SummaryThe North Carolina Children's Hospital Family Alert Initiative empowers and encourages families who suspect that their child may need immediate resuscitative or medical attention to activate the hospital's rapid response team by dialing an easy-to-remember number from any hospital telephone. Staff can also activate the team based on their own concerns or those of the family. The team then immediately comes to the bedside to assess the child, initiating life-saving interventions and/or directing transfer to the intensive care unit when necessary. Pre- and post-implementation data show that the program increased calls to the rapid response team by approximately 50 percent, with most of the additional calls coming from staff rather than family members (due to the increased visibility of the program and a perceived reduction in barriers to calling the team). The broader rapid response system at the hospital has significantly reduced both cardiac arrests outside of the intensive care unit and overall hospital mortality rates.Moderate: The evidence consists of pre- and post-implementation comparisons of key outcomes measures, including calls to the rapid response team, cardiac arrests outside the ICU, and mortality rates.
Developing OrganizationsNorth Carolina Children's Hospital
Chapel Hill, NC
Date First Implemented2007
Age > Adolescent (13-18 years); Child (6-12 years); Vulnerable Populations > Children; Age > Infant (1-23 months); Newborn (0-1 month); Vulnerable Populations > Non-English speaking/Limited English proficiency; Age > Preschooler (2-5 years)
Problem AddressedEach year, more than 60,000 people die in hospitals due to "failure to rescue," a situation in which caregivers fail to notice or respond to signs that a patient is dying of preventable complications.1 Rapid response teams were developed as a solution to this problem; a rapid response team is a team of clinicians with critical care expertise called to the patient’s bedside to quickly provide resuscitative care and/or other necessary medical attention.2 Although rapid response teams have been found to be effective in studies3 and are promoted by the Institute for Healthcare Improvement's Five Million Lives Campaign, relatively few hospitals have established them for pediatric patients.2 Those hospitals with teams typically do not allow family members to activate them directly, even though they are often the first to notice a concerning change in a child’s health status or stability.
- Few pediatric teams, despite proven benefits: When staff do not respond adequately or swiftly enough to deterioration in a patient's condition, preventable complications and even death can occur.2 Studies have shown that pediatric rapid response teams can address this problem, reducing the incidence of cardiac arrest, respiratory arrest, and mortality.4-6 However, as of 2006, only about 20 medical centers nationwide have established such teams for pediatric patients.7
- Failure to allow family activation of existing teams: Family members may be the first to detect a significant change in the patient's clinical status, yet they often lack readily available channels to communicate concerns to the staff.2 In fact, most hospitals with rapid response teams do not allow family members to activate the team directly, even in hospitals that include “family concern” as a justification for team activation by clinical staff.8,9 For example, an analysis at North Carolina Children’s Hospital found “family concern” to be the primary reason behind 20 percent of calls to its rapid response team and that 50 to 70 percent of these calls resulted in patient transfer to the pediatric intensive care unit (ICU), thus confirming the validity of the call.10
Description of the Innovative ActivityThe Family Alert Initiative encourages families who suspect that their child may need immediate resuscitative or medical attention to activate the hospital's rapid response team by dialing an easy-to-remember number from any hospital telephone. The rapid response team immediately comes to the bedside to assess the child, initiating life-saving interventions and/or directing transfer to the ICU when necessary. Key elements of the program include the following:
- Education about appropriate activation: The admitting nurse educates family members about the rapid response team and how to activate it, using both verbal instructions and written materials. (Staff receive separate education on when and how to activate the team, including the specific clinical criteria for doing so.*) The core message is to encourage family members to call the team if they fear their child’s condition is acutely worsening; families do not have to provide any specific criteria to justify the call. Key aspects of the family education process are described below:
- Verbal instruction: Prompted by an electronic admission form checklist, the admitting nurse provides families with the telephone number for team activation along with a description of the circumstances in which a call is warranted (i.e., acute emergencies or situations of significant concern). The nurse also instructs families on how to contact staff for nonurgent needs and to register complaints to the patient relations department. The nurse uses a mock script to ensure complete discussion of the topic and documents the provision of this education in the patient chart.
- Special education for non–English-speaking families: Translators facilitating the admission process instruct non–English-speaking families on the rapid response team and how to activate it. These families can activate the team by handing a tear-off card located in all patient rooms to an English-speaking staff member. The card instructs the staff member to contact the team immediately on behalf of the family.
- Written materials promoting phone number: A variety of written materials prominently promote the phone number for the team and encourage families to call if needed, including bilingual brochures (written in both English and Spanish) distributed to families at admission, flyers posted in family lounges, and posters hanging in every patient room and waiting area. The previously mentioned tear-off cards for non–English-speaking families are located adjacent to the posters.
- Family activation of the team: Families can directly dial “64111” from any hospital telephone to activate the team. When they do so, an operator asks the family if it wants to activate the rapid response team and confirms the patient’s location/room number. (The operator asks no clinical questions.) Families can also ask a nurse to dial the emergency number if they do not feel comfortable activating the team themselves.
- Rapid response team care: Whenever the team is activated, the operator makes an announcement on the overhead system and sends a group page to all team members, which include a critical care physician (a pediatric ICU fellow or attending physician), critical care charge nurse for the pediatric ICU, a pediatric ICU respiratory therapist, a senior pediatric resident, and the patient’s primary medical team. The team, per hospital records, typically arrives in less than 5 minutes to provide onsite care and expedite transfer to a higher level of care as necessary.
*Staff criteria for activation includes staff or family member concern; acute change in heart rate, systolic blood pressure, respiratory rate, or oxygen saturation level; mental status changes; a new or prolonged seizure; and difficult-to-control pain or agitation.
References/Related ArticlesHanson CC, Randolph GD, Erickson JA, et al. A reduction in cardiac arrests and duration of clinical instability after implementation of a pediatric rapid response system. Qual Saf Health Care. 2009:18(6):500-4. [PubMed].
Miller E, Smith, R, Massie S, et al. Family alert: how to implement direct family activation of a pediatric rapid response team. Jt Comm J Qual Patient Safety. In press.
Institute for Healthcare Improvement. North Carolina Children’s Hospital: where parents are considered part of the medical team. June 1, 2008. Available at: http://www.ihi.org/knowledge/Pages/ImprovementStories/NorthCarolinaChildrensHospitalWhereParentsareConsideredPartoftheMedicalTeam.aspx.
Institute for Healthcare Improvement. IHI.org story: children count in the 100,000 Lives Campaign. August 3, 2006. Available at: http://www.ihi.org/knowledge/Pages/ImprovementStories/ChildrenCountinthe100000LivesCampaign.aspx.
Davis R. Medical teams swoop in at family's behest. USA Today. January 29, 2007. Available at: http://www.usatoday.com/news/health/2007-01-28-rapid-response_x.htm.
Contact the InnovatorTina Schade Willis, MD
Departments of Anesthesiology and Pediatrics
Chief, Division of Pediatric Critical Care Medicine
Medical Director, PICU and ECLS
University of North Carolina at Chapel Hill
214 MacNider Building
Chapel Hill, NC 27599-7221
Phone: (919) 966-7495
Fax: (919) 966-6164
Web site: http://www.med.unc.edu/cce
Cherissa C. Hanson, MD
Assistant Professor of Anesthesia and Pediatrics, Division of Pediatric Critical Care Medicine
Director, Pediatric Rapid Response System
The University of North Carolina
214 MacNider Building
Chapel Hill, NC 274599-7221
Phone: (919) 966-7495
Innovator DisclosuresDr. Willis and Dr. Hanson have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
ResultsPre- and post-implementation data show that the Family Alert Initiative increased calls to the rapid response team by approximately 50 percent, with most of the additional calls coming from staff rather than family members (see below for explanation). The broader rapid response team program has led to a decline in cardiac arrests outside of the ICU and to a marked reduction in mortality rates.7,8
Moderate: The evidence consists of pre- and post-implementation comparisons of key outcomes measures, including calls to the rapid response team, cardiac arrests outside the ICU, and mortality rates.
- More calls to rapid response team, mostly from staff: The number of calls to the rapid response team increased from 16 per 1,000 discharges before the Family Alert Initiative implementation (roughly 8 calls per month) to 24 per 1,000 discharges afterward (roughly 12 per month). Although calls increased significantly, only one to three calls per year are made directly by family members. The vast majority of additional calls came from staff, likely due to the increased visibility of the rapid response team and a reduction in perceived barriers to activating the team.
- Appropriate calls from families: Calls made by family members after implementation of the Family Alert Initiative were found to be necessary and medically appropriate, with all patients requiring transfer to the ICU.
- Better outcomes resulting from rapid response team implementation: Implementation of the rapid response team itself has had a beneficial impact, as follows:
- Fewer cardiac arrests: The number of cardiac arrests occurring outside the ICU fell from roughly 10 to 12 per year before implementation of the rapid response team to 1 to 3 per year afterward. Measured another way, the median number of days between cardiac arrests rose from 34 to 104 after implementation. The cardiac arrest rate per 1,000 ward admissions decreased from 1.25 to 0.45. No change occurred in the frequency of non-ICU cardiac arrests after the addition of the Family Alert Initiative. Program developers did not expect a further decline, given how rare the event had become at the hospital.
- Fewer deaths: The hospital experienced a decline in mortality after implementation of the rapid response team; mortality rates fell from 1.5 per 1,000 admissions before initiation of the program to 0.45 per 1,000 admissions afterward.
- Quicker ICU assessment: The time from the first documented antecedent to ICU assessment decreased from 9 hours, 55 minutes before implementation to 4 hours, 15 minutes post-implementation.
- Consistent with results from other settings: The declines in cardiac arrests and mortality are consistent with findings from rapid response teams used in other settings.1
Context of the InnovationNorth Carolina Children’s Hospital, a 150-bed pediatric institution that handles approximately 5,900 admissions each year, is part of the University of North Carolina Hospitals, which also runs a large 800-bed academic medical center in Chapel Hill. On August 1, 2005, North Carolina Children’s Hospital implemented a pediatric rapid response team—the first in North Carolina and one of the first in the nation. Initially, the director of critical care medicine and other rapid response team champions wanted to include family activation as part of the process. However, because the controversy surrounding this idea would have significantly delayed implementation, the idea was temporarily put on the back burner. One year after implementation, a review of rapid response team usage revealed “family concern” as a reason for staff activation in 20 percent of the calls and found that 50 to 70 percent of these cases required the patient to be transferred to the ICU, thus confirming that the calls were justified. Based on these findings, the critical care team decided to develop the Family Alert Initiative so that families would feel empowered to activate the team themselves.
Planning and Development ProcessKey elements of the planning and development process included the following:
- Planning team: A Family Alert Initiative team formed, consisting of a critical care physician champion, assistant nurse managers from the floors working with the rapid response team, ICU physicians, respiratory therapists, and ICU nurse managers.
- Leadership buy-in: The team obtained approval from the hospital’s senior administrators to add a family activation component to the rapid response team process.
- Discussions with other pediatric institutions: Team members called colleagues at pediatric institutions across the nation, learning that most existing rapid response team programs did not allow family activation. Interviewees reported difficulty in convincing faculty and staff of the merits of such an approach, given concerns that families might activate the rapid response team inappropriately.
- Decision to test concept first: Due to the controversy surrounding family activation, team members decided to test the concept on a few units first; they obtained Institutional Review Board approval for a pilot study.
- Notification of rapid response team and critical care clinicians: The Family Alert Initiative team informed members of the rapid response team and other critical care physicians about the pilot study. As part of this process, critical care team members head presentations during grand rounds that incorporated real patient stories (including testimonials by parents).
- Nurse focus groups: The Family Alert Initiative team conducted focus groups with nurses to obtain guidance on best practices for educating families about activating the rapid response team. During these sessions, nurses also received data on the clinical validity of “family concern” as a prompt for staff to activate the rapid response team.
- Development of standardized education materials: The nurses, in collaboration with communications department staff, developed brochures, flyers, posters, and scripts for educational communications. The team and the nurses also developed an assessment tool to evaluate the family education process tested as part of the pilot.
- Staff education: Nurses received an educational briefing on the standardized assessment tool, family education process, and educational materials. Operators received training on how to handle calls from families to the rapid response team line.
- Initial pilot study and program expansion: The program was pilot tested on two nursing units for 2 months (April to May 2007). Based on the success of this study, leaders decided to expand the Family Alert Initiative throughout the hospital.
Resources Used and Skills Needed
- Staffing: Despite the increase in calls to the rapid response team, the program required no new staff (due primarily to the low total volume of calls, even after implementation).
- Costs: Data on program development costs are unavailable; the bulk of expenses related to the production of brochures and posters.
Funding SourcesNorth Carolina Children's Hospital
Tools and Other ResourcesInformation about establishing and deploying rapid response teams, including the North Carolina Children’s Hospital family activation brochure, poster, and family education assessment tool, is available from the Institute for Healthcare Improvement's Web site:
General information on Rapid Response Systems is available at: http://psnet.ahrq.gov/primer.aspx?primerID=4.
Getting Started with This Innovation
- Secure senior leadership support: Program success depends on the support of senior leaders, particularly with respect to managing initial staff resistance.
- Use data and stories to win staff buy-in: Use data and real-life stories to demonstrate the merits of the program to staff. North Carolina Children’s Hospital used the aforementioned data showing that 20 percent of staff-activated calls were prompted by family member concern and that the majority of these calls were justified.
- Address different sources of resistance: Typically, physicians will resist the initial development of a rapid response team (due to concerns that their oversight of patient care will be undermined), whereas nurses generally like the idea. By contrast, nurses may be apprehensive about the family activation component because of their own perceived loss of control. Holding separate focus groups with each key stakeholder can help address these different sources of resistance.
- Conduct a pilot study: A pilot study can help acclimate staff to the idea of family activation, because such studies need not be presented as a permanent change and offer the opportunity for staff feedback. In addition, data from the pilot study can assuage staff concern that families will activate the rapid response team in circumstances that are not clinically appropriate.
Sustaining This Innovation
- Emphasize verbal education: The aforementioned family education assessment tool found that verbal explanations from caregivers are more effective than written brochures in teaching patients when and how to activate the rapid response team.
Use By Other OrganizationsThe Children’s Hospital of Pittsburgh also allows family activation of a rapid response team; more information can be found at Dean BS, Decker MJ, Hupp D, et al. Condition HELP: a pediatric rapid response team triggered by patients and parents. J Healthc Qual. 2008;30(3):28-31. [PubMed]
Aleccia J. Before code blue: Who’s minding the patient? Little-known ‘failure to rescue’ is most common hospital safety mistake. MSNBC. Available at: http://www.msnbc.msn.com/id/24002334
Bellomo R, Goldsmith D, Uchino S, et al. A prospective before-and-after trial of a medical emergency team. Med J Aust. 2003;179(6):283-7. [PubMed]
Anonymous. Study is first to show RRTs decrease pediatric deaths. Healthcare Benchmarks Qual Improv. 2008 Aug;15(8):80-3. [PubMed]
Brilli RJ, Gibson R, Luria JW, et al. Implementation of a medical emergency team in a large pediatric teaching hospital prevents respiratory and cardiopulmonary arrests outside the intensive care unit. Pediatr Crit Care Med. 2007;8(3):236-46, quiz 247. [PubMed]
Sharek PJ, Parast PJ, Leong LM, et al. Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a children's hospital. JAMA. 2007;298(19):2267-74. [PubMed]
7 UNC Healthcare. UNC Hospitals is first in North Carolina, and one of few medical centers nationwide, to establish Pediatric Rapid Response Team. January 5, 2006.
Hanson CC, Randolph GD, Erickson JA, et al. A reduction in cardiac arrests and duration of clinical instability after implementation of a pediatric rapid response system. Qual Saf Health Care. 2009;18(6):500-4. [PubMed]
10 Miller E, Smith, R, Massie S, et al. Family alert: how to implement direct family activation of a pediatric rapid response team. Jt Comm J Qual Patient Saf. In press.
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Service Delivery Innovation Profile
Original publication: September 30, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: October 03, 2012.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: September 28, 2011.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.