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“Run, Don’t Walk”The Rapid Response Team Intervention at

LPCH

Paul Sharek, MD, MPHAssistant Professor of Pediatrics, Stanford

UniversityMedical Director of Quality Management

Chief Clinical Patient Safety OfficerLucile Packard Children’s Hospital

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Overview of LPCH

LPCH166 Peds

52 OB

LPCHEl Camino16 Gen Peds 15 Eating Dis.

LPCHSequoia

6 NICU

LPCHWashington

9 NICU

Facilities:On-Campus 218

bedsMed-surg 76 beds

3 satellites 46 beds

Total 264 beds

Patient Activity (FY06):Inpatient Days 80,600

Discharges 13,877

Outpatient Visits105,837

Surgeries 4319

Births 5418

Peds CMI 1.8

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LPCH is a Recognized Leader in PediatricPatient Safety and Quality Outcomes

Recognized by national community (USNWR, Child Magazine)

Recognized by Payers “Excellence in Patient Safety and Health Care Quality Award” (Aetna, Blue Shield, CIGNA, and United Health

“Honor Role Hospital, Quality and Safety Data Reporting”: Health Net

Research First place award, Patient Safety Category, Pediatric Resuscitation Cart study, 5th International

Meeting for Medical Simulation conference, February 2005 Miami, FL

Sustained Reduction in Hospital-Wide Mortality Associated with Implementation of a Rapid Response Team in an Academic Children’s Hospital, JAMA. 2007;298(19):2267-2274

Leapfrog Survey: #1 of 1269 regarding implementation of NQF’s 30 evidence based best practices (21 relevant to

pediatrics) (2006)

#1 of 858 participating hospitals (2005)

Children’s Hospitals: Two-time winner, Race for Results Award (CHCA) Adverse drug event prevention work (2005) Outcomes from Rapid Response Team (2007)

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You would think we would have had a pretty good idea of how to address our

“codes outside of ICU” problem…

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Path ended up looking more something led by Yogi Berra…

“When you come to a fork in the road…take it”

“It’s tough to make predictions, especially about the future”

“The future ain’t what it used to be” “If you don’t know where you are going, you

might wind up someplace else”

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Reducing Codes Outside of the ICU at LPCH

A tale of futility…

and perseverance

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Why this project? LPCH

Codes outside of the ICU setting increasing dramatically after sudden change in severity of illness

Multiple interventions tried and failed Measure was/remains on LPCH Quality, Safety and

Service dashboard Board of Directors at LPCH tracking aggressively

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Prelude: Literature at the Time of Addressing Codes Outside of ICU

6 to 8 hour period of escalating instability that precedes nearly every cardiopulmonary arrest

Many causative physiological processes prior to an arrest are treatable

Post-cardiac arrest survival 24 hour survival: 33%*-36%**

Survival to discharge: 24***-27%*

1 year survival: 15%*, **

*Reis, et al. Pediatrics.2002;109:200-209**Nadkarni et al. JAMA.2006;295:50-57***Young et al. Annals of emerg med. 1999;33:195-205

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Chapter 1 of our tale…“There Was Joy in Mudville…or Was There?”

Codes Outside of ICU LPCH: Jan 2001 thru Dec 2001

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CT Surgery service

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Chapter 2 of our tale…“No Need to Panic-We Can Do This”

Codes Outside of ICU LPCH: Jan 2001 thru July 2003

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Education

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Surprise-education didn’t help…

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Chapter 3 of our tale…“If All Else Fails… Go To The Literature”

Codes Outside of ICU LPCH: Jan 2001 thru Jan 2004

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EducationHospitalists 7/03

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Looks like the hospitalists didn’t help…

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Chapter 4 of our tale…“Panic in Palo Alto: The Hero Gets Desperate”

Codes Outside of ICU LPCH: Jan 2001 thru Sep 2005

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EducationHospitalists 7/03

Patient progression (8/03)

CHCA handoffs collaborative (1/04)

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New World Emerging…IHI

Formal kick off of the 100,000 Lives Campaign, with RRT as 1 of 6 “evidence based” recommendations to decrease needless deaths in the US (12.2004)

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Thank goodness for the Aussies…

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New Literature Emerging

…Medical Emergency Team coincident with a reduction of cardiac arrest and mortality…

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LPCH decided to take the plunge…

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Chapter 5LPCH finally gets it right!

Codes Outside of ICU LPCH: Jan 2001 thru Sep 2005

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EducationHospitalists 7/03

Patient progression (8/03)

CHCA handoffs collaborative (1/04)

Rapid ResponseTeam 9/05

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Operationalization of the RRT at LPCH

Step 1: “building the will” Committee discussions (critical care committee, patient safety

committee, quality improvement council, etc) Approaching the multidisciplinary services (MDs, RNs, RT,

Nursing supervisors)

Step 2: “building the team”. Membership ICU MD (fellow or attending) ICU RN ICU trained RT RN supervisor

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Operationalization of the RRT at LPCH

Step 3: “rolling it out”: Educational strategies Multiple meetings to discuss/champion Emails Fliers 3 X 5 cards for all affected staff Pins Bribes Etc…

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Operationalization of the RRT at LPCH

Step 3: “rolling it out”: Activation Reasons for activation

Any staff member worried about a patient Acute changes in respiratory rate Acute change in O2 saturation Acute change in heart rate Acute change in blood pressure Acute change in level of consciousness

Logistics of activation Call hospital operators for “Rapid Response Team” Expectation: arrive in 5 minutes

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Operationalization of the RRT at LPCH

Step 3: “rolling it out”: RRT Expectations Arrive with a smile Announce “how can I help you” Use “S-BAR” communication format Write orders Determine disposition (ICU vs med-surg unit, vs…) Communicate to primary care providers

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Results: Codes Outside of the ICU:Absolute Number

Codes Outside of ICU LPCH: Jan 2001 thru March 2007

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Rapid ResponseTeam 9/05

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Results: Codes Outside of ICU:Rate (per 1000 pt days)

Codes Outside of ICU Rate

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

2.00

Co

de

Rat

e (p

er 1

000

elig

ible

pt

day

s)

Mean Code Rate 0.52Baseline Pre-RRT period

Mean Code Rate 0.15Post- RRT period

P < 0.01Decrease of 71%

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Codes Outside of ICU Rate

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Jan-

01

Apr-0

1

Jul-0

1

Oct-01

Jan-

02

Apr-0

2

Jul-0

2

Oct-02

Jan-

03

Apr-0

3

Jul-0

3

Oct-03

Jan-

04

Apr-0

4

Jul-0

4

Oct-04

Jan-

05

Apr-0

5

Jul-0

5

Oct-05

Jan-

06

Apr-0

6

Jul-0

6

Oct-06

Jan-

07

Co

de

Rat

e (p

er 1

000

elig

ible

ad

mis

sio

ns) Mean Code Rate 2.45

Baseline Pre-RRT period Mean Code Rate 0.69Post- RRT period

Results: Codes Outside of ICU:Rate (per 1000 admissions)

P < 0.01Decrease of 72%

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Hospital-Wide Mortality Rate

1.01

0.00.20.40.60.81.01.21.41.61.82.0

Jan-

01

Mar

-01

May

-01

Jul-0

1

Sep

-01

Nov

-01

Jan-

02

Mar

-02

May

-02

Jul-0

2

Sep

-02

Nov

-02

Jan-

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Mar

-03

May

-03

Jul-0

3

Sep

-03

Nov

-03

Jan-

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Mar

-04

May

-04

Jul-0

4

Sep

-04

Nov

-04

Jan-

05

Mar

-05

May

-05

Jul-0

5

Sep

-05

Nov

-05

Jan-

06

Mar

-06

May

-06

Jul-0

6

Sep

-06

Nov

-06

Jan-

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Mar

-07

Mo

rtal

ity

Rat

e (p

er 1

00 a

dm

issi

on

s)

Baseline Pre-RRT period Post-RRT period

Mean Mortality Rate 1.01 Mean Mortality Rate 0.83

Mortality Rate-Housewide

p < 0.01

34 kids lives saved in 19 mo!

18% reduction

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Conclusions: RRT at LPCH

Cost No added FTE (143 calls x 20 minutes per call x 4 people x $100/hour)/34

kids lives saved = $560 per life saved!

Statistically significant decrease in : Codes outside ICU per 1000 pt days Codes outside ICU per admissions Hospital-wide Mortality

Translation: 34 kids alive today as a result of LPCH RRT

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Conclusions at LPCH:One happy faculty pediatrician…

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“Take Aways” from LPCH

RRT provided immediate impact on outcomes-ramp up time very short

Transparency of data critical to driving/sustaining change

Return on investment very high for RRT Outcomes excellent No new personnel required 20 minutes per call

You can improve your mortality rate significantly with RRT implementation

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Questions???