The Impact of the Institution of a Rapid Response Team on Cardiorespiratory Arrests

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The Impact of the Institution of a Rapid Response
Team on Cardiorespiratory Arrests

• Keshava M N Gowda, MD
• Madaiah K. Talakadu, MD
• Ramon J Rivera, MD , FAAP
• Alexandre T. Rotta, MD, FCCM, FAAP

Department of Pediatrics and Department of
Anesthesiology and Critical Care Driscoll
Childrens Hospital Corpus Christi, TX
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Abstract

• In hospital pediatric cardiopulmonary arrests
  that occur outside of the intensive care unit
  carry a very poor prognosis and high mortality
  rates. We hypothesized that the institution of a
  Rapid Response Team would decrease the number of
  unexpected episodes of cardiorespiratory arrest
  in a Childrens Hospital. We retrospectively
  evaluated the incidence of cardiorespiratory
  arrests 3 years prior to and after the
  institution of a Rapid Response Team. A large
  proportion of patients (60) required critical
  care after a Rapid Response call. The institution
  of a rapid response team was associated with a
  significant decrease in the occurrence of
  cardiorespiratory arrest outside of the PICU
  (0.19/1000 admissions vs. 0.81/1000 admissions)
  and improved survival to discharge (75 vs. 46)
  compared to historical controls. We determined
  that patients directly admitted to the hospital
  from the primary pediatricians office and those
  transferred from referring institutions were at
  greater risk for hyperacute Rapid Response
  calls (calls within the first hour of
  hospitalization). We concluded that the
  institution of a Rapid Response Team reduced the
  occurrence of cardiorespiratory arrest outside
  of the PICU and reduced mortality. Patients
  directly admitted to the hospital from a
  pediatricians office of transferred from another
  institution are at greater risk for hyperacute
  Rapid Response calls and constitute a potential
  target for future interventions aiming at further
  reducing the incidence of unexpected arrests and
  unrecognized clinical instability.

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Background

• In-hospital pediatric cardiopulmonary arrests
  that occur outside of the intensive care unit
  account for between 8.5 and 14 of the total
  number of in-hospital arrests
• Arrests outside of the PICU carry a very poor
  prognosis with mortality rates of 50 to 67
• Reduction or elimination of such arrests should
  be a high priority

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Background

• According to the Institute of Medicine, errors
  result in 44000 to 98000 deaths annually in the
  US
• One of the strategies recommended by Institute
  for Healthcare Improvement ( IHI -100,000 Lives
  campaign) was the implementation of a Rapid
  Response Team (RRT) in every hospital

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Background

• Compared to historical controls, the institution
  of RRTs in adult hospitals has led to
• Decreased arrest rates
• Lower mortality rates
• A controlled randomized trial of RRTs in adults
  failed to show significant benefit .
• In children, implementation of a RRT appears to
  be associated with a reduction in hospital-wide
  mortality rate and code rate outside of the PICU
  setting

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Background

• The Pediatric Early Warning Score (PEWS) is a
  clinical tool designed to assess the likelihood
  of future clinical deterioration in children
• Since 2008, an adapted version of PEWS has been
  obtained for every patient at DCH upon admission,
  transfer or as dictated by changes in clinical
  condition

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Background

• Duncan et al (J Crit Care 2006) suggest that a
  PEWS of 5 could successfully identify 75 of all
  out of ICU arrests with at least 1 hour to spare,
  when applied to patients in a general care unit,
  with a sensitivity of 78 and specificity of 95

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Hypothesis

• We hypothesized that the institution of a RRT
  would decrease the number of unexpected
  cardiorespiratory arrests outside the PICU
  environment and its attendant mortality
• We also sought to uncover areas of potential
  weakness trough clinical trends in order to more
  readily identify patients at risk or vulnerable
  situations

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Methods

• Study protocol approved by the DCH IRB
• Retrospective study involving a review of
  patients who required evaluation or treatment by
  the RRT during their stay at DCH (01/01/2008 to
  12/31/2008)
• Sample identified through the RRT case registry
  and Code Blue registry
• Clinical records obtained by the Health
  Information System and reviewed by at least two
  of the investigators

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Statistics

• Statistical analysis performed with the aid of
  dedicated statistical software (SigmaStat v2.03,
  SPSS Inc)
• T-test
• Normally distributed continuous variables
• Mann-Whitney Rank Sum test
• Non-normally distributed continuous variables
• Chi-Square or Fisher Exact tests
• Categorical variables
• Z Test
• Comparison of proportions of an occurrence
  between two groups from independent observations
  (e.g., rate of cardiorespiratory arrests pre and
  post RRT)

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Results

• In 2008, there were
• 6558 total admissions to DCH
• 5475 routine admissions (excludes PICU, NICU)
• 65 Rapid Response Team (RRT) calls
• Mean age 4.8 years
• Mean PEWS 5.17
• Mean elapsed time from admit to RRT 74.69 hours
• Cases transferred to the PICU 39 (60)

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Results- Care Site After RRT
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Results - Patient Age
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Results - PEWS
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Results - Survival per Site
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Results - Intubation after RRT
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Results - PEWS
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Results - Survival
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Results - Code Blue Ratios

• 2005 to 2007
• 15,962 routine admissions
• 13 code blue calls
• 0.81 per 1,000 admissions
• 2008
• 5475 routine admissions
• 3 controlled code blue calls
• 1 code blue
• 0.19 per 1000 admissions

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Results - Code Blue Survival
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ROC of PEWS vs need for PICU care

• PEWS of 6 or higher predicts need for PICU care
• Sensitivity 0.64
• Specificity 0.81

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Results - Admit Source and RRT
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Results - Admit Source and RRT
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Hyperacute RRT (lt 1 hour from Admit)
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Conclusions

• A majority of patients (60) require critical
  care monitoring or treatment after a RRT call
• The institution of a Rapid Response Team at DCH
  was associated with a significant reduction in
  episodes of cardiorespiratory arrest outside of
  the PICU and increased survival
• A PEWS of 6 or higher is highly predictable of a
  subsequent need for Critical Care

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Conclusions

• Direct admits from referring hospitals and from
  primary pediatricians offices are associated
  with an unacceptably high occurrence of
  hyperacute RRT calls (RRT within the 1st hour
  of admission)

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References

• Sharek PJ, Parasat LM, Leong K, et al. Effect of
  a rapid response team on hospital-wide mortality
  code rates outside the ICU in a childrens.
  JAMA 2007 298(19)2267-2274.
•  
• Suominen P, Olkkola K, Voipio V, et al.Utstein
  style reporting of in-hospital pediatric
  cardiopulmonary resuscitation. Resuscitation
  2000 4517-25.
•  
• Reis A, Nadakarni V, Perondi M, et al. A
  prospective investigation into the epidemiology
  of in hospital pediatric cardiopulmonary
  resuscitation using the international Utstein
  reporting style. Paediatrics 2002 109200-209.
•  
• Nadakarni V, Larkin G, Peberdy M, et al. First
  documented Rhythm clinical outcome from in
  hospital cardiac arrest among children adults.
  JAMA 200629550-57.
•  
• Lopez-Herce J, Garcia C, Dominquez P, et al.
  Characteristics and outcome of cardiorespiratory
  arrests in children. Resuscitation 2004
  63311-320.
•  
• Hillman K, Chen J, Cretikos M, et al.Merit study
  investigators. Introduction of the medical
  emergency team (MET) system a cluster-randomized
  control trial. Lancet.2005 3652091-2097.
•  
• Priestley G, Watson W, Rashidian A, et al.
  Introducing critical care outreach a ward
  randomized trial of phased introduction in a
  generalh ospital. Intensive Care Med.2004 30
  1398-1404.
•   Duncan H, Hutchinson J, Parshuram C. The
  pediatric early warning score a severity of
  illness score to predict urgent medical need in
  hospitalized children. J Crit Care.200621
  271-279.
•  
• Brilli RJ, Gibson R, Luria JW, et al.
  Implementation of a medical emergency team in a
  large pediatric teaching hospital prevents
  respiratory and cardiopulmonary arrests outside
  the intensive care unit. Pediatric Crit care Med
  2007 8 (3)236-46.
•  
• Frost P, Wise M P. Cardio respiratory arrests
  rapid response teams in JAMA.2008 299(12)
  1423-1424

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Future Considerations

• Considering
• Successful roll out of RRT at DCH
• Low incidence of cardiac or respiratory arrests
  (code blue) outside of the PICU
• Focus on strategies that
• Improve triage
• Match optimal resource allocation to severity of
  illness on direct admissions (outside hospital
  transfers and private MDs).