Host of the 2019 Congress of the World Federation of the

Societies of Intensive and Critical Care Medicine

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MELBOURNE

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THE ROLE OF RAPID RESPONSE TEAMS IN THE DETERIORATING CHILD

Simon Erickson Princess Margaret Hospital for Children

• Laila: 11 months old

• Unwell 1 week with Hand, Foot and Mouth Disease.

• More unwell and vomiting today.

• Brought by mum to ED; admitted to the Paediatric Ward

• Diagnosis: “HFMD with 5% Dehydration”

• Treatment IV fluids

• RR 50/min • SaO2 98% (R/A) • Heart Rate 160 bpm • BP 120/70 • CRT <3s • Temp 39°C axilla • Ulcers on mouth • BSL 6.1 mmol/L

Coronial review Failure to Rescue

“death following complications”

Implies common risk factors were not recognised in a timely manner or treated appropriately

Reactive care

RRT in Paediatrics

Why is there a need in paediatric hospitals?

Clinical deterioration common

Poor outcome of cardiac arrests

What is a Rapid Response Team?

Specific features in paediatrics

Is there any evidence that they work?

Review current use in Australia and New Zealand

Conclusions

Contributing Factors in Acute Crises

Patient state

Nature of disease

Variability of patient response

Human component/response

Outcome: in-hospital arrests

Inpatient arrests

n=880

ROSC n=459 (52%)

Survival to discharge

n=236 (27%)

Good outcome

n=136 (15%)

Nadkarni et al, First documented rhythm and clinical outcome from in-

hospital cardiac arrest among children and adults. JAMA 2006

Survival 24 hrs n=317 (36%)

Culture of Safety-Aviation

Detection and elimination of latent failures

Anticipation of human fallibility

Reduction of hazards

Removal of barriers to error detection

Blame allocation does not increase safety

- It merely changes the players

Failure to Recognise

Clinical assessment: Investigation, Diagnosis, Treatment

Patient monitoring: frequency and reliability

Clinical reasoning: individual judgment varies in accuracy according to training, experience, professional attitude, working environment, hierarchical position, and previous responses to alerts

Pediatric Critical Care Medicine 2015

Failure to Recognise

Clinical assessment: Investigation, Diagnosis, Treatment

Monitoring frequency and reliability

Clinical reasoning: individual judgment varies in accuracy according to training, experience, professional attitude, working environment, hierarchical position, and previous responses to alerts

What vital signs are performed?

UK Confidential Enquiry into Maternal and Child Health Services (Why children die: a pilot study 2006) showed “inadequate observations” as a contributory factor in 126 child deaths

ACT survey of paediatric nurses (June 2009) - Signs indicating deterioration ranked: 1.Resp rate 6.Work of breathing 2.Heart rate 7.Perfusion 3.Level of consciousness 8.Core body temperature 4.SpO2 9.Parental concern 5.BP

Establishment of observation charts with early warning signs indicating deviations from normal physiological variables

Failure to Recognise

Clinical assessment: Investigation, Diagnosis, Treatment

Monitoring frequency and reliability

Clinical reasoning: individual judgment varies in accuracy according to training, experience, professional attitude, working environment, hierarchical position, and previous responses to alerts

Decision-Making

Normative decision-making:

Systematic approach to a problem

Avoid errors through identification and management of bias

Relatively time-consuming

“extensive deliberation”

Naturalistic decision-making:

– Pattern-matching process

– Rule-based

– Fast and often accurate

– Prone to cognitive bias

– “fast and frugal”

Acute Paediatric Services

Fewer “experts” in recognition and management of the deteriorating child

Doctors in training no longer work excessively long shifts:

Increased dependence on handover information

Patient / problem ownership not always clear

Paediatric nurse:patient ratios vary / paediatric nurse availability

Critical illness and cardiopulmonary arrest are rare events

Intensive care resources may be distant and out of hospital / area

Practical and ethical issues need to be overcome in order to conduct robust research into the deteriorating child

Established clinical advice and transport networks do exist

Collegiality among workers in child health is strong but hierarchical approach may remain a barrier to calling for assistance

Rapid Response Systems

Definition: a coherent and integrated system of care that is designed to detect, respond to and manage patients who are deteriorating or at risk of clinical deterioration

Four main components:

Afferent limb

Efferent limb: Rapid Response Team

Data collection and feedback

Governance

Jones DA, DeVita MA, Bellomo R, NEJM 2011

Afferent limb Protocolised

Deviation of physiological parameters

Other clinical information-UOP, labs, pain

Single parameter triggers or composite score (EWS)

Staff or family concern

Many paediatric hospitals

Parental ability to detect deterioration especially chronic illness

Adherence to protocols crucial

Adjustment of parameters-may be indicated

Staff overriding calls reported frequently

Parent/carer initiated MET

Established in many paediatric hospitals

Often following coronial recommendations Josie King

Ryan’s rule

Parental ability to detect deterioration especially chronic illness

Risk of inappropriate use

Earlier recognition by parents?

Figure adapted from Kodali, S. Situational Awareness and Emergent Response Systems in the Context of Stages of Clinical Deterioration in the Hospital. J Nurs Care 2014; 3(4):171

Deterioration risk factors

1. Family concern

2. High risk therapies

3. Elevated EWS

4. ”Watcher” = “gut feeling”

(tacit knowledge)

5. Communication concern

Brady PW, Muething S, Kotagal U, Ashby M, Gallagher R,

Hall D, et al. Improving Situation Awareness to Reduce

Unrecognized Clinical Deterioration and Serious Safety

Events. Pediatrics. 2013; 131(1):e298-e308.

Efferent limb

Responding team Usually ICU based

Tiered approach Evidence varies

Staff composition varies No data to support composition

Resources important Negative impact elsewhere

Ward interaction critical Positive

Collaborative

Review/audit/governance

Review of afferent limbs Number of calls

Missed calls

Criteria adjustments

Call overrides

Review of responses Time to review

Outcomes

Resource use

Performance and outcome audit

Hospital characteristic Not managed by ICU Managed by ICU p - val u e

ICU level (CICM) N(%)

Level 1 (15)

Level 2 (59)

Level 3 (73)

2 (13.3)

5 (8.5)

18 (24.7)

13 (86.7)

54 (91.5)

55 (75.3)

0.045

Ho spital classification N(%)

Metropolitan (26)

Private (45)

Rural/regional (36)

Tertiary (40)

2 (7.7)

4 (8.9)

4 (11.1)

15 (37.5)

24 (92.3)

41 (91.1)

32 (88.9)

25 (62.5)

0.001

Jurisdiction N(%)

Australia (136)

New Zealand (11)

22 (16.2)

3 (27.3)

114 ( 83.6)

8 (72.7)

0.346

Hospital Bed numbers

Median (IQR) 362 (170 - 607) 250 (160 - 390) 0.08

Available ICU beds

Median (IQR) 13.0 (8.5 - 19.0) 11.0 (6.0 - 15.0) 0 .112

ICU admissions

Median (IQR) 1039 (596 - 1708) 831 (543 - 1360) 0.286

RRTcall : ICU admission r atio 0.51 (0.26 - 0.83) 0.57 (0.24 - 1.03) 0.17

Resource Utilisation, Governance, and Case Load of Rapid Response Systems in Australia and New Zealand in 2014 The Joint CICM - ANZICS SIG on RRS and ANZICS CORE. Critical Care and Resuscitation 2016

Resource Utilisation, Governance, and Case Load of Rapid Response Systems in Australia and New Zealand in 2014 The Joint CICM - ANZICS SIG on RRS and ANZICS CORE. Critical Care and Resuscitation 2016

Hospital characteristic Medical & nurse Medical only Nurse only p - value

ICU level (CICM) N(%)

Level 1 (14)

Level 2 (59)

Level 3 (73)

8 (57.1)

45 (76.3)

59 (79.7)

0 (0)

5 (8.5)

10 (13.5)

6 (42.9)

9 (15.3)

5 (6.8)

0.005

Hospital cla ssification N(%)

Metropolitan (26)

Rural/regional (35)

Tertiary (41)

Private (45)

21 (80.8)

23 (65.7)

32 (78.0)

36 (80.0)

1 (3.8)

2 (5.7)

7 (17.1)

5 (11.1)

4 (15.4)

10 (28.6)

2 (4.9)

4 (8.9)

0.04

Jurisdiction N(%)

Australia (13 6 )

New Zealand ( 11)

107 (78.7)

5 (45.5)

14 (10.3)

1 (9.1)

15 (11.0)

5 (45.5)

0.006

Hospital Bed numbers

Median (IQR)

256 (169 - 450)

280 (203 - 500)

220 (96 - 393)

0.089

Available ICU beds

Median (IQR)

12.0 (8.0 - 16.0)

10.0 (5.5 - 16.5)

8.0 (4.0 - 11.5)

0.034

ICU admissions

Median (IQR)

941 (553 - 1483) 1018 (752 - 1446) 643 (479 - 1235) 0.293

MERIT study (Lancet 2005)

Cluster randomised trial

Concluded that RRT did not substantially reduce unexpected cardiac arrest or death

-incidence of cardiac arrest and death decreased significantly in both study and control hospitals

-implementation of MET is study hospitals was poor

Post hoc analysis: data re-analysed in an “as-treated” model rather than intention-to-treat (“as-assigned”) model

significant improvement in outcomes (fewer deaths and cardiac arrests) significant and linear decrease in poor outcomes as MET responses

increased

Chen J, Bellomo R, Flabouris A, Hillman K Finfer S. CCM 2009

Meta-analyses suggesting that RRSs decrease the incidence of in hospital cardiac arrests (adults)

Study Effect on adult cardiac arrest Effect on paediatric cardiac arrest

Chan PS 2010 RR = 0.66 (95 % CI 0.54–0.80) N/A

Winters B 2013 RR = 0.66 (95 % CI 0.54–0.80) RR = 0.62 (95 % CI 0.46–0.84)

Maharaj 2015 RR = 0.65 (95 % CI 0.61–0.70) RR = 0.66 (95 % CI 0.55–0.74)

Qual Saf Health Care (BMJ)2009;18:500-504

Is there an optimal dose? Paediatric Rapid Response Calls vs. Cardiac arrests per 1000 separations in NSW from 2013-2015

33

12.7 13.4 16.3

18.9 21.9

0

5

10

15

20

25

30

Jul-Dec 2013 Jan-Jun 2014 Jul-Dec 2014 Jan-Jun 2015 Jul-Dec 2015

Ra

pid

Re

spo

nse

ca

ll r

ate

pe

r 10

00

se

pa

rati

on

s

2009

2010

2011

2012

2013

2014

R² = 0.9638

0

2

4

6

8

10

12

0 5 10 15 20 25 30 35 40 45 50

PIC

U M

ort

ali

ty (

%)

PICOS DOSE (Urgent ward reviews/1000 Hospital Admissions)

Relationship Between RRT Dose and PICU Mortality Children’s Hospital at Westmead PICOS (2009-2014)

Relationship between RRT Dose and PICU Admission Children’s Hospital at Westmead PICOS (2009-2014)

20

16

29

40 43 43

6.3 6.3 5.5 6.5 6.3 6.3

2009 2010 2011 2012 2013 2014

Urgent calls per 1000 hospital admissions (Dose)

PICU Admission from wards after urgent call per 1000 hospital admissions

Between the Flags

WA data-Code Blue vs. MET

MET outcomes

CEWT score

introduced

MET established

Review of WA data

True cardiorespiratory arrest remains uncommon

Preventable and predictable events were not seen

The threshold for MET calls remains low with the proportion of patients requiring transfer to PICU remaining very low

The majority of emergency calls were made after hours when the on-site PICU staffing levels, both medical and nursing, are at their lowest

MET calls are an increasing burden on PICU staff and this is a risk for patients in and outside the PICU

A sustainable solution with an alternative MET team structure is required so that a prompt and appropriate response can be delivered at all times

What should be the effect of the RRT?

More potentially deteriorating infants and children seen by an experienced clinician from outside the home team “someone who gets it… with prescribing rights”

Decreased score to door time: Earlier interventions and earlier resolution of physiological instability

Opportunities for collaborative approach to patient management and education

Increased opportunities for immediate and delayed event review

Change in culture from reactive to proactive and learning

Improved survival in deteriorating patients

Beneficial effects on outcomes Cardiac arrest frequency and outcomes Mortality in deteriorating children PICU admission rates NFR documentation

Potential downsides

Decrease learning opportunities of junior staff

Disempower/disenfranchise ward staff

May conceal hospital problems inadequate staffing levels

inadequate training

inadequate availability of senior staff

premature patient transfers

May negatively impact critical care areas by taking staff

Conclusion

Rapid response teams in children Not going away Current evidence in paediatrics limited

?Reduce in-hospital cardiac arrests ?Improve PICU survival in deteriorating ward patients Do not increase PICU admissions EPOCH study recently completed recruitment

Empowerment of concerned ward staff Education/collaborative approach with ward staff No consistent model Need to be adequately resourced Need to ensure RRT’s don’t negatively impact PICU

resources