Application of Realist metrics providing enhanced look at pediatric rapid response

March 30, 2022

As reported by The Joint Commission, rapid response (RR) systems provide a process for early detection and management of clinically deteriorating patients to prevent out-of-ICU cardiopulmonary arrest (CPA) and mortality.

Because evaluations of RR systems traditionally rely on CPA and mortality, rare in children, alternative pragmatic metrics for pediatric RR evaluation are needed.

A report from the April 2022 issue of The Joint Commission Journal on Quality and Patient Safety (JQPS), “Longitudinal Evaluation of a Pediatric Rapid Response System with Realist Evaluation Framework,” by Darlene E. Acorda, PhD, RN, CNE, CPNP-PC, represents part of ongoing work of a multidisciplinary team led by Aarti Bavare, MD, MPH, at Texas Children’s Hospital and Baylor College of Medicine, Houston, Texas. The team developed a new metric called REACT (Rapid Escalation After Critical Transfer) to review clinical outcomes after RR events to appraise pediatric RR systems and identify improvement opportunities.

The researchers applied the realist evaluation (context-mechanism-outcomes) framework to review significant RRs defined as REACT events, including all with 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.

From 2015 to 2019, 5,581 RR events occurred, of which 67.2% were transferred to the ICU, and 24.9% were identified as REACTs. In the first two years, 100% identification and review within three months of 90% of REACTs was accomplished. Findings showed after five years:

  • Proportion of REACTs with crisis resource management (CRM) gaps decreased from 62.3% to 26.5%
  • Proportion of REACTs with multiple deficiencies reduced from 72.5% to 23.2%
  • CPAs outside ICUs decreased from 15 to 3 per year 

The realist evaluation framework facilitated a holistic assessment of an RR system. Review of REACTs yielded useful information to guide systemwide improvement.

“With this report by Acorda and colleagues, the foundation for RRS that was proposed more than 15 years ago is finally being realized more fully,” notes an accompanying editorial by Michael DeVita, MD, FCCM, FRCP. “The quality arm, long neglected, may now bear fruit to save even more lives by preventing the events that lead to RRS activation. They [healthcare organizations] should be analyzing why the events occur and reporting reductions in the care gaps that result from analysis of RRS events (both event review and database analysis). This report explains not only how to, but why.”

The Joint Commission release