Association of Hospitalization-Level Characteristics With Pediatric Rapid Response Team Outcomes.

Simulation Testing of Pediatric Rapid Response Teams: Can Simulation Be Used to Determine the Best Team Structure?

Rapid response teams (RRTs) were implemented to provide critical care services for deteriorating patients outside of intensive care units. To date, research on RRT has been conflicting, with some studies showing significant mortality benefit and reduction in cardiac arrest events and others showing no benefit. However, studies have consistently showed improved outcomes when RRTs work closely with primary services. Baseline data analysis at our institution found that primary services were present only on 50% of RRT activations. This quality improvement project aimed to improve the presence of primary services during RRT activations by 25%. With a survey, the main barrier that prevented primary services to be present was identified as the primary services' failure to recognize them as a crucial part of the RRT. Education tools and in-person sessions were implemented reinforcing the importance of primary services presence during RRT activations. The intervention leads to increasing presence of primary services at RRT activations, transfers to higher level of care, and changes in code status. However, there was no difference in hospital or intensive care unit length of stay or in survival.

Rapid response teams (RRT) influence the issuing of NFR orders, with up to 24% of RRT calls involve documentation of NFR orders. This is to be expected as certain conditions demonstrate physiological disturbances as death approaches or such circumstances are precipitated by acute deterioration following an acute, unrelated illness. Furthermore, up to 35% of RRT calls are for patients with preexisting NFR orders, often within 24 h of their time of death. Overtime, RRT activity has evolved to be associated with issuing of other, related orders (e.g., not for RRT, modified RRT). The role of the RRT in end of life decisions and care will continue to evolve as RRT activity continues to increase and hospital wide strategies to better identify and manage patients at their end of life also evolve. There is potential for patient benefit of a closer association between critical care based RRT and palliative care services.

One factor impacting patient outcomes in the acutely deteriorating patient is a delay by nursing staff to activate a rapid response team (RRT); however, a gap in knowledge exists concerning factors influencing activation of an RRT by nursing staff working in adult areas outside the medical-surgical and telemetry setting. The purpose of this study was to examine beliefs and behaviors that influence registered nurses' decision to activate an adult rapid response team in a community hospital that includes 3 specialties: medical-surgical and telemetry, peripartum, and psychiatric areas. One hundred sixty-three nurses were surveyed using a 17-item Likert-style instrument to assess registered nurses' beliefs and attitudes on and barriers to utilizing an RRT. The survey was analyzed yielding 3 factors: RRT barriers, RRT positive/intent to activate, and patient management beliefs. Barriers cited by other research to activate RRT including criticism by the team and perception that the RRT increases workload or reduces skills were not found to be influential considerations. A significant difference was found among the 3 specialty groups related to RRT positive/intent to activate (F2,159 = 6.09, P = .003) and patient management beliefs (F2,159 = 5.87, P = .003). A strong negative correlation was found between years of experience as an RN and RRT barriers (ρ161 = -0.250). Organizations should examine RRT activation delays particularly in the area of calls to covering physicians prior to RRT activations. Differences between specialty groups highlight the need for education across specialties on the recognition of the acutely deteriorating patient. The findings indicate that the inexperienced nurse requires support from experienced colleagues and temporary adjustments to workload during situations of acute deterioration of a patient.

Analysis of High Flow Nasal Cannula Utilization During Pediatric Critical Care Transport

Background: There is limited evidence on the implementation and outcomes of rapid response teams (RRTs) in hematology/oncology centers. This study aims to evaluate the outcomes, clinical characteristics, and risk factors associated with 30-day mortality in pediatric hematology/oncology patients following RRT activation. Methods: This retrospective study included RRT encounters at a pediatric hematology/oncology center in Riyadh, Saudi Arabia, from 2020 to 2021. Results: Of 660 RRT encounters, 60.0% were males with a median age of 5 years interquartile range ((IQR): 2–10). Common reasons for rapid response team (RRT) activation were sepsis (47.7%), respiratory (16.1%), and cardiovascular disease (14.7%). The most encountered diagnosis classes were leukemia (36.4%), solid tumors (18.5%), and bone marrow transplant (BMT) (14.2%). The pediatric intensive care unit admission rate was 28.5%, with a median stay of 3 days (IQR: 2–7). The univariate analysis identified respiratory distress (p = 0.004), BMT (p = 0.042), desaturation (p < 0.001), tachypnea (p < 0.001), and high-flow nasal cannula (HFNC) use (p < 0.001) were associated with 30-day mortality. However, cardiovascular (p = 0.044) and fever (p = 0.014) were negatively associated with mortality. The multivariate analysis identified desaturation (p = 0.032), tachypnea (p = 0.027), and HFNC use (p < 0.001) were significantly linked to higher mortality. Meanwhile, fever was associated with reduced mortality risk (odds ratio: 0.4, p = 0.024). Conclusion: The study highlights the need for more evidence on RRT use in immunocompromised pediatric populations and those with complex diseases. Early recognition of high-risk symptoms, personalized RRT activation criteria, and advanced respiratory monitoring could significantly reduce mortality and improve care for critically ill pediatric patients in hematology/oncology settings.

Introduction: The optimal role of the primary service in Rapid Response Team (RRT) has not been well studied. We previously evaluated the impact of primary service presence on RRT activations in a retrospective review, finding their presence to positively correlate with transfers to higher levels of care and changes in code status. As part of a continuing quality improvement (QI) initiative, we sought to study RRT activations prospectively to identify future quality improvement interventions. Methods: For a one month period, RRT team leaders were asked to complete a survey following individual inpatient activation. Items evaluated included quality of communication with the primary service, barriers to their presence, reasons for transfer, and changes in goals of care. These were correlated with patient's medical record to determine demographics, type of service (surgical or medical), and RRT activation date and time. Results: A total of 180 RRT activations occurred in February. Thirty eight were excluded as being outpatients. Completion of 135 surveys occurred, giving a completion rate of 95%. Primary team presence at the bedside was associated with increased transfers to higher levels of care (Odds ratio [OR] 2.27, 95% CI 1.01-5.08). Code status was addressed more often during the activation when the primary service was present (OR 1.66; 95% CI 0.72-3.88). Visual analog scale subjectively demonstrated a more positive rating of communication by the RRT leader when the primary service was actively involved (p<0.0001) and present (p<.001), with during RRT assessment. In 16% of cases, the primary service was not contacted prior to or at time of RRT activation. In 22% of cases, the primary team was not physically present during the RRT. Of these, the most common reasons were resolution of the RRT evaluation before the primary team arrived (37%), and primary team home call (21%). Conclusions: The primary service should be viewed as an essential component of a RRT activation. They are able to provide meaningful insight into the patient's clinical course, and if needed, facilitate code status discussions. The physical presence of the primary team is more desirable than phone interactions. Future QI interventions will focus on improving bedside presence of the primary service to facilitate communication.

High flow nasal cannula for respiratory support in term infants.

Can proactive rapid response team rounding improve surveillance and reduce unplanned escalations in care? A controlled before and after study

The Pediatric Early Warning Score (PEWS) is an evidence-based tool that allows early collaborative assessment and intervention for a rapid response team (RRT) activation. The goal of our quality improvement initiative was to reduce the percentage of unnecessary RRT activations by 50% over 2 years without increasing PICU transfers or compromising patient safety and timely evaluation. A PEWS system replaced preexisting vital signs-based pediatric RRT criteria and was modified through plan-do-study-act cycles. Unnecessary RRT activations, total RRT activation rate, transfers to the PICU, total clinical interventions performed per RRT, and missed RRT activation rate were compared between intervention periods. Likert scale surveys were administered to measure satisfaction with each modification. There was a significant decrease in the percentage of unnecessary RRT activations from 33% to 3.5% after the implementation of the PEWS and modified-PEWS systems (P < .05). The RRT activation rate decreased from 22.6 to 13.3 RRT activations per 1000 patient care days after implementation of the PEWS and modified-PEWS systems (P < .05), without changes in PICU transfer rates. Physicians reported that the PEWS system improved nursing communication and accuracy of RRT criteria (P < .05). Nursing reported that the PEWS system improved patient management and clinical autonomy (P < .05). The PEWS systems have been an effective means of identifying deteriorating pediatric patients and reducing unnecessary RRT activations. The new system fosters collaboration and communication at the bedside to prevent acute deterioration, perform timely interventions, and ultimately improve patient safety and outcomes.

Benchmarking the Use of a Rapid Response Team by Surgical Services at a Tertiary Care Hospital

Introduction: Early recognition of clinical deterioration in inpatient subjects seems to be one of the main factors associated with prevention of in-hospital severe adverse events occurrence. Previous studies failed to demonstrate that the implementation of a rapid response team (RRT) could reduce in-hospital mortality rate. Hypothesis: Could a RRT implementation reduces in-hospital mortality and/or hospitalizations costs in a private general hospital in Brazil? Methods: This is a retrospective cohort built from data of electronic medical database of consecutive adult inpatients admitted to general wards who had to be transferred to an ICU after an acute clinical deterioration between May 1st, 2012 and June 30th, 2016. Subjects were divided into two groups as follows: group 1 (G1) with those admitted to ICU before RRT implementation on June 1st, 2014 and group 2 (G2) with the ones admitted to ICU after the implementation. All patients in G2 received care by the RRT before ICU admittance. In cases in which a patient had more than one hospital admission, only the first admittance was used for analyses. Results: Patients data are shown in table 1.Outcome data are shown in table 2. Conclusions: From these data, it is possible to infer that this RRT implementation at this hospital was associated with improvement in clinical outcomes of inpatients who needed an ICU admittance after an acute clinical deterioration, as well as a significant reduction of their hospitalization costs. These data reinforce the hypotheses that MERIT study was underpowered. Further multicenter randomized trials, with appropriate statistical power, shall be proposed to address these questions.

Analysis of High Flow Nasal Cannula Utilization During Pediatric Critical Care Transport

Introduction: The Rapid Response Team (RRT) is designed to bring critical care services to the bedside of patients outside of the intensive care unit (ICU) environment. A major barrier to effective implementation of the RRT is timely identification of deteriorating patients. At our institution, RRTs can be activated by objective vital sign parameters, and/or subjective assessment of patient decline. Methods: For the month of February 2013, RRT team leaders answered a survey immediately following a RRT activation. The survey queried RRT team leaders as to activation criteria (subjective or objective), and rationale for patients transferring to a higher level of care. Reasons for transfer were broadly classified as "team/service uncomfortable with patient condition," "monitoring beyond floor capabilities," "critical medical condition" and "intervention intensity exceeding the current unit capability." Each survey was correlated to the medical record to determine if the patient received any of the following critical care interventions in the next 24 hours: vasoactive medications or other medications requiring ICU monitoring, central line placement, initiation of noninvasive mechanical ventilation, invasive mechanical ventilation, unplanned surgical intervention, or unplanned urgent/emergent nonsurgical procedure (i.e. endoscopy), etc. Results: A total of 135 surveys were completed on 142 eligible patients (95%). The majority of activations met objective RRT criteria (82%). Overall, 61% transferred to a higher level of care. Patients not meeting objective criteria for RRT were significantly less likely to transfer (odds ratio [OR] 0.37, 95% CI 0.15-0.92). However, patients transferred for subjective reasons were equally likely to receive a critical care intervention in the next 24 hours (OR 1.07, 95%CI 0.25-4.52). We attempted subgroup analyses to look at the impact of subjective versus objective criteria on repeated RRT activations, but the number of repeated calls was too small for analysis. Conclusions: Although objective criteria identified the majority of patients requiring critical care services, approximately one in ten patients requiring critical care services were recognized based on subjective assessment of the primary nursing and medical team.

High flow nasal cannulae (HFNC) are small, thin, tapered binasal tubes that deliver oxygen or blended oxygen/air at gas flows of more than 1 L/min. HFNC are increasingly being used as a form of non-invasive respiratory support for preterm infants. To compare the safety and efficacy of HFNC with other forms of non-invasive respiratory support in preterm infants. We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 1), MEDLINE via PubMed (1966 to 1 January 2016), EMBASE (1980 to 1 January 2016), and CINAHL (1982 to 1 January 2016). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. Randomised or quasi-randomised trials comparing HFNC with other non-invasive forms of respiratory support in preterm infants immediately after birth or following extubation. The authors extracted and analysed data, and calculated risk ratio, risk difference and number needed to treat for an additional beneficial outcome. We identified 15 studies for inclusion in the review. The studies differed in the interventions compared (nasal continuous positive airway pressure (CPAP), nasal intermittent positive pressure ventilation (NIPPV), non-humidified HFNC, models for delivering HFNC), the gas flows used and the indications for respiratory support (primary support from soon after birth, post-extubation support, weaning from CPAP support). When used as primary respiratory support after birth compared to CPAP (4 studies, 439 infants), there were no differences in the primary outcomes of death (typical risk ratio (RR) 0.36, 95% CI 0.01 to 8.73; 4 studies, 439 infants) or chronic lung disease (CLD) (typical RR 2.07, 95% CI 0.64 to 6.64; 4 studies, 439 infants). HFNC use resulted in longer duration of respiratory support, but there were no differences in other secondary outcomes. One study (75 infants) showed no differences between HFNC and NIPPV as primary support. Following extubation (total 6 studies, 934 infants), there were no differences between HFNC and CPAP in the primary outcomes of death (typical RR 0.77, 95% CI 0.43 to 1.36; 5 studies, 896 infants) or CLD (typical RR 0.96, 95% CI 0.78 to 1.18; 5 studies, 893 infants). There was no difference in the rate of treatment failure (typical RR 1.21, 95% CI 0.95 to 1.55; 5 studies, 786 infants) or reintubation (typical RR 0.91, 95% CI 0.68 to 1.20; 6 studies, 934 infants). Infants randomised to HFNC had reduced nasal trauma (typical RR 0.64, 95% CI 0.51 to 0.79; typical risk difference (RD) -0.14, 95% CI -0.20 to -0.08; 4 studies, 645 infants). There was a small reduction in the rate of pneumothorax (typical RR 0.35, 95% CI 0.11 to 1.06; typical RD -0.02, 95% CI -0.03 to -0.00; 5 studies 896 infants) in infants treated with HFNC. Subgroup analysis found no difference in the rate of the primary outcomes between HFNC and CPAP in preterm infants in different gestational age subgroups, though there were only small numbers of extremely preterm and late preterm infants. One trial (28 infants) found similar rates of reintubation for humidified and non-humidified HFNC, and two other trials (100 infants) found no difference between different models of equipment used to deliver humidified HFNC. For infants weaning from non-invasive respiratory support (CPAP), two studies (149 infants) found that preterm infants randomised to HFNC had a reduced duration of hospitalisation compared with infants who remained on CPAP. HFNC has similar rates of efficacy to other forms of non-invasive respiratory support in preterm infants for preventing treatment failure, death and CLD. Most evidence is available for the use of HFNC as post-extubation support. Following extubation, HFNC is associated with less nasal trauma, and may be associated with reduced pneumothorax compared with nasal CPAP. Further adequately powered randomised controlled trials should be undertaken in preterm infants comparing HFNC with other forms of primary non-invasive support after birth and for weaning from non-invasive support. Further evidence is also required for evaluating the safety and efficacy of HFNC in extremely preterm and mildly preterm subgroups, and for comparing different HFNC devices.