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Improving Quality of Care: Role of Rapid Response Team and Quick Assessment Unit
Department of Pediatrics and
Department of Anesthesiology and Critical Care,
Driscoll Children’s Hospital,
Corpus Christi, TX May 2010Corpus Christi Pediatric Society May 2009Corpus Christi Pediatric Society May 2009
Corpus Christi Pediatric Society May 2009 Corpus Christi Pediatric Society May 2009 Corpus Christi Pediatric Society May 2009
Ranjana Sarma, MDMadaiah K. Talakadu, MDKeshava M N Gowda, MDRamon J Rivera, MD ,
FAAPAlexandre T. Rotta, MD, FCCM, FAAP
AbstractThe number of in-hospital pediatric
cardiopulmonary arrests that occur outside of the intensive care unit and carry a very poor prognosis, has significantly decreased with the institution of a Rapid Response Team (RRT)
We continue to analyze the role of the RRT and also hypothesize that the implementation of a Quick Assessment (QA) unit would optimize resource allocation and triage by identifying the sicker subset of patients, intervening early and hence reduce the number of hyperacute rapid response calls (occurring within 4 hours of hospitalization)
RESULTS: Among the patients admitted from the pediatrician’s office, the number of rapid response calls dropped from 17 (in 2008) to just 1 (in 2009 after QA) and there were no hyperacute rapid response calls from the same patient population since the institution of the Quick Assessment unit.
The time to a rapid response call also increased from 67.6 hours in 2008 to 87.2 hours again symbolizing the success of the QA unit in buying more time to actively intervene and stabilize patients.
Restrospective analysis of the number of cardiorespiratory arrests 3 years before and 2 years after the implementation of the rapid response team showed that RRT was associated with a significant decrease in the occurrence of cardiorespiratory arrest outside the PICU (0.68/1000 admissions in 2009 vs 0.73/1000 admissions in 2008 vs 0.81/1000 admissions from 2005-2007) and improved survival to hospital discharge after a code blue event from 46% (2005-2007) to 75% (2008) and an ideal 100% (2009)
We concluded that the rapid response team continues to improve patient survival and that Quick Assessment has effectively decreased the number of hyper acute RRs among direct admissions and also improved quality of patient care
BackgroundAccording to the Institute of Medicine, 44000
to 98000 preventable deaths occur annually in the US
One of the strategies recommended by Institute for Healthcare Improvement ( IHI -100,000 Lives campaign) was the implementation of a Rapid Response Team (RRT) in every hospital
BackgroundIn-hospital pediatric cardiopulmonary arrests
that occur outside of the intensive care unit account for between 8.5% and 14% of the total number of in-hospital arrests
Arrests outside of the PICU carry a very poor prognosis with mortality rates of 50 to 67%
Reduction or elimination of such arrests should be a high priority
BackgroundThe Pediatric Early Warning Score
(PEWS) is a clinical tool designed to assess the likelihood of future clinical deterioration in children
Since 2008, an adapted version of PEWS has been obtained for every patient at DCH upon admission, transfer or as dictated by changes in clinical condition
PEWS: Behavior/Cardiovascular/Respiratory
BackgroundRRT was instituted at DCH in January 2008 Analysis of 2008 RRT data revealed that Direct
admits from referring hospitals and from primary pediatrician’s offices were associated with a very high occurrence of Rapid Response (RR) calls within the 1st hour of admission
The Quick Assessment (QA) unit was instituted in our ER on July 13th, 2009 to improve triage and to match optimal resource allocation to severity of illness on direct admissions and hence improve the overall quality of care.
BackgroundQuick Assessment is a process used to
evaluate a patient that presents to the triage area of the ED to determine the suitability of such patient for direct admission or the need for a full evaluation and treatment in the ED.
Vital signs are obtained by the nursing staff and the patient is assessed by ED physician utilizing the quick assessment tool.
HypothesisThe institution of a QA unit at DCH would
decrease the number of hyperacute RRT calls among direct admissions
RRT at DCH will continue to positively impact the number of unexpected cardio-respiratory arrests outside the PICU environment and its attendant mortality
Uncover areas of potential weakness through clinical trends in order to more readily identify patients at risk or vulnerable situations
MethodsStudy protocol approved by the DCH IRB
Retrospective study involving a review of patients who required evaluation or treatment by the RRT and QA unit during their stay at DCH (01/01/2008 to 12/31/2009)
Sample identified through the RRT case registry and Code Blue registry
Clinical records obtained by the Health Information System and reviewed by at least two of the investigators
MethodsRelevant clinical data extracted onto
customized Excel spreadsheetsStatistical analysis performed with the help
of
Dr. Jose Guardiola, Phd, Assistant Professor of Statistics, TAMUCC
MethodsT-test:
Normally distributed continuous variablesWilcoxon test
Non-normally distributed continuous variables
Chi-Square or Fisher Exact testsCategorical variables
Z TestComparison of proportions of an
occurrence between two groups from independent observations
Patient distribution
54%15%
31%
0% 0%Private MD
ED
Referral hospital
PICU
Specialty MD
50%50%
0%0%
0%Private MD
ED
Referral hospital
PICU
Specialty MD
9 4
2008 hyperacute RRs< 1 hr 2-4 hrs
1 5
2009 hyperacute RRs< 1 hr 2-4 hrs
Hyperacute RRs in 2009
75%
25%
0%0% 0%
RRs before QA
Private MDED
Referral hospitalPICU
Specialty MD
0%
100%
0%0% 0%
RRs after QA
Private MDED
Referral hospitalPICU
Specialty MD
PEWS of pts transferred to PICU after a RR call 2008 2009
-1
0
1
2
3
4
5
6
7
8
9
10
PE
WS
N Y
PICU Transfer
-1
0
1
2
3
4
5
6
7
8
PE
WS
No Yes
PICU Transfer
Time to RR call from registration (in hours)
0
100
200
300
400
500
600
Tim
e (h
rs)
After QA Before QA
Private MD Referral hospital
PICU Specialty MD ED1 1 0
6 106 2 4
5
1817
5 6
14
23
Number of RR Calls based on admission source
2009-After QA 2009-Before QA 2008
Patient disposition post RR 2008 2009
Patient disposition post RR Before QA After QA
Code blue ratios (per 1000 admissions) and survival (percentage) trend
2005-20072008
2009
46%
75%100%0.81
0.730.68
Code blue survival Code blue ratio
Some quality improving QA facts…141 of all QAs were turned to ED
evaluations 2 pts transferred to PICU instead of floor 2 pts taken to OR from ED directly after
evaluation (Foreign body, Appendicitis)1- taken to radiology for reduction
(intussusception)Total number of QA pts discharged from
ED after evaluation – 5Only 1 pt who came through QA had a RR
call (the patient was from an outside hospital)
ConclusionsRapid Response Team at DCH continues to
cause a significant reduction in episodes of cardio-respiratory arrest outside the PICU and increased patient survival
Higher PEWS is still highly predictable of a subsequent need for Critical Care
>50% patients continue to require critical care monitoring or treatment after a RRT call
QA has effectively decreased the number of hyper acute RRs among direct admissions and also improved quality of patient care
Concern..RRT utilization at DCH:
2008 – 0.56/100 occupied beds 2009 – 0.48/100 occupied beds• National aggregate of RRT utilization 10/100 occupied beds
Future ConsiderationsConsidering…
Continuing success of RRT at DCHPositive impact of QA on lowering the incidence
of hyper acute RRs among direct admitsStrategies to focus on ..
Improve RRT utilization Closer monitoring of patients with higher PEWS
score Ensure that all direct admits to go through QA-
including Specialty MDAim for lower PEWS (0-2) before admitting a pt
from ED
At DCHWe care….
We deliver…..