Pediatric Rapid Response Systems: Identification and Treatment of Deteriorating Children

Abstract

Opinion statementRapid response systems (RRSs) aim to identify deteriorating hospitalized patients outside of the intensive care unit, respond quickly, and escalate to a higher level of care if needed. Despite a decade of evaluation, how to best design an RRS is still under study and debate. When considering your RRS, our recommendation is to start with the outcomes: what improvements in patient care are most needed in your environment? These may include reducing cardiac arrest or mortality, reducing critical deterioration, reducing length of stay in intensive care, or avoiding all preventable patient harm. Then, select a strategy for identification of at-risk patients, a response team structure that meets your institution's needs, and a quality improvement and governance structure to ensure you monitor process and outcome variables. The identification limb detects at-risk patients. For this, we recommend an aggregate pediatric early warning score (EWS), clear guidance regarding monitoring type and frequency, flagging of diagnostic risk factors, and a mandatory escalation system that uses the expertise of nurses, patients, and families and works around barriers to enhance response team activation. The structure and function of the response limb are also dependent upon the needs of the institution. We recommend a multidisciplinary team with the skills and resources to assess and manage emergencies. Proactive identification through a rover team or scheduled safety huddles may help with earlier identification of at risk patients. The quality improvement and governance structure should be designed around the desired outcomes. Regular monitoring and review of successes, near misses, and failures are vital for the system to improve outcomes.

Developing and Optimising Observation and Monitoring Guidance for a Paediatric Early Warning System

“…Much of the literature surrounding early warning has focused on the content and performance of the varied scores and response teams [11][12][13] . There is little guidance about how frequently the observations and monitoring that contribute to the early warning scores should be and are performed [12][13][14] .…”

“…Much of the literature surrounding early warning has focused on the content and performance of the varied scores and response teams [11][12][13] . There is little guidance about how frequently the observations and monitoring that contribute to the early warning scores should be and are performed [12][13][14] . The systematic literature review of Lambert et al identi ed 16 studies relating to the cultural and socio/technical PEW system implementation strategies, none of which dealt with which vital signs should be monitored or the frequency, escalation and deescalation of monitoring practice 12 .…”

“…Because it is broad guidance for all health care environments, it therefore lacks detail of how often and which observations and monitoring should be performed in different circumstances and settings. Like the overall PEW system, the guidance needs to be adapted to the context and the resources available for each organisation 12,13 .…”

Improving Pediatric Rapid Response Team Performance Through Crew Resource Management Training of Team Leaders

“…Interestingly, we would have postulated that RRTs caring for patients who remain on the floor after RRT involvement might have had poorer team performance based on previous research. [46][47][48][49][50] ICU team members often perceive that floor patients do not require ICU expertise, transfer occurs primarily due to nurse staffing issues on the acute care floor, and leaving the ICU for a RRT call compromises the care of patients in the ICU. Floor team members often perceive that they have difficulty accessing the resources they need on the floor, have received punitive responses from the ICU team for activating the RRT, and experience stress involved in having to justify a transfer.…”

Clinical progress note: Situation awareness for clinical deterioration in hospitalized children

“…Unrecognized clinical deterioration is a common and significant source of preventable harm. An estimated 16% of serious harm events involve failed escalation of deterioration, but when deterioration is recognized earlier, cardiopulmonary arrest survival rates improve from 27% to 80% 1 . Mitigation of this harm is dependent upon situation awareness (SA) for a patient's current and anticipated clinical status.…”