the rapid response team in pediatric settings: now and into the future wednesday, sept 26, 2007...
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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)
https://www115.livemeeting.com/cc/chca/joinMeeting ID: 5MLIves092607 (case sensitive)
Dial in: 866-436-9172Confirmation Number: 18408566
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 Kids' Campaign - 2007 Pediatric Webcast Series 3
The article…
The Kids' Campaign - 2007 Pediatric Webcast Series 4
Objective of the Study
The Kids' Campaign - 2007 Pediatric Webcast Series 5
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
The Kids' Campaign - 2007 Pediatric Webcast Series 6
About us…
Lucile Packard Children's HospitalCase Mix Index Ranking Among 76 Pediatric Hospitals (9/1/05-9/30/06)
The Kids' Campaign - 2007 Pediatric Webcast Series 7
Context
The Kids' Campaign - 2007 Pediatric Webcast Series 8
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
The Kids' Campaign - 2007 Pediatric Webcast Series 9
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
The Kids' Campaign - 2007 Pediatric Webcast Series 10
Project Aim• Decrease codes outside of the ICU to 1 or less per
quarter, within 12 months of implementation of RRT
The Kids' Campaign - 2007 Pediatric Webcast Series 11
Design of Study
The Kids' Campaign - 2007 Pediatric Webcast Series 12
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
The Kids' Campaign - 2007 Pediatric Webcast Series 13
Chapter 2 of our tale…“No Need to Panic-We Can Do This”
Codes Outside of ICU LPCH:
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
The Kids' Campaign - 2007 Pediatric Webcast Series 14
Chapter 3 of our tale…“If All Else Fails… Go To The Literature”
Codes Outside of ICU LPCH:
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
The Kids' Campaign - 2007 Pediatric Webcast Series 15
Chapter 4 of our tale…“Panic in Palo Alto: The Hero Gets Desperate”
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
EducationHospitalists 7/03
Patient progression (8/03)
CHCA handoffs collaborative (1/04)
The Kids' Campaign - 2007 Pediatric Webcast Series 16
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)
The Kids' Campaign - 2007 Pediatric Webcast Series 17
New Literature Emerging
…Medical Emergency Team coincident with a reduction of cardiac arrest and mortality…
The Kids' Campaign - 2007 Pediatric Webcast Series 18
LPCH decided to take the plunge…
The Kids' Campaign - 2007 Pediatric Webcast Series 19
Intervention
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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
The Kids' Campaign - 2007 Pediatric Webcast Series 21
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…
The Kids' Campaign - 2007 Pediatric Webcast Series 22
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
The Kids' Campaign - 2007 Pediatric Webcast Series 23
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!
The Kids' Campaign - 2007 Pediatric Webcast Series 24
Main outcome measures
The Kids' Campaign - 2007 Pediatric Webcast Series 25
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
EducationHospitalists 7/03
Patient progression (8/03)
CHCA handoffs collaborative (1/04)
Rapid ResponseTeam 9/05
The Kids' Campaign - 2007 Pediatric Webcast Series 26
Results: Codes Outside of the ICU:Absolute Number
Codes Outside of ICU LPCH:
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
The Kids' Campaign - 2007 Pediatric Webcast Series 27
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%
The Kids' Campaign - 2007 Pediatric Webcast Series 28
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-02Nov-02Jan-03Mar-03May-03Jul-03
Sep-03Nov-03Jan-04Mar-04May-04Jul-04
Sep-04Nov-04Jan-05Mar-05May-05Jul-05
Sep-05Nov-05Jan-06Mar-06May-06Jul-06
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
The Kids' Campaign - 2007 Pediatric Webcast Series 29
Results
The Kids' Campaign - 2007 Pediatric Webcast Series 30
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
The Kids' Campaign - 2007 Pediatric Webcast Series 31
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
The Kids' Campaign - 2007 Pediatric Webcast Series 32
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
The Kids' Campaign - 2007 Pediatric Webcast Series 33
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
The Kids' Campaign - 2007 Pediatric Webcast Series 34
Conclusions-Study
The Kids' Campaign - 2007 Pediatric Webcast Series 35
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