1. Chicago 2014 Pediatric RRT/MET Teams #397 TFQO: Dianne Atkins COI #7 EVREV 1: Dianne Atkins EVREV 2: Kee Chong Ng COI #113 Taskforce: Peds

2. Chicago 2014 COI Disclosure Dianne Atkins Commercial/industry None Potential intellectual conflicts None Kee Chong Ng Financial None Potential intellectual conflicts None

3. Chicago 2014 2010 Treatment Recommendation Pediatric RRT or MET systems may be beneficial to reduce the risk of respiratory and/or cardiac arrest in hospitalized pediatric patients outside an intensively monitored environment.

4. Chicago 2014 C2015 PICO Population: In infants and children in the in-hospital setting Intervention: do medical emergency teams (MET) or rapid response teams (RRT) Comparison: compared to standard care ( no teams) Outcomes: Change: 9-Critical: Cardiac Arrest outside the ICU 9-Critical: All codes (respiratory and cardiac) outside the ICU 9-Critical: Respiratory arrest outside the ICU 6-Important: Cardiac arrest frequency 5-Important: Overall hospital mortality

5. Chicago 2014 Inclusion/Exclusion & Articles Found Inclusions/Exclusions Inclusion of heart arrest, cardiac arrest, respiratory arrest asystole, PEA, VF/VT combined with Pediatric search terms, AND MET, RRT, (Full search on SEERS) Exclusions: Early warning scores, traumatic arrest, adults, case reports, reviews The search yielded 113 abstracts Excluded:, mixed adult/pediatric population when data could not be analysed separately, other languages than English, publications before 2000.

6. Chicago 2014 Inclusion/Exclusion & Articles Found 10 papers completely reviewed 0 RCTs 9 non-RCTs, all before and after studies

7. Chicago 2014 2015 Proposed Treatment Recommendations We suggest implementation of pediatric RRT-METs in comparison with no RRT in hospitals that care for children.. (Weak recommendation, very low quality of evidence).

8. Chicago 2014 Risk of Bias in studies * Data are provided as rates: Event/hospital days, events/hospitals admissions or discharges, etc Non-RCT bias asssesment StudyYearDesign Total Patients Population Industry Funding Eligibility Criteria Exposure/Outcome Confounding Follow up Brilli 2007, 236 2007 Non-RCT N/A*IHCANoLow HighLow Sharek 2007, 2267 2007 Non-RCT N/A*IHCANoLow HighLow Zenker 2007, 418 2007 Non-RCT N/A* IHCA NoLow HighLow Hunt 2008, 117 2008 Non-RCT N/A*IHCANoLow HighLow Hanson 2009, 500 2009 Non-RCT N/A* IHCA NoLow HighLow Tibballs 2009, 306 2009 Non-RCT N/A* IHCA NoLow HighLow Ul-Haque 2010 273 2010 Non-RCT N/A* IHCA NoLow HighLow Kotsakis 2011, 72 2011 Non-RCT N/A* IHCA NoLow HighLow Hayes 2012, e785 2012 Non-RCT N/A* IHCA NoLow HighLow Bonafide 2014, 25 2014 Non-RCT N/A* IHCA NoLow HighLow

9. Chicago 2014 Evidence profile table #1

10. Chicago 2014 Evidence profile table #2

11. Chicago 2014 Evidence profile table #3

12. Chicago 2014 Proposed Consensus on Science statements For the critical outcome of outcome of cardiac arrest outside the ICU, we found 7 observational studies of very low quality. One study (Ul-Haque, 2010, 418) demonstrated a decrease in cardiac arrest frequency (OR 0.52, 95 CI 0.12- 2.26) in a tertiary care hospital in Pakistan. The majority of the calls were for respiratory complaints. Mortality of patients transferred from the wards to the PICU also decreased by 50% (OR 0.18, 0.09-0.35) Of the remaining 5 studies (Hanson 2010,500; Brilli 2007,236; Hunt 2008,17; Tibballs 2009,306; Kotsakis 201172;, Bonafide 2014,25) from academic children’s hospitals in the developed world, the rate of cardiac arrest outside the ICU declined after institution of RRT-METs in all (RR < 1) but none achieved statistical significance.

13. Chicago 2014 Proposed Consensus on Science statements For the critical outcome of all codes (cardiac and respiratory) outside the ICU, we found 4 observational studies (Hunt 2008,117; Sharek 2007,2267; Zenker 2007,418; Hayes 2012,e785) of very low quality. The studies were from North American academic hospitals. One study demonstrated a statistically significant decline while the other 3 did not after institution of RRT-METs. For the critical outcome of respiratory arrest, we found 1 observational study (Hunt 2008, 117) of very low quality from an academic children’s hospital. This study did observe a decline in respiratory arrests after institution of an RRT-MET. (RR=0.27, 0.05-1.01, p = 0.035)

14. Chicago 2014 Proposed Consensus on Science statements For the important outcome of cardiac arrest frequency, we found 1 observational study (Brilli 2007,236) of very low quality from a large academic children’s hospital. There was a trend towards decline in cardiac arrest frequency that was not statistically significant (RR=0.3, 0-1.04, p = 0.07) For the important outcome of overall hospital mortality, we found 6 observational studies (Hanson 2010,500; Brilli 2007,236; Tibballs 2009,306;Kotsakis 2011,72; Sharek 2007,2267; Zenker 2007,418) of very low quality from academic children’s hospitals. Three studies (Brilli 2007,236; Tibballs 2009,306; Sharek 2007,2267) observed a decline in deaths and 3 did not.

15. Chicago 2014 2015 Proposed Treatment Recommendations We suggest implementation of pediatric RRT-METs in comparison with no RRT in hospitals that care for children. (Weak recommendation, very low quality of evidence).