Improving Quality of Care: Role of Rapid Response Team and Quick Assessment Unit

Department of Pediatrics and

Department of Anesthesiology and Critical Care,

Driscoll Children’s Hospital,

Corpus Christi, TX May 2010Corpus Christi Pediatric Society May 2009Corpus Christi Pediatric Society May 2009

Corpus Christi Pediatric Society May 2009 Corpus Christi Pediatric Society May 2009 Corpus Christi Pediatric Society May 2009

Ranjana Sarma, MDMadaiah K. Talakadu, MDKeshava M N Gowda, MDRamon J Rivera, MD ,

FAAPAlexandre T. Rotta, MD, FCCM, FAAP

AbstractThe number of in-hospital pediatric

cardiopulmonary arrests that occur outside of the intensive care unit and carry a very poor prognosis, has significantly decreased with the institution of a Rapid Response Team (RRT)

We continue to analyze the role of the RRT and also hypothesize that the implementation of a Quick Assessment (QA) unit would optimize resource allocation and triage by identifying the sicker subset of patients, intervening early and hence reduce the number of hyperacute rapid response calls (occurring within 4 hours of hospitalization)

RESULTS: Among the patients admitted from the pediatrician’s office, the number of rapid response calls dropped from 17 (in 2008) to just 1 (in 2009 after QA) and there were no hyperacute rapid response calls from the same patient population since the institution of the Quick Assessment unit.

The time to a rapid response call also increased from 67.6 hours in 2008 to 87.2 hours again symbolizing the success of the QA unit in buying more time to actively intervene and stabilize patients.

Restrospective analysis of the number of cardiorespiratory arrests 3 years before and 2 years after the implementation of the rapid response team showed that RRT was associated with a significant decrease in the occurrence of cardiorespiratory arrest outside the PICU (0.68/1000 admissions in 2009 vs 0.73/1000 admissions in 2008 vs 0.81/1000 admissions from 2005-2007) and improved survival to hospital discharge after a code blue event from 46% (2005-2007) to 75% (2008) and an ideal 100% (2009)

We concluded that the rapid response team continues to improve patient survival and that Quick Assessment has effectively decreased the number of hyper acute RRs among direct admissions and also improved quality of patient care

BackgroundAccording to the Institute of Medicine, 44000

to 98000 preventable deaths occur annually in the US

One of the strategies recommended by Institute for Healthcare Improvement ( IHI -100,000 Lives campaign) was the implementation of a Rapid Response Team (RRT) in every hospital

BackgroundIn-hospital pediatric cardiopulmonary arrests

that occur outside of the intensive care unit account for between 8.5% and 14% of the total number of in-hospital arrests

Arrests outside of the PICU carry a very poor prognosis with mortality rates of 50 to 67%

Reduction or elimination of such arrests should be a high priority

BackgroundThe Pediatric Early Warning Score

(PEWS) is a clinical tool designed to assess the likelihood of future clinical deterioration in children

Since 2008, an adapted version of PEWS has been obtained for every patient at DCH upon admission, transfer or as dictated by changes in clinical condition

PEWS: Behavior/Cardiovascular/Respiratory

BackgroundRRT was instituted at DCH in January 2008 Analysis of 2008 RRT data revealed that Direct

admits from referring hospitals and from primary pediatrician’s offices were associated with a very high occurrence of Rapid Response (RR) calls within the 1st hour of admission

The Quick Assessment (QA) unit was instituted in our ER on July 13th, 2009 to improve triage and to match optimal resource allocation to severity of illness on direct admissions and hence improve the overall quality of care.

BackgroundQuick Assessment is a process used to

evaluate a patient that presents to the triage area of the ED to determine the suitability of such patient for direct admission or the need for a full evaluation and treatment in the ED.

Vital signs are obtained by the nursing staff and the patient is assessed by ED physician utilizing the quick assessment tool.

HypothesisThe institution of a QA unit at DCH would

decrease the number of hyperacute RRT calls among direct admissions

RRT at DCH will continue to positively impact the number of unexpected cardio-respiratory arrests outside the PICU environment and its attendant mortality

Uncover areas of potential weakness through clinical trends in order to more readily identify patients at risk or vulnerable situations

MethodsStudy protocol approved by the DCH IRB

Retrospective study involving a review of patients who required evaluation or treatment by the RRT and QA unit during their stay at DCH (01/01/2008 to 12/31/2009)

Sample identified through the RRT case registry and Code Blue registry

Clinical records obtained by the Health Information System and reviewed by at least two of the investigators

MethodsRelevant clinical data extracted onto

customized Excel spreadsheetsStatistical analysis performed with the help

of

Dr. Jose Guardiola, Phd, Assistant Professor of Statistics, TAMUCC

MethodsT-test:

Normally distributed continuous variablesWilcoxon test

Non-normally distributed continuous variables

Chi-Square or Fisher Exact testsCategorical variables

Z TestComparison of proportions of an

occurrence between two groups from independent observations

Patient distribution

54%15%

31%

0% 0%Private MD

ED

Referral hospital

PICU

Specialty MD

50%50%

0%0%

0%Private MD

ED

Referral hospital

PICU

Specialty MD

9 4

2008 hyperacute RRs< 1 hr 2-4 hrs

1 5

2009 hyperacute RRs< 1 hr 2-4 hrs

Hyperacute RRs in 2009

75%

25%

0%0% 0%

RRs before QA

Private MDED

Referral hospitalPICU

Specialty MD

0%

100%

0%0% 0%

RRs after QA

Private MDED

Referral hospitalPICU

Specialty MD

PEWS of pts transferred to PICU after a RR call 2008 2009

-1

0

1

2

3

4

5

6

7

8

9

10

PE

WS

N Y

PICU Transfer

-1

0

1

2

3

4

5

6

7

8

PE

WS

No Yes

PICU Transfer

Time to RR call from registration (in hours)

0

100

200

300

400

500

600

Tim

e (h

rs)

After QA Before QA

Private MD Referral hospital

PICU Specialty MD ED1 1 0

6 106 2 4

5

1817

5 6

14

23

Number of RR Calls based on admission source

2009-After QA 2009-Before QA 2008

Patient disposition post RR 2008 2009

Patient disposition post RR Before QA After QA

Code blue ratios (per 1000 admissions) and survival (percentage) trend

2005-20072008

2009

46%

75%100%0.81

0.730.68

Code blue survival Code blue ratio

Some quality improving QA facts…141 of all QAs were turned to ED

evaluations 2 pts transferred to PICU instead of floor 2 pts taken to OR from ED directly after

evaluation (Foreign body, Appendicitis)1- taken to radiology for reduction

(intussusception)Total number of QA pts discharged from

ED after evaluation – 5Only 1 pt who came through QA had a RR

call (the patient was from an outside hospital)

ConclusionsRapid Response Team at DCH continues to

cause a significant reduction in episodes of cardio-respiratory arrest outside the PICU and increased patient survival

Higher PEWS is still highly predictable of a subsequent need for Critical Care

>50% patients continue to require critical care monitoring or treatment after a RRT call

QA has effectively decreased the number of hyper acute RRs among direct admissions and also improved quality of patient care

Concern..RRT utilization at DCH:

2008 – 0.56/100 occupied beds 2009 – 0.48/100 occupied beds• National aggregate of RRT utilization 10/100 occupied beds

Future ConsiderationsConsidering…

Continuing success of RRT at DCHPositive impact of QA on lowering the incidence

of hyper acute RRs among direct admitsStrategies to focus on ..

Improve RRT utilization Closer monitoring of patients with higher PEWS

score Ensure that all direct admits to go through QA-

including Specialty MDAim for lower PEWS (0-2) before admitting a pt

from ED

At DCHWe care….

We deliver…..