Pediatric Rapid Response Teams

Children's hospitals are quite different today than they were 20 years ago.

Today at Duke Children’s Hospital & Health Center, for instance, the majority of our patients are either in critical care or were just released from critical care. In the past many patients were admitted for what we would consider minor illnesses today -- such as croup or asthma.

To avoid unnecessary complications in their care it has become important to check on these vulnerable patients before they have difficulties. That's where rapid response teams come in.

Jane Mericle, RN, the clinical director of operations of the Duke Children's Hospital and Health Center, explains to us what rapid response teams are and how they work.

-- Dennis Clements MD, PhD, MPH

In December 2004, the Institute for Health Care Improvement (IHI) challenged hospitals and health care providers to improve patient safety and quality of care through its landmark 100,000 Lives Campaign.

In the almost three years since that call to action, many hospitals have responded to the challenge and invested considerable time and energy developing, implementing, and upgrading rapid response systems. These systems were identified by IHI as a means for reducing needless patient deaths and are intended to quickly evaluate and respond to changes in patient condition -- changes that may foreshadow an impending clinical deterioration.

The core elements of rapid response systems are rapid response teams -- skilled teams of clinicians who bring critical care expertise directly to the patient bedside, regardless of where that patient is in the hospital or in their continuum of care.

Prior to the implementation of rapid response teams, most hospitals used “code blue teams” as a means of responding to patient emergencies. Unfortunately, in many cases, these teams weren’t called until the patient actually stopped breathing or no longer had a pulse.

The intent of a rapid response system is to position providers so that they can respond to changes in patient condition when they are initially recognized, well before they progress to such a catastrophic level. In most entities, Rapid response teams can be called by anyone who is worried about a patient -- a nurse, physician, family member, or, in some cases, even the patient himself. The goal is to respond to a “spark” before it becomes a “forest fire.”

Duke’s Pediatric Rapid Response Team

At Duke Children’s Hospital, our Pediatric Rapid Response Team (PRRT) consists of a nurse practitioner or critical care physician, the pediatric intensive care unit (PICU) charge nurse, and a respiratory therapist.

This team responds to calls from any of the Duke Children’s units and works with the patient’s primary care team to address issues of concern. Since the signs of pending clinical deterioration are often subtle and indistinct, especially in pediatric patients -- some children may exhibit classic warning signs while others may demonstrate less obvious indications that something is wrong -- the PRRT works closely with the care team to identify changes that require intervention.

Often these interventions are carried out by the primary care team, with the PRRT simply providing recommendations and guidance. However, in more dire situations, the PRRT may play an active role in providing direct care to the patient pending transfer to an intensive care unit (ICU).

To facilitate the multiple complex interactions that are often part of a rapid response scenario, all members of the PRRT and the multidisciplinary team use SBAR (see below) communication. This focused communication technique provides a mechanism by which the primary care team can quickly and efficiently incorporate the PRRT into the patient’s immediate care requirements.

SBAR Briefing Technique

1. Situation: What specifically is worrying you about the patient?
2. Background: What is the relevant clinical information that could impact PRRT decision making (pertinent history, current therapy, code status)?
3. Assessment: What do you think the problem is?
4. Recommendation: What do you think the patient needs to improve or that will allow us better assess the situation?

Rover Teams

At Duke Children’s, we have taken the rapid response team concept one step further through the development of a rover team. The rover team expands the PRRT responsibilities to include a proactive routine assessment of children at risk for clinical deterioration.

Patients evaluated by the rover team include those who have recently been transferred from intensive care to intermediate care, or those that are newly admitted with diagnoses placing them at high-risk for adverse outcomes.

A member of the rover team routinely rounds on the intermediate care and step-down units to evaluate patients and to explore any concerns that the care teams may have. Since the PRRT and Rover Teams have been in place, the number of respiratory and cardiac arrests that occur in the Children’s Hospital have decreased by about 85 percent. In addition, staff and faculty members caring for patients in non-ICU settings have provided overwhelmingly positive feedback about the support that these teams bring.

We have found that the implementation of PRRT with a rover team model has proven to be a critically important step in our efforts to maximize patient safety and enhance the quality of care delivered at Duke Children’s Hospital. Other hospitals are also implementing rapid response teams, with a common goal of improving the care we provide to patients, regardless of location.

-- Jane Mericle, RN, is the clinical director of operations of the Duke Children's Hospital & Health Center.

-- Dennis Clements, MD, PhD, is the chief of primary care pediatrics at Duke Children's Hospital & Health Center.