CAPHC National Patient Safety Symposium: Family-triggered activation. J Gilleland, MD McMaster Children s Hospital

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1 CAPHC National Patient Safety Symposium: Family-triggered activation J Gilleland, MD McMaster Children s Hospital

2 Our PCCRT Model Provincial PCCRT demonstration project 24/7 team started Jan 2007 Ramp-down model May 2009 PACE MD PACE RN PICU Resident Ward RT Follow all PICU discharges for 48 hours

3 PACE Pediatric Assessment, of Critical Events Rapid Assessment, of Critical Events

6 As parents of sick children, we rely on experts to provide us with the appropriate level of care. We understand that at times a child s condition may worsen and that the accessibility and expertise if the PACE team is invaluable in evaluating the child s condition. We believe that by allowing parents the opportunity to contact the PACE team directly allows us control in an often uncontrollable situation

if the PACE team is invaluable in evaluating the child s condition.

9 The Experience with Family-Triggered Activation of the Critical Care Response Team at an Academic Children s Hospital in Ontario Gilleland J*, Watson J*, Lobos A**, Seidlitz W*, on behalf of the Ontario PCCRT Working Group * McMaster Children s Hospital, McMaster University, Hamilton, Ontario **Children s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario Introduction Education Materials Results Discussion McMaster Children s Hospital (MCH) is a participant of the multi-center Pediatric Critical Care Response Team (PCCRT) demonstration project with three other academic children s hospitals in Ontario. In keeping with a strong family centered-care philosophy, the role of parental observations in detecting significant clinical deterioration was included in the afferent limb of all four sites using two different models. At the McMaster site, direct activation of the PCCRT by families of admitted patients was incorporated into the activation criteria. Healthcare providers at the three remaining sites were encouraged to activate the PCCRT on behalf of families who raised concern about their children s clinical status. Given the relative paucity of data in the area of family-triggered activation of critical care response teams, we describe the experience with family-triggered activation over the 12-month prospective arm of the Ontario PCCRT demonstration project. Methods MCH is a 119 bed Children s Hospital in Hamilton, Ontario, Canada with a 12 bed PCCU. All families of admitted patients received specific education materials on the PCCRT and when activation of the PCCRT was appropriate. Immediately following family-triggered activation of the PCCRT clinical, demographic and outcome data were inputted into a centrally housed electronic database. At one other site, the Children s Hospital of Eastern Ontario (CHEO) in Ottawa, data following activation of the team from families via healthcare providers was also recorded providing a comparison to direct family-triggered activation. The education materials for parents evolved from an entirely text-based pamphlet inserted into the hospital orientation package to a larger poster mounted in each room to address varying levels of parent education. This process incorporated advice from a patient education specialist and the MCH Family Advisory Council. These new posters use simpler language and have a descriptive photo illustrating the type of bedside response to be expected when the CCRT is activated. From February 2007 to February 2008, 261 new activations to the PCCRT occurred with an average monthly activation rate ranging from / 1000 hospital admissions. In the same time period, 8 family-triggered activations occurred (3.0%) from 7 different families resulting in 1 admission to the PCCU. In one case the team was activated because a patient handover error occurred between two teams resulting in a patient not having been seen by a physician in a 24-hour period. CHEO reported 8 family calls (3.4%) resulting in no PCCU admissions from a similar denominator of 234 new activations with an average monthly activation rate ranging from /1000 hospital admissions. Patient Reason for call Intervention 1 2 3* Recurrent seizures Resp Distress Not seen by an MD Anticonvulsant advice CXR, bloodwork, reassurance Identification of handover error 4* Dehydration New onset seizure Resp distress Recurrent apnea Concern Fluid bolus, electrolyte correction Intubation and seizure control Salbutamol, trach suctioning Reassurance Reassurance There are many unsubstantiated fears surrounding family-triggered activation of critical care response teams; however, at our site we have shown that direct family-triggered activation accounted for an overwhelmingly small percentage of total call volume to our PPCRT and was similar to the experience at CHEO with an indirect family-calling algorithm. Other important benefits included improved team communication in at least one scenario, and particularly in a pediatric center represented a natural extension of family-centered care. As parents of sick children, we rely on experts to provide us with the appropriate level of care. We understand that at times a child s condition may worsen and that the accessibility and expertise if the PACE team is invaluable in evaluating the child s condition. We believe that by allowing parents the opportunity to contact the PACE team directly allows us control in an often uncontrollable situation. Council - McMaster Children s Hospital Family Advisory

Education Materials Results Discussion McMaster Children s Hospital (MCH) is a participant of the multi-center Pediatric Critical Care Response Team (PCCRT) demonstration project with three other

12 Jan 2007 July family-triggered activations Parent picked up the phone 11 Parent asked the RN 5 Couldn t tell 9 *1 PICU admission

13 Families may call, but we need to 5 year old boy listen Down Syndrome, repaired congenital heart defect AML Fever, neutropenia CVL infection Severe irritability? seizure and respiratory distress

14 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 21:05 new activation 10:55 planned follow-up 13:30 planned follow-up 12:15 planned follow-up 00:30 Unplanned follow-up 12:00 planned follow-up 05:45 family-triggered activation 11:20 signed off 20:11 PICU Admission 9 day PICU admission -Intubation -Chest tube -Epinephrine infusion

follow-up 12:00 planned follow-up 05:45 family-triggered activation 11:20

15 Sustaining the gain 5 month old couple of days out from an ENT procedure of the upper airway Recently discharged from the PICU Mild increased upper airway obstruction at 12:30 am RN staff could not get a hold of ENT resident Parent activated PACE when they realized ward staff could not get hold of the resident Activation = walked over to the PICU and asked for PACE

am RN staff could not get a hold of ENT resident Parent activated PACE when they realized

16 Dirty laundry If you think parents and families of patients don t know where the gaps in care are, then you re kidding yourself

18 Questions Jon Gilleland PACE Medical Director Acting Medical Director, PICU McMaster Children s Hospital jgille@mcmaster.ca

Sandra L. Andreychuk RN (EC), NCC (NNP), BScN, MHSc. (Bioethics), MSc. (Nursing) Curriculum Vitae

Sandra L. Andreychuk RN (EC), NCC (NNP), BScN, MHSc. (Bioethics), MSc. (Nursing) Curriculum Vitae Contact Information 905-521-5025, Ext 43643 (work) 905-381-7043 (fax) Work E-mail: andrey@hhsc.ca Professional