The Rapid Response Team in Pediatric Settings: Now and into the Future Wednesday, Sept 26, 2007...

The Rapid Response Team in Pediatric Settings: Now and into the Future

Wednesday, Sept 26, 2007(12:00 noon Eastern; 11:00 a.m. Central; 10:00 a.m. Mountain; 9:00 a.m. Pacific)

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The Kids' Campaign - 2007 Pediatric Webcast Series 2

“Run Don’t Walk”: The Rapid Response Team Intervention at LPCH

Paul Sharek, MD, MPHMedical Director of Quality Management

Chief Clinical Patient Safety OfficerLucile Packard Children’s Hospital at Stanford


The article…


Objective of the Study


About Us: Overview of LPCH

LPCH166 Peds

(76 med-surg beds)52 OB

LPCHEl Camino16 Gen Peds 15 Eating Dis.

LPCHSequoia

6 NICU

LPCHWashington

9 NICU

Facilities:On-Campus 218

beds3 satellites 46

bedsTotal 264

beds

Patient Activity (FY06):Inpatient Days 78,177

Discharges 13,265

Outpatient Visits105,837

Surgeries 4490

Births 5153

Peds CMI 1.8


About us…

Lucile Packard Children's HospitalCase Mix Index Ranking Among 76 Pediatric Hospitals (9/1/05-9/30/06)


Context


What Do We Know?

6 to 8 hour period of escalating instability that precedes nearly every cardiopulmonary arrestMany causative physiological processes prior to an arrest are treatablePost-cardiac arrest survival

24 hour survival: 33%*-36%**Survival to discharge: 24***-27%*1 year survival: 15%*, **

*Reis, et al. Pediatrics.2002;109:200-209**Nadkarni et al. JAMA.2006;295:50-57***Young et al. Annals of emerg med. 1999;33:195-205


Why this project? • Codes outside of the ICU setting increasing

dramatically after sudden change in severity of illness

• Multiple interventions tried and failed• Measure was/remains on LPCH Quality, Safety and

Service dashboard• Board of Directors at LPCH tracking aggressively


Project Aim• Decrease codes outside of the ICU to 1 or less per

quarter, within 12 months of implementation of RRT


Design of Study


Chapter 1 of our tale…“There Was Joy in Mudville…or Was There?”

Codes Outside of ICU LPCH:

Jan 2001 thru Dec 2001

0

1

2

3

4

5

6

7

01 Q1 01 Q3 02 Q1 02 Q3 03 Q1 03 Q3 04 Q1 04 Q3 05 Q1 05 Q3 06 Q1 06 Q3 07 Q1

Number of Codes

CT Surgery service


Chapter 2 of our tale…“No Need to Panic-We Can Do This”


Jan 2001 thru July 2003

0

1

2

3

4

5

6

7

01 Q1 01 Q3 02 Q1 02 Q3 03 Q1 03 Q3 04 Q1 04 Q3 05 Q1 05 Q3 06 Q1 06 Q3 07 Q1

Number of Codes

CT Surgery service

Education


Chapter 3 of our tale…“If All Else Fails… Go To The Literature”


Jan 2001 thru Jan 2004

0

1

2

3

4

5

6

7

01 Q1 01 Q3 02 Q1 02 Q3 03 Q1 03 Q3 04 Q1 04 Q3 05 Q1 05 Q3 06 Q1 06 Q3 07 Q1

Number of Codes

CT Surgery service

EducationHospitalists 7/03


Chapter 4 of our tale…“Panic in Palo Alto: The Hero Gets Desperate”


Jan 2001 thru Sep 2005

0

1

2

3

4

5

6

7

01 Q1 01 Q3 02 Q1 02 Q3 03 Q1 03 Q3 04 Q1 04 Q3 05 Q1 05 Q3 06 Q1 06 Q3 07 Q1

Number of Codes

CT Surgery service


Patient progression (8/03)

CHCA handoffs collaborative (1/04)


New World Emerging…IHI

Formal kick off of the 100,000 Lives Campaign, with RRT as 1 of 6 “evidence based” recommendations to decrease needless deaths in the US (12.2004)


New Literature Emerging

…Medical Emergency Team coincident with a reduction of cardiac arrest and mortality…


LPCH decided to take the plunge…


Intervention


Operationalization of the RRT at LPCH• Step 1: “building the will”

– Committee discussions (critical care committee, patient safety committee, quality improvement council, etc)

– Approaching the multidisciplinary services (MDs, RNs, RT, Nursing supervisors)

• Step 2: “building the team”. Membership– ICU MD (fellow or attending)– ICU RN– ICU trained RT– RN supervisor


Operationalization of the RRT at LPCH• Step 3: “rolling it out”: Educational strategies

– Multiple meetings to discuss/champion– Emails– Fliers– 3 X 5 cards for all affected staff– Pins– Bribes– Etc…


Operationalization of the RRT at LPCH• Step 3: “rolling it out”: Activation

– Reasons for activation• Any staff member worried about a patient• Acute changes in respiratory rate• Acute change in O2 saturation• Acute change in heart rate• Acute change in blood pressure• Acute change in level of consciousness

– Logistics of activation• Call hospital operators for “Rapid Response Team”• Expectation: arrive in 5 minutes


Operationalization of the RRT at LPCH• Step 3: “rolling it out”: RRT Expectations

– Arrive with a smile– Announce “how can I help you”– Use “S-BAR” communication format– Write orders– Determine disposition (ICU vs med-surg unit, vs…)– Communicate to primary care providers– As much as you might like, DO NOT CALL THE PRIMARY

CARE PROVIDERS CLUELESS MORONS!


Main outcome measures


Chapter 5LPCH finally gets it right!

Codes Outside of ICU LPCH: Jan 2001 thru Sep 2005

0

1

2

3

4

5

6

7

01 Q1 01 Q3 02 Q1 02 Q3 03 Q1 03 Q3 04 Q1 04 Q3 05 Q1 05 Q3 06 Q1 06 Q3 07 Q1

Number of Codes

CT Surgery service


Patient progression (8/03)

CHCA handoffs collaborative (1/04)

Rapid ResponseTeam 9/05


Results: Codes Outside of the ICU:Absolute Number


Jan 2001 thru March 2007

0

1

2

3

4

5

6

7

01 Q1 01 Q3 02 Q1 02 Q3 03 Q1 03 Q3 04 Q1 04 Q3 05 Q1 05 Q3 06 Q1 06 Q3 07 Q1

Number of Codes

Rapid ResponseTeam 9/05


Results: Codes Outside of ICU:Rate (per 1000 pt days)

Codes Outside of ICU Rate

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

2.00

Jan-01Apr-01Jul-01Oct-01Jan-02Apr-02Jul-02Oct-02Jan-03Apr-03Jul-03Oct-03Jan-04Apr-04Jul-04Oct-04Jan-05Apr-05Jul-05Oct-05Jan-06Apr-06Jul-06Oct-06Jan-07

Code Rate (per 1000 eligible pt days)

Mean Code Rate 0.52Baseline Pre-RRT period

Mean Code Rate 0.15Post- RRT period

P < 0.01Decrease of 71%


Hospital-Wide Mortality Rate

1.01

0.00.20.40.60.81.01.21.41.61.82.0

Jan-01Mar-01May-01Jul-01

Sep-01Nov-01Jan-02Mar-02May-02Jul-02





Sep-06Nov-06Jan-07Mar-07

Mortality Rate (per 100 admissions)

Baseline Pre-RRT period Post-RRT period

Mean Mortality Rate 1.01 Mean Mortality Rate 0.83

Mortality Rate-Housewide

p < 0.01

34 kids lives saved in 19 mo!

18% reduction


Results


Discussion: Reasons for Improved outcomes• LPCH children sicker than Cinci or Melbourne

– Higher severity of illness– Med-Surg patients sicker

• Longer time frame post intervention than Cinci or Melbourne

• Not likely due to– Education– hospitalists


Discussion: Study limitations• Cohort study with historical controls (a cooler

sounding design than “pre-post”)– Difference in pre-post populations

• No significant/relevant differences in demographics• No difference in CMI

– Confounders• None known• Immediate change in outcomes associated with RRT

intervention

• Single center study-? generalizable


Lessons Learned• RRT provided immediate impact on outcomes-ramp up time

very short• Transparency of data critical to driving/sustaining change• Return on investment very high for RRT

– Outcomes excellent– No new personnel required– 20 minutes per call

• You can improve your mortality rate significantly with RRT implementation


Tips and Advice for Other Hospitals• Call criteria must include “if anyone is uncomfortable

with patient” criterion• Debriefing after each RRT call critical to sustaining

gains• Involve primary care team before, during, and after

RRT call• RRT must arrive to scene with the right attitude• Use of standard communication structure (ex SBAR)

extremely helpful in effectiveness of RRT


Conclusions-Study


Conclusions: RRT at LPCH• Statistically significant decrease in :

– Codes outside ICU per 1000 pt days– Codes outside ICU per admissions– Hospital-wide Mortality

• Cost– No added FTE– (143 calls x 20 minutes per call x 4 people x

$100/hour)/34 kids lives saved = $560 per life saved! • Translation: 34 kids alive today as a result of LPCH

RRT

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The Rapid Response Team in Pediatric Settings: Now and into the Future Wednesday, Sept 26, 2007...

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