Proactive deployment of rapid response teams, even on a gut feel, to intervene in the care of sick hospitalized children, rather than cautious watching and waiting can significantly reduce deaths, said researchers and clinicians at Lucile Packard Children’s Hospital and the Stanford University School of Medicine in Stanford, California.
The first study to show that using rapid response teams (RRTs) proactively can reduce deaths and cardiopulmonary arrest rates in young patients is published in the November 21st issue of the Journal of the American Medical Association (JAMA).
Chief clinical patient safety officer at Packard Children’s Hospital, and assistant professor of pediatrics at Stanford University School of Medicine, Dr Paul Sharek, who co-authored the research, said that:
“Even in the hospital, sick children can deteriorate so quickly. They don’t have the energy reserves or muscle mass that most adult patients have.”
The researchers estimated that deploying RRTs led to an 18 per cent reduction in the monthly mortality rate at the pediatric hospital. Over the 19 month period of the study this added up to 33 lives saved by bringing in RRTs made up of staff trained to give supportive care before a child’s clinical condition becomes life-threatening.
The hospital brought in the RRT program in 2005 with the aim of decreasing the rate of “emergency codes” among child patients in the hospital who were not in the intensive care unit (ICU). An emergency code is triggered when a child patient’s heart stops or they stop breathing. Many hospitalized children, whose condition is not so acute that they have to be in the ICU, can still worsen quite rapidly.
As Sharek explained:
“Once a child codes, the odds of long-term survival are pretty small.”
“However, there’s often a period of about six to eight hours when a child who might later code begins to show subtle signs of distress. If we can intervene early in this process, the child is far more likely to improve than if we simply monitor and maintain the same approach to treatment.”
An RRT comprises existing intensive care staff who also have an additional RRT role. In this study an RRT team included: a pediatric intensive care physician, an intensive care nurse, an intensive care respiratory therapist and a nursing supervisor.
RRT team members are in the hospital 24/7 and arrive at the sick child’s bedside within 5 minutes of an emergency summons. The first thing they do is assess the patient’s condition and as required, in addition to the care already being administered, give extra respiratory support, intravenous fluids, or move the child to the ICU.
Sharek and colleagues found that subtle but measurable changes in the patient’s status were the main triggers to an RRT summons. For instance changes in breathing patterns, blood oxygen or blood pressure. However, in some cases, the alert occured because of “gut feel”, the medical person attending the child or a parent felt something “just wasn’t right”.
It appeared that “aggressive empowering” as they called it, and then supporting the nursing staff was a strong reason for the success of the RRT approach at Packard Children’s, said Sharek:
“We empower the nursing staff to act on their expertise by calling for RRT involvement when they are concerned about a child’s worsening clinical situation.”
Sharek and colleagues proposed that this approach meant the nursing staff at Packard Children’s brought in the RRT to intervene earlier in the deterioration of the patient’s condition compared to other hospitals that recently started using the RRT system. Another reason they suggested for the success of RRTs at Packard Children’s, was that the hospital specialized in highly complex cases that can lead to a patient’s condition worsening quite rapidly.
“The average level of illness at Packard Children’s is substantially higher than the vast majority of other children’s hospitals in North America,” said Sharek.
“Although the average child on our medical or surgical hospital units may not require the high nurse-to-patient ratio of the intensive care unit, he or she is still frequently quite ill,” he explained.
The Packard Children’s study, said the authors, is the first to show that RRTs lead to lower death rates in pediatric settings. Setting up RRTs at the hospital did not entail recruiting more staff or using additional funds, but the authors did suggest that the cost-effectiveness of RRTs should be explored further.
Sharek said they took a chance on setting up RRTs because at the time there was no evidence they decreased mortality in hospitalized children. The study required no outside funds he said, and added that “we’re very proud and excited about the results”.
“Effect of a Rapid Response Team on Hospital-wide Mortality and Code Rates Outside the ICU in a Children’s Hospital.”
Paul J. Sharek; Layla M. Parast; Kit Leong; Jodi Coombs; Karla Earnest; Jill Sullivan; Lorry R. Frankel; Stephen J. Roth.
JAMA 2007 298: 2267-2274
Vol. 298 No. 19, November 21, 2007
Written by: Catharine Paddock