Coordinated care boosts survival of very sick children, study finds
TUESDAY, Nov. 20 (HealthDay News) -- Incorporating a rapid response team of experts at a children's hospital can cut rates of patient deaths, heart attacks and respiratory arrests outside the intensive care unit, a new study suggests.
"This is the first paper to show an improvement in mortality, so that adds to the potential that having rapid response teams can really change the outcome," said Dr. Richard Brilli, author of an editorial that accompanies the article in the Nov. 21 issue of the Journal of the American Medical Association.
"This validates with research that this is a good process. It's sound, reliable and shows an improvement in outcomes," added Audrey Hubbard, director of children's services at The Children's Hospital at Scott & White in Temple, Texas.
A rapid response team (RRT) is composed of experts from different disciplines who are available 24-7 to evaluate patients who are hospitalized but not in the intensive care unit (ICU). The experts are frequently trained in ICU procedures.
Such teams have been extensively studied and have been shown to decrease mortality and cardiopulmonary arrest rates in hospitalized adults. The research in children is more limited.
"In pediatrics, there have only been three papers [including the current one], and that's not a very robust literature yet to say this is right or wrong," Brilli said.
Two of those papers (one led by Brilli) showed a benefit in cardiopulmonary arrest rates without a benefit in mortality.
There is a clear need for some kind of intervention, however.
"[There are] children who have deterioration while in the hospital, so much so that they end up having a cardiopulmonary arrest," Brilli said. "The question is what is the best method to recognize that patient who is getting sicker and do something about it before they get so sick?"
The current study was a before-and-after look at mortality and cardiorespiratory arrest rates at Lucile Packard Children's Hospital in Palo Alto, Calif.
After rapid response teams were added at the hospital on Sept. 1, 2005, the monthly death rate decreased by 18 percent, while the rate of cardiopulmonary arrests (what doctors call "codes") declined by almost 72 percent.
The authors estimated that 33 children's lives were saved over a 19-month period.
"What was particularly profound was both the codes outside of ICU and mortality rates dropped precipitously within a month of the intervention, which is fairly unusual for a quality-improvement initiative," said Dr. Paul J. Sharek, study lead author, assistant professor of pediatrics at Stanford University School of Medicine in Palo Alto, Calif., and chief clinical patient safety officer at Lucile Packard Children's Hospital. "Usually, it takes three to six months to roll out . . . I would say that this really encourages children's hospitals to really think hard about this being an intervention that truly improves the mortality rate."
Why did this study see improvements in mortality, while the other two did not? One possible reason was that it covered a longer time period. The second, and probably more important reason, was that many of the children studied at Lucile Packard tended to be extremely sick. "The kids are medically so fragile that if you happen to be able to catch their decompensation early, you're more likely to have a great outcome," Sharek said.
But the editorial authors are not completely convinced that rapid response teams, while helpful, are the most efficient answer to the problem.
For one thing, vital signs for adults are pretty much the same regardless of whether the person is 20 years old or 80, making it easier to respond to abnormalities. For children, vitals can vary drastically from a nine-month-old to a 15-year old.
"When you start to take all of the age distributions, the number of trigger points become very large, and as soon as it gets more complicated, it's harder to remember and to implement," Brilli said.
There's more on kids' health at the Nemours Foundation.
SOURCES: Paul J. Sharek, M.D., assistant professor, pediatrics, Stanford University School of Medicine, Palo Alto, Calif., and chief clinical patient safety officer. Lucile Packard Children's Hospital; Richard J. Brilli, M.D., professor, pediatrics and director, pediatric intensive care unit, Cincinnati Children's Hospital; Audrey Hubbard, M.S.N., R.N., director of children's services, Children's Hospital, Scott & White, Temple, Texas; Nov. 21, 2007, Journal of the American Medical Association
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