Simulation and educationRegular in situ simulation training of paediatric Medical Emergency Team improves hospital response to deteriorating patients☆
Introduction
Timely and effective response to deteriorating patients is of vital importance for patient safety in a hospital setting.
In this context, implementation of a Medical Emergency Team has been recommended by several organisations,1 supported by evidence of improved outcome from early intervention in evolving critical illness.2, 3 Several single-centre studies reported a reduction in cardiac arrests and hospital mortality following the introduction of early warning systems and Medical Emergency Teams (MET).4, 5 However, these improvements in adult care were not confirmed by the only randomised multi-centre study to date,6 and doubts remain to what extent the different elements (early warning system; Medical Emergency Team; education of staff) contribute to any benefits. In particular, the impact of a comprehensive education and training program was identified as requiring further study.7, 8
In paediatrics, single-centre reports have demonstrated either a significant reduction in, or a trend towards reduced incidence of, cardiac/respiratory arrests and hospital mortality following the introduction of paediatric Medical Emergency Teams.9, 10, 11, 12 All reports describe the need for major changes within organisations, with implications for clinical practice and audit, and the need for a hospital-wide education program prior to introduction. There is, however, little focus on training of paediatric Medical Emergency Teams. A survey of North American paediatric centres reported either no, or very infrequent, team training in the majority of hospitals with a paediatric MET.13 This is surprising, given emerging evidence about the importance of human factors for patient safety in medicine in general, and teamwork in emergency and critical care paediatrics in particular.14, 15
Within our institution, a tertiary stand-alone paediatric hospital, problems with the recognition of deteriorating children and a sometimes slow process of escalation through the medical hierarchy were identified at hospital mortality and morbidity meetings. Whilst there was some in-house training for individuals in resuscitation technique, there was no regular team training for the resuscitation team.
Concurrent with introduction of a paediatric MET, weekly in situ simulation team training became part of routine clinical practice. Registrars and senior nurses from the wards were included in the team and team training. Thereby, key decision makers from all hospital wards were exposed to regular training in the recognition and management of deteriorating patients.
The study aimed to evaluate the impact of regular team training on the hospital response to deteriorating in-patients with evolving critical illness and subsequent patient outcome.
Section snippets
Methods
All unplanned admissions of paediatric hospital in-patients to the Paediatric Intensive Care Unit (PICU) were prospectively audited for 1 year.
Patient deterioration was defined as a breach of physiological criteria or documented staff concerns (local adaptation of previously published criteria).17 The time from point of deterioration to first response and time from first response to point of PICU admission were recorded. Process measures were prospectively identified to analyse clinical
Pre-implementation of pMET
The response to deteriorating ward patients prior to implementation of pMET is detailed in Table 1. Delays in both the recognition of deteriorating patients and in the time from first response to PICU admission were most marked in the out-of-hours period (overnight, weekend). All deteriorating patients were reviewed by a doctor, but only 25/56 patients were seen by a consultant from point of deterioration to point of PICU admission. The resuscitation team was called in 3 cases.
Post-implementation of pMET
Following pMET
Response to deteriorating patients at ward level
This study demonstrated a significant improvement in ward response to deteriorating in-patients following introduction of a paediatric MET with concurrent in situ simulation-based team training. The deteriorating child was recognised faster, reviewed by more senior staff and escalation to intensive care happened more promptly.
To our knowledge, this is the first study to demonstrate significant improvements in response to deteriorating patients not only with attendance of a rapid response team,
Limitations
This quality improvement initiative was conducted in the format of an observational cohort study and as such cannot inform on cause and effect, as too many uncontrolled variables may have an effect on the outcomes. It is, therefore, not possible to conclude that the improved response to deteriorating ward patients caused the reduction in hospital mortality. However, given that pMET and concurrent team training reflected the largest change to hospital practice during the study period, it seems
Conclusion
The introduction of a paediatric Medical Emergency Team, accompanied by weekly in situ simulation team training with an emphasis on recognition of the deteriorating child, communication and early involvement of senior staff, improved the ability of ward staff to recognise and manage evolving critical illness, resulting in improved outcome for hospital in-patient with evolving critical illness. Integration of in situ simulation team training into routine clinical care requires further evaluation
Conflict of interest statement
No conflicts of interest to declare.
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A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2012.06.027.