Aim Our Trust, a tertiary centre, aims to eliminate predictable cardio-respiratory arrests (CRA) outside of intensive care by the end of 2013. Although CRA in hospitalised children is rare, the majority are preventable (Tibballs et al 2005). Local incident reports highlighted areas of concern such as poor documentation and incomplete monitoring. Review processes are lengthy and focus on errors rather than areas for improvement. The aim was to develop a new approach to rapidly review all CRA’s and share lessons with the relevant teams.
Method Experienced clinicians, safety experts and risk managers used a Plan-Do-Study-Act (PDSA) approach to develop RECALL:
PDSA cycles: detailed study of recent CRA’s by team to identify key areas to structure review tool
tested key areas for completeness, ease of use and relevance
key areas refined and tested again
categories identified for review: Assessment, Escalation, Clinical reviews, Interventions
tested proforma of questions to guide quick but systematic analysis of medical/nursing notes
Using care-bundle approach, five ‘must do’s’ identified for each category
A traffic-light approach was applied to each category to communicate findings: Green (no areas for improvement), Amber (areas for improvement identified but unlikely to have prevented CRA) or Red (areas for improvement identified which may have prevented CRA). The RECALL tool was then tested prospectively over 8 weeks.
Results RECALL is now used to review all CRA at weekly meetings, each case taking 30minutes. Lessons for learning are disseminated weekly to the medical director, safety team and local safety leads (discussed at monthly board meetings). Changes are implemented locally with trustwide learning incorporated into improvement goals. The project has moved towards local team review with dissemination trustwide. Early results are promising with a reduced number of CRA (fig 1) and increased staff engagement.
Conclusion RECALL has facilitated a culture of learning so clinical teams understand how to improve recognition/escalation of seriously ill children. Common themes include completeness of observations and timeliness of interventions. A simple rapid assessment tool can provide timely and useful data that can be used to drive improvement.