Executive Summary
A pediatric hospital has improved patient safety by implementing an early warning system that encourages earlier intervention with high-risk patients. The hospital also improved its rapid response team (RRT).
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Patients are scored every four hours on clinical measures, plus the subjective feelings of nurses and family members.
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The scores are color-coded to dictate the appropriate response, with the worst scores prompting an immediate RRT call.
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The system encourages residents to see patients in person more often, rather than relying mostly on data at a computer station.
An early intervention is often the best strategy for keeping patients healthy, and a pediatric hospital is reporting improved patient safety from an early warning system that helps identify patients most at risk for a gradual but severe decline toward being critically ill.
The Ronald McDonald Children’s Hospital (RMCH) at Loyola University Medical Center in Maywood, IL, also has revamped its rapid response team (RRT) as part of an overall effort to improve patient safety, says Julie Fitzgerald, MD, FAAP, division director of Loyola University Health System’s pediatric intensive care medicine unit and associate professor in the Department of Pediatrics at Loyola University Chicago Stritch School of Medicine.
“Children can become critically ill from sudden and unexpected events, but more often it is a gradual progression arising from various illnesses, which leaves a large window of opportunity to identify children at-risk in our children’s hospital,” Fitzgerald explains.
RMCH used the Cardiac Children’s Hospital Early Warning Scoring (C-CHEWS) tool developed at Boston Children’s Hospital. It focuses on three areas: neuro/behavioral, respiratory, and cardiovascular. Patient-specific concerns from the family and nursing staff also are taken into account for each child’s score. The child is evaluated using a specific nursing and physician response algorithm, and each patient is given a score from 0-10. A score is given every four hours, along with each set of vitals. (C-CHEWS is described fully in a report in the Journal of Pediatric Nursing. An abstract and access to the full text is available online at http://tinyurl.com/otzsc7b.)
RMCH introduced the C-CHEWS system in April 2015, so Fitzgerald says it’s too early to assess the results. But she also introduced the system at another pediatric hospital before coming to RMCH, and she says the effects there were significant. Fitzgerald saw the same benefits that Boston Children’s Hospital has reported in the literature: a reduction of mortality rates, improved clinical outcomes and decreased length of stay, better awareness of physiological deterioration or instability, and improved safety and satisfaction for patients, their families, and the children’s hospital staff.
The C-CHEWS system was developed in part to address in-house cardiac arrest and serious clinical decompensation that necessitates transferring children to an intensive care setting, she explains. Those problems can develop suddenly but more often are the result of a slow decompensation over hours or even days. “That gives us this large window of opportunity to identify those changes and perhaps intervene earlier so that the child doesn’t have that catastrophic event,” Fitzgerald says. “But with shift changes and patient handoffs, you can miss some of that slow slide downward over time. These early warning systems provide an objective score that can alert the staff to the patient who is on that path even if they haven’t put the clues together yet.”
Other scoring systems also are available and seek the same result, but Fitzgerald says RMCH and her previous hospital selected C-CHEWS because it not only scores the objective findings of clinical changes, but it also includes subjective findings from observers. “You can get a bonus point if the parents are worried, and you can get a bonus point if the nurse is worried,” she explains. “It incorporates those subjective, gut feelings that sometimes are important in medicine, when the nurse says, ‘I can’t put my finger on it, but something has changed with this child. Something is not right.’”
Protocol changed
Implementing this system also spurred a revamping of the hospital’s rapid response team (RRT). Previously, the RRT was not called out until a patient was confirmed to be in serious distress, Fitzgerald says. As a result, almost all RRT calls ended with the patient being transferred to the pediatric intensive care unit (PICU).
“That’s not the best way for a rapid response team to work,” Fitzgerald says. “If we can respond sooner and intervene in time, we can keep these kids from deteriorating to the point that the PICU is the only right choice.”
RMCH uses a color-coding system for the scores to indicate what action should be taken. A score of 0-2 is green, meaning the patient is stable and the staff can continue routine care and scoring every four hours. A score of 3-4 is yellow, prompting the staff to notify residents that the patient needs to be evaluated. Residents are expected to evaluate the child within 10 minutes of that notification, including a discussion with the parents. A yellow score also means the patient will be scored every two hours, instead of every four, for two rounds to make sure this score is not the beginning of a more rapid deterioration.
A total score of 5 or greater, or a score or 3 or greater in any single domain, triggers a mandatory activation of the RRT, which includes the senior resident in the PICU, the charge nurses, and a respiratory therapist. The RRT team must be at the bedside within five minutes to assess the patient, talk to the family, and intervene as necessary. The resident must contact the PICU attending directly to agree on whether the patient can stay on the unit or be moved immediately to the PICU.
If the patient stays on the floor, scoring is performed hourly, and the resident re-evaluates the child again until the score drops. Each hourly scoring and assessment includes a decision to keep the child on the floor or move to the PICU.
“This gets residents up and away from the computer. It’s easy to sit there and look at the numbers and labs all night long without actually going out there to be on the floors and see the patients and see the nurses,” Fitzgerald says. “It gets the kids on people’s radar, especially those who might be a little more fragile and who may need a closer look to understand what’s really going on.”
SOURCE
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Julie Fitzgerald, MD, FAAP, Division Director of Pediatric Intensive Care Medicine, The Ronald McDonald Children’s Hospital at Loyola University Medical Center, Maywood, IL. Email: [email protected].
