Published in the June 2008 issue of Today’s Hospitalist
TO REDUCE THE NUMBER OF CODES occurring outside of the ICU, physicians at Lucile Packard Children’s Hospital in Palo Alto, Calif., tried two large-scale interventions: establishing a hospitalist program and reconstructing how they did transfers and handoffs. But when neither initiative produced fewer codes, the hospital took a chance on a strategy that had not been proven in pediatric medical literature: It launched a pediatric rapid response team (RRT).
Studies of adult RRTs had shown mixed results in reducing mortality. As a result, many physicians at Packard and elsewhere were skeptical that RRTs could reduce mortality and non-ICU pediatric code rates. But as Paul J. Sharek, MD, MPH, points out, his hospital’s dramatic results may help put to rest any questions about the effectiveness of pediatric RRTs.
Dr. Sharek’s study, which was published in the Nov. 21, 2007, Journal of the American Medical Association, found that the use of pediatric RRTs resulted in a 70% decrease in the rate of cardiac and respiratory arrests outside of the pediatric ICU and an 18% decrease in monthly mortality rate. The authors concluded that the pediatric RRT saved approximately 33 lives during the study’s 19-month post-intervention period.
“Our study may be the final piece of evidence necessary to convince skeptics to recommend implementation of RRTs in children’s hospitals,” Dr. Sharek says. A pediatric hospitalist who is medical director of quality management and chief clinical patient safety officer at the 264-bed Packard Hospital, Dr. Sharek spoke with Today’s Hospitalist about his findings.
What was the most surprising study result?
Mortality rate is historically hard to improve and usually requires significant shifts in patient population. To reduce mortality by 18% with a single intervention was really quite surprising.
We were also surprised at how quickly mortality rates dropped after RRT implementation. Within three months, we decreased codes outside of the ICU setting and witnessed mortality rates dropping. It usually takes three to six months to disseminate this type of large-scale intervention.
Why do you think your results were so different “and definitive “compared to pediatric RRT studies that didn’t find improved mortality?
The severity of illness at our hospital is higher than at the vast majority of children’s hospitals in the U.S., so our patients are at increased risk for cardiac or respiratory compromise. In addition, when I’ve talked to colleagues around the world that have implemented pediatric RRTs, it seems as though we call for RRTs earlier in the course of decompensations, before irreversible decompensation occurs.
Culturally, I have the sense that our nursing staff felt more comfortable calling for the RRT earlier and more aggressively than at other sites. We worked hard to leverage nursing or ancillary-staff expertise, and we encourage early calls. We remind the RRT that a false positive is a good thing.
You tried bringing in hospitalists to bring the code rate down, but that didn’t work. What had you expected?
We implemented a hospitalist program for many reasons about two years before we implemented our RRT. With enhanced 24/7 coverage and more on-site attendings, we expected to see a decrease in the number of codes outside of the ICU, but we didn’t. We saw many other marvelous improvements, but we needed to explore other interventions to reduce codes.
Is putting together a pediatric RRT more challenging than creating one for adults?
It shouldn’t be a challenge in a children’s hospital because there should already be a house code team in place. Because most children’s hospitals also have access to a sophisticated pediatric ICU, it should be pretty straightforward to put together a multidisciplinary team of experts to fill the RRT role.
I suspect, however, that putting together a team to respond to pediatric calls would be more challenging in adult hospitals.
Adult-trained intensivists might very well be able to diagnose and treat the most common reasons why a pediatric RRT is called. But nurses who usually take care of adults may not pick up on subtle signs of pediatric decompensation until it is too late. Plus, the wide age range of children and variation in normal vital signs could also be challenging for adult-trained staff.
What tips do you give hospitals trying to put a pediatric RRT in place?
First, it’s reassuring to tell them that creating an RRT didn’t force us to add any extra resources. The RRT intervention costs our hospital about $600 per life saved. Compared to other interventions that are deemed to be cost-effective, such as vaccinations, this is remarkably inexpensive.
One of the challenges in implementing an RRT relates to a site’s culture of quality and safety. In facilities with a more hierarchical culture, it can be challenging to encourage and commend staff to call the RRT. In such sites, this type of intervention can’t happen overnight.
Another challenge is actually collecting data. I’m surprised at the number of sites that don’t have access to mortality rates or data on their non-ICU codes. In sites that don’t have these data immediately available, I would suggest working with the code committee so you don’t add another layer of bureaucracy.
Do you see a role for pediatric hospitalists on RRTs?
Having an inpatient pediatric specialist on the team would be critical, particularly at sites where there’s not 24/7 attending-level ICU expertise available. Just specializing in care for hospitalized children, having that set of fresh eyes there to evaluate kids, would be a huge addition to the quality of care for children, especially in adult hospital settings.
Can smaller hospitals use pediatric RRTs?
It’s hard to imagine a four-bed pediatric unit with a 24/7 pediatric RRT. Adult hospitals may need to blend pediatric RRTs into adult teams to evaluate kids. That, again, highlights a critical role for pediatric hospitalists.
Another idea in smaller hospitals would be to develop a virtual RRT. In sites where virtual pediatric ICUs exist, launching a virtual pediatric RRT with the use of telemedicine could be effective.
Where does the debate over RRTs stand now?
The Institute for Healthcare Improvement has recommended the implementation of RRTs since December 2004, and the Joint Commission has identified RRTs as a national patient safety goal.
From a scientific perspective, I believe that our study pretty much ended any controversy regarding the value of RRTs, at least in the pediatric population. Given the recommendations of safety and accrediting organizations and a growing body of literature, I believe that RRTs will become as much of a standard in hospitals as code teams.
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.