Rapid response events with multiple triggers are associated with poor outcomes in children.

Objective: We describe the characteristics and outcomes of pediatric rapid response team (RRT) events within a single institution, categorized by reason for RRT activation (RRT triggers). We hypothesized that events with multiple triggers are associated with worse outcomes. Patients and Methods: Retrospective 3-year study at a high-volume tertiary academic pediatric hospital. We included all patients with index RRT events during the study period. Results: Association of patient and RRT event characteristics with outcomes including transfers to ICU, need for advanced cardiopulmonary support, ICU and hospital length of stay (LOS), and mortality were studied. We reviewed 2,267 RRT events from 2,088 patients. Most (59%) were males with a median age of 2 years and 57% had complex chronic conditions. RRT triggers were: respiratory (36%) and multiple (35%). Transfer to the ICU occurred after 1,468 events (70%). Median hospital and ICU LOS were 11 and 1 days. Need for advanced cardiopulmonary support was noted in 291 events (14%). Overall mortality was 85 (4.1%), with 61 (2.9%) of patients having cardiopulmonary arrest (CPA). Multiple RRT trigger events were associated with transfer to the ICU (559 events; OR 1.48; p < 0.001), need for advanced cardiopulmonary support (134 events; OR 1.68; p < 0.001), CPA (34 events; OR 2.36; p = 0.001), and longer ICU LOS (2 vs. 1 days; p < 0.001). All categories of triggers have lower odds of need for advanced cardiopulmonary support than multiple triggers (OR 1.73; p < 0.001). Conclusions: RRT events with multiple triggers were associated with cardiopulmonary arrest, transfer to ICU, need for cardiopulmonary support, and longer ICU LOS. Knowledge of these associations can guide clinical decisions, care planning, and resource allocation.

Longitudinal Evaluation of a Pediatric Rapid Response System with Realist Evaluation Framework.

BACKGROUND: Rapid response (RR) systems' impact on clinical outcomes is influenced by institutional social factors. This study applied the realist evaluation (context-mechanism-outcomes) framework to review significant RRs defined as REACT (Rapid Escalation After Critical Transfer) events for appraising a pediatric RR system. METHODS: REACT events included all RRs with cardiopulmonary arrest (CPA) and/or ventilation and/or hemodynamic support instituted within 24 hours after RR. A continuous quality improvement process was employed to identify, debrief, and review REACT events to recognize and act on RR mechanistic and contextual deficiencies. The aim was to decrease REACT events with mechanistic/contextual gaps categorized into crisis resource management (CRM) themes by 25% over three years while ensuring process sustainability. RESULTS: From 2015 to 2019, 5,581 RR events occurred, of which 67.2% transferred to ICU, and 1,392 (24.9%) were identified as REACTs. In the first two years, 100% identification and review within three months of 90% REACTs was accomplished. One hundred percent of the 17 providers ascertained that the process was safe and transparent, and 80.0% of respondents expressed their commitment from perceived benefit to patient care. Over five years, the proportion of REACTs with CRM gaps decreased from 62.3% to 26.5%, those with multiple deficiencies reduced from 72.5% to 23.2%, and CPAs outside ICUs decreased from 15 to 3 per year. Improvement actions included modifications to RR system (activation, process, and management), hospital (resources and policies), dedicated RR training, and sharing of positive feedback. CONCLUSION: The realist evaluation framework facilitated holistic assessment of an RR system. Review of REACTs was feasible, sustainable, and yielded useful information to guide systemwide improvement.

Redefining the Relationship: Palliative Care in Critical Perinatal and Neonatal Cardiac Patients.

Patients with perinatal and neonatal congenital heart disease (CHD) represent a unique population with higher morbidity and mortality compared to other neonatal patient groups. Despite an overall improvement in long-term survival, they often require chronic care of complex medical illnesses after hospital discharge, placing a high burden of responsibility on their families. Emerging literature reflects high levels of depression and anxiety which plague parents, starting as early as the time of prenatal diagnosis. In the current era of the global COVID-19 pandemic, the additive nature of significant stressors for both medical providers and families can have catastrophic consequences on communication and coping. Due to the high prognostic uncertainty of CHD, data suggests that early pediatric palliative care (PC) consultation may improve shared decision-making, communication, and coping, while minimizing unnecessary medical interventions. However, barriers to pediatric PC persist largely due to the perception that PC consultation is indicative of "giving up." This review serves to highlight the evolving landscape of perinatal and neonatal CHD and the need for earlier and longitudinal integration of pediatric PC in order to provide high-quality, interdisciplinary care to patients and families.

Pediatric Palliative Care in the Heart Failure, Ventricular Assist Device and Transplant Populations: Supporting Patients, Families and Their Clinical Teams.

Heart failure is a life-changing diagnosis for a child and their family. Pediatric patients with heart failure experience significant morbidity and frequent hospitalizations, and many require advanced therapies such as mechanical circulatory support and/or heart transplantation. Pediatric palliative care is an integral resource for the care of patients with heart failure along its continuum. This includes support during the grief of a new diagnosis in a child critically ill with decompensated heart failure, discussion of goals of care and the complexities of mechanical circulatory support, the pensive wait for heart transplantation, and symptom management and psychosocial support throughout the journey. In this article, we discuss the scope of pediatric palliative care in the realm of pediatric heart failure, ventricular assist device (VAD) support, and heart transplantation. We review the limited, albeit growing, literature in this field, with an added focus on difficult conversation and decision support surrounding re-transplantation, HF in young adults with congenital heart disease, the possibility of destination therapy VAD, and the grimmest decision of VAD de-activation.