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) Meeting ID: 5MLIves (case sensitive) Dial in: Confirmation Number:

The Kids' Campaign Pediatric Webcast Series2 “Run Don’t Walk”: The Rapid Response Team Intervention at LPCH Paul Sharek, MD, MPH Medical Director of Quality Management Chief Clinical Patient Safety Officer Lucile Packard Children’s Hospital at Stanford

The Kids' Campaign Pediatric Webcast Series3 The article…

The Kids' Campaign Pediatric Webcast Series4 Objective of the Study

The Kids' Campaign Pediatric Webcast Series5 About Us: Overview of LPCH LPCH 166 Peds (76 med-surg beds) 52 OB LPCH El Camino 16 Gen Peds 15 Eating Dis. LPCH Sequoia 6 NICU LPCH Washington 9 NICU Facilities: On-Campus218 beds 3 satellites 46 beds Total264 beds Patient Activity (FY06): Inpatient Days78,177 Discharges13,265 Outpatient Visits105,837 Surgeries4490 Births5153 Peds CMI1.8

The Kids' Campaign Pediatric Webcast Series6 About us… Lucile Packard Children's Hospital Case Mix Index Ranking Among 76 Pediatric Hospitals (9/1/05-9/30/06)

The Kids' Campaign Pediatric Webcast Series7 Context

The Kids' Campaign Pediatric Webcast Series8 What Do We Know? 6 to 8 hour period of escalating instability that precedes nearly every cardiopulmonary arrest Many causative physiological processes prior to an arrest are treatable Post-cardiac arrest survival 24 hour survival: 33%*-36%** Survival to discharge: 24***-27%* 1 year survival: 15%*, ** *Reis, et al. Pediatrics.2002;109: **Nadkarni et al. JAMA.2006;295:50-57 ***Young et al. Annals of emerg med. 1999;33:

The Kids' Campaign Pediatric Webcast Series9 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 Pediatric Webcast Series10 Project Aim Decrease codes outside of the ICU to 1 or less per quarter, within 12 months of implementation of RRT

The Kids' Campaign Pediatric Webcast Series11 Design of Study

The Kids' Campaign Pediatric Webcast Series12 Chapter 1 of our tale… “There Was Joy in Mudville…or Was There?”

The Kids' Campaign Pediatric Webcast Series13 Chapter 2 of our tale… “No Need to Panic-We Can Do This”

The Kids' Campaign Pediatric Webcast Series14 Chapter 3 of our tale… “If All Else Fails… Go To The Literature”

The Kids' Campaign Pediatric Webcast Series15 Chapter 4 of our tale… “Panic in Palo Alto: The Hero Gets Desperate”

The Kids' Campaign Pediatric Webcast Series16 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 ( )

The Kids' Campaign Pediatric Webcast Series17 New Literature Emerging …Medical Emergency Team coincident with a reduction of cardiac arrest and mortality…

The Kids' Campaign Pediatric Webcast Series18 LPCH decided to take the plunge…

The Kids' Campaign Pediatric Webcast Series19 Intervention

The Kids' Campaign Pediatric Webcast Series20 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 Pediatric Webcast Series21 Operationalization of the RRT at LPCH Step 3: “rolling it out”: Educational strategies –Multiple meetings to discuss/champion – s –Fliers –3 X 5 cards for all affected staff –Pins –Bribes –Etc…

The Kids' Campaign Pediatric Webcast Series22 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 Pediatric Webcast Series23 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 Pediatric Webcast Series24 Main outcome measures

The Kids' Campaign Pediatric Webcast Series25 Chapter 5 LPCH finally gets it right!

The Kids' Campaign Pediatric Webcast Series26 Results: Codes Outside of the ICU: Absolute Number

The Kids' Campaign Pediatric Webcast Series27 Results: Codes Outside of ICU: Rate (per 1000 pt days) P < 0.01 Decrease of 71%

The Kids' Campaign Pediatric Webcast Series28 Mortality Rate- Housewide p < kids lives saved in 19 mo! 18% reduction

The Kids' Campaign Pediatric Webcast Series29 Results

The Kids' Campaign Pediatric Webcast Series30 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 Pediatric Webcast Series31 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 Pediatric Webcast Series32 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 Pediatric Webcast Series33 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 Pediatric Webcast Series34 Conclusions-Study

The Kids' Campaign Pediatric Webcast Series35 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