Gut feelings can save lives, say clinicians and researchers at Lucile Packard Children's Hospital and the Stanford University 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 cautiously 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 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 Hospital. "They don't have the energy reserves or muscle mass that most adult patients have."
Sharek, who is also an assistant professor of pediatrics at the medical school, estimated that 33 lives - equivalent to an 18 percent reduction in the monthly mortality rate - were saved during the 19-month study period by rapid response teams, or RRTs, trained to provide supportive care before a child's clinical condition becomes life-threatening.
Packard Children's implemented the RRT program in 2005 to reduce the frequency of emergency "codes" occurring in children who are hospitalized but outside the intensive care unit. A code occurs when a child's heart or breathing stops. Although the most unstable children are kept in the intensive care unit, many young patients 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 providing additional respiratory support, administering additional or different intravenous fluids or transferring the child to the intensive care unit for ongoing 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 empowering, and then supporting, the nursing staff may be one reason why the RRT effort was so successful at Packard Children's. The researchers hypothesize that nurses at Packard Children's involved the RRT earlier in the time course of the child's deterioration than those at other pediatric institutions that have recently implemented RRTs. The fact that Packard Children's specializes in highly complex cases, which can result in a rapidly changing clinical status, may be another reason why the RRT has been particularly successful at Packard Children's.
"The average level of illness at Packard Children's is substantially higher than 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 hospital first considered establishing a rapid response team in December 2004 when the Institute for Healthcare Improvement recommended RRTs for adult U.S. patients as part of its 100,000 Lives Campaign. At the time, rapid response teams had been shown to be effective in adult care settings. The Packard Children's study is the first to demonstrate that RRTs result in lower death rates in pediatric settings.
The use of 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."
Journal reference: JAMA. 2007;298(19):2267-2274.
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.
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