42 Enacting Meaningful Change in the Face of Adversity – Use of a Sentinel Event to Pilot the Creation of a Rapid Response System in a Tertiary Paediatric Care Centre

Abstract

Abstract Introduction/Background Although rare, in-hospital paediatric mortality occurs at a rate of 12.66 per 1000 admissions. Delayed recognition of clinical deterioration is a modifiable factor in such adverse events. In paediatric patients, subtle changes in vital signs often precede acute deterioration and provide an opportunity for early intervention and prevention of further deterioration. Based on this rationale, rapid response systems (RRS), which include a critical care response team (CCRT) and a Paediatric Early Warning Score (PEWS), have been established to facilitate the detection of clinical deterioration and mobilize resources for timely treatment. There is evidence that RRS can significantly decrease inpatient clinical deterioration events and PICU utilization. Objectives At our institution, serious patient safety events identified system failures in recognition, communication, and escalation of care in response to clinical deterioration. The root cause analysis led to a quality improvement and patient safety initiative to implement an RRS at our tertiary paediatric care centre. Design/Methods Process implementation of this pilot project required consultations with key stakeholders and designation of unit champions to mobilize resources and promote buy-in. Based on other successful implementation strategies, we adopted the Modified Brighton PEWS, defined a response algorithm, created bedside tools, constructed an interdisciplinary CCRT, and organized simulation activities to implement the new process. We used the Plan-Do-Study-Act method to carry out change based on weekly feedback from frontline workers. To assess the feasibility and acceptability of this initiative, all CCRT activations during the pilot phase were reviewed and a survey was distributed pre- and post-implementation. The number of code blues and mortality data will also be measured. Results The pilot period spanned June to September 2022 on our medical inpatient unit. Average response time to CCRT activation was 12 minutes (IQR 7-13.5), a median of three therapeutic interventions were required per activation, and 33% of activations resulted in PICU admissions. Among the 27 post–implementation survey respondents, 87% identified CCRT as a useful addition to optimize care and address patient safety concerns. Qualitatively, it has created a shared safety culture and empowered junior members of healthcare teams to escalate care. Conclusion This quality improvement initiative pilot study has demonstrated feasibility and acceptability of RRS implementation with a positive impact on patient safety culture and earlier detection and intervention for deteriorating patients. Further prospective comparative clinical benefits and cost-benefit analyses are needed to support hospital-wide implementation.