Study is first to show RRTs decrease pediatric deaths
Potential is 'dramatic'
Your hospital is likely in the process of implementing a rapid response team (RRT), if one is not already in place — but the team is probably focused on adult care. Now a small but growing number of hospitals are implementing pediatric RRTs to improve the care of children.
After a pediatric RRT was implemented at Lucile Packard Children's Hospital in Stanford, CA — a 264-bed academic children's hospital — hospital mortality rates were reduced by 18% over a 19-month period. Codes occurring outside the intensive care unit (ICU) were reduced by 72%.1
In December 2004, the Institute for Healthcare Improvement (IHI) recommended that hospitals implement RRTs as part of its 100,000 Lives campaign. But while a number of studies showed that RRTs decreased deaths and codes outside the ICU in adult inpatients, there wasn't much evidence that the same was true for children.
"There were a few other pediatric studies in the literature to help guide us," says Paul J. Sharek, MD, MPH, chief clinical patient safety officer at Lucile Packard. "The IHI recommendations were based totally on adult literature."
The hospital's journey began in 2002, when it set out to decrease the number of codes occurring outside the ICU, one of the indicators reported to the hospital's board on the quality and safety dashboard.
"We just weren't able to get improvements for that outcome measure, despite a number of expensive and thoughtful interventions," says Sharek. "For example, in part to improve this outcome, we implemented a hospitalist program." Although the quality and safety outcomes resulting from this new program are substantial, this program did not impact codes outside of the ICU setting at all, she says.
"Basically in some ways we were desperate," says Sharek. "We tried something that was not proven in pediatrics but made a whole lot of sense, and had been increasingly proven in the adult population."
Trend is growing
In 2005, Lucile Packard was one of only a handful of children's hospitals implementing an RRT. "But the landscape has changed a lot over the last couple of years," says Sharek. "Many more are attempting this now."
The hospital's patient safety department initiated the development of the RRT. "It's often the quality and safety department that ignites this intervention. They have a huge role," says Sharek. "And now that there is more supporting evidence in the pediatric literature, they are armed with a lot more information than they used to be."
Adult hospitals are also looking at implementing pediatric RRTs. "That is the question I get most frequently, 'How would you put together an RRT for children being taken care of in adult settings?'" says Sharek. "Over half the kids hospitalized in the U.S. are taken care of in adult-based settings. So that is a question that needs to be answered."
For example, hospitals want to know if they would need a separate RRT just for pediatric patients. Sharek says that ideally, the team should be comprised of pediatric specialists, but acknowledges that this is difficult for adult hospitals since their available pool of pediatric-trained staff is limited.
Still, despite the challenges, "the writing is on the wall" in terms of needing to implement RRTs for both adults and children, according to Sharek. "The evidence base is emerging from multiple angles, and there is massive pressure to implement these," he says. "The question is not if anymore — the question is how."
Two previous studies showed that pediatric RRTs decreased codes outside the ICU, but didn't demonstrate a change in mortality rates.2, 3
"Our study made the link from code decrease to mortality decrease," says Sharek. "It's a hard study to deny the findings of, truthfully. If you take care of children in your setting, you really have to strongly consider the use of these teams. The potential to decrease national mortality rates for children is dramatic."
Here are some ways to maximize the impact of a pediatric RRT:
• Encourage nurses to call the team.
Every time an RRT call is made at Lucile Packard, a debriefing meeting is held with the team to make sure the caller's concern was appreciated and there was no ill will.
"It does require a big cultural shift so nurses are not ridiculed for being too sensitive or nervous about their patients," says Sharek. "We spent a lot of time working on encouraging an environment of calling."
The goal is for nurses to feel comfortable calling the RRT, even if they just have a bad feeling about their patient.
Although many of the RRT calls at Lucile Packard were triggered by measurable changes in a patient's status — a change in breathing pattern, blood oxygen content or blood pressure — other calls were made because of a feeling that something just wasn't right. Those were the calls that turned out to be the most valuable, says Sharek.
"This gets back to the point that if the nurse feels supported, they are likely to call earlier," says Sharek. "I think we were more successful than others who implemented a pediatric RRT in part because the calls came in earlier. And we think that is because the nurses felt very supported in calling."
• Use a "patient-centric" model.
This is the key to successful RRT implementation, says Lori C. Marshall, PhD, RN, manager of patient care services at Children's Hospital Los Angeles. "Prior to implementation, you need to identify if there is resistance to the type of collaboration found in an RRT," says Marshall.
Next, build a culture that supports RRT collaboration. This means not taking away the autonomy of the primary attending physician as the decision maker, yet at the same time, giving nurses additional resources in the best interest of their patient, says Marshall.
"It is important to understand the perceptions held by the various disciplines who will be involved in RRT activation, and members of the RRT team," she says.
For responders, you have to consider their time constraints and activities that must be left when they are deployed to an RRT. For example, the team member may already be responding to a code or trauma.
"Your processes must be designed with contingencies so they function under all conditions," says Marshall.
• Implement the RRT in stages if necessary.
Children's Hospital Los Angeles chose to pilot its RRT on two units, to ensure there were enough pediatric intensive care unit (PICU) fellows to respond to calls. "We gradually spread the RRT to other inpatient areas as the numbers of PICU fellows was increased," says Marshall. "We knew by a certain date there would be a full set of resources. That became the target date to spread the change across all inpatient units."
• Collect data to measure effectiveness.
In addition to codes outside the ICU and mortality rates, IHI also recommends collecting data on the number of calls per month per number of patients, with a target of between 25 to 35 calls per 1,000 patients per month.
In addition, consider measuring satisfaction with the RRT by surveying both responders and unit staff, advises Tina Logsdon, MS, solutions manager at Child Health Corporation of America in Shawnee Mission, KS, which is spearheading an initiative to eliminate codes outside the ICU in pediatric hospitals. The initiative includes implementing, fine-tuning, and including families in pediatric RRTs, among other process changes. "Beyond that, it's difficult to find other reliable data to measure the impact of an RRT, especially once the volume of codes becomes low," she says.
To evaluate staff satisfaction, hospitals have developed a brief survey with questions such as:
For floor staff:
- Was the RRT supportive to you and the care of your patient?
- Were the RRTs assessment and recommendations helpful?
- Was the team respectful of your need for help?
For responders:
- When I arrived in the patient care area, was it clear who was requesting assistance?
- Was shifting your work assignments to accommodate your role on the team smooth or chaotic?
At Children's Hospital Los Angeles, the RRTs impact is evaluated with standardized measures that are part of the Child Health Corporation of America's Eliminating Codes Collaborative. "This provides a national comparative between us and others implementing RRTs, including code rates," says Marshall.
Internal measures are also collected, including response time, responders, documentation quality, and satisfaction with the RRT process for those initiating the calls.
"Additionally, we utilize post-RRT case review to analyze outcomes and address system and process issues that arise," says Marshall. "This helps us identify the just-in-time rapid cycle changes as part of our ongoing improvement efforts."
Quality professionals track RRT measures daily. These data are sent out to a small RRT committee for review. "We prioritize the situations where we know things didn't go well, as verbalized by the responders and those initiating the RRT," says Marshall. "The quality professional's role is then to verify whether the RRT outcomes met our established goals."
Early on, two RRT calls were converted into a "code blue" immediately upon arrival of the team. Since the initial concept of the RRT was not to emulate the code team, the PICU charge nurse did not bring the intubation drugs like she would normally do for a code.
However, after the two patients required an immediate need for intubation, a decision was made to have the team bring the intubation medications just in case.
"The quality professional's role in that circumstance was to get the RRT information available for a truly rapid cycle review and change," says Marshall. "Then, subsequent outcomes were monitored."
Reference
- Sharek PJ, Parast LM, Leong K, et al. Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a children's hospital. JAMA 2007; 298(19):2,267-2,274.
[For more information, contact:
Tina Logsdon, MS, Solutions Manager, Child Health Corporation of America, 6803 W 64th Street, Suite 208, Shawnee Mission, KS 66202. Phone: (913) 262-1436. Fax: (913) 262-1575. E-mail: [email protected].
Lori C. Marshall, PhD, RN, Manager, Patient Care Services, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA 90027. Phone: (323) 361-2883. E-mail: [email protected].
Paul Sharek, MD, MPH, FAAP, Medical Director of Quality Management/Chief Clinical Patient Safety Officer, Lucile Packard Children's Hospital, 725 Welch Road, Palo Alto, CA 94304. Phone: (650) 736-0629. Fax: (650) 497-8465. E-mail: [email protected].]
Your hospital is likely in the process of implementing a rapid response team (RRT), if one is not already in place but the team is probably focused on adult care. Now a small but growing number of hospitals are implementing pediatric RRTs to improve the care of children.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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