1. 1 “Run, Don’t Walk” The Rapid Response Team Intervention at LPCH Paul Sharek, MD, MPH Assistant Professor of Pediatrics, Stanford University Medical Director of Quality Management Chief Clinical Patient Safety Officer Lucile Packard Children’s Hospital

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3. 3 Overview of LPCH LPCH 166 Peds 52 OB LPCH El Camino 16 Gen Peds 15 Eating Dis. LPCH Sequoia 6 NICU LPCH Washington 9 NICU Facilities: On-Campus218 beds Med-surg 76 beds 3 satellites 46 beds Total264 beds Patient Activity (FY06): Inpatient Days80,600 Discharges13,877 Outpatient Visits105,837 Surgeries4319 Births5418 Peds CMI1.8

4. 4 LPCH is a Recognized Leader in Pediatric Patient 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)

5. 5 You would think we would have had a pretty good idea of how to address our “codes outside of ICU” problem…

6. 6 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”

7. 7 Reducing Codes Outside of the ICU at LPCH A tale of futility… and perseverance

8. 8 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

9. 9 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

10. 10 Chapter 1 of our tale… “There Was Joy in Mudville…or Was There?”

11. 11 Chapter 2 of our tale… “No Need to Panic-We Can Do This”

12. 12 Surprise-education didn’t help…

13. 13 Chapter 3 of our tale… “If All Else Fails… Go To The Literature”

14. 14 Looks like the hospitalists didn’t help…

15. 15 Chapter 4 of our tale… “Panic in Palo Alto: The Hero Gets Desperate”

16. 16 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)

17. 17 Thank goodness for the Aussies…

18. 18 New Literature Emerging …Medical Emergency Team coincident with a reduction of cardiac arrest and mortality…

19. 19 LPCH decided to take the plunge…

20. 20 Chapter 5 LPCH finally gets it right!

21. 21 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

22. 22 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…

23. 23 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

24. 24 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

25. 25 Results: Codes Outside of the ICU: Absolute Number

26. 26 Results: Codes Outside of ICU: Rate (per 1000 pt days) P < 0.01 Decrease of 71%

27. 27 Results: Codes Outside of ICU: Rate (per 1000 admissions) P < 0.01 Decrease of 72%

28. 28 Mortality Rate-Housewide p < 0.01 34 kids lives saved in 19 mo! 18% reduction

29. 29 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

30. 30 Conclusions at LPCH: One happy faculty pediatrician…

31. 31 “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

32. 32 Questions???