Implementation of a critical care outreach team in a children's hospital

Sanjiv Mehta; Meghan M Galligan; Kim Tran Lopez; Chip Chambers; Daniel Kabat; Kelly Papili; Hannah Stinson; Robert M Sutton

doi:10.1016/j.resplu.2024.100626

Implementation of a critical care outreach team in a children's hospital

Resusc Plus. 2024 Apr 11:18:100626. doi: 10.1016/j.resplu.2024.100626. eCollection 2024 Jun.

Authors

Sanjiv Mehta¹, Meghan M Galligan², Kim Tran Lopez², Chip Chambers³, Daniel Kabat⁴, Kelly Papili⁵, Hannah Stinson¹, Robert M Sutton^{1

6}

Affiliations

¹ Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania, United States.
² Department of Pediatrics, Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania, United States.
³ Perelman School of Medicine at the University of Pennsylvania, United States.
⁴ Department of Digital and Technology Services, Children's Hospital of Philadelphia, United States.
⁵ Department of Anesthesiology and Critical Care, Children's Hospital, United States.
⁶ Resuscitation Science Center, Children's Hospital of Philadelphia Research Institute, United States.

Abstract

Introduction: Proactive surveillance by a critical care outreach team (CCOT) can promote early recognition of deterioration in hospitalized patients but is uncommon in pediatric rapid response systems (RRSs). After our children's hospital introduced a CCOT in 2019, we aimed to characterize early implementation outcomes. We hypothesized that CCOT rounding would identify additional children at risk for deterioration.

Methods: The CCOT, staffed by a dedicated critical care nurse (RN), respiratory therapist, and attending, conducts daily in-person rounds with charge RNs on medical-surgical units, to screen RRS-identified high-risk patients for deterioration. In this prospective study, observers tracked rounds discussion content, participation, and identification of new high-risk patients. We compared 'identified-patient-discussions' (IPD) about RRS-identified patients, and 'new-patient-discussions' (NPD) about new patients with Fisher's exact test. For new patients, we performed thematic analysis of clinical data to identify deterioration related themes.

Results: During 348 unit-rounds over 20 days, we observed 383 discussions - 35 (9%) were NPD. Frequent topics were screening for clinical concerns (374/383, 98%), active clinical concerns (147/383, 39%), and watcher activation (66/383, 17%). Most discussions only included standard participants (353/383, 92%). Compared to IPD, NPD more often addressed active concerns (74.3% vs 34.8%, p < 0.01) and staffing resource concerns (5.7% vs 0.6%, p < 0.04), and more often incorporated extra participants (25.7% vs 6%, p < 0.01). In thematic analysis of 33 new patients, most (29/33, 88%) had features of deterioration.

Conclusion: A successfully implemented CCOT enhanced identification of clinical deterioration not captured by existing RRS resources. Future work will investigate its impact on operational safety and patient-centered outcomes.

Keywords: Clinical Deterioration; Critical Care Outreach; High reliability organizations; Patient safety; Pediatric; Proactive; Rapid Response System.