“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
1
2
Overview of LPCH
LPCH
Washington
9 NICU
LPCH
Sequoia
6 NICU
On-Campus
Med-surg
3 satellites
Total
218 beds
76 beds
46 beds
264 beds
LPCH
166 Peds
52 OB
LPCH
El Camino
16 Gen Peds
15 Eating Dis.
3
Facilities:
Patient Activity (FY06):
Inpatient Days
Discharges
Outpatient Visits
Surgeries
Births
Peds CMI
80,600
13,877
105,837
4319
5418
1.8
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)
4
You would think we would have had a pretty good
idea of how to address our “codes outside of ICU”
problem…
5
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”
6
Reducing Codes Outside of the ICU at LPCH
A tale of futility…
and perseverance
7
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
8
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
9
Chapter 1 of our tale…
“There Was Joy in Mudville…or Was There?”
Codes Outside of ICU LPCH:
Jan 2001 thru Dec 2001
CT Surgery service
7
Number of Codes
6
5
4
3
2
1
10
Q
1
07
Q
3
06
Q
1
06
Q
3
05
Q
1
05
Q
3
04
Q
1
04
Q
3
03
Q
1
03
Q
3
02
Q
1
02
Q
3
01
01
Q
1
0
Chapter 2 of our tale…
“No Need to Panic-We Can Do This”
Codes Outside of ICU LPCH:
Jan 2001 thru July 2003
CT Surgery service
7
Number of Codes
6
Education
5
4
3
2
1
11
Q
1
07
Q
3
06
Q
1
06
Q
3
05
Q
1
05
Q
3
04
Q
1
04
Q
3
03
Q
1
03
Q
3
02
Q
1
02
Q
3
01
01
Q
1
0
Surprise-education didn’t help…
12
Chapter 3 of our tale…
“If All Else Fails… Go To The Literature”
Codes Outside of ICU LPCH:
Jan 2001 thru Jan 2004
CT Surgery service
7
Number of Codes
6
Education
5
Hospitalists 7/03
4
3
2
1
13
Q
1
07
Q
3
06
Q
1
06
Q
3
05
Q
1
05
Q
3
04
Q
1
04
Q
3
03
Q
1
03
Q
3
02
Q
1
02
Q
3
01
01
Q
1
0
Looks like the hospitalists didn’t help…
14
Chapter 4 of our tale…
“Panic in Palo Alto: The Hero Gets Desperate”
Codes Outside of ICU LPCH:
Jan 2001 thru Sep 2005
CT Surgery service
7
Number of Codes
6
Education
5
CHCA handoffs
collaborative (1/04)
Hospitalists 7/03
4
3
2
15
Q
1
07
Q
3
06
Q
1
06
Q
3
05
05
Q
3
04
Q
1
04
Q
3
03
Q
1
Patient progression
(8/03)
03
Q
3
02
Q
1
02
Q
3
01
01
Q
1
0
Q
1
1
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)
16
Thank goodness for the Aussies…
17
New Literature Emerging
…Medical Emergency Team coincident with a
reduction of cardiac arrest and mortality…
18
LPCH decided to take the plunge…
19
Chapter 5
LPCH finally gets it right!
Codes Outside of ICU LPCH:
Jan 2001 thru Sep 2005
CT Surgery service
7
Education
5
Q
1
07
Q
3
06
Q
1
06
05
05
Q
3
04
Q
1
04
03
Q
3
Patient progression
(8/03)
Q
1
Q
3
02
Q
1
02
Q
3
01
01
Q
1
0
Q
1
2
Q
3
Rapid
Response
Team 9/05
3
1
20
Hospitalists 7/03
4
03
Number of Codes
6
CHCA handoffs
collaborative (1/04)
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




21
ICU MD (fellow or attending)
ICU RN
ICU trained RT
RN supervisor
Operationalization of the RRT at LPCH
 Step 3: “rolling it out”: Educational strategies







22
Multiple meetings to discuss/champion
Emails
Fliers
3 X 5 cards for all affected staff
Pins
Bribes
Etc…
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
23
Operationalization of the RRT at LPCH
 Step 3: “rolling it out”: RRT Expectations






24
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
Results: Codes Outside of the ICU:
Absolute Number
Codes Outside of ICU LPCH:
Jan 2001 thru March 2007
7
Rapid Response
Team 9/05
Number of Codes
6
5
4
3
2
1
25
Q
1
07
Q
3
06
Q
1
06
Q
3
05
Q
1
05
Q
3
04
Q
1
04
Q
3
03
Q
1
03
Q
3
02
Q
1
02
Q
3
01
01
Q
1
0
Results: Codes Outside of ICU:
Rate (per 1000 pt days)
Codes Outside of ICU Rate
Code Rate (per 1000 eligible pt days)
2.00
1.80
Mean Code Rate 0.52
Baseline Pre-RRT period
Mean Code Rate 0.15
Post- RRT period
1.60
1.40
1.20
1.00
0.80
0.60
0.40
0.20
0.00
Ja
n0
Ap 1
r- 0
1
Ju
l-0
O 1
ct
-0
Ja 1
n0
Ap 2
r- 0
2
Ju
l-0
O 2
ct
-0
Ja 2
n0
Ap 3
r- 0
Ju 3
l-0
O 3
ct
-0
Ja 3
n0
Ap 4
r- 0
4
Ju
l-0
O 4
ct
-0
Ja 4
n0
Ap 5
r- 0
5
Ju
l-0
O 5
ct
-0
Ja 5
n0
Ap 6
r- 0
Ju 6
l-0
O 6
ct
-0
Ja 6
n07
P < 0.01
Decrease of 71%
26
Ja
n0
Ap 1
r- 0
1
Ju
l-0
O 1
ct
-0
Ja 1
n0
Ap 2
r- 0
2
Ju
l-0
O 2
ct
-0
Ja 2
n0
Ap 3
r- 0
3
Ju
l-0
O 3
ct
-0
Ja 3
n0
Ap 4
r- 0
4
Ju
l-0
O 4
ct
-0
Ja 4
n0
Ap 5
r- 0
Ju 5
l-0
O 5
ct
-0
Ja 5
n0
Ap 6
r- 0
Ju 6
l-0
O 6
ct
-0
Ja 6
n07
Code Rate (per 1000 eligible admissions)
Results: Codes Outside of ICU:
Rate (per 1000 admissions)
Codes Outside of ICU Rate
27
10
9
Mean Code Rate 2.45
Baseline Pre-RRT period
Mean Code Rate 0.69
Post- RRT period
8
7
6
5
4
3
2
1
0
P < 0.01
Decrease of 72%
Mortality Rate (per 100 admissions)
28
2.0
1.8
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0.0
18% reduction
p < 0.01
Mar-07
Jan-07
Nov-06
Sep-06
Jul-06
May-06
Mar-06
Jan-06
Baseline Pre-RRT period
Nov-05
Mean Mortality Rate 1.01
Sep-05
Jul-05
May-05
Mar-05
Jan-05
Nov-04
Sep-04
Jul-04
May-04
Mar-04
Jan-04
Nov-03
Sep-03
Jul-03
May-03
Mar-03
Jan-03
Nov-02
Sep-02
Jul-02
May-02
Mar-02
Jan-02
Nov-01
Sep-01
Jul-01
May-01
Mar-01
Jan-01
Mortality Rate-Housewide
Hospital-Wide Mortality Rate
Mean Mortality Rate 0.83
34 kids lives saved in 19 mo!
1.01
Post-RRT period
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
29
Conclusions at LPCH:
One happy faculty pediatrician…
30
“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
31
Questions???
32