Hundreds of rapid responses happen in each of our hospitals each year, yet our heart rate rises each time the call goes out. This physiologic response is unavoidable, even desirable, as every patient and event are uniquely different. This heightened alertness focuses our attention to important and potentially overlooked details while injecting a clarity of purpose to our actions. Unfortunately, this fight-or-flight response can arise not just as a reaction to clinical uncertainty but also in anticipation of what is known, namely a feeling of anxiety or fear arising out of prior negative experiences with dysfunctional processes and team dynamics. These feelings can sometimes distract us from the necessary focus needed to provide safe, timely, and effective care. The interplay of these variables is what makes quality improvement around rapid response teams (RRT) a difficult endeavor but also vitally important.
In this month’s issue of Hospital Pediatrics, Phelps et al. authored “Optimizing Pediatric Rapid Response Teams: Stakeholder Focus Groups” and report the results of a single-center qualitative study to better understand RRT stakeholder experiences and perspectives (10.1542/hpeds.2023-007468). The motivation for this work came after initial data identified a perceived lack of interpersonal respect amongst RRT members and desire for ongoing education. Separate focus groups with 4 distinct stakeholders (floor nurses, pediatric residents, pediatric hospitalists, and PICU nurses and fellows) revealed a shared mental model of the general RRT stages (trigger, team arrival and information sharing, intervention, and disposition/follow-up). Deductive coding was then used to identify 10 potential solutions for improving RRT processes grouped into 3 major themes: 1) standardizing RRT workflow, 2) promoting a safety culture, and 3) ongoing RRT education. The absence of patient and family perspectives is a notable limitation of the study, as are concerns regarding generalizability from a single center and how these findings will be operationalized to ultimately improve patient outcomes.
The findings from this study provide an important foundation and general set of directions to improve RRT processes at the authors’ institution. However, it is also true that change is easier said than done. Who should be the designated leader? Does everyone convene inside or outside the room? Do you wait for everyone to arrive or start interventions immediately? How do you reliably create a supportive environment during the stress? How is conflict handled?
While there was broad agreement amongst stakeholder groups for most items, there were also areas of unresolved tension regarding a) when to trigger the RRT as some individuals expressed feeling threatened or dismissed by these decisions, b) whether the floor or PICU teams should lead the RRT, and c) how to resolve disagreements regarding patient disposition. Thinking back to my (KB) own experiences with RRTs as a med-peds resident and pediatric hospital medicine fellow, I was struck by a disconcerting sense of familiarity as I (and I suspect many of us) have experienced similar challenges. This reinforces that none of us are alone in struggling to develop better processes and we should not shy away from the difficult conversations in our pursuit of improved care for hospitalized children.
Quality improvement efforts around RRTs are unlikely to completely prevent a flight-or-fight response when the call goes out, but engaging with stakeholders to standardize processes while establishing a just safety culture will ensure our focus remains centered on the patient. While limited in scope and generalizability, this study group’s openness and vulnerability provide important insights for future discussions to improve patient safety during pediatric RRTs—these not-so-infrequent and often challenging moments that will continue elevating our heart rates as we strive to provide optimal, team-based care.
