Hospitals use RRTs to cut peds codes
A protocol built around the use of rapid response teams (RRTs) has reduced incidences of preventable codes among pediatric patients by 20% at a group of hospitals in Ohio, one of the best demonstrations yet of the success of that approach in improving patient safety. One hospital even saw a drop of 40%.
The protocol has yielded tremendous results for the Ohio Children's Hospital Association (OCHA) and its six member hospitals Akron Children's Hospital; Cincinnati Children's Hospital Medical Center; Dayton Children's Medical Center; Nationwide Children's Hospital, Columbus; Rainbow Babies & Children's Hospital, Cleveland; and Toledo Children's Hospital. The system recently announced groundbreaking results of the first-of-its-kind collaboration to improve quality in children's hospitals.
OCHA and its six member hospitals created the Ohio Children's Hospital Association's Quality Improvement Collaborative in 2006 to promote improved quality of care at children's hospitals, says David Kinsaul, FACHE, president and CEO of Dayton Children's Medical Center and chairman of OCHA. In its first initiative, the collaborative focused on reducing preventable codes cardiac and pulmonary arrests occurring outside of the neonatal and pediatric intensive care units. They settled on that specific goal because their internal data analysis revealed that a substantial number of codes occurred outside those areas where one might first assume the codes were concentrated, and where the staff and resources are most ready to respond.
As a result of its efforts, the collaborative identified a RRT protocol that, when implemented, reduced incidences of preventable codes by more than 20% throughout the six hospitals. The data suggest that the results get better over time, Kinsaul says. One of the hospitals has had the RRT protocol in place for more than three years and has seen a 40% drop in preventable codes.
"To our knowledge, this is the first time in the nation that a statewide network of children's hospitals has come together to focus on quality improvement to save children's lives," Kinsaul says.
Hospitals developed own RRTs
Kinsaul says OCHA served as the link among the various children's hospitals and helped coordinate the effort. One key, he says, was having all the hospitals agree not to use any successful results to market against their competitors.
"We all agreed that whoever came out with the absolute best results would not use that in advertising against some other children's hospital," he says. "This was not about seeing which hospital was best, but rather how we could improve care. I think this kind of effort is always going to be more successful if you have some type of hospital association that is willing to help facilities come together, put all their data on the table, and not be judgmental of others."
Each participating hospital adapted a RRT model to fit within its own patient care environment and culture," Kinsaul says. Bedside caregivers at participating hospitals were empowered to quickly call on the RRT when the caregiver determined that immediate intervention was warranted. Further, some hospitals created a process that enabled patient families to call upon the RRT when they felt their child was in need of assessment.
Rather than implementing a one-size-fits-all approach, OCHA encouraged each hospital to create its own RRT protocol. The basic plan was for bedside caregivers to assess the patient's status, determine or request a recommendation, and then immediately obtain a review of the situation by an interdisciplinary team of clinicians in less than 30 minutes. Some hospitals went a step further by allowing patients' families to call out the team, on the theory that a parent's intuition can be valuable in assessing the patient.
Aiming to eliminate some codes
Encouraging each hospital to determine the specifics of its own RRTs resulted in more vigorous participation and more buy-in from both hospital leadership and frontline staff, says Uma Kotagal, MD, vice president of quality and transformation, Cincinnati Children's Hospital Medical Center, and chair of the OCHA quality improvement collaborative steering committee. Another key to the program's success was meticulous data collection and sharing of that information among all the hospitals, she says.
Kotagal says as good as the results are so far, the project team is not satisfied.
"My goal is to eliminate preventable codes outside the ICU completely, and we're not there yet," she says. "I expect we will get there in the next three to six months. The improvements so far are exceptionally good and we're very pleased, but it makes us think we can do even better."
The hospitals developed their own protocols, but they all involve responding quickly to any signs of distress. Cincinnati Children's Hospital Medical Center, for instance, uses the Pediatric Early Warning Score (PEWS), an assessment tool developed at the Royal Alexandra Hospital for Sick Children in East Sussex, England. With PEWS, all patients are assessed on specific criteria at least every four hours and sometimes more often depending on the results of the previous assessments. The hospital's team also developed an algorithm for what should be done in reaction to each assessment, ranging from no action, to reassessment, to calling out the RRT.
The RRT program is built around the idea that increased diligence, that is, simply paying close attention to a patient's condition, will help prevent many bad outcomes, says Terry Davis, MD, interim medical director at Nationwide Children's Hospital in Columbus, OH, and a member of the OCHA quality improvement collaborative steering committee.
"We just have to look for patients who are not doing as well as they should," he says. "When a patient has cardiac arrest on the floor, that patient is sicker than we thought and probably shouldn't have been on the floor. We're trying to recognize patients that are deteriorating and escalating their care appropriately."
RRTs promote culture change
The RRT allows escalation when the nurse or someone else thinks something is amiss, even if that person cannot identify exactly what is wrong, Davis says. Nationwide Children's Hospital allows parents to call the RRT, and a placard in every room instructs them on how to call for help. Parents have called out the RRT only twice in the past six months, he says.
"We find that it doesn't happen very often that the parents call the RRT, and it is more likely with chronically ill patients," he says. "The parents know their children better than anyone, particularly if the patient is mentally challenged or has some other issue that the parent is more finely attuned to than the staff. They learn over the years to interpret their child's condition very accurately, so this gives them a way to get help if they don't think the bedside staff is listening to them."
Kotagal says the RRT program has prompted an overall culture change at the hospitals, with staff and physicians feeling more like a hospitalwide team, which makes nurses more comfortable in calling for help when needed.
"In the past, if we had a problem outside the ICU, the specialist who responded might have said, 'Well, if you had done this and this, your patient wouldn't be in this condition," she says. "Now we see much more of a sense of teamwork. Everyone works together and says, 'OK, I'm here. How can we help this patient?"
Sources
For more information on how RRTs can reduce preventable codes, contact:
- Terry Davis, MD, Interim Medical Director, Nationwide Children's Hospital, Columbus, OH. Telephone: (614) 722-2000.
- David Kinsaul, FACHE, President and CEO, Dayton (OH) Children's Medical Center. Tele-phone: (937) 641-3000.
- Uma Kotagal, MD, Vice President of Quality and Transformation, Cincinnati Children's Hospital Medical Center. Telephone: (513) 636-0178. E-mail: [email protected].
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