P0126 - Evaluation of Compliance with Activating a Rapid Response Team Based on Pediatric Early Warning Scores on an Inpatient Pediatric Ward: A Quality Improvement Project

Background: The pediatric early warning score (PEWS) is a validated tool for predicting clinical deterioration within the subsequent 24 hours and its use can prevent morbidity and mortality in hospitalized pediatric patients. When PEWS reaches a defined threshold, our institution’s protocol is to employ a pediatric rapid response team (PRRT) within 30 minutes, prompting real-time patient assessment by the primary care team, nurses, respiratory therapists and the intensive care (ICU) team. However, we found that compliance with activating a timely PRRT was poor, and even declining, despite educational interventions implemented based on our initial fishbone analysis.

Methodology: Our aim was to identify and eliminate barriers to timely PRRT activation, with a goal to improve compliance to 100% within 2 years. A multidisciplinary committee of nurses, nursing leadership, respiratory therapists, residents, hospitalists and intensivists met quarterly to review results, discuss barriers, and propose/refine interventions via Plan-Do-Study-Act (PDSA) methodology and ongoing A3 analysis. With each cycle, new interventions were implemented and compliance with PRRT activation was re-measured quarterly via retrospective chart review.

Discussion: Figure 1 shows quarterly compliance in the setting of each PDSA intervention. Over the last 6 quarters, compliance has improved steadily from 40% to 82% and has surpassed the initial baseline of 77%. In each of the last 3 quarters, the total number of “missed” PRRTs has been <5, despite a doubling in eligible PEWS scores within that time (from n=25 to n=50). Although not yet at our goal, the reduced variability in compliance in the most recent quarters has been encouraging. The overarching barriers identified to properly activating PRRT were communication breakdown and lack of provider education or buy-in. It was not until identifying and addressing institutional cultural barriers surrounding PRRT activation that compliance began to improve after an initial worsening. Our most significant successes came after interventions that focused on improving communication between providers and empowering key players to advocate for proper PRRT activation. However, we continue to face a lack of provider appreciation for PEWS predicting deterioration, even though 30% of all patients transferring to the ICU had PEWS scores eligible for a PRRT, and this likely has limited our ability to reach our goal within our timeframe.

Conclusion: Ongoing work is necessary to continue to shift the culture at our institution towards compliance with PRRT activation. While no code events occurred during our study period, we have not yet determined if there is a correlation between missed PRRTs and other clinical deteriorating events. Moving forward, we will retrospectively analyze correlation between PEWS and ICU transfers, length of stay, 30-day mortality, and the need for invasive or non-invasive ventilation over a 7-year period in order to evaluate the most appropriate activation threshold for specific patient subgroups.