A Quality Improvement Project to Improve the Utilization of an Intraoperative Rapid Response System

Abstract

Introduction: Rapid response teams (RRTs) improve morbidity by reducing the incidence of cardiac arrests. Although providers commonly activate RRTs on acute care wards, they are infrequently used perioperatively. At our institution, two intraoperative calls for help exist: staff assists (SAs) and code blues (CBs). The SA functions analogously to an RRT, and the CB indicates cardiopulmonary arrest. Given the success of RRTs, this project aimed to increase the use of the SA system. Our primary goal was to increase the ratio of SA to CB alerts by 50% within 6 months.

Methods: A quality improvement team led this project at an academic pediatric hospital in Northern California. The team analyzed the current state and identified an achievable goal. After developing key drivers, they implemented monthly simulations to teach providers the signs of clinical deterioration and to practice activating the SA system. In addition to measuring the ratio of SA to CB alerts, the team surveyed the etiologies of SA and measured process satisfaction.

Results: Before the introduction of this initiative, the ratio of SA to CB alerts were 1:13.3. These improvements efforts led to an increase of SA to CB alerts to 1.5:1 (P = 0.0003). Twenty-three anesthesiologists provided etiologies for SA, reporting laryngospasm as the most common reason (30.4%). Nineteen nurses completed the SA survey and reported high satisfaction.

Conclusion: This project successfully increased the utilization of a rapid response protocol in a pediatric perioperative setting using improvement methodologies and a simulation-based educational program.

Fig. 1.

Key driver diagram. A multidisciplinary team used QI methodology to perform a current state analysis and identify key drivers. Key drivers were used to create a series of interventions to increase the ratio of SAs to CB alerts by 50% within 6 months.

Fig. 2.

SA to CB activation ratio per monthly case volume. A statistical process control chart X bar chart was used to display the ratio of SA to CB alerts per monthly case volume. Process mean lines, representing average pre and postintervention ratios along with three SD CLs were displayed. Before the project, the SA-to-CB ratio was 1:13.3. After the team completed the interventions, the SA-to-CB ratio averaged 1.5:1.

Fig. 3.

Run chart of staff assist activations. A run chart was used to display the number of monthly SA system activations. Process mean lines representing pre and post interventions were displayed. A monthly average incidence of 0.18 SA alerts before the interventions increased to 3.18 after the interventions.

Fig. 4.

SA alert etiologies. Twenty-three staff anesthesiologists completed a survey to determine the reasons for SA activation. A Pareto chart was used to display the frequency and etiology of the various SAs.

Fig. 5.

Nurse satisfaction of SA alert process. Nineteen nurses completed the SA process survey and a bar graph was used to display the level of satisfaction for various aspects of the process.