Improving Patient Safety with a Pediatric Rapid Response Team and PEWS

Team Members: Thank you to all NLFH Pediatric Nurses, Pediatric Hospitalists, and Respiratory Care Therapists

Executive Sponsor Kim Nagy

Process Owners Sherrie Rodgers CPNP; Christine Somberg CNS

Sponsor Wendy Rusinak RN

Improvement Leaders Sarah Donahue MD; Sharon Dufault BSN, RN; Sherrie Rodgers CPNP; Christine Somberg CNS

Improving Patient Safety with a Pediatric Rapid Response Team and PEWSOverview• Linkage to Strategic Plan: Deliver Exceptional Care – Provide the highest quality, most effective and safest patient care

• Problem Statement: NLFH pediatric in-patient unit did not have a formalized tool and team to respond and identify pediatric patients at risk for deteriorating condition

• Goal/Benefit: By instituting a pediatric early warning system (PEWS) and pediatric rapid response team (RRT PALS) April 15, 2012 , it will impact patient safety by decreasing pediatric code blue calls and emergency intubations in the pediatric in-patient/ pediatric day surgery unit by Dec. 31, 2012

• Scope: This project encompasses the pediatric in-patient and pediatric day surgery unit from April 15, 2012 to Dec. 31, 2012

• System Capabilities/Deliverables: NLFH will develop a Pediatric Rapid Response Team and Pediatric Early Warning System Scorecard and Action Plan to enhance pediatric patient safety

• Resources Required: A PEWS scorecard and action plan to be developed reflecting NLFH pediatric patient population and resources . The PEWS scoring tool to be built into the electronic medical record. A Pediatric Rapid Response Team will be developed utilizing the 24/7 coverage of NLFH Lurie Children’s Pediatric Hospitalists, pediatric nurses , emergency department nurses, respiratory therapists, and other support staff.

Key Metric(s):

Outcome Measures: Decreased pediatric code blue and emergency intubation rates in 2012 compared to the same time period in 2011

Process Measures: Compliance with PEWS scoring evidenced by electronic medical record chart reviews

Executive Sponsor: Kim Nagy Sponsor: Wendy Rusinak RN Process Owners: Christine Somberg CNS & Sherrie Rodgers CPNPImprovement Leaders: Christine Somberg CNS, Sherrie Rodgers CPNP, Sharon Dufault BSN, RN

Improving Patient Safety with RRT PALS & PEWS - Define

Literature supports best practice of hospital pediatric rapid response teams and pediatric early warning systems to decrease pediatric morbidity and mortality rates

D M A I C

• Pediatric team realized that NLFH lacked a pediatric rapid response team and pediatric early warning system. Pediatric team could call for a pediatric code blue response only.

• Purpose is to influence the phenomena of patient safety in an in-patient pediatric community hospital setting. Objective was to determine if there was a difference in the number of pediatric code blue calls and emergency intubations between pre and post implementation of Pediatric Early Warning System (PEWS) and Pediatric Rapid Response Team (RRT PALS)

Improving Patient Safety with RRT PALS & PEWS – Measure/Analyze

Comparing 2011 to 2012 pediatric in-patient emergency intubations and pediatric code blue rates

D M A I C

0

0.5

1

1.5

2

2.5

2011 (pre-implementation) 2012 (post-implementation)

Num

ber

of c

ode

blue

s

Pediatric Code Blue Rate

0

0.5

1

1.5

2

2.5

2011 (pre-implementation) 2012 (post-implementation)

Num

ber

of e

mer

gent

in

tuba

tions

Emergency Intubation Rate

Improving Patient Safety with RRT PALS & PEWS –Improve

• PEWS scoring was developed using the literature, along with Lurie Children’s Hospital protocols, tailoring the tool to meet the needs of NLFH community hospital

• PEWS scoring tool was built into the electronic medical record• Nurses document PEWS scores on all patients within one hour of vital signs and

assessments• PEWS scores trigger specific nursing interventions • Nurses follow standardized PEWS scoring and action algorithms• The Promoting Action on Research Implementation in Health Services (PARIHS)

(Rycroft-Malone, 2004) was used to guide the implementation process

Developing a PEWS Scorecard/Action Plan and RRT PALS

D M A I C

NLFH Inpatient PediatricsPEWS SCORECARD

3 2 1 0Lethargic/confused Irritable or agitated Sleeping Playing

or but not consolable or Appropriate for patient

Behavioral Reduced pain response Irritable but consolable

Grey CRT at 4 seconds Pale Pink

or or or CRT at 1-2 seconds

Cardiovascular CRT >5 seconds Tachycardia of 20 CRT at 3 seconds

or above normal

Tachycardia of 30 above parameters

or

Bradycardia for age

5 below normal parameters with >20 above normal >10 above normal parameters

Within normal limits for age

Respiratory retractions Using accessory muscles Using accessory muscles

or or or

>50% FiO2 40-49% FiO2 or > 3 LPM 24-40% FiO2 or < 2 LPM

OR

Any initiation of O2

Additional Add 1 extra point for frequent If not on nebulizer treatments

(every hour or greater) nebulizer treatments

patient will receive no points

NLFH Inpatient Pediatrics PEWS ACTION ALGORITHM

Score 0 to 4

Score=5Or

3 in any one category Score=6 Score > 7

AssessmentConsult 2nd Pediatric Nurse

Consult 2nd Pediatric Nurse

Consult 2nd Pediatric Nurse

for second assessment for a second assessment for a second assessment

NotificationNotify Pediatric

HospitalistNotify Pediatric

Hospitalist or physicianNotify Pediatric Hospitalists or

Notify Pediatric Hospitalist or physician

or physicianfor specific concerns for assessment and to

physician and RRT PALS for

for immediate assessment

based upon clinical judgment

discuss whether interventions

assessment within 5 minutes*

and RRT PALS for additional

may be necessary assessment/intervention

within 5 minutes*

Re-assessment

Assess and score every 4

Assess and score every 2 Assess and score every Assess and score every

hours hours 1 hour 30 minutes

Note:

The status of a pediatric patient may quickly change and may not be evident in their PEWS scores. The RN, Physician or ancillary clinical staff may ALWAYS activate the RRT PALS or CODE BLUE PALS based upon their clinical judgment.

*** If, in the 5 minute RRT PALS response time, the pediatric hospitalist or physician has arrived and the pediatric unit (MD, RN, ancillary clinical staff) decides the RRT PALS is not needed, a call should be placed to the operator for cancellation ofRRT PALS.

Improving Patient Safety with RRT PALS & PEWS – Results

• Will Continue to monitor PEWS charting of new process • Rapid response team monitoring tool tracks all pediatric rapid response

team calls • Mock RRT PALS held regularly• PEWS scores serve as a trending tool for patient improvement and

deterioration

D M A I C

PEWS and RRT PALS influenced NLFH code blue and emergency intubation rates

PEWS in I-View

D M A I C