IHI.org Story: Children Count in the 100,000 Lives Campaign

​Mention cardiopulmonary arrest, in which both respiration and circulation stop, and most people think of adults, not children. And rightly so. But studies show that up to 0.7 percent of hospitalized children experience this sort of medical crisis. And outcomes are often poor, despite emergency response. 


As with adults, there’s now more attention being paid to identifying earlier signs that a child may be in trouble. That’s the premise behind the growing use in pediatrics of Rapid Response Teams, teams of clinicians who bring critical care expertise to the bedside (or wherever it is needed) at the first sign that the patient’s condition may be deteriorating, intervening before a medical crisis can occur.


One of six interventions in IHI’s 100,000 Lives Campaign, Rapid Response Teams are a natural fit in hospitals that serve children, says Charlie Homer, MD, MPH, Chief Executive Officer of the National Initiative for Children’s Health Care Quality (NICHQ). NICHQ is IHI’s partner-organization focused on improving care for children. It has teamed up with the Child Health Corporation of America (CHCA), the National Association of Children’s Hospitals and Related Institutions (NACHRI), and the American Academy of Pediatrics, along with a committed group of leadership hospitals, to form the Pediatric Affinity Group for the 100,000 Lives Campaign.


“When the 100,000 Lives Campaign was launched, people from the child health community got very fired up about the idea,” says Homer. “But there was uncertainty about what to do, since the six interventions seemed geared toward the adult world.” Pediatric care presents different challenges from adult care, both clinically and culturally, and interventions must be adapted accordingly.


To better tie the Campaign interventions to the needs of young children, the Pediatric Affinity Group has been hosting informational and “office hour” calls on five of the six areas slated for improvement (acute myocardial infarction is not included because it is so rare in children). Led by experts in children’s care, the calls have generated a high level of interest. “So far, we have had about 1,000 people from 150 different organizations participate,” says Homer.  The Affinity Group is also developing Pediatric Supplements to the 100,000 Lives Campaign “How-to Guides.” In order to highlight the importance of eliminating harm in children’s health care, all of these efforts have now been dubbed “Getting to Zero: The Kids Campaign.”


Just how many children’s hospitals are using Rapid Response Teams is hard to gauge, says Homer. “A children’s hospital within a larger hospital may be reporting their use of Rapid Response Teams under the name of that larger system.” Still, he says, about 30 of the nation’s free-standing children’s hospitals report that they are using or beginning to implement Rapid Response Teams, and many other pediatric programs in general hospitals may be doing so as well.


As with most improvement ideas, many institutions must adapt the concept to their own culture and needs. Pediatric practitioners say that there are differences in how and why children require the intervention of a Rapid Response Team compared to adults, and these differences influence how the teams operate within a pediatric setting. But common to both children’s and adult hospitals is a positive reaction among staff, patients, and families to the availability of critical care specialists at a moment’s notice, as well as encouraging indications that the concept of early intervention is saving lives.


Learning to Recognize the Signs in Children

“If you look at why children have cardiopulmonary arrest compared to adults, it seems that we should be able to prevent it. Yet it still happens,” says Rosemary Gibson, RN, MSN, a Clinical Nurse Specialist at Cincinnati Children’s Hospital Medical Center (CCHMC) in Ohio. “The key to preventing it is learning to recognize the signs and symptoms.”


The primary physiological difference, explains Gibson, is that cardiopulmonary arrest in children typically begins with respiratory failure, while in adults the origin is most often cardiac-related. “The signs and symptoms of respiratory failure in children are usually obvious. But the signs and symptoms of pediatric shock, which is an early and important clue, can be quite subtle, and are sometimes underappreciated or unrecognized,” says Gibson. “Children have a lot of reserve and resolve, and they can appear to be stable for quite a while, until suddenly they sort of ‘give in’ and their condition deteriorates quickly.” With adults, by contrast, there’s often a steadier drop in blood pressure and other symptoms that signal a deteriorating condition.


Worse, it’s harder to intervene effectively on a child who’s had an arrest. “If an adult has an arrest and someone quickly starts a rescue, the outcome can be pretty good,” says Gibson. “By the time a child goes into secondary cardiopulmonary arrest as a result of respiratory failure, they’ve been getting less and less oxygen over a period of time, and that compromises their kidneys, brain, and liver. Their outcomes can be a lot worse.”


Those poorer outcomes might also result from the fact that pediatric practitioners have a lot less experience managing resuscitations, compared to clinicians who care only for adults. “If you ask a pediatric resident how many codes they’ve attended, they’ll say three to five,” says Elizabeth A. Hunt, MD, MPH, pediatric intensivist at Johns Hopkins Children’s Center in Baltimore, Maryland, and chair of the hospital’s Pediatric CPR Committee. “If you ask an adult medicine resident they’ll say around 25, and for ED residents, it’s up around 45 or 50.”  


There’s one more factor that plays into all this, according to those who work in pediatric hospitals: As the nursing workforce ages and the most experienced nurses retire or move out of direct patient care roles, newer nurses are left trying to recognize signs of respiratory failure and the more subtle symptoms of pediatric shock they may never have seen before. “A good education is essential,” says CCHMC’s Rosemary Gibson, “but nothing sticks in your mind like the actual experience of managing a real child in respiratory distress and shock.”


All these factors support the rationale for pediatric Rapid Response Teams, both as a means of supporting a child’s care team when that child may need fast, specialized evaluation and/or treatment, and as a teaching tool for staff.


Heeding Intuition

For adult patients, IHI’s 100,000 Lives Campaign recommends that hospitals create a list of clinical thresholds to guide staff about when to call the Rapid Response Team. These lists typically include triggers such as acute change in heart rate to less than 40 or more than 130 beats per minute, or in systolic blood pressure to less than 90 mmHg, for example. At the same time, staff are encouraged not to rely too literally on the criteria, and to call the Team if they simply have a gut feeling that something’s wrong.


In pediatrics, the clinical triggers are not quite as straightforward, explains Betsy Hunt at Johns Hopkins. “There is no single list in pediatrics,” she says, because clinical thresholds differ depending on the child’s age and condition. “Children who are febrile may have very high heart rates, and that’s okay,” she explains. And what’s “normal” for an infant is not the same as what’s “normal” for a teenager.


Nevertheless, there are clues when a child begins to decompensate. At North Carolina Children’s Hospital at the University of North Carolina in Chapel Hill, pediatric intensivist Tina Schade Willis, MD, says that a recent chart review revealed that 73 percent of cardiopulmonary arrests in the hospital had antecedents that were detectable, “in one case for as long as 18 hours prior to the arrest.” But it can take training and experience to spot those clues. 


That’s why some hospitals would rather have extensive clinical criteria for calling the Rapid Response Team, even if that list is long. Clifford Bogue, MD, Chief of Critical Care Medicine at Yale New Haven Children’s Hospital, says his 125-bed hospital created such a list when the Rapid Response Team was implemented in 2004. “Some of the triggers were very specific, such as respiratory rates above or below certain ranges depending on the child’s age. We printed them up on laminated cards, and had large signs made with information about how to call the Rapid Response Team.”


Even so, Bogue says experience with the Team — which responds to five or six calls per month — has shown that intuition is perhaps an even more reliable guide. “We’ve found that the most common reason for calling the Team is simply concern on the part of the caregiver or a parent,” says Bogue.


Learning to trust that concern is essential, says Glenn Billman, MD, Medical Director of Patient Safety at Children’s Hospitals and Clinics of Minnesota. “The table of age-matched triggers has multiple columns, and no one can keep that table in their head. We have trained our staff to those numbers, but matching them can be hard. It underscores the critical need for staff to listen to their intuition,” says Billman.


What's Right for the Patient?

Today parents also play critically important roles in their child’s care. “It’s rare to walk into a pediatric room and not find a parent,” says Michael Apkon, MD, Vice President for Performance Management at Yale New Haven Health System in Connecticut, a former medical director of the ICU, and one of the hospital’s chief champions for the use of Rapid Response Teams in pediatrics.


“Parents are at the bedside, seeing things evolve,” says Apkon. And no one knows a young patient better than his or her parent. As a result, sometimes they can pick up on subtle signs or symptoms that caregivers miss. Yale’s Cliff Bogue agrees. “The longer I do this clinical work, the more attention I pay to what a parent says. More often than not, they are right.”


Rosemary Gibson at Cincinnati Children’s strongly echoes Bogue’s views. “I teach the ICU nurses that if parents are concerned that’s a big red flag, because of those intangible connections that occur between parents and children that we can’t measure.”


Listening to and acting on parents’ concerns is one thing. Allowing parents to call the Rapid Response Team directly when they feel they have no other recourse is a bigger leap of faith, say pediatric leaders. On both the adult and children’s sides of hospital care,  family members are only slowly being empowered in this respect.


“Giving families direct access to the Rapid Response Team challenges our control and the traditional hierarchy of care, and provokes the question of who knows what’s best for the patient,” says Glenn Billman at Children’s Hospitals and Clinics of Minnesota, where parents can now call the Team but rarely do. “At first, staff members feared that parents’ calls would overwhelm their ability to respond, or that the Team would be called inappropriately,” he says.


But Billman says he and his colleagues were determined not to shy away from the question that he calls the crucible in which all policy decisions must be made: What’s right for the patient?


“We actively solicited input from our Family Advisory Council,” he says. “We wanted to know how to tell parents that they might need to tell us when their child needs help.” The Council helped shape the message for parents about the purpose and use of the Rapid Response Team, and Billman says that family members have expressed appreciation that the Team is a resource, and have been respectful about its use. Billman says in the several months since they’ve enabled parents to call the Team, they’ve received “a very small number” of calls, each deemed appropriate.


At North Carolina Children’s Hospital, where the Team receives an average of five calls a month, staff are preparing to let family members call the Team directly, says Tina Schade Willis, who co-chaired the committee that oversaw the Rapid Response Team’s implementation in August 2005. 


“One of our criteria is if a family member is concerned,” says Willis, and so far that’s proving to be a solid indicator that something is amiss. In cases where family concern was the reason for calling the Rapid Response Team, 70 percent of the pediatric patients were transferred to the ICU.

Defining Success
The goal of any Rapid Response Team, whether caring for adults or children, is to reduce the number of cardiopulmonary arrests, or “codes,” by intervening early enough to prevent them. Because the concept itself is relatively new, data is not yet plentiful, particularly in pediatric settings. Moreover, pediatric mortality is rare compared to adult populations, so measuring the impact of Rapid Response on mortality among children could take years’ worth of aggregate data. 
Still, pediatric hospitals that have implemented Rapid Response Teams say they are seeing positive early trends. At Yale New Haven, where about 60 percent of calls result in a transfer to the ICU, data show a 50 percent reduction in respiratory and cardiac codes called outside the ICU. In addition, during the first 12 months that the Rapid Response Team was in use, chart reviews of pediatric patients who were transferred to the ICU or who actually did suffer a cardiac or respiratory arrest show a 45 percent reduction in the amount of time between the first documentation of vital sign abnormalities and a critical care response, indicating that floor nurses and other staff are picking up on trouble signs sooner.
At Cincinnati Children’s, Clinical Nurse Specialist Rosemary Gibson says they have achieved their goal of reducing codes outside the ICU by 50 percent. Their previous rate of 0.28 codes outside the ICU per 1,000 patient days — already considered a low rate, says Gibson — is down to 0.14.
Betsy Hunt at Johns Hopkins says her hospital has experienced a 75 percent increase in calls to the Team since its inception, and a 50 percent reduction in the rate of respiratory arrests. And while she is frustrated that the annual number of cardiac arrests has remained at five for two years running, she notes that the survival rate has improved. This, she says, may be the result of an intensive series of mock codes the CPR Committee oversaw that trained staff to handle these crises more effectively. 
At North Carolina Children’s Hospital, Tina Schade Willis reports that the length of time between cardiac arrests has dramatically increased, from a previous mean of 50 days to more than 300 days, with only one cardiac arrest in the last year and a half.
And at Children’s Hospitals and Clinics of Minnesota, Glenn Billman is encouraged by a number of indications that the Team is becoming a way of life and not just an idea-of-the-week. “For multiple months, the number of calls has increased, which means our nurses believe in the program,” he says. “Second, the Teams are meeting the goal of being at the bedside within five minutes, which indicates that everyone buys into the importance of what they are doing. And the third thing I am thrilled to see is that, in satisfaction surveys, bedside nurses are giving it the highest possible marks, and to me that means this initiative is really going to have staying power.” Billman also indicates that the hospital’s code rate appears to be decreasing, along with its mortality rate.  
Pediatric leaders report facing the same issues in introducing Rapid Response Teams that their counterparts in adult hospitals contend with: resistance from physicians who worry about losing control over their patients’ care, and from nurses concerned about appearing uncertain if they call for help. In both settings, the importance of laying the appropriate groundwork up front through in-depth education and training cannot be overstated.
Of course, nothing succeeds like success. When physicians and nurses begin to experience the value that the Rapid Response Team brings to patient care, their worries usually subside. Michael Apkon at Yale New Haven has seen this first-hand. “Some of the most vocal critics initially have turned into the staunchest supporters,” he says.
Minnesota’s Glenn Billman says that learning to work in new ways is always challenging, but that implementing Rapid Response Teams offers all clinicians an opportunity to re-examine their definition of success. “Success is not about retaining control, or being a hero,” he says. “Success is doing what’s right for the patient, and this tool helps us support that goal.”
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