Improving Communication by Standardizing Pediatric Rapid Response Team Documentation

Abstract

Background:

Rapid Response Teams (RRTs) have been employed by multiple hospital systems to enhance patient care and safety. However, processes to document Rapid Response Events (RRE) are often varied among providers and teams, which can lead to suboptimal communication of recommendations to both the primary medical team and family.

Methods:

A pre-intervention chart review was conducted from January-March 2018 and revealed sub-optimal baseline documentation following RREs. A literature review and survey of RRT team members led to the creation of a standardized document with an EPIC^™ SmartPhrase which included six key elements of RRE documentation: physical exam, intervention performed, response to intervention, plan of care, communication with care team and communication with family. A post-intervention chart review was completed from April-June 2019 to assess improvements in documentation with the use of this SmartPhrase.

Results:

There were 23 RRE activations in the post-intervention period, of which 60.8% were due to respiratory distress. The documentation of the six key elements improved (p<0.05) following SmartPhrase creation and serial educational interventions.

Conclusion:

Standardized RRE documentation of six key elements significantly improved with the implementation of an EPIC^™ SmartPhrase. Improved quality of documentation enhances communication between team members and can contribute to safer patient care.

INTRODUCTION

A Rapid Response Team (RRT) is a multi-disciplinary team that provides urgent assessment and intervention when a medical care team member or a family member is concerned about a patient’s deteriorating health condition while in the hospital. This approach to patient safety is based on early detection and action, which was first implemented in adult patients in Australia in the 1990s, and has now become a critical component of patient safety in major hospitals worldwide.¹ In 2004, the Institute for Healthcare Improvement (IHI) promoted RRTs as one of the key strategies to reducing patient harm and death.² By recognizing patient decompensation sooner and engaging in earlier interventions, RRTs have been shown to lower unplanned pediatric ICU transfers, decrease the immediate need for mechanical ventilation and vasopressors as well as reduce cardiopulmonary arrest and in-hospital mortality.^3–6

Prior pediatric RRT studies have provided some basis for standard expectations during Rapid Response Events (RRE).^4,5,7 However, RRT processes continue to vary widely across different institutions. Importantly, there has been no published standard for medical documentation following an RRT. This study defined key documentation elements to facilitate communication and proposed a standardized flowchart for future practice. Further, to ensure timely and efficient documentation of the RRE, an EPIC^™ SmartPhrase (i.e., dot phrase) was constructed to ensure that a single medical note provided a concise care plan when reviewed.

METHODOLOGY

Study Design:

This study was undertaken as a Quality Improvement (QI) initiative at our institution with the approval of our institutional review board (IRB 00006882) and a waiver for informed consent. Using appropriate quantifiable metrics, our baseline data validated the need for this QI project. We utilized a modified Delphi method for generating expert consensus and then we proceeded to roll out interventions using the Plan-Do-Study-Act methodology.

Setting:

Our free-standing, 250-bed, tertiary care children’s hospital first implemented RRTs in 2016. At our institution, RRTs may be initiated on a pediatric medical-surgical unit, but we employ different processes for responding to patient deterioration on our newborn and pediatric intensive care units and in our emergency departments. An RRT responding team consists of a pediatric intensive care unit (PICU) fellow, PICU registered nurse (RN) and a respiratory therapist (RT). An RRT can be activated by any staff or family member on the pediatric floor and will both evaluate the patient and take appropriate action based on the RRT’s consensus. A patient may either be transferred to the PICU or care may continue on the pediatric medical-surgical unit with recommendations implemented from the RRT. If the latter, a scheduled follow-up by the RRT personnel is undertaken to ensure the patient’s condition remains stable.

We conducted a retrospective chart review of all Rapid Response Events (RREs) at our institution from January to March 2018 (Pre-implementation). This demonstrated that our baseline state of RRE documentation was either missing entirely or it occurred in different places in the electronic medical record (EPIC^™): in the nursing flowsheet, respiratory therapy flowsheet or in physician-written free text medical notes. This medical information could not be easily retrieved by other members of the team. Moreover, when documentation occurred, the content of the documentation was inconsistent in terms of core information and proposed action items.

Procedures:

To improve the RRT documentation process, we first reviewed existing literature and concurrently formed a team utilizing a modified Delphi method that included pediatric hospitalists, pediatric ICU physicians and fellows, registered nurses (RN), and respiratory therapists from within our institution. Pediatric hospitalists are not a part of the RRT at our institution, however their input was valuable as RREs are primarily activated on the medical-surgical units. Individual interviews were undertaken with all medical-surgical floor nurse managers, charge nurses, lead RTs and bedside RNs to explore optimal RRE needs and delineate and define project goals. All interviewed were receptive and enthusiastic to RRE optimization. The project leadership team then met in-person quarterly, developed an ideal state process map and created a standardized EPIC^™ SmartPhrase in an SBAR (Situation, Background, Assessment and Recommendation) format. Once activated by the PICU fellows in the EMR’s “Documentation” interface, this would generate the standardized RRE document (see Appendix A) with a drop-down menu within respective fields and would encompass the six key elements of ideal documentation we had identified. These six elements included physical exam, intervention performed, response to intervention, plan of care, communication with the care team and communication with the family. The SmartPhrase was thus built to enforce inclusion of all relevant details, retain efficiency in use and to be accessible to all team members to address the communication deficits between providers. Accessibility of the note to all team members was particularly important in constructing the SmartPhrase since our EPIC nursing flowsheets are not easily accessible to physicians and respiratory therapists and thus contributing to prior communication barriers. Additionally, an ability to deviate from drop-down options with free text was included in most fields to account for unique patient situations. An in-person meeting of the key stakeholders, via a second modified Delphi panel, led to feedback and final approval of the SmartPhrase.

The implementation process required process mapping, simulation, EPIC SmartPhrase creation and ongoing education for all team members. An educational email was sent quarterly to all PICU fellows on the use of the SmartPhrase to include all six essential documentation elements, particularly as new trainees had joined in the interim. The effectiveness and sustainability of the intervention was then reassessed with data collection at the twelve-month mark. The investigators believed this time gap would then reflect the true receptivity of SmartPhrase adoption.

Data Analysis:

There were 23 patients in each of two groups (Pre- versus Post- Implementation). For each of the key elements, a two-sided Fisher’s Exact Test was used to compare the Pre-versus Post results. P-values less than 0.05 were considered significant. There was no adjustment for multiple comparisons.

RESULTS

In the pre-implementation period (January- March 2018), a total of 23 RRTs were activated. 82.6% of those were by the bedside RN, 8.7% by the pediatric residents and 4.3% by the pediatric hospitalists. No documentation on why or by whom the RRT was activated was found on 4.3% of charts reviewed. Respiratory distress (82.6%) was the most common reason for RRT activation followed by acute neurological changes (13%) (see Table 1). 43.5% of the charts did not mention if the primary specialty listed for the patient was contacted following the RRE. 91.3% of the medical records did not mention if the RRT or floor team communicated the plan with the family. Furthermore, the pre-implementation phase demonstrated RRT reassessment and follow-up in only 47.8% of patients who remained on a pediatric medical-surgical floor following RRE. The transfer rate to the PICU following RRT activation was 60.9%. We found 69.5% of the RREs between 7PM-7AM.

Table 1:

Clinical Scenarios that led to RRT Activation, Pre- and Post- RRT SmartPhrase Implementation

	Pre-implementation	Post- implementation
Respiratory distress	19 (82.6%)	14(60.8%)
Acute neurological changes	3 (13.0%)	7 (30.4%)
Poor perfusion	1 (4.3%)	0
Hypertensive crisis	0	1 (4.3%)
Hematemesis	0	1 (4.3%)

We then analyzed data from April-June 2019, one year after the SmartPhrase was implemented. There were also 23 RRT activations in this time period, with respiratory distress being the most common reason (Table 1). The RNs activated 87% of RRE with the remaining 13% by the pediatric residents. The overall compliance with the use of the RRT SmartPhrase was 78.3%.

The average time for the RRT team to arrive bedside was 4.1 minutes with RRE lasting for approximately 23 minutes from activation time to until the team left the patient’s room.

The documentation of the critical elements of RRE after the SmartPhrase was built compared to pre-implementation with respective p-values is shown in Table 2. There was a statistical difference in all elements except for “Intervention performed,” and an unanticipated decrease in documentation regarding the “Response to intervention” field (p=0.033).

Table 2:

Documentation Comparison Pre- and Post- RRT SmartPhrase Implementation

N=46 Key Elements:	Pre-implementation	Post-Implementation	p-values
Physical Exam	(17/23) 73.9%	(23/23) 100%	0.022*
Intervention Performed	(15/23) 65.2%	(19/23) 82.6%	0.314
Response to intervention	(13/23) 56.5%	(5/23) 21.7%	0.033*
Plan of care	(15/23) 65.2%	(22/23) 95.6%	0.022*
Communication with care team	(10/23) 43.4%	(23/23) 100%	<0.001*
Communication with family	(1/23) 4.3%	(20/23) 86.9%	<0.001*

^*Statistically significant

In the post- implementation phase, 69.5% of RREs were also found to be activated between 7PM-7AM with the other 30.5% from 7AM-7PM. The RRT outcomes in terms of disposition to continue floor management (34.8%) versus PICU transfer (65.2%) was clearly documented in all RRE notes utilizing the SmartPhrase for medical documentation. Also, the documentation in the nursing flowsheet as standard follow-up for patients who remained on the medical-surgical unit increased from 48% to 85%.

LIMITATIONS

Sample size and implementation at a single academic center are limitations in this study. Not all bedside nurses were interviewed in the pre-implementation phase, thus limiting some feedback. However, all charge nurses, nursing managers and RT leaders were interviewed to allow for representation input and opinions. Follow-up analysis over multiple time points would add greater validity to conclusions and areas for further study. Our study was primarily focused on standardizing documentation; we did not set out to examine patients’ clinical outcomes, as has been done in prior RRT studies.

DISCUSSION

Rapid response team implementation has been widely reviewed in the adult population. While studies have demonstrated significant benefits in reducing in-hospital cardiopulmonary arrest and mortality, the only adult multicenter randomized control trial (MERIT) failed to demonstrate this.⁸ Pediatric studies appear to have more variability in terms of improved outcomes. Tibballs et al. and Sharek et al. in their single center study found that after implementing RRTs, there was a reduction in cardiopulmonary arrest and mortality outside the PICU.^4,5 However, Kotsakis et al. and his team did not find a reduction in cardiopulmonary arrest when they implemented RRTs across four pediatric academic centers in Ontario, Canada.⁷ This discrepancy has been partly explained by Bonafide et al. in which they suggest cardiopulmonary arrest is not as common in pediatric compared to adult patients, and therefore to find a significant statistical difference would require a very large population study.⁹ The authors, rather, suggested “Critical Deterioration” events (defined as mechanical ventilation or vasopressor use within 12-hours following PICU transfer) as a proximate marker to assess the benefit of RRT implementation in pediatrics, and further validated this marker with a follow-up study.^3,9 There certainly is a benefit to having a system in place that is activated for any deteriorating patients which provides the link between the pediatric medical-surgical units and the PICU. However, what specifically is used as an end point to determine its true efficacy needs further research. RRT implementation has been shown to be cost effective despite the added operational cost of the team by reducing unplanned PICU transfer and Critical Deterioration events.¹⁰

The six core elements we defined for ideal assessment and documentation were suggested by existing literature^4,5,7 and our multidisciplinary team’s consensus using the modified Delphi method. Given that the creation of a shared workflow and clear communication mitigates medical error, documentation of this communication with the primary team and parents was deemed vital. As evident in the post-implementation phase, 34.8% of patients remained on a pediatric medical-surgical unit with new recommendations from the RRT. Thus, there is a need for a standard medical documentation that details this information. We included documentation of family communication as literature supports the important role parents serve in RREs, from activation to shared decision-making for further plans.^11–13 As we move into the electronic medical record (EMR) era, SmartPhrase medical documentation has become an invaluable tool. Scattered medical information is unhelpful when dealing with an acutely decompensating child. A SmartPhrase in the EMR provides automation and, if used, ensures relevant information is documented, thus reducing room for communication errors in patient care.^14,15 Another advantage of utilizing a SmartPhrase was that it served to prompt PICU fellows and nurses to complete all the standard information fields and define follow-up parameters. This defined expectation likely contributed to increased RRT nursing follow-up (85%) in the post-implementation phase.

Overall, in the post-implementation phase, our documentation improved significantly. While we encouraged PICU fellows to use the standard SmartPhrase, there were no reminder triggers in the EMR if it was not used for documentation following RRE. We also had multiple simultaneous projects including some directed at EMR efficiency, which may be challenging for new trainees to navigate and complete. These are likely reasons for a compliance rate of only 78%. While creating reminder triggers to use a SmartPhrase is technically challenging, our team expects with further knowledge dissemination on its availability and its efficiency, the compliance rate for using this RRT EPIC SmartPhrase will increase.

“Intervention Performed” was the one element that did not reach statistical significance in this study (p=0.314). Also, “Response to intervention” while statistically different (p=0.033), reflected an ongoing deficiency in documenting this key element (56.5% versus 21.7% in the post-implementation period). A reason for this may be a higher patient transfer rate. Specifically, since 65.2% of patients were transferred following RRE, the PICU fellows typically marked the “intervention performed” field as “N/A”. Further specific plans for these critically ill patients were likely made post-transfer in the PICU and not during the documentation immediately following RRE. Such documentation is captured in the PICU admission note. If we therefore consider “N/A” to be a valid field with this context, both “Intervention performed” and “Response to intervention” will have a higher documentation rate than our current data.

We found that the majority of our pediatric RREs triggered were due to respiratory distress (82.6% and 60.8% in the pre- and post-intervention period respectively) which is consistent with other studies that have looked at the etiology.^4,7 It is likely that seasonality with data collected in the respiratory viral season in the pre-intervention phase has led to a difference between the two. The PICU transfer rate (60.9% versus 65.2% in the pre- and post-intervention period respectively) is however similar. An increased frequency of primarily acute neurological situations likely accounts for a higher post-intervention transfer rate. We found following RRT activation, it took on an average of 4.1 minutes for the team to arrive to the bedside, which is superior to what Sharek et al. expected to achieve in their study.⁴ This does seem to be fairly quick for an RRT response, which may be attributed to general awareness of the implementation of this project in the hospital. We also found the majority of RRE was activated in the night hours (7PM-7AM) in both pre- and post-implementation. This is contrary to the findings by Humphreys et al. where most RRE occurred during the daytime.¹⁶ Reasons for more frequent nighttime RRE occurrences at our institute include the absence of a pediatric hospitalist during the nighttime (during our study phase) and the routine ‘safety huddle’ practice at 10 PM every night with the in-house RNs and PICU staff.

CONCLUSION

We found that consistent and standardized documentation of RREs could be significantly improved through the creation of an EPIC SmartPhrase. The specific content of our SmartPhrase was approved by expert consensus. We then enhanced compliance with serial educational interventions. Along with other measures of more complete documentation, we demonstrated significant improvement in recording of communication with families (87% post-intervention) and clearer communication between patient care team members (100%). Our framework should improve adherence to literature-supported best practices, enhance communication and bolster patient safety.

IMPLICATIONS.

Rapid response teams have a decades-long history of acceptance in the medical community for improving patient safety. Prior research has demonstrated that multiple health outcomes can be positively impacted by the earlier recognition of patient deterioration with RRTs, leading to the widespread acceptance. This is the first study, to our knowledge, that defines and measures a standard for documentation following pediatric rapid response events.

Documentation enhances communication between medical teams caring for a given patient and also provides a medicolegal record of the care provided. Thus, improving the standards of documentation is beneficial for both a given patient and the health system providing that care. Similar to a Code response team, any hospital that employs an RRT system in which an interdisciplinary team is on-call 24/7 to respond to an urgent page will encounter frequent turnover in that role; whether the team members come from nursing, respiratory therapy, ICU fellows or staff, anesthesia, or other disciplines, laying out standard training and expectations for those often-rotating individuals is essential. We believe other institutions aiming to enhance patient safety will benefit from replicating our framework (see Appendix A) for building a standard EMR medical note to include all the key elements we have defined.

Follow-up on patients who remain on the medical surgical floor after RRE is integral to ensuring efficacy of care. Similarly, a future direction may include use of the RRT to ensure safe patient transition from the ICU to the general floor. This multifaceted RRT model complements continuity of care.

Biographical Sketches

1. Riwaaj Lamsal, MD completed his Pediatric Critical Care fellowship training at University of Minnesota and is currently an Assistant Professor of Pediatrics at East Tennessee State University, Tennessee. He helped with data collection, implementation as well as preparation of the manuscript.

2. Jenna K. Johnson Jenna Johnson is an MD/PhD student at the University of Minnesota located in Minneapolis, Minnesota. She is pursuing a PhD in immunology and plans to pursue pediatrics in the future. She has taken courses on quality improvement at the UMN Medical School and helped with designing and executing the project as well as editing the manuscript.

3. Mehdijaffer Mulla, MHA is an MD student at the University of Minnesota located in Minneapolis, Minnesota with plans to pursue emergency medicine in the future. He earned his Lean Six Sigma Black Belt at the University of Miami Herbert Business School where he worked to reduce variation of clinical outcomes as well as the hospital financial revenue cycle. He helped design and execute the early stages of this study and helped edit the manuscript.

4. Jordan Marmet, MD is an Associate Professor of Pediatrics at the University of Minnesota, Minneapolis, Minnesota. He works clinically as a Pediatric Hospitalist, serves as the Division Director for Pediatric Hospital Medicine and holds organizational and educational roles in quality improvement and patient safety. He assisted with study design and substantial editing of the manuscript.

5. Arif Somani is an Assistant Professor of Pediatrics at the University of Minnesota and serves as the Medical Director of the Pediatric Intensive Care Unit at the University of Minnesota Children’s Masonic Hospital. He led the design, execution, and authorship of the following manuscript and is instrumental in quality assurance and patient safety at our institution.