4.1 N.C. Children’s Hospital and Pediatric Rapid Response Teams
N.C. Children’s Hospital at the University of North Carolina at Chapel Hill (UNC) is structured to provide family-centered care that ensures “care and support for the entire family, not just the individual child” (http://www.ncchildrenshospital.org). UNC’s multidisciplinary team serves more than 33,000 children from all of North Carolina’s counties. When a patient at any UNC Hospital goes into cardiopulmonary arrest, a “Code Blue” is called, and an emergency resuscitation team is called into action. In August 2005, N.C. Children’s Hospital became the first medical center in North Carolina to implement the use of pediatric rapid response teams with the goal of preventing pediatric patients from reaching the point of cardiac and respiratory arrest. Rather than waiting until a child is in a state of cardiopulmonary arrest to call a Code Blue, a pediatric rapid response team is called at the first sign that a child’s condition is deteriorating and responds within 2 to 3 minutes.
The teams are available 24 hours a day, 7 days a week, and any member of the team or the hospital’s staff can call a team into action. The team may be called when staff or a family member is worried about the patient; there are acute changes in the patient’s heart rate, blood pressure, respiratory rate, oxygen saturation, or mental status; a new or prolonged seizure occurs; or the patient has difficult-to-control pain or agitation. These teams are composed of a Pediatric Intensive Care Unit (PICU) physician team leader, PICU charge nurse and respiratory therapist, senior pediatric resident, and the patient’s primary team of physicians and nurses.
UNC Health Care’s patient safety officer was aware of work being conducted in Australia on rapid response teams and had exchanged articles about it with the chairman of a cardiopulmonary resuscitation committee, of which she was a member. She recognized the promise of this innovation and began searching for an opportunity to move it forward in the UNC Health Care System. This opportunity presented itself in 2004 when the director of the PICU, who shared her interest in protecting their patients from preventable harms, asked the patient safety officer to interview a physician for a role in the PICU. This energetic pediatric critical care physician also had a personal interest in patient safety. This physician was aware of rapid response teams from journal articles and had done some independent research to learn more about them. Shortly after she was hired, she agreed to champion this innovation.
Both the physician champion and the patient safety officer attended an IHI conference in December 2004 along with some members of UNC’s administration. At this conference, IHI announced its 100,000 Lives campaign, and the administrators signed UNC Health Care to participate. The development of a rapid response team is one of six recommended interventions that are part of the 100,000 Lives campaign. UNC Health Care’s commitment to participate in the campaign and thus implement the campaign’s recommended interventions throughout its hospital system gave the physician champion and patient safety officer the momentum needed to move forward with implementation of this innovation in the pediatric hospital. The physician champion proceeded to develop a concept proposal for senior administrators, such as the chief of staff and executive associate dean of clinical affairs and the pediatric chairman.
As with many other large medical centers, UNC frequently fills its staff vacancies with new graduates. As the proportion of relatively inexperienced staff increases, the acuity and complexity of their typical patient loads also increase:
“We added about 100 FTEs [full-time equivalents] of RNs [registered nurses] to the Children’s Hospital in the first 5 years I was here and we continue to add because our patients are sicker. Our acuity data show that. We also have more novice nurses caring for patients. Add to that your residents and interns who are novices in health care and medicine themselves. What we found was that we were having far more events, it seemed [in which] something [was] happening with a child that possibly could have been prevented. The signs were there. When we sat in a root cause analysis meeting later to look at what happened that led up to these events, what we found is that different people saw different things, but then they pretty much validated each other’s perception. Some of it was because of being novice. Some of it was due to workload. Some of it was being novice and not knowing what you are seeing. When the physician says, ‘Yeah, it’s all right, the patient is okay,’ the novice nurse said, ‘All right. It’s okay.’”
With the rate of preventable events on the rise, UNC needed to find a solution. Leadership recognized that the capabilities, time, and equipment of the house staff were no longer a good match for dealing with deteriorating patients. This solution needed to be one that would both improve care for these patients and give less experienced house staff a way to escalate the level of attention received by a deteriorating patient without going up the chain of command. As one member of leadership explained:
“We’ve been struggling with how to get staff comfortable with saying it’s okay going up the chain of command…. This idea was something that you didn’t need to go up the chain of command. You could act. That is the part of this we all liked. You didn’t have to hurt somebody’s feelings.”
The physician champion did a chart review to gather historical information on cardiac and respiratory arrests in the institution. By telling powerful stories of patients from their own hospitals that could have benefited from the use of these teams, she was able to demonstrate effectively to administrative leadership the need for seizing this opportunity to intervene earlier to improve outcomes. She explained, “I presented all of the very ugly cases I could find from our hospital that I could say, look, this is in writing from charts. This is happening and we need to do something about it.” Although national examples were also helpful for obtaining buy-in, she emphasized the added impact achieved by using examples from her own organization.
Although senior leadership raised a few concerns, such as whether it would be appropriate for a new group to take over care, negative pushback was minimal. They expected various benefits in addition to the main benefit of reducing cardiac and respiratory arrests. The decisionmakers expected nursing staff satisfaction to increase because they would be empowered by having the option of calling a team 24 hours a day without ramifications for false alarms. Other expected major benefits included improved communication and cooperation between caregivers and breakdown in the hierarchy of caregivers. They also expected that this innovation would be visible to the families of their pediatric patients, although this was not a major focal point during the adoption decisionmaking process.
The physician champion presented data to the N.C. Children’s Hospital leadership and administrative leadership separately because they had different levels of awareness about rapid response teams and commitments to the IHI campaign. After their buy-in was obtained, a multidisciplinary task force led by the champion was formed to plan for and guide implementation.
Before this innovation could be adopted, one important thing to assess was staff availability. Thus, the champion generated estimates of the number of team activations that could be expected based on the number of activations in the adult hospitals that had implemented teams. Additionally, the physician champion and leadership reviewed the availability of staff who would compose the teams. At that time, N.C. Children’s Hospital had an intensive care unit (ICU) physician who also served as a fellow and was available to lead the team 24 hours a day, ICU charge nurses without patient assignments, and two ICU respiratory therapists. The hospital asserted that it had the staff available to make this work. Because the length of time involved in responding is relatively short, staff would not be taken away from their normal responsibilities for very long, which was an important factor for senior decisionmakers.
Given the weight of the need, the expected benefits, and the fact that no additional staff or staff hours were required for this innovation, the physician champion was not required to make a business case to proceed with the implementation of the pediatric rapid response teams. The innovation had an anticipated potential to reduce costs in the long run by eliminating time spent during and after responding to codes by taking care of patients before intubation and ventilator support became necessary. To estimate financial costs, the champion produced estimates of expected call volumes. As one decisionmaker explained,
“With a little more sophistication, a business case would be very easy to make. Some things are the right thing to do. It doesn’t matter that you will have positive financial impact downstream. We didn’t believe there would be immediate negative financial impact. A more sophisticated look at the financial aspect would be good for moving this forward nationally.”
In considering strategic and operational risks, UNC decisionmakers’ primary concern was the potential for problems in the culture of patient ownership. One fear was that conflicts would result because of perceived interference by a noncaretaker group. To address this concern, physicians received in-depth education about the purpose of the teams and their role in care.
To obtain staff buy-in, the champion also made presentations to stakeholders such as the senior vice president for nursing, who wanted to know how nurses’ and respiratory therapy staff’s workload would be affected. Obtaining the buy-in of physicians required more work; the chief of staff and executive associate dean of clinical affairs helped by arranging for the champion to make presentations to the Quality Council and Medical Staff Executive Committee. She also made presentations to many small groups of physicians. Loss of control was their main concern:
“None of the physicians who had a problem were concerned about us doing something harmful to the patient. Instead, it was that we would do something with their patient and they wouldn’t know about it, or they’d be left out, or we’d take their patient to the ICU and not tell them, or we’d come out and take over care and they wouldn’t be able to write orders on their patient once we arrived.”
This barrier was addressed by telling physicians from the beginning that they were expected to be part of the team, but “they [physicians] didn’t get rid of the barriers until everyone had seen how useful the team was.”
Residents welcomed this innovation as a resource. Obtaining resident buy-in facilitated the process of obtaining the buy-in of the attendees, who had expressed concerns that learning opportunities would be lost whenever “a resident is not at the bedside learning because somebody steps in.”
To identify pockets of resistance (which the informants described as very minimal), leadership creatively investigated after a team had been activated to find out whether there was any reluctance on the part of any particular service or individual. In cases of observed reluctance, the champion engaged in further education with the reluctant individual(s) to reinforce the importance and benefits of this innovation. Positive feedback about the innovation was also reinforced through patient safety rounds, weekly updates sent to staff, and posters in every unit. To encourage staff to activate the teams, the organization president sent a thank you email to staff members who activated a team, with a copy to their supervisor. They “used every communication mechanism [they] had” to get this “propaganda” out there:
“It was important for us to really emphasize the point that this is a good thing to do for patient care and safety. This is part of the rollout of patient safety initiatives… . If we kept talking about it in a positive manner, we felt that it wouldn’t be a problem.”
The decisionmakers we spoke with shared some examples of innovations that N.C. Children’s Hospital had considered but decided against adopting. Some reasons that they provided for not moving forward with these innovations included:
- Lack of teamwork exhibited between different types of house staff.
- Requiring too much time from overloaded nursing staff.
- Lack of personnel with background in health care systems quality improvement.
- Lack of core staff to focus on innovation.
- Lack of a champion.
- Lack of buy-in from physicians.
- Competing priorities.
One member of the administrative leadership explained that one reason quality improvement innovations are not adopted is the intensive consultative assistance required to both ramp them up and operate them.
“The cost and lack of internal development of staff turned out to be very negative. It caused us to discontinue and look at other methods to do this ourselves. If you are always depending on an outside consultant, you haven’t changed the culture.”
The importance of having a champion was clearly paramount in the adoption process for this innovation. As one decisionmaker explained, “If we didn’t have a champion, this wouldn’t have worked. That made the difference. “This informant described the effectiveness of this innovation’s champion as stemming from her role in the ICU, her interpersonal skills enabling her to move the innovation forward in a way that was nonthreatening to the primary care and nursing groups, and the way that her visibility at a senior level of the hospital allowed her to positively reinforce activation of the teams. This champion’s willingness “to work outside of the silo of physicians” was also of the utmost importance. This innovation required the cooperation of multiple disciplines, and she was very successful in harnessing the expertise of other professions.
Another thing that contributed to N.C. Children’s Hospital’s success was setting parameters from the outset and settling such details as what the team’s services would cover and the logistics of responding in atypical locations. With limited time to respond, clear decisions are needed regarding where the teams can respond, which team will respond, and what that team should do afterward. At N.C. Children’s Hospital, it was decided when the system was established that teams would respond to the lobby, cafeteria, or any other location in the hospital where a child, whether a patient yet or not, needs urgent attention.
The adoption and implementation of pediatric rapid response teams has truly been, as one informant put it, “one of [their] success stories.” In August 2006, a story was released on http://www.IHI.org reporting that N.C. Children’s Hospital had observed a substantial increase in the length of time passing between cardiac arrests “from a previous mean of 50 days to more than 300 days, with only one cardiac arrest in the last year and a half.“1
1 Institute for Healthcare Improvement. Children Count in the 100,000 Lives Campaign. 2006. Retrieved October 18, 2006, from http://www.ihi.org/knowledge/Pages/ImprovementStories/ChildrenCountinthe100000LivesCampaign.aspx.
This innovation has spread to adult units at UNC Health Care, and UNC has been named one of IHI’s “mentor hospitals” that health care organizations across the United States can turn to for advice about developing, implementing, and sustaining the pediatric rapid response team program.