Run, Don’t Walk: Improving Outcomes in Pediatrics Using a Rapid Response Team Wednesday, June 4, :00 – 6:00 p.m. EDT © American Academy of Pediatrics 2008

Moderator: Paul Sharek, MD, MPH, FAAP Assistant Professor of Pediatrics, Stanford School of Medicine Medical Director of Quality Management Chief Clinical Patient Safety Officer Lucile Packard Children’s Hospital Palo Alto, California

This activity was funded through an educational grant from the Physicians’ Foundation for Health Systems Excellence.

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CME CREDIT Live Webinar Only The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAP designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity. This activity is acceptable for up to 1.0 AAP credits. These credits can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the American Academy of Pediatrics.

OTHER CREDIT Live Webinar Only This program is approved for 1.0 NAPNAP contact hours of which 0 contain pharmacology (Rx) content per the National Association of Pediatric Nurse Practitioners Continuing Education Guidelines. The American Academy of Physician Assistants accepts AMA PRA Category 1 Credit(s) TM from organizations accredited by the ACCME.

Speaker: Annie Moulden, MBBS, FRACP Clinical Leader, Patient Safety and Risk Royal Children’s Hospital Melbourne, Victoria, Australia

Speaker: Jim Tibballs, MBBS Physician Intensive Care Unit and Resuscitation Officer Royal Children’s Hospital Melbourne, Victoria, Australia

Speaker: Sharon Kinney, RN, MN Royal Children’s Hospital Melbourne, Victoria, Australia

Run, don’t walk: Improving outcomes in pediatrics using a rapid response team The Melbourne experience Dr Annie Moulden Assoc Prof Jim Tibballs Ms Sharon Kinney Royal Children’s Hospital Melbourne, Australia

Why did we introduce the MET? Annie Moulden Clinical Leader, Patient Safety & Risk

Dr Jim Tibballs Intensive Care Physician & Resuscitation Officer Royal Children’s Hospital, Melbourne, Australia

RAPID RESPONSE TEAMS Medical Emergency Team (MET) Rapid Response Team (RRT)

WHY DO SOME CHILDREN DIE UNEXPECTEDLY IN HOSPITAL? n SOMETIMES CARDIAC ARREST IS NOT PREDICTABLE n SOMETIMES CARDIAC ARREST IS PREDICTABLE, BUT … Severity of illness is not recognized Help is not requested until cardiac arrest No assistance is available Assistance is available but delayed

‘RATIONALE’ of MET/RRT … prevent predictable cardiac arrest n Outcome from cardiac arrest is poor n Some cardiac arrests are ‘unexpected’ … but which are predictable (‘foreseeable’) on basis of symptoms and signs … and which might be prevented if child treated intensely early

MET or RRT is … n ORGANIZATIONAL CHANGE n ANY staff, no matter how junior or senior, may call MET/RRT … Without discussion with seniors Without discussion with colleagues Without permission of seniors Without discussion with doctors

MET at Royal Children’s Hospital Melbourne, Australia SYSTEMS SOLUTION … One–tier system Team of doctors (3) and nurse (1) from intensive care/emergency dept Respond immediately to call for assistance on wards/departments - Can manage medical/surgical emergencies - Treat patient on ward to stabilize, transfer etc

What does MET do? n Assess and treat the patient as required n Discuss management of the patient with the members of the treating (attending) unit n Admit the child to ICU or continue to help manage on ward as required

Elements of MET/RRT n Educate staff to recognize serious illness n Establish MET calling criteria n Call for assistance n Provide immediate assistance n Collect data, feedback to staff, educate

1. Nurse or doctor WORRIED about clinical state 2. Airway threat 3. Hypoxaemia: SpO 2 <90% in any amount of oxygen SpO 2 <60% in any amount of oxygen (cyanotic heart disease) ANY one or more of the following: MET calling criteria

4. Severe respiratory distress, apnoea or cyanosis AgeRespiratory Rate Term-3 months> months> years> years>30 12 years+>30 5. Tachypnoea

MET calling criteria 6. Tachycardia or bradycardia AgeBradycardiaTachycardia Term- 3 months <100 > months <100> years<90> years<80 > years+<60 >130

MET Calling Criteria 7. Hypotension AgeBP (systolic) Term- 3 months< months< years< years<80 12 years+<90

8. Acute change in neurological status or convulsion 9. Cardiac or respiratory arrest MET calling criteria

Does MET make any difference to cardiac arrest and mortality?

PREDICTABLE (PREVENTABLE) CARDIAC ARREST & DEATH (per 1000 admissions) BEFORE MET AFTER MET 1 YEAR AFTER MET 4 YEARS CARDIAC ARREST (p=0.02) 0.07 (p=0.04) DEATH (p=0.04) 0.01 (p=0.001)

TOTAL UNEXPECTED CARDIAC ARREST & DEATH (UNPREDICTABLE + PREDICTABLE) (per 1000 admissions) BEFORE MET ( ) AFTER 1 YEAR MET AFTER 4 YEARS MET CARDIAC ARREST DEATH (p=0.03)

Sharon Kinney MET Coordinator, Royal Children’s Hospital, Melbourne

Implementing MET (initial) n Support from the executive n Introduction letter to all medical staff and heads of department n Educational sessions +++ Emphasis on empowering nursing & medical staff n MET posters n MET staff Supportive & positive attitude to callers of MET

Implementing MET (ongoing) n Other education Sick child workshops  number of places for staff on PLS/APLS courses n Regular clinical practice meetings reviewing MET data & selected cases n MET coordinator role within the Clinical Quality & Safety Unit n Ongoing review of critical events (identify & follow up problems with the MET system and/or other hospital processes of care)

Possible concerns n De-skilling ward staff n There will be too many unnecessary (trivial) calls n Taking resources away from ICU (or elsewhere) especially at night time

Time of day for MET calls (4 year period, n = 809)

Take away points n Do you have potentially preventable cardiac arrests/deaths? n What resources are available/needed to support a 24 hour service that can promptly respond to a MET call? n Enlist support from the hospital leadership team n Educate and empower ward staff to request MET n Ensure MET staff adopt a supportive attitude to ward staff initiating the MET call irrespective of perceived appropriateness n Collect data – ongoing evaluation & feedback to staff