Patient Quality

Codes Outside the Intensive Care Unit

Quarterly Average of Codes

An improvement team was chartered in 2004 to focus on preventing codes outside the Intensive Care Unit (ICU). The group was charged with creating a Medical Response Team (MRT), identifying clinical warning signs that indicate children may be at risk for cardiopulmonary arrest, and developing guidelines for activating the MRT. Once activated, the role of the MRT is to consult with bedside staff to determine the best course of action for a patient whose condition is deteriorating and, when appropriate, quickly move the child to the ICU.

The team's initial goal was to reduce codes outside the ICU by 50 percent within six months of implementing the MRT. We have demonstrated a statistically significant decrease in patient mortality since the implementation of the medical response team.

 

January - March 2008

Emergency Codes Outside the Critical Care Unit: How many patients required resuscitation outside of the ICU?

(The number of cases per 1,000 non-ICU patient days when a patient required chest compressions or assisted ventilation)

View our performance over time. (.pdf, 18k)		 0

What We're Doing to Improve: Creation of the Medical Response Team (MRT)

The Medical Response Team (MRT) is a new process at Cincinnati Children's Hospital Medical Center. The MRT was created to help facilitate recognition of patients who are getting "sicker" and to bring additional consultation to the bedside to help with appropriate triage and clinical intervention decisions, resulting in fewer codes outside the intensive care unit (ICU).

The members of the MRT include a nurse and fellow from the Pediatric Intensive Care Unit, a senior pediatric resident, resource unit respiratory therapist and a manager of patient services. This team can by activated by any member of the patient's care team.

The MRT is available 24 hours a day to evaluate and assist in the triage of patients who may be getting "sicker" and who are potentially in need of additional interventions or transfer to a place of higher level acuity.

Our goal now is 0 preventable codes outside the ICU. In light of feedback, outcome data and lessons learned, we are launching phase II with some changes in guidelines for activating the MRT:

  1. Clinical triggers
    • Increased work of breathing
    • Worsening retractions
    • Oxygen saturations < 90% despite supplemental oxygen
    • Cyanosis or gray skin color
    • Agitation or decreased level of consciousness
    • Persistent increased heart rate > 180 in the absence of fever, pain, anxiety
    • Pediatric Early Warning System (PEWS) score ≥ 7 (or appropriate for unit algorithm)
      • Our staff are concerned
      • Parents are concerned
        • We will be inviting parents to activate the team if they feel it necessary

          PEWS: Pediatric Early Warning System

          The Pediatric Early Warning System (PEWS) was developed by a nurse in England. PEWS measures breathing, heart rate, pulse and behavior.

          Nurses regularly check patients for these measures to update the PEWS score. A score of 0-2 means the child is stable; 3-5 means the child is at risk of clinical deterioration. The highest score is 9. As patients go up in score, more experienced clinicians are called to the bedside, along with the intern and bedside nurse. A score of 7 or more triggers evaluation by the MRT.

          At Cincinnati Children's, the system was first tested on a pilot unit. We are spreading PEWS (pediatric early warning system) from a pilot unit to other units in the hospital as a tool to aid in the early recognition of patient's possible deterioration.

          Transparency

          On the pilot unit, PEWS scores were posted in plain view of staff and families. Color dots identified the status of each patient so staff can quickly evaluate needs: green (stable), yellow (caution) or orange and red (intervention needed). Initially, some staff were reluctant to be so open for fear of scaring parents, but a survey of parents found they embraced the system. As one parent said, "If my child is a red dot, I want it to be up there on the board, because the doctor will pay more attention to my child."

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          We Want Your Feedback

          We would like to know what you think of the information presented here. Please send us an email to let us know if you found this web page helpful and easy to understand, or if you there's any additional information you need but couldn't find (childrens-quality@cchmc.org).

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          Last updated May 2008.