1. Run, Don’t Walk: Improving Outcomes in Pediatrics Using a Rapid Response Team Wednesday, June 4, 2008 5:00 – 6:00 p.m. EDT © American Academy of Pediatrics 2008

2. 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

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

4. Visit our website: http://www.aap.org/saferhealthcare Resources: Useful strategies, valuable information links, and expert advice on reducing or eliminating medical errors affecting children. Webinars: Register for an upcoming, live Webinar, and earn a maximum of 1.0 AMA PRA Category 1 Credit™. Or, access a full archive, including audio, from one of the past Webinar offerings. Or, download just the Podcast or slide set from an archive. Latest News: Links to recent articles relating to pediatric patient safety. Email List: An e-community dedicated to pediatric patient safety issues and information exchange with other clinicians. Parents’ Corner: Resources to help parents understand what they can do to help ensure their optimal safety in the health care that their child receives.

5. DISCLOSURES None of the individuals involved in this webinar (Speakers, Moderator, Project Advisory Committee members, or Staff) has disclosed any relevant financial relationships or any financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities. None of the individuals (Speakers, Moderators, Project Advisory Committee members, or Staff) has disclosed that they intend to discuss or demonstrate pharmaceuticals and/or medical devices that are not approved. Refer to full AAP Disclosure Policy & Grid available below for download.

6. 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.

7. 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.

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

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

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

11. 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

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

13. Dr Jim Tibballs Intensive Care Physician & Resuscitation Officer Royal Children’s Hospital, Melbourne, Australia james.tibballs@rch.org.au

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

15. 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

16. ‘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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 4. Severe respiratory distress, apnoea or cyanosis AgeRespiratory Rate Term-3 months>60 4-12 months>50 1-4 years>40 5-12 years>30 12 years+>30 5. Tachypnoea

23. MET calling criteria 6. Tachycardia or bradycardia AgeBradycardiaTachycardia Term- 3 months <100 >180 4-12 months <100>180 1- 4 years<90>160 5-12 years<80 >140 12 years+<60 >130

24. MET Calling Criteria 7. Hypotension AgeBP (systolic) Term- 3 months<50 4-12 months<60 1- 4 years<70 5-12 years<80 12 years+<90

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

26. Does MET make any difference to cardiac arrest and mortality?

27. PREDICTABLE (PREVENTABLE) CARDIAC ARREST & DEATH (per 1000 admissions) BEFORE MET AFTER MET 1 YEAR AFTER MET 4 YEARS CARDIAC ARREST 0.160.00 (p=0.02) 0.07 (p=0.04) DEATH0.110.00 (p=0.04) 0.01 (p=0.001)

28. TOTAL UNEXPECTED CARDIAC ARREST & DEATH (UNPREDICTABLE + PREDICTABLE) (per 1000 admissions) BEFORE MET (1999-2002) AFTER 1 YEAR MET AFTER 4 YEARS MET CARDIAC ARREST 0.190.110.17 DEATH0.120.060.04 (p=0.03)

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

30. 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

31. 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)

32. 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

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

34. 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