Implementing a Pediatric Rapid Response System to Improve Quality and Patient Safety
Section snippets
Medical error and adverse events
A problem closely linked to the rising complexity of hospitals, and a factor in a significant proportion of life-threatening events, is medical error. In its 2000 report, To Err is Human, The Institute of Medicine concluded that between 44,000 and 98,000 patients die each year in US hospitals as a result of preventable clinical errors.7 There are many terms used to describe inappropriate care and adverse outcomes experienced by patients. A list compiled by Andrews and colleagues8 includes
Outcomes for cardiac arrest
Research over the past several decades has led to improved understanding of the epidemiology and pathophysiology of cardiac arrest in both adults and children. Corresponding advances in resuscitation, particularly coordinated strategies to strengthen the community chain of survival, have resulted in a marked improvement in outcomes for arrests that occur outside of the hospital setting.15 Efforts by the American Heart Association and other groups have brought these advances to the public in
Warning signs and symptoms
Observations over the past two decades have changed the belief that most incidents of cardiopulmonary arrest are sudden and unpredictable. In fact, cardiopulmonary arrest is often preceded by up to several hours of warning signs and symptoms that predict subsequent deterioration. This pattern has been demonstrated repeatedly and reliably in a series of prospective studies of adult patients who experience cardiac arrest on a general inpatient ward. In each of the studies listed in Table 1,
Outcome measures of pediatric rapid response systems
As rapid response systems are implemented and sustained with specific outcomes in mind, process and outcome measures must be followed to detect changes at the institution level as well as provide a framework for benchmarking. In 2007, the International Liaison Committee on Resuscitation (ILCOR) published “recommended guidelines for monitoring, reporting, and conducting research on medical emergency team, outreach, and rapid response systems: an Utstein-style scientific statement.”33 In addition
Implementation of a successful rapid response system
According to the Medical Emergency Team Consensus Conference, successful rapid response systems include four necessary components: (1) an afferent limb, (2) an efferent limb, (3) an evaluative/process improvement limb, and (4) an administrative limb.34 The afferent limb is defined as the component of the emergency response system that is able to detect an event and trigger a response. The efferent limb provides a crisis response including resources such as a medical emergency team (MET) or
Case example: University of North Carolina-Chapel Hill
An institution-wide pediatric rapid response system (PRRS) has been active at North Carolina Children's Hospital since August 2005. Antecedents described in the adult literature along with pattern antecedents identified in detailed institution-specific chart reviews were used to establish the criteria for activation of the RRT. Calling criteria were designed without numeric vital sign parameters to be highly sensitive for pre–cardiac arrest states. The criteria for activation are displayed in
Case example: Levine Children's Hospital
An institution-wide Pediatric Early Response Team (PERT) was initiated at Levine Children's Hospital (LCH) in 2004, and has evolved considerably since then. The initial afferent system for identifying a deteriorating patient used evidence-based criteria for airway, breathing, circulatory, and neurologic concerns, but activating the efferent response was inefficient and cumbersome. The nurse typically paged the inpatient physician and charge nurse and waited for recommendations or “permission”
Implementation of family activation
At Levine Children's Hospital, family members are encouraged to immediately notify a staff member when they are concerned about their child. The NC Children's Hospital used a similar approach initially. During the first year after implementation of the PRRS at NC Children's Hospital, “family concern” was one of the reasons for activation in 8% of the calls. More than half of those patients required transfer to the ICU, demonstrating that the calls were appropriate and necessary. In the spring
Use of rapid response system for quality improvement
There are many reported benefits of rapid response systems beyond a reduction in cardiac arrest and mortality rates. These include improved staff satisfaction and safety culture, improved nursing documentation, earlier palliative care, and improved education for physician trainees.26, 40, 41, 42, 43 In addition, rapid response and medical emergency team activations can be used for detection of medical errors and system safety issues. In fact, at one institution, more than 30% of RRT activation
Summary
Life-threatening events are common in today's complex hospital environment, where an increasing proportion of patients with urgent admission for severe illness are cared for by understaffed, often inexperienced personnel. Medical errors play a key role in causing adverse events and failure to rescue deteriorating patients. Outcomes for in-hospital cardiac arrest in both adults and children are generally poor, but these events are often preceded by a pattern of deterioration with abnormal vital
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