Association of Pediatric Medical Emergency Teams With Hospital Mortality

Kutty, Shelby; Jones, Philip G.; Karels, Quentin; Joseph, Navya; Spertus, John A.; Chan, Paul S.

doi:10.1161/circulationaha.117.029535

Cited by 23 publications

(18 citation statements)

References 17 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Seventeen interventions involved the introduction of a new PTTT,13 15–18 60–72 one intervention introduced a mandatory triggering element to an existing PTTT71 and one study reported a large, multicentre analysis of MET introduction with no details on PTTT use 73. Twelve interventions included the introduction of a new MET or RRT,13 15–18 60–65 69 while four further interventions introduced a new PTTT in a hospital with an existing MET or RRT.…”

Section: Resultsmentioning

confidence: 99%

Validity and effectiveness of paediatric early warning systems and track and trigger tools for identifying and reducing clinical deterioration in hospitalised children: a systematic review

et al. 2019

View full text Add to dashboard Cite

ObjectiveTo assess (1) how well validated existing paediatric track and trigger tools (PTTT) are for predicting adverse outcomes in hospitalised children, and (2) how effective broader paediatric early warning systems are at reducing adverse outcomes in hospitalised children.DesignSystematic review.Data sourcesBritish Nursing Index, Cumulative Index of Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effectiveness, EMBASE, Health Management Information Centre, Medline, Medline in Process, Scopus and Web of Knowledge searched through May 2018.Eligibility criteriaWe included (1) papers reporting on the development or validation of a PTTT or (2) the implementation of a broader early warning system in paediatric units (age 0–18 years), where adverse outcome metrics were reported. Several study designs were considered.Data extraction and synthesisData extraction was conducted by two independent reviewers using template forms. Studies were quality assessed using a modified Downs and Black rating scale.Results36 validation studies and 30 effectiveness studies were included, with 27 unique PTTT identified. Validation studies were largely retrospective case-control studies or chart reviews, while effectiveness studies were predominantly uncontrolled before-after studies. Metrics of adverse outcomes varied considerably. Some PTTT demonstrated good diagnostic accuracy in retrospective case-control studies (primarily for predicting paediatric intensive care unit transfers), but positive predictive value was consistently low, suggesting potential for alarm fatigue. A small number of effectiveness studies reported significant decreases in mortality, arrests or code calls, but were limited by methodological concerns. Overall, there was limited evidence of paediatric early warning system interventions leading to reductions in deterioration.ConclusionThere are several fundamental methodological limitations in the PTTT literature, and the predominance of single-site studies carried out in specialist centres greatly limits generalisability. With limited evidence of effectiveness, calls to make PTTT mandatory across all paediatric units are not supported by the evidence base.PROSPERO registration numberCRD42015015326

show abstract

Section: Resultsmentioning

confidence: 99%

Validity and effectiveness of paediatric early warning systems and track and trigger tools for identifying and reducing clinical deterioration in hospitalised children: a systematic review

et al. 2019

View full text Add to dashboard Cite

show abstract

“…In contradiction of the 'longer time to embed' hypothesis is a longitudinal time series with the introduction of paediatric Medical Emergency Teams in the USA. [25] There is no additional improvement in mortality or cardiac arrest over the baseline time trends. What isn't known about these centres is how well the early identi cation was developed and embedded.…”

Section: Discussionmentioning

confidence: 98%

“…[11,[57][58][59] Guidance on developing, implementing, evaluating and publishing complex interventions are available [13,59], but there are few actual case studies of implementing complex interventions in healthcare and relating to early warning systems. [60,61] The early warning or rapid response literature has focused broadly on 'does the score/response team work' [1,2,3,8,10] and, more recently, attempts to understand why the score/response team appears to work in single-centre studies and not large multi-centre studies [3,10,25,56,62,63]. It could be that the score/response team doesn't work or it could be that the implementation science is key.…”

Section: Discussionmentioning

confidence: 99%

“…[2,3,9,10,[18][19][20][21][22] However, Randomised Controlled Trials (RCTs) and large interrupted time series have not demonstrated improved survival. [11,[23][24][25] RCTs produce high-level evidence; however, the iterative processes between environment, culture, policy and human action cannot be explored adequately within the constraints of this methodology and relatively short timescales for studies. [13,17] Data collected from our specialist children's hospital during a multicenter trial showed that our patients had infrequent and inconsistent observations [1].…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Quality Improvement Implementation and Maintenance of a Paediatric Early Warning System

Duncan¹,

Oliver²,

Emms³

et al. 2020

Preprint

View full text Add to dashboard Cite

Background: Paediatric Early Warning (PEW) systems have led to earlier identification and escalation of treatment with subsequent admission to Paediatric Intensive Care (PIC) in deteriorating children. The impact on reductions in cardiac arrest and mortality vary between the heterogeneous studies, showing both unchanged and reduced cardiac arrest, morbidity and mortality. Identifying and managing critical illness on wards is a complex and dynamic process involving technology, human interaction, cultural context and environment. We introduced a PEW system to reduce potentially avoidable cardiac arrest and death.Methods: We report an Implementation Science Quality Improvement (QI) natural experiment using the Medical Research Councils (MRC) Guidelines for Developing and Evaluating Complex Interventions, Action Research, Action Research Theory and methods. The aim of this program was to identify learning, refinement and improvement opportunities to reduce poor outcomes. The interventions were 1) developing an observation and monitoring policy to standardise practice and provide a template for optimal care, 2) standardized charting with an embedded PEW score, 3) clinical skills training, 4) clinical process audit and feedback and 5) outcome surveillance.The process measures were 1) timeliness and impact for unplanned Paediatric Intensive Care (PIC) admissions, 2) clinical assessment skills and 3) chart completion compliance. The outcome measures included 4) total and predictable cardiac arrests and 5) hospital mortality. Data collection started in 2004, the PEW system was implemented in 2008, and the outcomes were reported through 2018.Results: In our specialist children’s hospital, we completed six improvement cycles over 10 years. 1) Timely PIC admissions improved after implementation (39% to 92%). Patients with unplanned PIC admissions had significantly lower severity of illness and mortality but a longer length of stay. 2) Routine clinical observation accuracy improved (66 to 82%) following multimodal training. 3) Chart completion compliance improved (87 to 99%). In 2018, 2% of observations had missing or inaccurate parameters with a consequent inaccurate total PEW score. 4) The total cardiac arrest rate was significantly reduced (0.36 to 0.16 per 1000 admissions). The small numbers of predictable cardiac arrests showed a decreasing trend. 5) Hospital mortality was significantly reduced (3.46 to 2.24 per 1000 admissions). Outcomes improved approximately 18 months after implementation and have not changed significantly since 2010 despite increasing critical care resources in and out of PIC. The impact of the PEW system on these outcomes is possible but not conclusive.Conclusion: Implementation of the PEW system as a complex intervention using QI methods is associated with improved clinical skill accuracy, chart compliance and detection of deterioration associated with more timely unplanned PIC admissions. These improvements were associated with a significant reduction in cardiac arrest and mortality.

show abstract

“…Alternatively, a prospective, multicenter trial examining deployment of a standardized pediatric rapid response team at four pediatric academic hospitals in Canada demonstrated a reduction in PICU mortality only after readmission, but no reduction in the rate of cardiopulmonary arrests or PICU mortality (20). Using the PHIS database, an interrupted time series analysis examined the effect of implementation of a rapid response team on annual risk-adjusted mortality rates at 38 freestanding pediatric hospitals and found no association with a reduction in hospital mortality (21).…”

Section: Moving the Patient Before They Code: Implementation Of Pediamentioning

confidence: 99%

No more pediatric code blues on the floor: evolution of pediatric rapid response teams and situational awareness plans

Sandquist

Tegtmeyer

2018

Transl Pediatr

View full text Add to dashboard Cite

Reducing or eliminating code blues that occur on the inpatient, noncritical care units of children's hospitals is a challenging yet achievable goal. The mechanism to accomplish this involves several levels of effort. The implementation of effective pediatric rapid response teams is a well identified part of the process. Rapid response teams can allow for appropriate clinical interventions for deteriorating patients and may ultimately result in a reduction in hospital-wide mortality as well as efficient transfer to the pediatric intensive care unit (PICU) when necessary. The timely deployment of rapid response teams is dependent upon the appropriate recognition of patients at risk for deterioration. This recognition can be optimized by relying on assessments as simple as utilization of parental intuition to those as complex as big data models which utilize multiple predictor variables extracted from the electronic medical record. Ultimately, the goal to proactively identify patients at risk of deterioration may allow for prevention of clinical decline via appropriate and timely interventions, and if unsuccessful at that level, may allow for improved outcomes via optimized resuscitation care in the PICU.

show abstract

Association of Pediatric Medical Emergency Teams With Hospital Mortality

Abstract: Implementation of medical emergency teams in a large sample of pediatric hospitals in the United States was not associated with a reduction in hospital mortality beyond existing preimplementation trends.

Cited by 23 publications

References 17 publications

Validity and effectiveness of paediatric early warning systems and track and trigger tools for identifying and reducing clinical deterioration in hospitalised children: a systematic review

Validity and effectiveness of paediatric early warning systems and track and trigger tools for identifying and reducing clinical deterioration in hospitalised children: a systematic review

Quality Improvement Implementation and Maintenance of a Paediatric Early Warning System

No more pediatric code blues on the floor: evolution of pediatric rapid response teams and situational awareness plans

Contact Info

Product

Resources

About