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

Optimizing Pediatric Rapid Response Teams: Stakeholder Focus Groups

OBJECTIVES

Rapid response teams (RRTs) can improve outcomes in both adult and pediatric hospitals. Most pediatric hospitals have RRT-type systems; however, little is known about stakeholders' perspectives regarding how to optimize RRT quality and efficiency. We aimed to better understand multidisciplinary stakeholder perspectives on how to improve the RRT process.

METHODS

We held 4 stakeholder focus groups including floor nurses, pediatric trainees (interns and residents), pediatric hospitalists, and the responding PICU team (PICU fellows and nurses). We used deductive coding to identify potential solutions and subsequent themes.

RESULTS

Focus groups identified 10 potential solutions within 3 major themes. Themes included (1) the value of a standardized RRT workflow based on stages, (2) the benefit of promoting a safety culture, and (3) the need to implement ongoing RRT education. Stakeholders described a shared mental model of RRT workflow with important events or tasks occurring within each stage. These stages were coded as 1: trigger, 2: team arrival and information sharing, 3: intervention, and 4: disposition and follow-up. Additional proposed solutions included waiting for the entire team to arrive, a systematic information sharing process, and closed loop communication for follow-up plans for patients remaining on the general care floor.

CONCLUSIONS

RRT stakeholder focus groups provide valuable insight into efforts to optimize RRT events. Standardizing RRT workflow into a staged process may facilitate communication and information sharing. Promoting a culture of safety and implementing ongoing education may help reinforce RRT standardization.

How do we detect and respond to clinical deterioration in hospitalized children? Results of the Pediatric Care BefOre Deterioration Events (CODE) survey

Systems to detect and respond to deteriorating hospitalized children are common despite little evidence supporting best practices. Our objective was to describe systems to detect/respond to deteriorating hospitalized children at Pediatric Resuscitation Quality Collaborative (pediRES-Q) institutions. We performed a cross-sectional survey of pediRES-Q leaders. Questionnaire design utilized expert validation and cognitive interviews. Thirty centers (88%) responded. Most (93%) used ≥1 system to detect deterioration: most commonly, early warning scores (83%), watcher lists (55%), and proactive surveillance teams (31%). Most (90%) had a team to respond to deteriorating patients and the majority of teams could be activated by clinician or family concerns. Most institutions (90%) collect relevant data, including number of rapid responses (88%), arrests outside intensive care units (100%), and serious safety events (88%). In conclusion, most pediRES-Q institutions utilize systems to detect/respond to deteriorating hospitalized children. Heterogeneity exists among programs. Rigorous evaluation is needed to identify best practices.

Patients Undergoing Elective Inpatient Major Therapeutic Procedures in Florida Had No Significant Change in Hospital Mortality or Mortality-Related Comorbidities Between 2007 and 2019

BACKGROUND

In a recent study, rapid response team implementation at 1 hospital was associated with only a 0.1% reduction in inpatient mortality from 2005 to 2018, characterized in the accompanying editorial as a "tepid" improvement. The editorialist postulated that an increase in the degree of illness of hospitalized patients might have masked a larger reduction that otherwise might have occurred. Impressions of greater patient acuity during the studied period might have been an artifact of efforts to document more comorbidities and complications, possibly facilitated by the change in diagnosis coding from the International Classification of Diseases , Ninth Revision ( ICD-9 ) to the Tenth Revision ( ICD-10 ).

METHODS

We used inpatient data from every nonfederal hospital in Florida from the last quarter of 2007 through 2019. We studied hospitalizations for major therapeutic surgical procedures with lengths of stay ≥2 days. Using logistic regression with clustering by the Clinical Classification Software (CCS) code of the primary surgical procedure, we evaluated the trends for decreased mortality, changes in the prevalence of Medicare Severity Diagnosis Related Groups (MS-DRG) with complications or comorbidities (CC) or major complications or major comorbidities (MCC), and changes in the van Walraven index (vWI), a measure of patient comorbidities associated with increased inpatient mortality. Also incorporated in the modeling was the change from ICD-9 to ICD-10 .

RESULTS

There were 3,151,107 hospitalizations comprising 130 distinct CCS codes and 453 MS-DRG groups among 213 hospitals. Despite a progressive increase of 4.1% per year in the odds of a CC or MCC ( P = .001), there were no significant changes in the marginal estimates of in-house mortality over time (net estimated decrease, 0.036%; 99% confidence interval [CI], -0.168% to 0.097%; P = .49). There was also absence of a significantly greater fraction of discharges with vWI >0 attributable to the year of the study (odds ratio, 1.017 per year; 99% CI, 0.995-1.041). The changes in MS-DRG to those with CC or MCC were not increased significantly from either the ICD-10 coding change or the number of years after the change.

CONCLUSIONS

Consistent with the previous study, there was at most a small decrease in the mortality rate over a 12-year period. We found no reliable evidence that patients undergoing elective inpatient surgical procedures were any sicker in 2019 than in 2007. There were substantively more comorbidities and complications documented over time, but this was unrelated to the change to ICD-10 coding.

Implementation of a non-intensive-care unit medical emergency team improves failure to rescue rates in cardiac surgery patients

OBJECTIVE

Failure to rescue (FTR) is an emerging measure in cardiac surgery, defined as mortality after a postoperative complication. We hypothesized that establishing a medical emergency team (MET) reduced rates of FTR in adults undergoing cardiac surgery.

METHODS

All patients (N = 11,218) undergoing a The Society of Thoracic Surgeons index operation at our center (1994-2018) were stratified by pre-MET or MET era based on the 2009 institutional implementation of a MET to respond to clinical decompensation in non-intensive-care patients. Patients missing The Society of Thoracic Surgeons predicted risk of mortality were excluded from all cohorts. Risk adjusted multivariable regression analyzed the association of postoperative complications, operative mortality, and FTR by era. Nearest neighbor propensity score matching utilizing patients' The Society of Thoracic Surgeons predicted risk of mortality was performed to create balanced control and exposure groups for secondary subgroup analysis.

RESULTS

In the risk-adjusted multivariable analysis, surgery during the MET era was associated with decreased mortality (odds ratio [OR], 0.51; 95% CI, 0.45-0.77; P < .001), postoperative renal failure (OR, 0.57; 95% CI, 0.46-0.70; P < .001), reoperation (OR, 0.75; 95% CI, 0.59-0.95; P = .017), and deep sternal wound infection (OR, 0.16; 95% CI, 0.04-0.45; P = .002). Surgery performed during the MET era was associated with a decreased rate of FTR in the risk-adjusted analysis (OR, 0.46; 95% CI, 0.34-0.70; P < .001).

CONCLUSIONS

The development of an institutional MET program was associated with a decrease in major complications and FTR. These findings support the development of MET programs to improve FTR after cardiac surgery.

Admission Source Is Associated With the Risk of Rapid Response Team Activation in a Children's Hospital

OBJECTIVE

To evaluate source of admission to a children's hospital as a predictor of rapid response team (RRT) activation, both in the first 48 hours of admission and over the entire hospitalization.

METHODS

Retrospective cohort study of all patients admitted to the pediatric ward between March 1, 2013 and December 31, 2015. Source of admission was categorized as from the emergency department, transfer from another hospital facility, admission following a planned surgery, direct admission planned in advance, or unplanned direct admission. Information was collected including whether or not the patient had a RRT activation and survival to discharge. A Fisher's exact test was used to assess the association between source of admission and risk of rapid response.

RESULTS

Of 8083 admissions included in the study, 194 had at least one RRT event. The odds of having an RRT was significantly associated with source of admission (P < .001). Using admission from the emergency department as a reference group, planned elective admissions (odds ratio [OR] 0.27; P < .001) and admissions following planned surgery (OR 0.07; P < .001) were significantly associated with reduced odds of having at least one RRT activation during the admission. Planned elective admissions also demonstrated reduced odds of RRT in the first 48 hours of hospitalization (OR 0.14; P = .002). Source of admission was also associated with survival to discharge (P < .05).

CONCLUSION

Source of admission is associated with likelihood of RRT activation as well as with survival to discharge and should be considered by providers when assessing inpatient risk of decompensation.

Capturing Parents' Perspectives of Child Wellness to Support Identification of Acutely Unwell Children in the Emergency Department

OBJECTIVE

Early signs of serious illness can be difficult to recognize in children and a delayed response can result in poor outcomes. Drawing on the unique knowledge of parents and carers may improve identification of the deteriorating child. However, there is a lack of evidence exploring parental perspectives as part of track and trigger systems. This study examines the utility of capturing parent-reported child wellness, using the Patient Wellness Questionnaire for Pediatrics, to support identification of acutely unwell children presenting to the Emergency Department.

METHODS

Parent-reported child wellness was recorded alongside the Pediatric Observation Priority Score (POPS), a multidimensional scoring system akin to a Pediatric Early Warning Score, used as part of routine care. Multiple linear regression assessed the independent effects of 3 variables (parent-reported child wellness, nurse concern, and child age) on POPS and hospital admission.

RESULTS

Data were collected for 407 children. All 3 variables explained a statistically significant proportion of variance in POPS (F(3, 403) = 7.525, P < 0.001, R2 = 0.053), with parent-reported child wellness (B = 0.223, SE = 0.054, β = 0.202, P < 0.001) having the strongest effect. Approximately 10% of the children with no physiological derangement were rated as "very poorly" by their parents.

CONCLUSIONS

The findings suggest that parents have insight in to the wellness of their children that is reflected in the physiological assessment. Some parents' perceptions about their child's wellness were not consistent with the score captured in the same assessment. More work is needed to understand how to use and address parental perspectives and concerns to support clinical decision making and the management of acute illness.

A Qualitative Analysis of Observed Behavior of Pediatric Rapid Response Team Performance

BACKGROUND AND OBJECTIVES

Pediatric rapid response teams (RRTs) enhance patient safety, reduce cardiorespiratory arrests outside the PICU, and detect deteriorating patients before decompensation. RRT performance may be affected by failures in communication, poor team dynamics, and poor shared decision-making. We aimed to describe factors associated with team performance using direct observation of pediatric RRTs.

METHODS

Our team directly observed 73 in situ RRT activations, collected field notes of qualitative data, and analyzed the data using conventional content analysis. To assess accuracy of coding, 20% of the coded observations were reassessed for interrater reliability. The codes influencing team performance were categorized as enhancers or threats to RRT teamwork and organized under themes. We constructed a framework of the codes and themes, organized along a spectrum of orderly versus chaotic RRTs.

RESULTS

Three themes influencing RRT performance were teamwork, leadership, and patient and family factors, with underlying codes that enhanced or threatened RRT performance. Novel factors that were found to threaten team performance included indecision, disruptive behavior, changing leadership, and family or patient distress. Our framework delineating features of orderly and chaotic RRTs may be used to inform training and design of RRTs to optimize performance.

CONCLUSIONS

Observations of in situ RRT activations in a pediatric hospital both verified previously described characteristics of RRTs and identified new characteristics of team function. Our proposed framework for understanding these enhancers and threats may be used to inform future interventions to improve RRT performance.

Improved outcomes after implementation of a specialized pediatric cardiac rapid response team

INTRODUCTION

The efficacy of a specialized pediatric cardiac rapid response team is unknown. We hypothesized that a specialized cardiac rapid response team would facilitate team-wide communication between the cardiac stepdown unit and cardiac intensive care unit (ICU) teams and improve patient care.

MATERIALS AND METHODS

A specialized pediatric cardiac rapid response team was implemented in June 2015. All pediatric cardiac rapid response team activations and outcomes from implementation through December 2018 were reviewed. Cardiac arrests and unplanned transfers to the cardiac ICU were indexed to 1000 patient-days to account for inpatient volume trends and evaluated over time.

RESULTS

There were 202 cardiac rapid response team activations in 108 unique patients during the study period. After implementation of the pediatric cardiac rapid response team, unplanned transfers from the cardiac stepdown unit to the cardiac ICU decreased from 16.8 to 7.1 transfers per 1000 patient days (p = 0.012). The stepdown unit cardiac arrest rate decreased from 1.2 to 0.0 arrests per 1000 patient-days (p = 0.015). There was one death on the cardiac stepdown unit in the 5 years since the implementation of the cardiac rapid response team, compared to four deaths in the previous 5 years.

CONCLUSIONS

A reduction in unplanned cardiac ICU transfers, cardiac arrests, and mortality on the cardiac stepdown unit has been observed since the implementation of a specialized pediatric cardiac rapid response team. A specialized cardiac rapid response team may improve communication and empower the interdisciplinary care team to escalate care for patients experiencing clinical decline.

The prevalence and characteristics of rapid response systems in hospitals with pediatric intensive care units in Japan and barriers to their use

OBJECTIVE

The use of pediatric rapid response systems (RRSs) to improve the safety of hospitalized children has spread in various western countries including the United States and the United Kingdom. We aimed to determine the prevalence and characteristics of pediatric RRSs and barriers to use in Japan, where epidemiological information is limited.

DESIGN

A cross-sectional online survey.

SETTING

All 34 hospitals in Japan with pediatric intensive care units (PICUs) in 2019.

PARTICIPANTS

One PICU physician per hospital responded to the questionnaire as a delegate.

MAIN OUTCOME MEASURES

Prevalence of pediatric RRSs in Japan and barriers to their use.

RESULTS

The survey response rate was 100%. Pediatric RRSs had been introduced in 14 (41.2%) institutions, and response teams comprised a median of 6 core members. Most response teams employed no full-time members and largely comprised members from multiple disciplines and departments who served in addition to their main duties. Of 20 institutions without pediatric RRSs, 11 (55%) hoped to introduce them, 14 (70%) had insufficient knowledge concerning them and 11 (55%) considered that their introduction might be difficult. The main barrier to adopting RRSs was a perceived personnel and/or funding shortage. There was no significant difference in hospital beds (mean, 472 vs. 524, P = 0.86) and PICU beds (mean, 10 vs. 8, P = 0.34) between institutions with/without pediatric RRSs.

CONCLUSIONS

Fewer than half of Japanese institutions with PICUs had pediatric RRSs. Operating methods for and obstructions to RRSs were diverse. Our findings may help to popularize pediatric RRSs.

Characteristics of Pediatric Rapid Response Systems: Results From a Survey of PRIS Hospitals

BACKGROUND

Many hospitals use rapid response systems (RRSs) to identify and intervene on hospitalized children at risk for deterioration.

OBJECTIVES

To describe RRS characteristics across hospitals in the Pediatric Research in Inpatient Settings (PRIS) network.

METHODS

We developed the survey through a series of prospective respondent, expert, and cognitive interviews. One institutional expert per PRIS hospital (n = 109) was asked to complete the web survey. We summarized responses using descriptive statistics with a secondary analysis of univariate associations between RRS characteristics and perceived effectiveness.

RESULTS

The response rate was 72% (79 of 109). Respondents represented diverse hospital types and were primarily physicians (97%) with leadership roles in care escalation. Many hospitals used an early warning score (77%) for identification with variable characteristics (46% automated versus 54% full or partially manual calculation; inputs included vital signs [98%], physical examination findings [88%], diagnoses [23%], medications [19%], and diagnostic tests [14%]). Few incorporated a validated prediction model (9%). Similarly, many RRSs used a rapid response team for intervention (93%) with variable team composition (respiratory therapists [94%], ICU nurses [93%], ICU providers [67%], and pharmacists [27%]). Some used the early warning score to trigger the rapid response team (50%). Only a few staffed a clinician to proactively surveil hospitalized children for risk of deterioration (18%), and these tended to be larger hospitals (annual admissions 12 000 vs 6000, P = .007). Most responding experts stated their RRSs improved patient outcomes (92%).

CONCLUSIONS

RRS characteristics varied across PRIS hospitals.

Emergency Medicine Physicians' Perceptions of Pediatric Tele-Emergency Services

Introduction: This study evaluated general emergency medicine (GEM) physicians' opinions on the barriers, perceptions, and utility of pediatric tele-emergency services, or the use of telemedicine for critically ill children in the emergency department (ED). Methods: Based on previously published surveys, a 27-item survey was created to assess GEM physicians' perspective on tele-emergency services provided by a regional group of pediatric critical care physicians. The survey was distributed to ED medical directors at 15 hospitals who actively participate in tele-emergency services. Results: Twelve of the 15 medical directors responded to the survey (80%). Results demonstrated that GEM physicians consider the pediatric critical care tele-emergency consultations clinically helpful (92%), particularly for the management of patients with respiratory distress, congenital anomalies, and cardiovascular processes. The most common barriers to using tele-emergency services included limited time (42%), integrating new technology and processes in existing workflows (42%), and the lack of clinical utility (42%), particularly for patients with nonacute and/or routine conditions. Lastly, half of GEM physicians felt that families preferred telemedicine to telephone consultations (50%). Conclusion: GEM physicians support the premise that pediatric tele-emergency services help with the clinical management of critically ill children. However, physicians do not consistently believe that tele-emergency services are always clinically necessary and time constraints continue to be a significant barrier. Selected use on specific clinical conditions and improving the integration in workflow processes would help increase the appropriate use of tele-emergency services in the ED.

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.

Involving patients in recognising clinical deterioration in hospital using the Patient Wellness Questionnaire: A mixed-methods study

Background

Measures exist to improve early recognition of, and response to deteriorating patients in hospital. Despite these, 7% of the deaths reported to the National Reporting and Learning System from acute hospitals in 2015 related to a failure to recognise or respond to deterioration. Interventions have been developed that allow patients and relatives to escalate patient deterioration to a critical care outreach team. However, there is not a strong evidence base for the clinical effectiveness of these interventions, or patients' ability to recognise deterioration.

Aims

The aims of this study were as follows. (a) To identify methods of involving patients in recognising deterioration in hospital, generated by health professionals. (b) To develop and evaluate an identified method of patient involvement in practice, and explore its feasibility and acceptability from the perspectives of patients.

Methods

The study used a mixed-methods design. A measure to capture patient-reported wellness during observation was developed (Patient Wellness Questionnaire) through focus group discussion with health professionals and patients, and piloted on inpatient wards.

Results

There was limited uptake where patients were asked to record ratings of their wellness using the Patient Wellness Questionnaire themselves. However, where the researcher asked patients about their wellness using the Patient Wellness Questionnaire and recorded their responses during observation, this was acceptable to most patients.

Conclusions

This study has developed a measure that can be used to routinely collect patient-reported wellness during observation in hospital and may potentially improve early detection of deterioration.

Efficacy and Safety of Pediatric Critical Care Physician Telemedicine Involvement in Rapid Response Team and Code Response in a Satellite Facility

OBJECTIVES

Satellite inpatient facilities of larger children's hospitals often do not have on-site intensivist support. In-house rapid response teams and code teams may be difficult to operationalize in such facilities. We developed a system using telemedicine to provide pediatric intensivist involvement in rapid response team and code teams at the satellite facility of our children's hospital. Herein, we compare this model with our in-person model at our main campus.

DESIGN

Cross-sectional.

SETTING

A tertiary pediatric center and its satellite facility.

PATIENTS

Patients admitted to the satellite facility.

INTERVENTIONS

Implementation of a rapid response team and code team model at a satellite facility using telemedicine to provide intensivist support.

MEASUREMENTS AND MAIN RESULTS

We evaluated the success of the telemedicine model through three a priori outcomes: 1) reliability: involvement of intensivist on telemedicine rapid response teams and codes, 2) efficiency: time from rapid response team and code call until intensivist response, and 3) outcomes: disposition of telemedicine rapid response team or code calls. We compared each metric from our telemedicine model with our established main campus model.

MAIN RESULTS

Critical care was involved in satellite campus rapid response team activations reliably (94.6% of the time). The process was efficient (median response time 7 min; mean 8.44 min) and effective (54.5 % patients transferred to PICU, similar to the 45-55% monthly rate at main campus). For code activations, the critical care telemedicine response rate was 100% (6/6), with a fast response time (median 1.5 min). We found no additional risk to patients, with no patients transferred from the satellite campus requiring a rapid escalation of care defined as initiation of vasoactive support, greater than 60 mL/kg in fluid resuscitation, or endotracheal intubation.

CONCLUSIONS

Telemedicine can provide reliable, timely, and effective critical care involvement in rapid response team and Code Teams at satellite facilities.

Is there a role for patients and their relatives in escalating clinical deterioration in hospital? A systematic review

BACKGROUND

Measures exist to improve early recognition of, and response to, deteriorating patients in hospital. However, deteriorating patients continue to go unrecognized. To address this, interventions have been developed that invite patients and relatives to escalate patient deterioration to a rapid response team (RRT).

OBJECTIVE

To systematically review articles that describe these interventions and investigate their effectiveness at reducing preventable deterioration.

SEARCH STRATEGY

Following PRISMA guidelines, four electronic databases and two web search engines were searched to identify literature investigating patient and relative led escalation.

INCLUSION CRITERIA

Articles investigating the implementation or use of systems involving patients and relatives in the detection of clinical patient deterioration and escalation of patient care to address any clinical or non-clinical outcomes were included. Articles' eligibility was validated by a second reviewer (20%).

DATA EXTRACTION

Data were extracted according to pre-defined criteria.

DATA SYNTHESIS

Narrative synthesis was applied to included studies.

MAIN RESULTS

Nine empirical studies and 36 grey literature articles were included in the review. Limited studies were conducted to establish the clinical effectiveness of patient and relative led escalation. Instead, studies investigated the impact of this intervention on health-care staff and available resources. Although appropriate, this reflects the infancy of research in this area. Patients and relatives did not overwhelm resources by activating the RRT. However, they did activate it to address concerns unrelated to patient deterioration.

CONCLUSIONS

Activating a RRT may not be the most appropriate or cost-effective method of resolving non-life-threatening concerns.

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.

Improving Pediatric Rapid Response Team Performance Through Crew Resource Management Training of Team Leaders

BACKGROUND

Rapid response teams (RRTs) improve the detection of and response to deteriorating patients. Professional hierarchies and the multidisciplinary nature of RRTs hinder team performance. This study assessed whether an intervention involving crew resource management training of team leaders could improve team performance.

METHODS

In situ observations of RRT activations were performed pre- and post-training intervention. Team performance and dynamics were measured by observed adherence to an ideal task list and by the Team Emergency Assessment Measure tool, respectively. Multiple quartile (median) and logistic regression models were developed to evaluate change in performance scores or completion of specific tasks.

RESULTS

Team leader and team introductions (40% to 90%, P = .004; 7% to 45%, P = .03), floor team presentations in Situation Background Assessment Recommendation format (20% to 65%, P = .01), and confirmation of the plan (7% to 70%, P = .002) improved after training in patients transferred to the ICU (n = 35). The Team Emergency Assessment Measure metric was improved in all 4 categories: leadership (2.5 to 3.5, P < .001), teamwork (2.7 to 3.7, P < .001), task management (2.9 to 3.8, P < .001), and global scores (6.0 to 9.0, P < .001) for teams caring for patients who required transfer to the ICU.

CONCLUSIONS

Targeted crew resource management training of the team leader resulted in improved team performance and dynamics for patients requiring transfer to the ICU. The intervention demonstrated that training the team leader improved behavior in RRT members who were not trained.

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.

Developing and evaluating the success of a family activated medical emergency team: a quality improvement report

BACKGROUND

Family-activated medical emergency teams (MET) have the potential to improve the timely recognition of clinical deterioration and reduce preventable adverse events. Adoption of family-activated METs is hindered by concerns that the calls may substantially increase MET workload. We aimed to develop a reliable process for family activated METs and to evaluate its effect on MET call rate and subsequent transfer to the intensive care unit (ICU).

METHODS

The setting was our free-standing children's hospital. We partnered with families to develop and test an educational intervention for clinicians and families, an informational poster in each patient room and a redesigned process with hospital operators who handle MET calls. We tracked our primary outcome of count of family-activated MET calls on a statistical process control chart. Additionally, we determined the association between family-activated versus clinician-activated MET and transfer to the ICU. Finally, we compared the reason for MET activation between family calls and a 2:1 matched sample of clinician calls.

RESULTS

Over our 6-year study period, we had a total of 83 family-activated MET calls. Families made an average of 1.2 calls per month, which represented 2.9% of all MET calls. Children with family-activated METs were transferred to the ICU less commonly than those with clinician MET calls (24% vs 60%, p<0.001). Families, like clinicians, most commonly called MET for concerns of clinical deterioration. Families also identified lack of response from clinicians and a dismissive interaction between team and family as reasons.

CONCLUSIONS

Family MET activations were uncommon and not a burden on responders. These calls recognised clinical deterioration and communication failures. Family activated METs should be tested and implemented in hospitals that care for children.

Cost-benefit analysis of a medical emergency team in a children's hospital

OBJECTIVES

Medical emergency teams (METs) can reduce adverse events in hospitalized children. We aimed to model the financial costs and benefits of operating an MET and determine the annual reduction in critical deterioration (CD) events required to offset MET costs.

METHODS

We performed a single-center cohort study between July 1, 2007 and March 31, 2012 to determine the cost of CD events (unplanned transfers to the ICU with mechanical ventilation or vasopressors in the 12 hours after transfer) as compared with transfers to the ICU without CD. We then performed a cost-benefit analysis evaluating varying MET compositions and staffing models (freestanding or concurrent responsibilities) on the annual reduction in CD events needed to offset MET costs.

RESULTS

Patients who had CD cost $99,773 (95% confidence interval, $69,431 to $130,116; P < .001) more during their post-event hospital stay than transfers to the ICU that did not meet CD criteria. Annual MET operating costs ranged from $287,145 for a nurse and respiratory therapist team with concurrent responsibilities to $2,358,112 for a nurse, respiratory therapist, and ICU attending physician freestanding team. In base-case analysis, a nurse, respiratory therapist, and ICU fellow team with concurrent responsibilities cost $350,698 per year, equivalent to a reduction of 3.5 CD events.

CONCLUSIONS

CD is expensive. The costs of operating a MET can plausibly be recouped with a modest reduction in CD events. Hospitals reimbursed with bundled payments could achieve real financial savings by reducing CD with an MET.