Rapid response teams save children's lives at Packard Children's Hospital

Paul Sharek

Gut feelings can save lives, say clinicians and researchers at Lucile Packard Children's Hospital and the School of Medicine.

Deploying the hospital's 'rapid response teams' proactively at the first inkling of trouble in hospitalized children, rather than taking the standard course of watching and waiting, can significantly reduce death rates, they found.

The finding is the first to reveal lower death rates and cardiopulmonary arrest rates resulting from rapid response teams in a pediatric setting and could spark similar programs in other children's hospitals around the country.

'Even in the hospital, sick children can deteriorate so quickly,' said Paul Sharek, MD, chief clinical patient safety officer at Packard Children's. 'They don't have the energy reserves or muscle mass that most adult patients have.'

Sharek, also assistant professor of pediatrics at the medical school, estimated that 33 lives - equivalent to an 18 percent lower monthly mortality rate - were saved during the 19-month study by rapid response teams, or RRTs, trained to provide care before a child's condition becomes life-threatening. The study was published Nov. 21 in the Journal of the American Medical Association.

Packard Children's started the RRT program in 2005 to reduce the emergency 'codes' occurring in children who are hospitalized but not in the intensive care unit. A code occurs when a child's heart or breathing stops. Although the most unstable children are kept in the ICU, many in non-ICU settings are very ill and can worsen rapidly.

'Once a child codes, the odds of long-term survival are pretty small,' said Sharek. 'However, there's often a period of about six to eight hours when a child who might later code begins to show subtle signs of distress. If we can intervene early in this process, the child is far more likely to improve than if we simply monitor and maintain the same approach to treatment.'

Rapid response teams - made up of existing staff members - consist of a pediatric intensive care physician, an intensive care nurse, an intensive care respiratory therapist and a nursing supervisor. The teams, which are present at the hospital 24/7, arrive at a child's bedside within five minutes after a summons to assess his or her condition. Interventions in addition to the medical management already under way include additional respiratory support, additional or different intravenous fluids or transferring the child to the ICU for monitoring and more intensive therapy.

The researchers found that although many RRT calls were triggered by measurable changes in a patient's status - a change in breathing pattern, blood oxygen content or blood pressure - some occurred simply because the child's medical caretaker or parent felt that something just wasn't right.

'We empower the nursing staff to act on their expertise by calling for RRT involvement when they are concerned about a child's worsening clinical situation,' said Sharek.

Aggressively supporting nursing staff may be one reason why RRTs were so successful at Packard Children's. The researchers hypothesize that nurses at Packard Children's involved the RRT earlier in the course of a child's deterioration than those at other pediatric settings with recently implemented RRTs. Packard Children's specializes in complex cases with often rapidly changing clinical status, and that may be why the hospital's RRTs have been so successful.

'The average level of illness at Packard Children's is substantially higher than at the vast majority of other children's hospitals in North America,' said Sharek. 'Although the average child on our medical or surgical hospital units may not require the high nurse-to-patient ratio of the intensive care unit, he or she is still frequently quite ill.'

Packard Children's first considered starting a rapid response team in 2004 when the Institute for Healthcare Improvement recommended RRTs for adult U.S. patients in its 100,000 Lives Campaign. Rapid response teams had been shown effective in adult care settings. The Packard Children's study is the first to show that RRTs result in lower death rates in pediatric settings.

The RRT program at Packard Children's did not require any additional staffing or financial resources. The study authors added, however, that cost-effectiveness of the RRT program should be studied in more depth.

'Basically, despite the fact that RRTs had never been shown to decrease mortality in hospitalized children, we decided to take a chance on this,' said Sharek, who added that the study required no outside funding. 'We're very proud and excited about the results.'

Co-authors on the study were Layla Parast, MS; Kit Leong; Jodi Coombs, RN; Karla Earnest, RN, MS, MSN; Jill Sullivan, RN, MSN; Lorry Frankel, MD, associate professor of pediatrics, and Stephen Roth, MD, the James Baxter and Yvonne Craig Wood Director of Pediatric Cardiovascular Intensive Care and associate professor of pediatrics.

Stanford Medicine integrates research, medical education and health care at its three institutions - Stanford University School of Medicine, Stanford Health Care (formerly Stanford Hospital & Clinics), and Lucile Packard Children's Hospital Stanford. For more information, please visit the Office of Communication & Public Affairs site at http://mednews.stanford.edu.

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