eighteen studies examining facilitators of and barriers to implementation suggested that the rate of use of RRSs could be improved.

Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events

BACKGROUND AND OBJECTIVE

Failure to recognize and treat clinical deterioration remains a source of serious preventable harm for hospitalized patients. We designed a system to identify, mitigate, and escalate patient risk by using principles of high-reliability organizations. We hypothesized that our novel care system would decrease transfers determined to be unrecognized situation awareness failures events (UNSAFE). These were defined as any transfer from an acute care floor to an ICU where the patient received intubation, inotropes, or ≥ 3 fluid boluses in first hour after arrival or before transfer.

METHODS

The setting for our observational time series study was a quaternary care children's hospital. Before initiating tests of change, 2 investigators reviewed recent serious safety events (SSEs) and floor-to-ICU transfers. Collectively, 5 risk factors were associated with each event: family concerns, high-risk therapies, presence of an elevated early warning score, watcher/clinician gut feeling, and communication concerns. Using the model for improvement, an intervention was developed and tested to reliably and proactively identify patient risk and mitigate that risk through unit-based huddles. A 3-times daily inpatient huddle was added to ensure risks were escalated and addressed. Later, a "robust" and explicit plan for at-risk patients was developed and spread.

RESULTS

The rate of UNSAFE transfers per 10,000 non-ICU inpatient days was significantly reduced from 4.4 to 2.4 over the study period. The days between inpatient SSEs also increased significantly.

CONCLUSIONS

A reliable system to identify, mitigate, and escalate risk was associated with a near 50% reduction in UNSAFE transfers and SSEs.

Rapid response systems: identification and management of the "prearrest state"

Rapid response systems (RRS) are both intuitive and supported by data, but the institution of an RRS is not a panacea for in-hospital cardiac arrest or unexpected deaths. RRS implementation should be one component of an institution-wide effort to improve patient safety that includes adequate nursing education and staffing, availability and involvement of a patient's primary caregivers, and hospital provision of sufficient resources and efficiency.

Rapid response team in an academic institution: does it make a difference?

BACKGROUND

Although data remain contradictory, rapid response systems are implemented across US hospitals. We aimed to determine whether implementation of a rapid response team (RRT) in a tertiary academic hospital improved outcomes.

METHODS

Our hospital is a tertiary academic medical center with 24-h in-house resident coverage. We conducted a retrospective cohort study comparing 27 months after implementation of the RRT (April 1, 2006, to June 31, 2008) and 9 months before (January 1, 2005, to September 31, 2005). Outcomes included incidence of codes (cardiac and/or respiratory arrests), outcome of the codes, and overall hospital mortality.

RESULTS

We analyzed 16,244 nonobstetrics hospital admissions and 70,208 patient days in the control period and 45,145 nonobstetrics hospital admissions and 161,097 patient days after the RRT was implemented. The RRT was activated 1,206 times (7.7 calls per 1,000 patient days). There was no difference in the code rate (0.83 vs 0.98 per 1,000 patient days, P = .3). There was a modest but nonsustained improvement in nonobstetrics hospital mortality during the study period (2.40% vs 2.15%; P = .05), which could not be explained by the RRT effect on code rates. The mortality was 2.40% in the control group and 2.06%, 1.94%, and 2.46%, respectively, during the next three consecutive 9-month intervals.

CONCLUSIONS

In our single-institution study involving an academic hospital with 24-h in-house coverage, we found that RRT implementation did not reduce code rates in the 27 months after intervention. Although there was a decrease in overall hospital mortality, this decrease was small, nonsustained, and not explained by the RRT effect on code rates.

An implementation strategy for a multicenter pediatric rapid response system in Ontario

A rapid response system using a medical emergency team was implemented across four pediatric hospitals in Ontario, Canada, in a social marketing approach.

Successful use of a rapid response team in the pediatric oncology outpatient setting

In a clinic setting, the RRT, in conjunction with the ICU intensivist, succesfully treated a septic patient with fluid resuscitation and a vasoactive medication, and subsequently facilitated a quick transport to a higher level of care. St. Jude Children's Research Hospital's successful use of the RRT in the clinic setting suggests that RRTs can be used to improve patient outcomes across the spectrum of inpatient as well as outpatient hospital settings. Our experience suggests that RRTs can be beneficial in filling a gap in patient safety in outpatient clinics.

Reduction of hospital mortality and of preventable cardiac arrest and death on introduction of a pediatric medical emergency team

OBJECTIVE

To determine the effect of a medical emergency team (MET) on the incidence of unexpected cardiac arrest and death.

DESIGN

Comparison of retrospective data (pre-MET) before introduction of MET with prospective data after introduction of MET system (post-MET).

SETTING

Tertiary care pediatric hospital.

PATIENTS

A total of 104,780 admissions during a 41-month period pre-MET; 138,424 admissions during 48 months post-MET.

INTERVENTIONS

Introduction of a MET.

RESULTS

Total hospital deaths decreased from 4.38 to 2.87/ 1000 admissions (risk ratio 0.65, 95% confidence interval [CI] 0.57-0.75, p < 0.0001). Ward unexpected death decreased from 13 (0.12/1000) to 6 (0.04/1000) (risk ratio 0.35, 95% CI 0.13- 0.92, p = 0.03) but unexpected cardiac arrests did not change from 0.19/1000 to 0.17/1000 (risk ratio 0.91, 95% CI 0.50 -1.64, p = 0.75). Thirty-four hospital deaths, including three unexpected deaths (1 out of 72 MET calls), were prevented each year of MET operation. Preventable cardiac arrest (children whose symptoms or signs fulfilled MET calling criteria) decreased from 17 (0.16/ 1000) to 10 (0.07/1000) (risk ratio 0.45, 95% CI 0.20-0.97, p = 0.04) and in whom death decreased from 12 to 2 (0.11/1000 to 0.01/1000) (risk ratio 0.13, 95% CI 0.03-0.56, p = 0.001). Nonpreventable cardiac arrest (children whose symptoms or signs did not fulfill MET calling criteria) increased from 3 to 14 (0.03/1000 to 0.10/1000, p = 0.03) but death did not increase. Survival from cardiac arrest increased from 7 of 20 patients to 17 of 23 (risk ratio 2.11, 95% CI 1.11- 4.02, p = 0.01). Annual calls for urgent assistance were 202 in the post-MET era and 46 during the pre-MET era (ratio 4.4:1).

CONCLUSIONS

Introduction of a MET was associated with reduction of total hospital death and reduction of preventable cardiac arrest and death with increased survival in wards of a pediatric hospital. MET calling criteria identified some but not all children at risk of unexpected cardiac arrest and death.

Clinical triggers: an alternative to a rapid response team

DHMC's clinical triggers program is a promising approach that addresses an unmet patient need. We have seen dramatic reductions in our non-ICU cardiopulmonary arrest rates, along with our ICU bounceback rates. In the context of our hospital, this program aligns well with our teaching mission while maximizing the resources that are currently available. RRTs are certainly one way to prevent the unnoticed deterioration of patients, but programs such as ours, which focus on prevention of ongoing deterioration, may yield more benefit for the patients in institutions similar to DHMC. Although our study does not alter the weight of evidence in the literature, it does offer a new focus on the afferent limb by clarifying the expectations of the primary responders. This was the essence of the deficiency in the aforementioned case study. Death is the natural, albeit sad, endpoint of all lives; the overarching goal of DHMC's clinical triggers system is to prevent the premature death of a hospitalized patient and thereby improve patient safety.

Paediatric Rapid Response Systems: a literature review

BACKGROUND

Paediatric cardiorespiratory arrest carries a poor prognosis. The most common cause is respiratory insufficiency or hypotension/shock, which can be reversible. The use of RRSs in adult hospitals that proactively intervene when signs of physiological instability occur is widespread and increasing although the level of evidence for their efficiency is a matter of debate.

METHODS

A systematic literature review was undertaken to evaluate and summarise the current knowledge about paediatric RRSs.

RESULTS

Paediatric RRSs are in use in several places around the world. One study shows a statistically significant decrease in mortality rate after implementation. Two studies show a non-significant association with decreased mortality rate. Cardiac and/or respiratory arrest rates decreased in all four before-after studies with statistical significance in two.

CONCLUSIONS

Cardiac arrest and death are rare in paediatric hospitals, which can in part explain the difficulties to demonstrate statistically significant benefits. There are also specific problems regarding calling criteria due to age related physiological diversity as well as chronic disease.

Medical emergency and rapid response teams

Hospitals that care for children are establishing medical emergency or rapid response teams as system solutions for preventing unexpected but foreseeable respiratory and cardiac arrest on inpatient units. Typically, an experienced team of doctors and nurses responds quickly to a direct request by any level of staff or even a parent for assistance with a child whose physiologic parameters meet predetermined criteria or whose condition causes concern to them. Several pediatric studies comparing outcomes before and after introduction of these rapid response systems reported reductions in rates of respiratory or cardiac arrest and death but no prospective study has compared pediatric hospitals that have implemented rapid response teams to hospitals that have not.

Clinical profile of hospitalized children provided with urgent assistance from a medical emergency team

OBJECTIVE

The purpose of this work was to describe the frequency, characteristics, and outcomes of critical events and hospitalized children requiring medical emergency team review.

PATIENTS AND METHODS

We conducted an audit of prospectively collected medical emergency team forms and a retrospective review of medical charts during an 18-month period at a tertiary pediatric hospital in Australia. Critical events were defined as cardiac arrest, endotracheal intubation on the ward, reversal of analgesia or sedation, fluid resuscitation at >/=40 mL/kg, hyponatremia (serum sodium level of </=125 mmol/L), hypernatremia (serum sodium level of >/=155 mmol/L), hypoglycemia (glucose level of </=2 mmol/L), or severe metabolic acidosis (pH </= 7.1).

RESULTS

A total of 172 children had 225 medical emergency team calls (10.6 calls per 1000 hospital admissions and 2.0 calls per 1000 patient-days). Forty-two percent of calls were for infants <1 year old. Preexisting chronic disease was common, with 20% having a chronic underlying neurologic disorder. Forty-four percent of the children were postoperative. The mortality rate of the 172 children was 7.6% in the hospital and 13.4% within 1 year. Thirty-three children had a critical event, with reversal of analgesia being the most common event (n = 11). Postoperative children were more frequently seen in the critical-event group (64% vs 40%). Hospital and 1-year mortality rates were higher for children who had a critical event (16.1% vs 22.6%, respectively) than those who did not (5.7% vs 11.3%).

CONCLUSIONS

Chronic and complex illnesses were prevalent among children provided with urgent medical assistance from the medical emergency team in a tertiary hospital. Children in the postoperative phase were overrepresented among those with a critical event. A critical event significantly increased the risk of hospital mortality. Greater knowledge of high-risk groups is required to further improve outcomes for hospitalized children.