Initiative gives families access to rapid response team

Pediatric RRT 'another communication vehicle' for family members

Many hospitals with rapid response teams have recognized the importance of expanding their programs to enable families to call the team. A large number say they plan to do so — as soon as they figure out a way to overcome key barriers. A much smaller number has actually done it.

One facility that has clearly succeeded is North Carolina Children's Hospital, Chapel Hill, which recently received the Socius Award from the National Patient Safety Foundation (NPSF) for its "Family Alert" initiative that enables family members to call for help in the hospital. The staff see the initiative not only as an integral part of the pre-existing rapid response system, but as an additional way of identifying effective partnering opportunities between staff and families. In addition, according to NPSF, the program "has at its core the recognition of the . . . critical role that patients and families play in the development and implementation of patient safety solutions."

"Actually, the term 'Family Alert' is what we chose to identify the program for a study we are conducting," notes Tina Schade Willis, MD, assistant professor of pediatrics, division of critical care medicine, and medical director, ECLS (Extracorporeal Life Support) program, at the University of North Carolina at Chapel Hill, and head of the team that created the initiative. "The patients and their family just know it all as the pediatrics rapid response team."

Willis and her team started talking about family involvement even before the rapid response team was activated in 2005. "We wanted to get the team activated as soon as possible after reviewing the code blues for the three previous years," she explains. "But even when we began, one of the criteria for calling the team was a family concern, and in the first year we found that in around 20% of the cases, family concern was one of the reasons the team was called. That convinced our staff it was appropriate for families to be educated to call as well."

Modeling others

In determining exactly how the system would work, Willis and her team talked with other centers that had implemented a similar system, conferred with the hospital staff as well as with parents, "and decided to do it as a study so it could be published and shared with other places."

It initially was decided to pilot the program on one floor, which was done in March and April of 2007. In June, the decision was made to take it hospitalwide.

"We developed some fairly decent-sized posters for the rooms, which indicate that families are part of the medical team; we educated the nurses on how to, in turn, educate families about the team on time of admission — and then use the poster as a reminder," explains Willis.

The family member calls exactly the same number for the rapid response team as the staff do. "The staff are trained to ask the family for the room number," says Willis. "We also have a system for non-English speakers." When a patient is admitted, she explains, Spanish translators are available on-site. For other languages, a telephone service is available to explain the system. Then, family members are given cards they can present to any medical professional, which instructs them to call the rapid response team.

"The family is not given a long list of criteria," notes Willis. "They are simply told that they should call the team if they are seriously concerned."

The system was not universally welcomed at first, notes Rebecca Smith, MD, who was chief resident at the time and drove the study. (She currently is a fellow in pediatric critical care at the University of Pittsburgh Medical Center.)

"For us staff, buy-in was probably the most important part of the whole project," she says. "With the families, the minute you told them about it, their eyes lit up — they were just happy to have another communication vehicle. But for the staff, we did a lot of personal interacting with nurses and physicians in small group meetings and focus groups, so they felt their concerns would be heard.

"Parent perception is very different from staff perception," adds Smith. "Among staff, the biggest problem is an 'us-vs.-them' attitude between ward staff and the ICU team. But families don't understand hospital silos; they see the team as a hospitalwide extension of the team that is taking care of them already."

The staff had "some really good concerns," Smith recalls. "A lot of their concerns made us attack the need in a different fashion," she concedes. "A good example was they felt the idea of likening Family Alert to a 911 call was a really simple way to explain it to the family; that way they would not see it as undermining the process, the team, or the primary care group." (Smith likens it to the fact that calling 911 does not undermine your relationship with your primary care physician — it's just something you do in an emergency.)

"Their greatest fear was that families would call the team for nonemergent things, like linen changes," notes Willis.

Smith concurs. "They definitely raised concerns, and some were afraid that it would be overutilized," she says. "We just had to tell them we expected that there would be nonmedical emergency activation, but that when the emergency team shows up and asks what the emergency is, the family who activated will recognize the seriousness of the team and will not do it again."

A similar concern led to the involvement of the patient relations department. "We could then explain to that family that if there is a nonmedical issue that is nonetheless important, there is another group that can help you as well," notes Willis. Patient relations, she adds, "thought it was a great idea" to involve them.

There were several things the team wanted to learn from the study, says Smith. "We wanted to find out if creating this team would give families a higher level of satisfaction," she says. "In other words, does knowing you have this safety net make you feel safer, more comfortable, and more satisfied?"

One of the challenges was that parental satisfaction was already quite high. "To show a change from pre-program to post-program would be difficult," Smith notes. "But what was interesting was we had an area of the pre-test survey where they could write in any concerns they had. It was very worthwhile to see the comments families wrote — like there were gaps in the system, or the team did a good job managing emergencies."

Since these were totally anonymous and randomized, the families were comfortable with being completely candid, says Smith, noting that the feedback was "generally pretty positive."

Follow-up was conducted by Jordan Erickson, pediatric quality improvement specialist and Six Sigma Black Belt, and Emily Miller, a research assistant, both of whom speak Spanish.

"We conduct random audits, so some patients may have gotten here this morning, and some a week ago," Miller notes. "The first question I ask them is, 'Have you been told about the pediatric rapid response team'?"

If they say yes, Miller asks them to explain the program to her in their own words. "Based on their response, I evaluate if they know when and how to use the phone number," she says. "If they do not, I inform them about the program and then allow them to ask questions."

Just recently, Miller surveyed families on the original pilot floor, and 50% of the family members surveyed understood the system. On the other floors, that number currently is between 25% and 30%. "We don't expect it will ever really be at 100%," Miller admits. "The nurse may be telling them about it, but that does not necessarily mean they have retained the information — but I do think the percentage will continue to rise."

Few calls expected

The team doesn't necessarily expect to see that many calls from family members. "We theorize that based on the experiences of other centers, we may get only five calls in the first year from parents — and that reassured the staff," says Willis.

They already are collecting data, and so far have had just one call and a slight increase in code calls, Willis reports. "The one case was a baby that had severe respiratory distress," she says. "The parent called the team and the child did require a short stay in the ICU. This was obviously a valid call; the baby was later discharged and is doing fine."