A Qualitative Analysis of Observed Behavior of Pediatric Rapid Response Team Performance

BACKGROUND AND OBJECTIVES Pediatric rapid response teams (RRTs) enhance patient safety, reduce cardiorespiratory arrests outside the PICU, and detect deteriorating patients before decompensation. RRT performance may be affected by failures in communication, poor team dynamics, and poor shared decision-making. We aimed to describe factors associated with team performance using direct observation of pediatric RRTs. METHODS Our team directly observed 73 in situ RRT activations, collected field notes of qualitative data, and analyzed the data using conventional content analysis. To assess accuracy of coding, 20% of the coded observations were reassessed for interrater reliability. The codes influencing team performance were categorized as enhancers or threats to RRT teamwork and organized under themes. We constructed a framework of the codes and themes, organized along a spectrum of orderly versus chaotic RRTs. RESULTS Three themes influencing RRT performance were teamwork, leadership, and patient and family factors, with underlying codes that enhanced or threatened RRT performance. Novel factors that were found to threaten team performance included indecision, disruptive behavior, changing leadership, and family or patient distress. Our framework delineating features of orderly and chaotic RRTs may be used to inform training and design of RRTs to optimize performance. CONCLUSIONS Observations of in situ RRT activations in a pediatric hospital both verified previously described characteristics of RRTs and identified new characteristics of team function. Our proposed framework for understanding these enhancers and threats may be used to inform future interventions to improve RRT performance.

Failure To Rescue, What Can Be Done To Prevent It?

Introduction: Failure to Rescue (FTR) is the failure to prevent a patient’s death after a complication. It measures the ability of a hospital to prevent the death of patients who develop one or more complication that was not present at the time of admission. Therefore, the aim of this study is to review the factors that contribute to FTR, and the measures and strategies that can be applied to prevent the FTR events, in order to discuss the best way to improve patient outcomes in the hospital setting. Methods: A search was conducted on PUBMED retrieving a total of 464 articles. A review of the selected articles’ bibliography was conducted to find other relevant articles. Sixty studies were reviewed in this paper. Results: Patient factors as increasing age, comorbidities and frailty increase the risk of FTR, as well as an increasing number of complications. Several hospital factors, nursing care, and microsystem also influence FTR. Some track and Trigger Systems (TTS) and Early Warning Scores (EWS) have been shown to predict clinical deterioration. On the other hand, machine learning systems have outperformed EWS. Rapid response teams have become the standard approach to delivery and escalation of care, and cognitive aids and crisis checklists also have potential to help reduce FTR. Conclusion: Patient and hospital factors are often non-modifiable; thus, microsystem factors could be a target for improvement. Creating clinical pathways can improve surveillance, and communication tools like SBAR can help relay information. EWS, machine learning models and continuous monitoring are strategies that can help detect clinical deterioration. In the efferent limb rapid response teams have shown to reduce FTR.

Abstract 11781: Association of Rapid Response Teams With Hospital Mortality in Medicare Patients

Background: Rapid response teams (RRT) have been promoted as a strategy to reduce unexpected hospital deaths, as they are designed to evaluate and treat patients experiencing sudden decline. However, evidence to support their effectiveness in reducing in-hospital mortality remains uncertain. Methods: Using data from 56 hospitals participating in Get With The Guidelines Resuscitation linked to Medicare, we calculated annual rates of case-mix adjusted mortality for each hospital during 2000-2014. We constructed a hierarchical interrupted time series model to determine whether implementation of a RRT was associated with a reduction in mortality that was larger than expected based on pre-implementation trends alone. Results: Over the study period, the median annual number of Medicare admissions across study hospitals was 5214 (range: 408-18,398). The median duration of the pre-implementation period was 7.6 years comprising ~2.5 million admissions, and the median duration of the post-implementation period was 7.2 years comprising ~2.6 million admissions. Before implementation of RRTs, hospital mortality was already decreasing by 2.7% annually (Figure). Implementation of RRTs was not associated with change in mortality in the initial year of implementation (RR for model intercept: 0.98; 95% CI 0.94-1.02; P= 0.30) or in the mortality trend over time (RR for model slope: 1.01 per-year; 95% CI 0.99-1.02; P =0.30). Within individual hospitals, a RRT was associated with a significantly lower than expected mortality at 4 (7.1%) of hospitals, and significantly higher than expected mortality at 2 (3.6%), when compared to pre-implementation trends. Conclusion: Among a diverse sample of U.S. hospitals, we found that the implementation of a RRT was not associated with a significant reduction in hospital mortality. Given their prevalence in most U.S. hospitals, further studies are needed to understand best practices in composition, design, and implementation of RRTs.

CUSTOMER PERCEPTION ON THE OVERALL QUALITY OF SERVICE DELIVERED A CASE STUDY OF THE ELECTRICITY COMPANY OF GHANA (ECG)

Purpose: The purpose of this study was to ascertain customer perception on the overall quality of service delivered by ECG Methodology: The study adopted an explanatory research design in order to achieve the study objectives. The population for this research was made up of the employees of ECG and the customers of ECG, who were systematically sampled. Data was then analyzed through descriptive statistics using the Statistical Package for Social Science. The study employed descriptive statistics, multivariate data analysis as well as regression modelsResults: The study found out that customers perceived the quality of services being offered by the energy company as unsatisfying.Unique contribution to theory, practice and policy: To improve service quality, ECG would have to isolate the dimensions that were noted to be weak; being empathy and responsiveness. These may be addressed by professional training and retraining front line personnel and technical rapid response teams to address the concerns of customers with urgency and a human face

Paediatric cardiac rapid response systems: a survey of multicentre practices

Introduction: While the efficacy and guidelines for implementation of rapid response systems are well established, limited information exists about rapid response paradigms for paediatric cardiac patients despite their unique pathophysiology. Methods: With endorsement from the Paediatric Cardiac Intensive Care Society, we designed and implemented a web-based survey of paediatric cardiac and multidisciplinary ICU medical directors in the United States of America and Canada to better understand paediatric cardiac rapid response practices. Results: Sixty-five (52%) of 125 centres responded. Seventy-one per cent of centres had ∼300 non-ICU beds and 71% had dedicated cardiac ICUs. To respond to cardiac patients, dedicated cardiac rapid response teams were utilised in 29% of all centres (39% and 5% in centres with and without dedicated cardiac ICUs, respectively) [p = 0.006]. Early warning scores were utilised in 62% of centres. Only 31% reported that rapid response teams received specialised training. Transfers to ICU were higher for cardiac (73%) compared to generalised rapid response events (54%). The monitoring and reassessment of patients not transferred to ICU after the rapid response was variable. Cardiac and respiratory arrests outside the ICU were infrequent. Only 29% of centres formally appraise critical deterioration events (need for ventilation and/or inotropes post-rapid response) and 34% perform post-event debriefs. Conclusion: Paediatric cardiac rapid response practices are variable and dedicated paediatric cardiac rapid response systems are infrequent in the United States of America and Canada. Opportunity exists to delineate best practices for paediatric cardiac rapid response and standardise practices for activation, training, patient monitoring post-rapid response events, and outcomes evaluation.

The peri-urban leopards of Kathmandu: assessing determinants of presence and predation on domestic animals

The conservation of large carnivores in human-dominated landscapes needs to be reconciled with the safety of humans and domestic animals. This is especially true for the leopard Panthera pardus, which occurs extensively in agricultural landscapes and remnant forest tracts embedded within peri-urban areas such as Kathmandu district in Nepal. We carried out interviews in 321 households in this district to determine the extent of leopard habitat use and predation on domestic animals (dogs and goats) during October 2015–April 2016. We used multi-state occupancy models, and estimated probabilities of leopard habitat use (Ψ1) and predation on domestic animals (Ψ2) as a function of covariates, while accounting for imperfect detection. Our findings indicate that the rapidly urbanizing outskirts of Kathmandu city are used extensively by leopards. The estimated probability of fine-scale habitat use in 2 km2 sample units was 0.96 ± SE 0.05 and the probability of predation on domestic animals was 0.76 ± SE 0.15. Leopard attacks occurred in areas with high vegetation cover and abundant goats. Addressing the problem of leopard attacks on domestic animals will require developing a comprehensive mitigation plan that includes educational activities to raise awareness, measures to address grievances of affected local communities, interventions to prevent attacks on livestock, compensation programmes, and rapid response teams to ensure human and animal welfare in conflict-prone areas. Land-use planning in these peri-urban landscapes needs to facilitate the safe sharing of space between people and leopards.