All right. Good morning, everybody. Welcome to Congress. Exciting day, the first day. We have a great session coming up, starting now on emergency response teams. And I want you guys to hold your questions until the end so that we can ask the entire panel. But our first speaker today is Jibran Majeed from Sloan Kettering. Good morning, everyone. Up to a few months ago, I was overseeing the rapid response team at Memorial Sloan Kettering Cancer Center as a clinical program manager. Most recently, I took on a new role as the advanced practice provider manager overseeing the urgent care clinics in the ambulatory sites at MSK. The APPs in those clinics also respond to the medical emergencies, which I think is pretty cool. I want to thank the organizers for the opportunity to come and speak on a topic that's very near and dear to my heart. I have no disclosures. So in this talk, we're going to try to answer the question who should lead, who should be in charge of a code by describing the various types of code teams that exist around the world, describe the factors for a successful code team, also share the experience of the critical care APP-led rapid response team at Memorial Sloan Kettering, which I was very privileged to be part of. I will be sharing some of the data and the innovative approaches of that team to medical emergencies. So as we're thinking about who should lead, who should be in charge, let's see how these teams exist in the world. Most often in literature, you'll see them as described as RT, rapid response team, or MET, medical emergency teams. They may be critical care based. They may be anesthesiology based, ED, hospitalist, or others. It may be the same team that responds to the code calls, or maybe a different team than the one that responds to the code calls. So let's take a poll. Who works in hospitals where their RRT and MET is the same team that responds to the code calls? Okay. About 50-50. How many work in hospitals where their MET and RRT is critical care based? Okay. Most of the audience. Who works in hospitals whose MET RRTs led by physicians? Could be training, attendings. Okay. Nurses. Respiratory therapist. Advanced practice providers, NPPAs. Other. And then we'll define what other is. So there is no other. Okay. So let's just look at some of the literature. This was a study done in Australia and New Zealand hospitals. There were 147 hospitals. Most of the hospitals, the RRT was critical care. Two-thirds of the hospital include a response, which was a mixed bag of physicians and nurses. The discipline, the clinicians, weren't always dedicated. But if a physician and a nurse showed up together, a physician was usually leading the rapid response team. There was another paper looking at hospitals in Denmark in which 44 hospitals participated. And 59% of those hospitals, there was a team leader identified. And as you can see in the pie chart, most of the leads were either house officers or specialist registrars. So if we were to translate that into United States, that's either training, resident, or a fellow. Now this was a study done by Dr. Bernard Smith looking at 43 hospitals, 33 of which were in UK and 10 non-UK. The hospitals that were mostly in UK were the RRTs were led by ICU nurses. Where in non-UK hospitals, which were primarily the hospitals from Australia, Denmark, Netherlands, most of those RRTs were led by either senior ICU physicians or junior ICU physicians. Now this was a paper that was recently published in 2019 looking at 103 hospitals in 30 states of the United States. And what the authors found was there was a lot of variability in team compositions, structure, and leads. If you look at the pie chart, most of the RRT leads were provided by physicians. You had training physician followed by attending physicians providing most of the leads. APPs were leading in 17% of the hospitals in that study and a nurse in 21%. They also looked at cardiac arrest team leads. And what they saw there, most of the cardiac arrest calls were led by physicians and training followed by attendings. APPs led in only 5% of the cases or the hospitals and 1% led by nurses. This was a paper that was published in 2012 in ANCC where the authors looked at NP versus intensivists in two Canadian hospitals. It was a small study. It was a descriptive study. And what they saw, they were looking at the performance of the nurse practitioner leading an RRT and comparing it to an intensivist. And it was measured by, through surveys, by the front line or the bedside nurses. And it was felt that the NPs were just as safe as intensivists. Again, it was a descriptive study, but it was interesting. Now, how about APPs in critical care and why not? The rapid response team is often an extension of critical care. And on the screen, on this slide, we have two papers, one by Dr. Kreftenberg and one by Ruth Kleinpal, where they looked at literature looking at APPs in critical care from over the years. And what those studies suggest, that there was no difference in outcome in critical care when care was provided by an APP compared to a training physician. APPs were also associated with a significant reduction in time to ICU transfers and lowered the chance of ICU readmissions. They were also associated with quality improvement and a positive financial impact. So just to summarize the literature, there's a lot of variability in team compositions and team leads, just like in this room. And there's really limited direct comparison study to really know which team lead is better. Now, back to the question, who should be in charge? Who should lead? Well, it really depends. It depends on the hospital, where the hospital is, what sort of resources does the hospital has? It depends on the three Cs. Consistency. Whatever team you decide to have, it should be a consistent team, dedicated group of providers that sort of seeing all the medical emergencies in the building. This way they can get to know the hospital. They can get to know the challenges, the workflow. And in turn, the bedside nurses can get to know them. I think it makes a difference. Critical care. Does the hospital have critical care? Can the critical care team be the RRT? Does the hospital have enough funds and resources? I mean, it makes sense. If a patient is quite sick and you can initiate critical care interventions right off the bat, it's the best thing for the patient. Cost. Does the hospital have money? What is the most cost-effective approach for that hospital? Now, let's compare these disciplines one by one. Physicians. Ideally, you want an intensivist leading the RRT. You want them at the bedside if the patient is sick and needs ICU-level care. You have the highest level of expertise. However, they're expensive. They're not always around. There's a workforce shortage. How about a training physician? Well, yeah, but there's variable expertise. And they're not a steady workforce. They rotate. How about an ICU nurse? It's cost-effective. They can lead. However, they can't always prescribe. They can't always initiate invasive procedures if patients need critical care. And most often, they may need an ICU physician on standby. That brings us to APPs. You may get the best of both worlds there. They can prescribe. They can initiate critical care interventions. Importantly, they can also bill and generate revenue for their services. They're a steady workforce that can grow with experience and time. They may or may not always need an ICU physician on standby. So now I'm going to just shift gears and talk about the RRT code experience at MSK and hopefully convince you that APPs can lead RRTs and code calls. So for those that don't know, Memorial Sloan Kettering Cancer Center is a freestanding cancer center, meaning it only takes care of patients with cancer. It has about 500 beds, 23,000 admissions per year. Because of the federal regulations, it does not have an ER. Instead, what it has is an urgent care but only for MSK patients. Patients at MSK can get quite sick, prompting RRT activations. Some of the challenging aspects when we show up to these patients' bedside is their presentations often atypical or unclear. You may not appreciate right off the bat what is going on. It's because those patients may be on these phase one trials with unknown side effects or they may be on immunomodulating therapies such as CAR T-cells, where your body's own immune system is engineered to fight the cancer. Or the clinical deterioration may be in a setting where a patient has a very complicated anatomy, either from the cancer or as a result of the surgery. You may see in their mouth they need to get intubated. You may see that tumor that's right sitting in their throat. Or you may not appreciate how the different body parts may be connected after the surgery. So you really have to learn that information at the bedside. That syncope that you get called for may be more serious than just vasovagal. While MSK takes care of many sick patients, it does not offer services like endovascular interventions for conditions such as acute MI or ischemic stroke. Therefore, we will see how the rapid response team really facilitates a timely transfer and care for these patients that need to go to these appropriate centers. So where does the rapid response team live within MSK? Well, it lives in the critical care medicine world. The critical care medicine teams are made up of two ICU teams and a consult team. The two ICU teams are one APP team and the other one is the house staff team. There's fellows and attendings on all the teams, the two ICU teams and the consult team. All the clinicians on the consult team are primarily ICU clinicians that spend majority of their time in the ICU and then rotate to the consult service. Now the consult service has a lot of responsibilities. They see new consults, they see discharge follow-ups, and they're the gatekeepers of the ICU. And there are a lot of ways to get to the ICU, but the quickest is to call the RRT. When you call the RRT, the frontline response is APP, nurse, and a respiratory therapist. These clinicians are showing up. I just want to say the role of the APP on the rapid response team is very important. They're leading the RRT calls. These are critical care providers that can initiate critical care interventions. They know how to perform a point-of-care ultrasound. They know how to place lines. If the patient is really sick and they need help, you will also be calling an ICU attending and a fellow to the bedside. So what you really have is the whole critical care team going to the bedside on a floor to provide care for a patient. Now if a code is called rather than an RRT, you have the rapid response team that goes, plus an ICU fellow just to provide support, anesthesiology so they can intubate, and the house staff. Now what makes the APPs in MSK on the rapid response team so successful? Well, one is it's a critical care-based team. It's the same team that sees all medical emergencies in the building. All the medical emergencies and the specialized algorithms, such as stroke, MI, sepsis, is streamlined through the same team. And there's also backup provided by critical care fellows and attendings at all times. Now why are they so competent and confident? Well, because of the rigorous training that they go through while in the ICU, which consists of didactic lectures, simulation training that focuses on code response, RRT response. There is also ongoing in-situ mock code training. There's also ongoing quality improvement. All code calls are reviewed. Certain RRT cases are reviewed. There's also post-code debriefing. Now let's just look at how we evolved over the last few years. In 2006, the RRT was initiated at MSK with only night coverage. In 2008, it became a joint commission mandate, and that's when critical care medicine took it over. At that time, the ICU team, the rapid response team, only had six advanced practice providers. In 2009, we started providing 24-7 coverage. In 2010, we were realizing that some of those RRT calls that we were being called to were being declined. Therefore, we eliminated the possibility of declining RRT calls. One, because we looked at those patients and we realized in 48 hours, those patients would end up in the ICU. Two, it also created an animosity sometimes between the bedside nurse who called the RRT and the primary team. In 2010, we also started sending the APPs to enhance communication training because many of our calls do deal with end-of-life and closer care discussions. In 2012, we started to streamline ACS calls. We initiated RRT case reviews. We were always responding to codes, but in 2015, we assumed the leadership, the responsibility of the leadership of leading the codes. In 2017, ICU RNs became part of the rapid response team. We began ultrasound training for the APPs on the rapid response team. We started responding to computerized sepsis alerts. In 2018, the stroke alert and behavioral emergency algorithm were launched. And most recently, in 2019, we have a night intensivist. So, we have intensivists around the clock. And we have grown from six to 34 advanced practice providers. That's because MSK as an institution has really provided the rapid response team with the resources so it can deliver the kind of care that it does. Now, let's just look at some of our data. This doesn't include 2009, but one thing you should appreciate is the number of RRT calls over the years have significantly gone up. In 2018, there was a 38% in RRT calls. And this does not even include the computerized sepsis calls. In the red line, that's represented by the number of code calls. That has also gone up. We were over 100 last year. Just to look at those code calls a little bit closer, most of them used to happen on the floors. And then over the years, we sort of shifted more in the ICU. So, it's about 60% in the ICU and 40% on the inpatient units. Now, what happens to the RRTs? As you can see by this line graph, almost a one-third of the RRT calls right from the RRT gets admitted to the ICU. You go to the patient. You look at them. You know they're sick. You know they need ICU. But those calls that we resolve, meaning we show up at the bedside, we take care of the issue, and we realize they don't need us anymore. Because one, maybe whatever the issue was resolved. Two, maybe there's no critical care need. Or three, the focus is now DNR end of life. There's been a downward trend on those calls, while an upward trend in those calls that we upgrade to ICU consult follow-up, meaning we see the patient. We know they're not that sick for the ICU yet, but they're sick enough to be followed by the ICU. So, if you can look at 2018, you can see that two-thirds of the calls needed some sort of critical care, either an admission or ongoing follow-up. We did an abstract a few years ago looking at ICU admissions that came in that were admitted either from a consult pathway versus RRT. And as you can see, those patients that came in through an RRT pathway had higher ICU mortality and hospital mortality. Well, we weren't surprised because those patients that came in through an RRT pathway were sicker. They were more likely to need vasopressors and intubation at the time of RRT or upon admission to the ICU. Now, let's just go over what sort of tools that we get trained with to help us during emergencies, during sick RRTs or during code calls. Point-of-care ultrasound. We have this enhanced diagnostic tools that we bring to all the emergencies. Many of the APPs are certified through CHEST. Leon Chen, he's in the pictures, is speaking in another room. He leads the ultrasound program with Joanna, who's also in the audience. Now, this is a picture from an actual RRT of a patient who had a cardiac tamponade. We have had a few RRTs that we saw patients that we were called for syncope and we found clots in transit and we gave TPA and they survived. So, this tool is very helpful to us. Emergency intubation. We perform a pre-intubation assessment to categorize the patients into either anatomically challenging airway or physiologically challenging airway and starting certain interventions prior to the intubation. If a patient has a tumor in their mouth, you know they're a high risk airway. But if they have a mediastinal mass or they have increased ICP, we will do different things. So, there's no physiological compromise post-intubation. End of life. Many of our cases, many of our RRTs are end of life. As we saw in the abstract, almost 35% to 40% of the RRTs died within three months. Oftentimes, we initiate goals of care discussions right at the RRT. We bring in palliative care team. We bring in social work team. We bring in primary team. Certain cases, we may be calling ethics. The APPs go through this communication skill training, which is this enhanced training. It's simulation based training for all the APPs to help improve communication, team dynamic, and help them with these end of life conversations. Metrics. We really rely on our metrics. We have an RRT dashboard where you can get minute up to the minute RRT and code data. You can compare your RRT code data for your service with another service. You can compare your RRT code data for your location with another location. Point of care testing. All of the APPs and the other RRT members are privileged and trained in point of care testing. They know how to use the blood gas analyzers. Within minutes of an RRT or a code, we can have protein in labs. I remember a case from a few years ago that we were called for this patient's very toxic, hypotensive, and we put the cardiac monitor on them. It looked like VTAC, and we were like ready to begin to defibrillate, but we were like, let's just wait. It doesn't look like VTAC. It looks like sine waves. We did see AKI in the morning labs. We gave calcium. The rhythm got narrower, but within minutes, the test, the blood gas test confirmed hyperkalemia. So just to summarize APPs, Leading Codes in Medical Emergencies, I think they can work. They're a consistent and dedicated workforce that can become highly skilled and trained. They can communicate well and orchestrate complex care. They can importantly enhance their RRT and MET program by bringing valuable expertise. So in summary, there's wide variability in compositions of code teams around the world, and there are many factors to consider in developing a successful code team, but whatever code team you want to develop really depends on your hospital, the resources, but you want to have a consistent and a dedicated team. Our experience at MSK shows that APPs can be trained to successfully lead codes and medical emergencies. Thank you. I just want to acknowledge these group of individuals who have helped shape this talk in one way or another. Thank you, everyone. Thank you, Jibran. That was amazing. As a friendly reminder, please hold all your questions till the end. If you want, write them down so you don't forget your question because we will have some time at the end to do question and answers. All right. Up next, we have Dr. Betsy Hunt, who's going to talk to us about processes to improve rapid response teams. Thank you. I really appreciate that. I appreciate the invitation, and I'll be speaking about different processes that we can think about to improve rapid response, and I had a little latitude in terms of how I interpreted that. In terms of disclosures, I want to talk about some funding that I have in terms of the NIH, American Heart, and Inspire, but also that I have some interactions with the Zoll Medical Corporation in terms of speaking, and also some patents that I have that they've licensed, none of which I'll be speaking about in this talk. In terms of objectives, they asked me to talk about two different types of procedures or protocols that we can do to improve rapid response teams, and I thought about how could we interpret that. Ultimately, I ended up going into the field that I know best, so I ended up speaking about simulation and debriefing because those are two of the areas that I have spent a lot of time on and thought that I could share my experiences. Basically, I thought that we would go down the road of saying how can we use simulation as both a training tool and a QI tool to really improve our rapid response systems. Then the second one was really how can we use clinical event debriefing in both our rapid response and cardiac arrest because, as we said, many of us have the overlapping rapid response cardiac arrest systems. Then also, I was asked to speak about this idea of team chemistry and how it changes in our rapid response events, so if you have a call to a psychiatry floor or if your event is a septic event versus a cardiac arrest event or a trauma event, an in-hospital trauma, how does that affect things? We'll be talking about each of these as we go along. First, we're going to talk about simulation as a training tool, and this is the outline that I've looked at, procedural training versus medical knowledge, communication, institutional-specific logistics, or systems integration. Thinking of procedural training, the items that I wanted to look at was thinking first of thinking of time-sensitive or high-risk, so I'll go over what I mean by that, but I also wanted to think about who needs to be trained, retraining intervals because I think that that, as I've been doing this now about 20 years, one of the things I realized is that a lot of our initiatives we put a lot of time and energy into, we get really excited about, and then it's, you know, two years later or five years later and something happens and you realize because you put all that energy into I.O. training and now they haven't been trained again in four years, and so, you know, thinking about, well, when do we need to train them again because just doing it once obviously isn't sufficient. And then one of the things that has been a recurrent theme over the past year has been this idea of where do our teams get the required equipment that they need for their training? I know that sounds like a really minor issue, but I think it'll come up a little bit later of why that's so important. And then how we use our, for instance, we call it, we used to call it our patient safety network, now we call it HEROES, but our various reporting systems to help us guide, you know, what training we should be doing. And so in terms of the who, who to train, so those of you that follow the rapid response literature may be aware that it was way back in 2010, Mike DeVita at our consensus conference, we essentially looked at how should we think about the different components of the rapid response system, and there's the afferent limb and the efferent limb, and that idea of the who's on the floor calling the team versus who's responding as the team. And so I wanted to look and think about it from that perspective, and so we're going to start with the afferent limb. And when we were speaking as a panel before we came up here, it was this idea that a lot of times when we think about training or preparing your rapid response team, we forget to think about the people that are sitting there waiting prior to the team arriving, and we don't necessarily think about what do we need to do to train them. And when you think about that, that's really sort of that first few minutes training about what are they going to do before we get there. And so when you think about that, it really comes down to the high stakes and the time sensitive components. What should they potentially be doing before we even get there? And this is a summary, and I'm going to speak about that in more detail, but really it's essentially the bagging, the defibrillation, the EpiPen, the trach change. So what are the things that, for instance, if it takes three minutes, five minutes, seven minutes for our team to get there, it would be catastrophic for the patient if they didn't do those things before we got there. And so I think that can be very helpful for you. Of course, a lot of times when we think of simulation training, I think we tend to think of these high fidelity simulations that are more the whole team interacting. But the reality of it is sometimes we really need to step back and go back to the partial task simulation training first and make sure that they know how to do the micro skill and that they are very, very facile at that micro skill first and then that they can interact as a team and do the entire component. So let's look at those. So the first one I'm going to look at is this idea of just bag mask ventilation. It's one of the most basic skills, but the reality of it is every time I do either a high fidelity sim or when I do one of my sims where one of my studies where I essentially take 70 residents or 70 respiratory therapists, if I take a cohort of non-anesthesiologists, non-intensivists through, the large majority of them are not able to manage a difficult to bag patient. And that's because we don't teach it very well or we just don't teach it. The mannequins that we have these days make it quite easy to teach someone how to bag if you cannot move the chest, but we don't actually make that a learning objective a lot of the time. And one of the ways you can think about that is, you know, how am I going to do that? So first I wanted to highlight some of the work by Walter Eppich from many years ago. This was actually in 2010, where what he did was he did a survey of pediatric residents, internal medicine residents, and emergency medicine residents. And he included anesthesia residents, but he had a low response rate for them, so he wasn't able to include that data. But the idea was giving them a patient who essentially was not ventilating well, oxygenating well. It was essentially a postictal patient they're seizing, and now they're, you know, not really protecting their airway. What would you do next? And so when preparing the gold standard answer, pretty much all anesthesiologists and intensivists had a very standard, you know, solution of what they would do as their next steps. But when you asked these various trainees what they would do, they basically would describe a series of things that were like, reposition, reposition, reposition, but all different words for that. And very rarely did they say things like, two-handed bag, oral airway, call for help, get an LMA. And so it was very clear that they don't have a clear mental model of what to do when I can't move the chest. That's not actually being taught to them as a very clear curriculum. What's interesting is that Julie Perretta, who's one of our colleagues, she did a study where she took a respiratory therapist who are actually quite skilled and brought them all into a simulated situation. You know, you're coming into a patient who is essentially deteriorating, desaturating, and watched what they did and how long it took them to do this. And they all clearly have the skills to be able to do two-handed bagging, oral airway, nasal airway, LMA placement, etc. But they didn't have the mental model of how quickly they should move to these things. And one of the great things about these higher fidelity mannequins, not the basic ones that we use for our BLS classes, but the ones where you can obstruct the airway and you can make it so the chest doesn't move. And you can say, it will not move until you do bagging, two-person airway, oral airway. And when you do those things, you will win. And I will release the valve and allow you to move the chest. So you can see what proportion of them will, in fact, go through the various steps you want to. And in doing so, you can essentially measure that it's very disappointing is what you'll find in most cases. And then, of course, if you get a very, very specific curriculum, you know, almost everybody we work with is highly intelligent and very trainable. And once you train them, they'll be amazing at it. And especially if you have them do it ultimately over and over again, they'll be like, oh, nobody ever taught me this. You know, now I know the recipe. And they'll be great at it. And it's just that we don't train them to do it. And so understanding that we want people to be able to do this, we essentially need to be able to do that. Another thing is they may not know where is the oral airway. So getting back to that question of where is the equipment. So for instance, one of the things that we talk about, a lot of times we create scripts for people. So we'll say something like, OK, I'm not able to, we have a gold standard choreography video that we create for our first three minutes of the arrest for our adults, for instance. And so when we say in the script, OK, there's no pulse, I'm starting compressions. But they also say, I'm not able to bag. Can you come over here and help me? And then if they say, I'm still not able to bag, can you get me the oral airway? It's in the top drawer of the cart. So we have that in the video so that everybody's hearing that over and over again. So they're learning that the oral airway is in the top drawer of the cart. Similarly, we have another video. I'm sorry, it's in a video as well. But we have our pharmacists have a script that they use. They have five questions that they have to ask every time they walk in the room. And they'll say, who's the leader? So, OK, you're the leader. What algorithm are you in? And they ask these questions. But one of them is, do you have working access? And if they say no, then they say, might I suggest an IO? It's in the third drawer of the cart. So that it's essentially reinforcing again and again in case anybody's like, I don't know where the IO is. The pharmacist essentially knows because it's on their badge. And they've been reinforcing this. So that's the bagging. The second one we're going to look at is defibrillation. Many moons ago, those of you that know me know my PhD thesis was measuring a series of residents and how long did it take them to start compressions? How long did it take them to defibrillate? And what we measured at that time was performance was distressing. And that having PALS was not correlated with performance. But what we did see was that people who had actually shocked before, if they'd actually defibrillated either a mannequin or a human, they were 87% faster at shocking than those who hadn't. Of course, that makes sense. If you've done something before, you're going to be faster at it. But a lot of our courses don't actually make us walk up and operate the defibrillator. You get to pass if you've run the megacode for v-fib and the other person has operated the defibrillator. And you don't actually have to press all the buttons yourself. So the problem is, is we don't make people press all the buttons, you know, charge, you know, find this. And so if we don't make them do all the steps, then they're not going to be able to do it. And then the question is, with which frequency, right? How frequently do they need to do that? Because we certainly know that that skill decays. Justin Jeffers, when he was at Lurie Children's, he took people who had graduated from medical school and then arrived as brand new interns. And he measured them on arrival and essentially was able to say a minority of them were able to pass, you know, a reasonable test on arrival that would say, are you starting compressions by the time I want you to? Are you defibrillating by the time I want you to? Meaning medical school did not prepare them. I am excited to say that all the Johns Hopkins graduates did pass that test on arrival because we make them go through BLS and ACLS and PALS type activities three times during school. And we make them do it contextually relevant and we drill them again and again to be able to meet those goals. But most schools don't do that. So we say, you cannot graduate without having done this. And then, you know, we all set our goals. Like, what is it that we want them to be able to do by the time they graduate? So what he did then was essentially mastery learning and said, you know, by the end of your orientation of your internship, you will be able to do this. So you can imagine that for your rapid response teams slash code teams, you have to decide when you're onboarding these people and they're going to be part of your team, what is it you want them to be able to do when they arrive? And then versus what is it you want the floor team to be able to do? Again, getting back to EpiPen. So we're saying to this, I'm saying EpiPen, but this can also be, of course, instead you're preparing, you're drawing up epinephrine, you're, you know, going to be administering it in the lateral thigh. What we know is that people don't do that quickly. We see a lot of errors. We see both dosing errors. We see that people, you know, do it in the wrong location in terms of the actual international guidelines. We see that people actually go to give it IV, you know, even though they're giving these high concentration doses, which is associated with arrhythmias and even cardiac arrest. And so certainly there is the belief, although we don't have clear data to be true, that EpiPens would be safer. And we know that there are fewer errors with EpiPens. And so whether it's EpiPen or whether it's drawn up Epi, what we know is that there is clearly the need to train people. We do know that people who have actually prescribed epinephrine and done training for their patients are actually more likely to answer questions correctly. And so, you know, having gone through that exercise, it shows that training is helpful. But we cannot assume that people know how to do this. And so regularly when we do SIMS, we see people that are like looking at them and they don't know what to do or they hold them wrong. They're very delayed. And we know, I'm not sure if many of you are aware of this, but if you look at autopsy results of patients who die of anaphylaxis, the subset, you know, the horrible like, oh, those who die of anaphylaxis, the mean time to death is five minutes. So if you're that group where it was like a humdinger, you need to act fast. And that's where we don't have time to be like trying to remember where it is, where it's kept, you know, how to draw it up. And so people really need to know how to do this quickly. And getting back to it being the afferent limb, the idea there would be that the reality of it is they need to administer that first dose before we arrive. We're probably going to be giving the second dose if they need to be given a second dose. And then getting back to the trach care replacement, that is the idea of an obstructed trach. So we recently had a cardiac arrest in our wards. We'd actually gone 504 days with no chest compressions on our wards, which was like, yay. And then we had, you know, a child who needed chest compressions, but it was a child who had an obstructed trach. And, you know, sometimes these things happen. But what was more upsetting was that the team had not replaced the trach by the time we got there. We were excited that they'd put the pads on and that they were doing compressions and that the child came back quickly. But this should have been absolutely in their skillset to be able to pop this out and put the trach in. And our team did arrive and very, very quickly, you know, essentially assess, you know, that yes, this was obstructed, take it out, pop it in. They had the other trach there. It was in their mental model. So why didn't they do it? And there was clearly like the angst. You know, there wasn't the confidence. And so we need to be doing something. And is it that they need to do this every year, every six months, every quarter? What was the reason that they didn't do it? There was a hospitalist there. There was a resident there. There was nursing staff there. So, you know, who is the population? Is it all of them? So we have to really think about that afferent limb. Okay, so now the efferent, that's the team that arrives. So what are we doing for them? We know our actual team. And so now this might be a little bit different. So yes, we of course are gonna train all the people on high quality BLS. But when we also think about the team that arrives, we're just needing to be exquisite at excellent, excellent CPR and of course defibrillation. In addition to the study that I spoke of on my own, there's Nancy Sullivan who's a colleague of mine for her DNP project. She did this excellent study of an in situ 15 minute curriculum where they essentially did either a two month, three month, six month or not at all refresher. So really they were just saying, hey, I'm gonna bring a mannequin to you and we're essentially gonna do a 15 minute refresher of come in, try to save the mannequin and then practice, practice, practice for 15 minutes of the dance, of the priorities, of the first three minutes. And in doing so, we were really able to show that doing every three minute refreshers was associated with this team being able to shock within 180 seconds. So that was a really important thing to show that if you don't refresh, people are not able to shock within 180 seconds. They're not able to meet the goal. They don't move quickly enough. So that's something we have to think about. Now in terms of seizure management, it's an interesting question because we don't think of it as that complicated, right? You know, it's like, okay, so you do a jaw thrust, you give some Ativan or whatever, your benzo of choices, et cetera. But what we're seeing is that different populations have different needs. So the neurologists will move on with the AEDs but really not think about protecting the airway. And then the pediatricians will be essentially looking at different things. They don't even think to give benzos. They don't think about what would be the second line agent be, but in the meantime, they're essentially getting the bag ready. So they might be thinking of the airway management. So you might have to think of a very standard training or it might need to be different for different populations. And then you're thinking about like, for instance, shock management, that's another type of category where we essentially can show very, very clearly that a lot of times people do not get the volume in that we need, get the presser started, get the oxygen started. And so simulation can be a really, really great tool to help people follow protocols. Now, this is a picture of one of our mannequins at the end of a simulation. And I like to show it just to show like, if you really get them playing and you really make them do things, I think it shows them how hard it is to do things. So here you can see, they actually had to put the IO in, they actually had to do the D-stick, they actually were giving fluid boluses. I think this shows you when they're having to be immersive, they're actually stabilizing the IO. These are the kind of sims where they learn things. I think many moons ago, we used to make it quite easy for people to do these types of things. And in fact, I don't think that they learned nearly as much because they would say, oh, the fluid boluses in and you're like, it's not that easy, you know? Or one of the things that I noticed is we would say, they'd say, what's the glucose? You know, and we would say 23. And then the whole room knew at once that the patient was hypoglycemic. For those of you that don't use our units, that's low in the world that I'm talking about. And so what would happen is they're not having to think about how to communicate that information. And so instead, I think it's important during a sim to figure out how to say it's 23. And then they have to figure out how to say it's 23 because what you'll find is that a lot of times, the person has information but doesn't get it to the leader and then it doesn't get treated or it never gets rechecked. So I recently ran a code that the child had to be treated four times before the glucose came up, some massive adrenal insufficiency or something, but it needed to be rechecked and rechecked and rechecked. So it's important during our sims that we don't just like announce it to the whole room and create a shared mental model of hypoglycemia when it's not actually that easy. So making them do all the steps is actually a really important component. Okay, so that's the procedural component of sims that sometimes we forget about these days when we only do our high-fidelity sims. Now, when we think about the medical knowledge, I want to think about how we translate our protocols that are nationally but to our local environment. We also, of course, are going to think about how frequently, of course, maybe when we onboard people, but then also, of course, the retraining that we just talked about. And I'm going to think about some of the more difficult scenarios. So now we're talking about, for instance, difficult airway. And you see here I'm talking about like stroke, elevated intracranial pressure, and massive transfusion protocols. We're not going to go through all of these, but these are some of the examples. So let's think about difficult airway. So I think each of us has a different approach to this. Some people have created very, very robust difficult airway teams, and some still have to have their own mental model of what would they do in a difficult airway, who would they call, do they have their own secret telephone number for the ENT, but that it's not actually something that's available as an institution. And so these two references are for, over the years, a system that was created at Johns Hopkins by Lynette Mark. She did a lot of work. It's called our DART, our Difficult Airway Response Team, and then the various education that we've done over the years in terms of simulation. Just thousands of people trained now in a multidisciplinary way. You know, my plan A is this, my plan B is this, my plan C is this. And in the beginning, we used to have people come and fight, you know, like, I want the airway, I want the airway. And how did we make it so that people just don't do that anymore? You know, and they're saying the anesthesiologist is going to take the first look. If he isn't able to get it, then he's going to try with the glide scope. And then if he can't get it, then ENT is going to try with the Hollinger. And if he can't get it, then we're going to try with the trach. And we have the trach tray ready. So it's bam, bam, bam, bam. We have a shared mental model. In the meantime, the intensivist is watching the vital signs. And so the whole room is very, very clear on what we're all doing. And just practicing those can be very helpful to have a shared mental model of how will we approach a difficult airway. Similarly, in terms of stroke, it can be very, very helpful if people know, yes, we're going to call a brain attack team, a BAT team, if we have those. But if you don't have them, then what's going to be a trigger for calling? So our ward teams, I think that can be very, very tricky for people that don't understand that asymmetric vital signs equals calling the team and what makes you decide to do that. And so having simulation training for that can be quite important. Now, I think the brain code is one that's even more important, potentially. So there's that idea of being able to reverse herniation. And a lot of people don't understand that you absolutely can reverse herniation. So thinking about how to make that just as protocolized. The first thing you're going to do is lift the head of the bed. And then you're going to start bagging. You're going to put entitled CO2 in. And you're going to go for an entitled CO2 of what? OK, we're going to go for 30. And if that doesn't work, so how do you protocol that? And just do it again, do it again, and make that second nature. And so they have a recipe. And they can do it beautifully. Similarly, massive transfusion protocol. So once we develop them, many of us have instituted them. I've just seen again and again, they don't go as well as people think. Because they order them, and then they don't magically appear. Or they come to the bedside, and they give all the PAX cells, but they don't give the FFP and the platelets that are in there. They give the FFP and the platelets, but they don't give calcium. And so until you sim them, they typically don't go well. And so how can we use simulation both to figure out our protocols, but actually then to roll them out really well? Now this is a picture that I love from a sim that we did, and where I say immersion is engaging. And so when you look at this picture, I want to show you a couple of things. This is a real team of ours. And a couple of the things I want to highlight who's here. So the person with the blonde ponytail, so she is a respiratory therapist. She is carrying, they all came. And what this was was a child on the floor who was bleeding, airway bleeding, and is just very, very hypotensive, and is now going to be going to the OR. She is carrying her red airway backpack. You can see the pharmacist, the person with the other backpack, that's the pharmacist with his GO team. They are going around the corner, and they are trying to get to the OR really fast. But this next one's even more fun for me. They're in the elevator, and you can see these are the real players. They came, and they are playing. So we have a surgeon that's our pediatric surgeon. We have our pharmacist. We have a PICU nurse. We have our PICU fellow. We have an anesthesia fellow, and we have a pediatric resident. There are more people, but that's who you can see in this picture. And then I'm going to show you some circles that highlight how seriously they are taking this, okay? So you can see he is carrying all the meds that he prepared with him. Because what if this patient arrests, or I need to administer meds on the way? He has the meds ready. These aren't fake. You know, I have to administer these meds. See the nurse? She's pushing volume as they're rolling, right? The fellow, she is also pushing volume, because this patient is hypotensive, and they do not want to arrest. In fact, I think she may actually have phenylephrine there. You know, so she is actually like watching the blood pressure. Now look at the anesthesia fellow. Actually, I'm sorry. Look at the pediatric resident. Her hand is on the chest. Is it moving? Is he breathing? Is he still breathing? I want to know if he's breathing, because if he's not breathing, I might have to stop and start bagging. Look at the anesthesia resident. Her hand is on the pulse. Does he still have a pulse? What the really thing is, is Betsy going to make him code, you know? But I want them to take this very, very seriously. And then the other thing is, look where their eyes are, or they're watching the monitor. They're all watching the monitor. This is for real. If you do SIMs for real, they take this seriously. This is how we roll out the Massive Transfusion Protocol SIM, right? Okay, so then SIM is a training tool. I'm going back to, they gave us this slide, community, culture, collaboration, right? But that's what it's all about, right? We're trying to create culture. We're trying to make sure that people play together. If people train together, it's hard to be a jerk to them in real life. And so if you train together, then hopefully when they come, you're going to collaborate in real life too. So here are some examples that we published in a variety of ways. But so the first one was when we would watch and teams would show up and the nurses would start talking and they would give very, very useful information, except that it's overwhelming to the person who's arriving and trying to assess the patient. And so they'd say, this is a patient who's seizing, who's so-and-so. And I'm just going to be honest, all I would hear was Charlie Brown's, you know, wah, wah, wah, wah, wah. And I'm like, oh my God, I'm trying to listen to you. But all I want to know is like, is this airway open? And so we'd realize over the years that there was this disconnect and that they were trained to speak in S-bar and I was trained to not listen to you because I have to do ABCs. And so we created what we call ABC S-bar. And once we started doing ABC S-bar, like someone walks in the room and we say, his airway's open, he has bilateral breath sounds, he has a strong pulse. Then I'm like, oh, okay, well then why did you call me? And then they'd say, but he seized and he's postictal right now. He's protecting his airway, but I'm worried about blank. Or, you know, some other version of that. He, you know, his airway's open, but he doesn't have breath sounds on the right and he has thready pulses and I'm worried he might have a tension pneumothorax. So I think we need to needle, needle it. The situation is I think we need to needle the chest. So the ABC S-bar has been very helpful in terms of a way to communicate for us. H1N1 sims, that was when we had our, it's, you know, maybe similar to our situation now with this novel coronavirus. It was basically, we had people, you know, running in and going in to see real patients who we would then find out had H1N1 and realize, ugh, we probably, during all rapid responses, should assume that they may in fact be infected. So we should probably put everybody, have everybody put gowns on. But nobody wants to put gowns on when you're getting called for a rapid response, right? Because you want to run in and put, you know, so we were like, well, let's measure how long it takes people to put on a gown and then go, you know, check a pulse and start compressions. And what we found is that by having a gatekeeper that's at the door who essentially makes you stop and like put on your gown and mask, put on your gown and mask, put on your gown and mask, they actually were more organized when they got in the room and the patient got better care. You know, so the time to compressions, time to defibrillation, time to bagging was actually better in our sims once we actually had a gatekeeper that forced them to be more compliant and they were more compliant with PPE. So that was a really interesting thing. And then for cardiac arrest, this was the idea with Kasper Lordsen recently and he's out of Aarhus, Denmark, but he's working at CHOP right now of having very standardized communication during cardiac arrest of our pauses. So it's a complimentary to our work with the CPR coach, but of saying, okay, we're about to do an intubation. So this is how we're going to continue to try to do compressions. We're not going to pause, but if we pause, this is how we are going to do the pause. So very, very standardized communication. Okay, in terms of institutional logistics, in terms of using simulation, the idea here is that, you know, sometimes you have very, very weird things going on and we need to do very specific simulations. This isn't the one that I could come to your institution and do the same one at yours as mine. It's something specific. So for instance, we just decided we're going to have our pediatric team respond to our own adult events instead of having the adult team come over just for a variety of reasons. So we needed to do some sims to train them up. But in doing that, we needed to orient them to adult protocols, to where's the stretch are going to be, to our specific cognitive aid. You might do things for your combative patients. What are your specific protocols? We recently put Narcan in all of our AED boxes on our first floor because we keep having overdoses in the bathrooms on our first floor in Baltimore. Active shooter protocols, each of ours is going to be different. What if you have a trauma in your institution? For us, we decided we would scoop and run and take them to the emergency department because we recently had done a thoracotomy on the floor and decided that that probably wasn't the right way to go. So what are your protocols? If you have EHR downtime, how are you going to plan for that? And then finally, in terms of this section is systems integration. One of the things that has been published again and again is teams who do mock codes have higher survival rates. So institutions that don't do mock codes with Get With The Guidelines actually had lower survival rates in the institution. And having one standardized member of the code teams or rapid response team is associated with higher survival. So certainly also we know that using simulation as when you're doing your mock codes, not just for training, but doing it as a probe, a system probe. So where you're doing it, I'm not just here to train you, but I'm doing it to look and see how, like, you know, for instance, we do it in the echo lab and we realize that you can't even have your oxygen reach the patient or, you know, looking to see how long did it take to get the stretcher to the patient. So diagnosing our systems. Again, for us, a lot of times we're using sim to create our standard operating procedures. So we do sims again and again and again to figure out our standardized choreography, where people are going to stand. We do a lot of, like, Grand Prix pit crew. This is where you're going to stand. This is, you know, our script. This is where you're going to do. And then we create our standard operating procedures through simulation. For those of you that know the work that I've done before with teaching rapid cycle deliberate practice, we also call it rapid cycle deliberate prototyping, where we do the sim again and again and we say, what if I stood here? What if I stood here? What is the most efficient way? And once we've got it, then we publish. This is how we're going to be doing it at our institution. Okay, and then finally, debriefing. This is the last bit. So certainly when you think of debriefing, either a cardiac arrest or a rapid response, there's two types. One is what we call hot debriefs, where you do it at that moment or, you know, within the next hour or so. And one is later, whether it be a week later or, you know, a month later. That's called cold debriefs. But ideally, you want to have a debriefing system that everybody's aware of and sort of familiar with how that's going to work. So I'm just going to talk about one. Certainly, we're aware of literature that shows that, for instance, in cardiac arrest, if you debrief with data that's associated with improved performance and survival. Donald Edelson, Heather Wolfe. So this data is coming out again and again. This is a paper that we published last year in JAMA Network that essentially showed, as a bundle, a debriefing program where what we did was we debrief every single cardiac arrest, every single week, and then what we do is we make changes, many, many changes to say, like, huh, okay, so based on that, what should we change? You know, we instituted the CPR coach. You know, we instituted standardized ergonomics. So based on that, what we were able to see was that we saw a 3.2 increase in the odds of compliance with AHA guidelines by having this entire system in place. So that was pretty exciting. So in terms of debriefing programs, you know, really, really, we want to think about metrics of success. How are we going to know if we have made a difference? So what I wanted to do to end this was to talk about, this is on our adult side at Johns Hopkins, here's something where we were failing. So the Get With The Guidelines database said that the average across the hospital, 77% of the hospitals were meeting the metric of shocking within 180 seconds for shockable rhythms. And at Hopkins, we were only 64% of the time shocking within 180 seconds. Whereas survival for that rhythm, similarly, we were below the rest of the hospitals. So 43% survival to discharge for that rhythm, and we were only 33%. Our overall survival was really good. And what this said was like, if we could work on this, you know, our survival will be really, really good. It just, you know, we were not shocking when we needed to. So this was like a really good place to focus. So what we did, we took that data, and we started doing first few minutes training. We started essentially doing those, you know, bedside training with the floor responders. So both the team and the floor responders really, really started debriefing all cardiac arrests with data. And then we got to see that over the next three years, these are our colleagues, you know, across the country. They really didn't move the needle. That wasn't, I guess, their focus. So it essentially stayed 78, 77%. And what you'll see in terms of Johns Hopkins, compliance with the guideline for shocking within 180 seconds, we went from 64 to 85 to 95%, which was really exciting, right? And if you looked over the subsequent years, we were 89 one year and 96 this year, 96% shocking within 180 minutes. 80 minutes, that would be horrible, 180 seconds. So targeting, you know, guys, we've got to do this. We've got to do this. And what did that translate to? And so this was the survival for that rhythm. Remember that our peers were 45% for that rhythm? We went from 33% up to 60% for that rhythm. So this year, our survival to discharge for adults was 36%, which is great for adults, right? That's fantastic. You know, we were 28% and most of our peers are lucky if they get to 30% for that. And so that translated to 14 more patients we discharged from Johns Hopkins every year, and most of them are neurologically intact. And so that idea of like, you know, you really focus on a metric that you're not meeting and you hit it. And so what were my objectives just to kind of summarize? Simulation as a broadly applicable tool for training and a quality improvement tool, clinical event debriefing to continuously probe for opportunities for improvement and concentrate on, you know, what metric am I trying to move the needle on? And that's what I really want to think about. And then finally, this idea of a team chemistry, and we can prepare for specific events, you know, whether it be MTP or a certain kind of team event. So thank you. I appreciate that. Thank you. Thank you very much, Dr. Hunt. That was excellent. Simulation is near and dear to my heart, so I appreciate your perspective. Next up, we have Jackie Elegant from Lori Children's, who's going to talk to us about metrics and outcomes of RRT. Thank you. Good morning, everyone. Thank you, Heather, for the introduction. I'm delighted to be here to give this talk on metrics for evaluating outcomes of rapid response teams. I have no disclosures to report. I am the nurse practitioner lead of the critical assessment review team at Lori Children's. In this talk, I plan to give an overview of the current metrics in the literature used to assess outcomes of rapid response teams, as well as elements that can impact the data. I will also discuss gaps in the literature, where there is room for improvement, and how institutions can customize rapid response teams to meet their individual needs. Finally, I will speak of the critical assessment team at Lori Children's. To start with some background, what is the purpose of a rapid response team? To bring critical care expertise to the bedside of a deteriorating patient before an arrest occurs. DeVita et al first described a rapid response system in 2006 as a whole system for providing a safety net for patients who suddenly become critically ill and have a mismatch of needs and resources. The Institute for Healthcare Improvement launched the 100,000 Lives campaign in 2005 with the goal to improve care and reduce patient harm. One of the steps included deploying a rapid response team at sign of first decline. In 2008, the Joint Commission launched the National Patient Safety Goal that required hospitals to implement systems to enable healthcare staff members to directly request additional assistance from specially trained individuals when the patient's condition appeared to be worsening. As critical care clinicians, we know it can take time to get resources to the bedside when someone is in trouble, especially outside of the ICU. A rapid response team makes clinical and logical sense. So the next question is, how to prove that rapid response teams are the answer? How well is the system working and how do you know? The International Society for Rapid Response Systems published recommendations for metrics that measure the function of rapid response teams to guide quality improvement after their third consensus conference in July of 2018. The intent was to produce metrics that permit hospitals to measure the function of their own rapid response teams through identification of areas of suboptimal performance for subsequent quality improvement processes. They have recommended different system structures, tracking escalation of care, and surveillance of specific clinical outcomes. These metrics will be incorporated into this talk. Multiple factors are at play that can influence outcomes of rapid response teams. It's especially difficult to prove universally applicable metrics. Afferent and efferent teams can function and interact differently. The afferent team, the team next to the patient providing care on the ward, they are responsible for triggering the call to the efferent team with signs of patient deterioration. A factor to consider is that it takes a while for ward staff to become confident in calling the rapid response team. The efferent limb, or the rapid response team, who responds to the call and conducts a rapid assessment and facilitates interventions to avoid clinical worsening and potentially death. We will further discuss team composition and skillset, but it is important to factor in how well does this team function and what are their capabilities? Quantitative factors that can influence outcomes include, is the system being utilized to reliably identify patients at risk before a life-threatening event occurs? In order to assess, one must compare the volume of calls coming in with the generally accepted norms. The Institute for Healthcare Improvement says hospitals need 20 to 25 calls per 1,000 patient discharges to demonstrate a decrease in overall hospital mortality. For time of day, a decreased utilization of the rapid response team at night may increase mortality of critically ill ward patients. In a study by Chirpik et al, it was described that the least number of calls was between 1 a.m. and 6.59 a.m. and 7 a.m. hour having the highest rate of in-hospital mortality. Was there a specific reason for fewer calls at night when the patients remain with the same level of acuity? This would certainly affect outcomes when looking at the effectiveness of a rapid response team. For qualitative factors, is the afferent team feeling the need to provide justification about calling? Also, what hospital resources and support are available to meet the demands of deteriorating ward patients? Finally, how do high-risk patients factor into outcomes? How do we differentiate those that come into the hospital with multiple comorbidities? Also, the longer a patient has been in the hospital equates to a higher risk of in-hospital mortality. So how does the number of hours since hospital admission to rapid response call influence these outcomes for this subgroup of patients as well as validity of outcome results for rapid response teams? When considering the success of rapid response teams, it is important to remember how the team is composed and what are each individual's skillsets. Rapid response teams are multi-professional, as Mr. Majeed already discussed. While the literature has not proven that physician-led teams equal better patient outcomes, teams who have members with critical care training and a specialized skillset to assess, intervene, and triage can lead to efficiency and faster time to life-sustaining interventions. One must remember that it takes time for rapid response team clinicians to mature as responders, especially for those whom are newer to the assessment and management of critically ill patients. What about the relationship between the rapid response team and the ward staff? Is there a formalized system for handoff in place to ensure the important information is being communicated? This dynamic warns consideration when evaluating effectiveness of rapid response teams. Lastly, there is a difference in time spent between separate teams whose sole focus is patients on the ward at risk for deterioration versus those whom are responsible for patients in other areas of the hospital. The investment in a siloed team approach is difficult to justify as there is literature lacking to prove these separate teams improve patient outcomes. Now that I have given an introduction to the variables influencing how one can measure the effectiveness of rapid response team outcomes, I will discuss the published findings regarding what the metrics are. Patient outcomes remain dismal following in-hospital cardiopulmonary arrest with an overall survival to hospital discharge estimated at around 17%. Actual reduction in mortality might be small, hard to prove over a shorter period of time if the hospital is already performing at a high level or too diluted by unpreventable deaths to make an impact on total hospital mortality. In pediatrics, traditional outcome measures are exceedingly rare given the low occurrence of cardiac or respiratory arrest in this patient population. In a study of greater than 200,000 rapid response team calls at 274 institutions, there was proof that rapid response team patients who die in the hospital have more deranged vital signs such as tachypnea, hypotension, and hypoxia, and more hours since hospital admission. Are these patients being recognized too late? Historic studies show that cardiopulmonary arrests are preceded by changes in patient vital signs for up to eight hours prior to the deteriorating event. In children, most early warning systems use expert-derived normal vital sign ranges for children. However, recent data suggests that normal distributions for heart rate and respiratory rate in well and sick hospitalized children are significantly different from published ranges. Thresholds should be reconsidered based on actual patient trends. These figures represent rates of cardiac arrest and hospital mortality in a study by Davis et al. in 2014 aimed to improve training and education regarding rapid response team concepts while achieving the outcome of decreasing non-ICU cardiopulmonary arrests. Hospital mortality was also reported. Four years of post-implementation rapid response team data was studied. Both rates of cardiopulmonary arrest and overall hospital mortality had a decrease that was statistically significant. This study included multifaceted life support training curriculum, a novel configuration while still utilizing standard metrics. An important caveat of the study is also implementation of a watcher program on individual wards where the ward charged nurses routinely rounded on at-risk patients throughout their shift. This culture change is what moves the needle in terms of outcomes. This study by Hayes et al. in 2012 looked at the Child Health Corporation of America's collective to reduce inpatient pediatric cardiopulmonary arrests. Similar to the previous study, multiple practices were implemented regarding prevention, detection, and correction of deteriorating patients on the wards. As you can see on the above graph, the change in median code rate did not change significantly or reach statistical significance. These results are predictable. As a multicenter study, each hospital was starting from a different place along the continuum of existing rapid response teams. And each hospital implemented different elements of the change package to varying degrees. Reducing codes is complicated. Depending on how effective implementation of these change packages were at individual institutions, it is possible that additional code-reducing behaviors could be extracted from individual hospitals even though the compilation of data from all hospitals looked at together in this study was not meaningful. Now to discuss some newer, more common, proximate measures that are now being validated and described in the literature to study effectiveness of rapid response teams in both adult and pediatric populations. Failure to rescue was defined by the Agency for Healthcare Research and Quality. It was originally designed to calculate hospital mortality rate among medical surgical patients with specific hospital complications. Once the complication occurred, the rapid response team could play a role in affecting outcomes for those patients. Critical deterioration events are a validated measure in pediatrics published by Bonafide et al. in 2012. These are events resulting in unplanned transfer to the ICU with noninvasive or invasive ventilation or vasopressor support initiated within 12 hours of admission. This metric is eight times more likely than the standard metric to occur in pediatrics. This matters because it has been documented in the research that there is a 13-fold increase in hospital deaths associated with critical deterioration events. Earlier recognition of shock and respiratory insufficiency with early warning systems means earlier rescue of these patients, smoother transition to the ICU, and allowing for time before life-sustaining interventions need to occur. Patient and family activated rapid response team calls come down to safety versus non-safety issues. While some calls lead to an actual necessity of a rapid response team, it has been unable to be proven that there is an overall effect on patient outcomes. More research is needed to determine how the participation of patients and families can be used in conjunction with clinician judgment for optimal patient outcomes. As we look at how to focus efforts for improvement regarding functionality and outcomes of rapid response teams, there are several areas of focus. Cultural barriers. Is there a hierarchy that must be followed? Are there punitive consequences for calling the rapid response team? The phenomenon of criticism culture, or the need to justify the activation, can equal a potential delay in care, whereas customer service-focused teams thank people for calling and don't belittle anyone for calling. The Intermountain Medical Center in Salt Lake City proved a drop in codes related to a public relations campaign to educate staff and encourage customer service. They were able to decrease their code rate from six down to two codes per month in a four-month period of time. It is also important to encourage a continued level of responsibility of ward clinicians to manage their patients, as critical care resources continue to be precious. We do not want to overutilize these, especially for hospitals whose rapid response team members have additional clinical responsibilities. Future areas of focus should consider feasibility to correctly study the metrics, an emphasis on validity, and long-term outcomes beyond hospital mortality. Afferent and efferent limb training on communication, team dynamics, and critical care skill set development should be studied in order to provide recommendations for standards. What improvements in patient care are most needed in your environment? Is your hospital catching patients too late? Then focus on the afferent limb, or consider a watcher program, or pre-rounding on ward patients at risk. Timely interventions not being accomplished? Consider additional training for rapid response team members in the form of simulation and debriefing, as Dr. Hunt discussed. In conclusion, implementation of a rapid response team is a complex clinical project. It requires intensive staff education, staff awareness, and resource allocation efforts. Those who feel passionate about changing the culture and dynamic of the wards, as well as the interaction between the wards and the ICU, is truly what is needed at any institution. There is no one-size-fits-all to measure effectiveness. The definition of metrics can vary between populations and between institutions. The differences in the standard metrics that we discussed, such as non-ICU cardiac arrest and overall hospital mortality, may be difficult to prove. But the overall beneficial effects of rapid response teams has led the American Heart Association, the Society for Critical Care Medicine, to endorse this concept. The Institute for Healthcare Improvement has also recommended rapid response teams. And the Joint Commission has a goal for some sort of emergency response team to be established in all hospitals. There remains a need for additional research to understand rapid response team effectiveness related to an expanded view of its benefits. To integrate all that you have just heard, I'd like to highlight the critical assessment team at Lurie Children's. The team is comprised of a pediatric critical care nurse practitioner or pediatric hospitalist, a pick-you-charge nurse, as well as a respiratory therapist. The team responds to all calls within 15 minutes of being paged. We service all inpatient areas, the ambulatory infusion center, the oncology day hospital, and the post-anesthesia care unit. The team leads conduct a monthly review meeting where all calls are tracked, audited, and metric trends, such as time spent, number of calls, and critical deterioration events are discussed. We have participation from several acute care floors. And we partner with the chief residents to create learning opportunities for the residents. We have a highly attended education series within the Division of Critical Care that is a case conference presented by pediatric hospitalists or a pediatric critical care nurse practitioner. We discuss interesting and provocative cases. We have also instituted regular simulation training to foster critical care knowledge and communication skills. We have implemented a formal communication tool for handoff from the ward teams to the critical assessment team to ensure no lapses in communication of important patient information occur. Our team continues to evolve. And this year, we are looking to propose a plan for a separate team, as well as development of a watcher program. Thank you, again, for this opportunity to speak on such an important topic. Thank you so much. All right. Up next is Allie Killian from Emory HealthCare to give us the pharmacist perspective. I'd like to say thank you for the invitation to speak and for the introduction. So my talk will be a little bit unique and drilled down into the pharmacist-specific role on rapid response teams. I will also use some latitude and talk about various types of code event teams, if you will, throughout the hospital as pharmacist data, as you might imagine, is sparse in some areas and a little bit healthier in some other areas. I have nothing to disclose. The objectives of my talk will be to list the types of code events that have data available in the literature on pharmacist participation, review the pharmacist's roles in various types of code events, and then discuss available data specific to the pharmacist's role in CPR teams and rapid response teams. Just a quick review for the non-pharmacists in the room, a number of pharmacy services have been associated with favorable outcomes in the literature. You can see those examples here. Different types of outcomes have been described, including reductions in adverse drug events, hospital and ICU length of stay, various infection rates and other clinical outcomes, reduction in prescribing and administration errors, and certainly cost. Most pertinent to our talk today, there's a healthy amount of literature on a variety of these outcomes with regards to CPR team response. To talk about the metric that maybe we are all most concerned about in reduced mortality, over 20 years ago now, a multivariate regression analysis was done that looked at a variety of clinical pharmacy services and found which ones were associated with reduced mortality. Specifically, the central services of clinical research and drug information, in addition to the patient-specific services of admission medication histories, and pertinent to today's talk, participation on CPR teams. Each of these was found to be associated with reduced mortality. And we'll go into the CPR team portion of this regression analysis in a little bit more detail in a few slides. So these are various types of code or emergency events that may be found within various health care systems. As has already been discussed, there may be different teams for each of these types of code events. Some of the same people may respond to various types of codes. And some medical centers may actually not have formal teams to deal with these types of codes. CPR and rapid response being probably most common, I wanted to take a quick poll of the audience and ask you if you know how many institutions where you work have a pharmacist who are required to attend cardiopulmonary resuscitation events. What about rapid response or medical emergency teams? So less, which I think you'll see is very consistent with what's available in the literature. And actually, at my own institution, I'm along with you guys in the majority. Any for sepsis teams? A few. How about anticoagulation reversal? A couple strokes? More, OK. We recently instituted a program using our pharmacy residency program. I was hoping to have some data to share with you today, but as we all know, things move more slowly than you would like sometimes. So the program's only been in place for about a month, so no data yet. But our specific program is that our PGY1 pharmacy residents respond to the code stroke pager, along with a multidisciplinary team, primarily composed of neurology specialists, and actually go to the bedside to determine whether or not TPA is going to be administered, and then actually mix TPA at the bedside. This is all obviously in a goal to reduce our door-to-needle time. And anecdotally, I can say that there are more code strokes being called than we anticipated. And as you might imagine, and we'll talk about this barriers to implementation of some of these programs, as you might imagine, there's a lot of waiting. You go when the code stroke is first called, and you're waiting to determine if the patient has a contraindication to TPA. You're waiting on imaging. And then a relatively small percentage of the time, do you actually mix and administer TPA? But I think that it's a unique program, and our residency program is actually moving to a 24-7 in-house call with the next residency class. So we really hope to be able to expand pharmacist participation on a number of these emergency events since we will have more dedicated people in-house who could potentially, we could provide those resources. We are not a trauma center, but how many of you guys have pharmacists as part of your trauma team in the ED? Yeah, relatively common. And then an MI team, dedicated MI team with a pharmacist? A few people, okay. So before we delve into some of the available literature, let's talk about, especially again for some of you who may not be familiar with the role of pharmacists in code events, let's talk about the role that the pharmacist can play. 20 years ago now, there was actually a joint task force by SECM and the American College of Clinical Pharmacy who published a position paper describing a huge variety of clinical pharmacy services and then dictating whether they thought that they should be considered fundamental services, desirable services, or optimal services. So fundamental services were examples of things like ability to answer drug information questions. Not necessarily, it could be a centralized services. And keep in mind, this was 20 years ago, to be fair. Desirable services, specific to this talk, participation in CPR events for ACLS-trained pharmacists was deemed to be a desirable activity. And then there were optimal services. Patient care rounds were also included under the desirable category. So some things that pharmacists can do actually during a code event. Probably most common and what you're familiar with is, quote, manning the code cart. So we, some of us, especially probably critical care-trained pharmacists, like to have control of the code cart, make sure it's opened if it needs to be opened and not if it doesn't, and being able to keep track of what's coming out of the code cart and what's being administered. So this may be, I actually sit there with my iPhone and the timer on my iPhone to track three minute intervals for epi, for example. And you can be a nice time tracker for the team to not kind of miss your optimal window of administration. It may involve knowing what the rhythm is and anticipating the next medication that may be needed, whether that means simply getting it out of the drawer, or you may actually have to prepare an IV medication. And then, obviously, you may anticipate the next medication needed simply by a change in condition of the patient. Obviously, making clinical recommendations regarding compliance with ACLS guidelines and other in-house protocols, making dosing and drug information recommendations, and then coordination with the inpatient pharmacy for medications that may not be available readily depending on where the code occurs. Or certainly in the post-code time period, coordination with the inpatient pharmacy to receive medications that might be necessary. So the bulk of the data, as I've already mentioned, is in CPR, regarding CPR teams. So we'll spend some time talking about some available medical literature in that category. Specific to mortality, several slides ago, you'll remember I mentioned the multivariate regression analysis that found those four pharmacy services that were associated with reduced mortality. And this analysis was conducted utilizing a database from Medicare mortality rates from the Health Care Financing Administration. They then paired that database with the National Clinical Pharmacy Services Database from 1992. So again, some older data. It included over 1,000 hospitals and the evaluation of 14 different clinical pharmacy services. The authors did a simple regression model in which they found 12 of those 14 clinical pharmacy services were associated with reduced mortality. They then did a multivariate regression analysis where they found those four that I mentioned previously were associated with reduced mortality. And this multivariate regression analysis was adjusted for several severity of illness parameters, specifically ICU days to total inpatient days, ED visits to average daily census, and then Medicaid discharges to total discharges. The authors went through each of the services that were associated with reduced mortality and tried to hypothesize why that service may have been associated with reduced mortality. Related to the CPR teams, they found that potentially it is actually the pharmacist promoting better drug therapy during the CPR event and resulting in better outcomes. It may be a marker of a medical staff that's more open to pharmacist input on drug therapy in critical care settings. Specifically they found a reduction in over 5,000 deaths per year in the 282 hospitals that provided pharmacist services on CPR teams. This worked out to about 18 deaths saved per hospital per year. The authors went on to say if you extrapolated these numbers to all 37 or so hospitals that were in the potential study pool, it would result in over 67,000 fewer deaths. Four years prior to this paper, the same authors actually looked at some cost parameters and found that the median yearly pharmacist salary cost per hospital for a pharmacist participating on the CPR team was about $600 or $8 per patient receiving CPR. Again, these numbers are from 1995. We've all gotten a little bit more expensive since then, but I think that we can all agree that this is a relatively minor cost if you have a significant savings with regards to mortality. So let's change gears a little bit and talk not about mortality, but talk about compliance with ACLS guidelines with the presumption that better compliance with guidelines will result in better outcomes. This particular retrospective analysis of 74 consecutive in-hospital arrests was completed at a 350-bed community hospital. It should be noted that at this particular institution, ACLS training was not mandatory for pharmacists, but about 90% of the codes were led by an ACLS-certified critical care physician. Per hospital policy at the time of this study, pharmacists were supposed to attend code events in the hospital. You can see here that it was only about a third of resuscitations where a pharmacist was present. Given the retrospective nature of the study, the authors could not determine what the barriers or reasons for the pharmacist not being present were, but I found that to be interesting and hopefully not the norm. There was noncompliance found in over half of resuscitations, and this could have been one measure of noncompliance. This could have been multiple measures of noncompliance. They then looked at 650 individual interventions that were documented and found that about 10% of those interventions could be categorized as noncompliant. They categorized the noncompliant interventions into four groups, errors in dose, which could have been incorrect defib energy or an incorrect drug dose, a delay in the intervention, an omission of an indicated treatment, or a derivation from a treatment guideline. The study found that compliance was significantly more likely when a pharmacist was present, 59% compliance versus 32% compliance, which was statistically significant. About twice as many noncompliant interventions occurred when the pharmacist was not present. A second study looking at compliance with ACLS guidelines was completed in an emergency department that had a pharmacist present on certain shifts but not others. Specifically, they had a pharmacy resident to provide clinical coverage during evening shifts Monday through Friday. So that was their pharmacist group, and then the other shifts did not have a pharmacist present, had an off-site pharmacist, if you will. There were 71 total events, 21 with the pharmacist versus 51 without, and this was over a six-month time period. They found an increase in the percentage of medications administered that was in compliance with ACLS guidelines that was statistically significant, 78% versus 67%. They also found an increase in compliance for the composite putting both medications and appropriate defibrillations together, 76% versus 65%. And interestingly, they found an increase in survival to hospital admission. They did not find an increase in survival to hospital discharge. This study also looked at cost avoidance as that is a metric that is often used to justify pharmacist services outside of normal clinical responsibilities or normal distributive responsibilities. And by placing a pharmacy resident who, again, is less expensive than a pharmacist, but by placing them in the emergency room on certain shifts, they actually found about a 300,000 cost avoidance per year. And this was both as it related to code events and ACLS guidelines in addition to other clinical interventions that that pharmacist documented during the study period. This paper I found to be really unique. It was looking at a unique role of the pharmacist as the documenter. So this was completed at about a 1,500-bed tertiary care academic medical center. And they identified that documentation of the recessive activities was an area for quality improvement. So part of the effort to improve documentation was to include a pharmacist during cardiac arrest events, which was not consistently done prior to this program. They integrated pharmacists into the unique role of actually documenting what happened during the code and also a pharmacotherapy consultant. So very different than your, quote, manning-the-code-cart role that you might typically see. They found that the percentage, I should say it was a before and after study designed over a two-year period, 80 events, 26 events before the pharmacist was involved and 54 events after the pharmacist was involved. They found that the percentage of forms with all documentation components complete, they did not comment on accuracy, but complete, increased from 0% at baseline to 28%. So a significant increase, although probably not the number they were shooting for, but it was statistically significant. They also found that they looked at ACLS guideline compliance as well and found that that increased significantly from 8% to 31%. As a result of the program, the hospital was actually able to do a number of things. They were able to extend pharmacist coverage hours as far as response to CPR teams and participation as the documenter. They were able to expand to the other hospitals within their system. And they also incorporated pharmacist trainees into the program without requiring additional funding of pharmacist resources. So something similar to utilizing your pharmacy residents who are maybe already in-house, if you have an in-house on-call program, for example, allowing them to maybe respond to off-shift events where there are less people around to respond and resources may be more limited. So that was some of the most significant available data, I should say, on CPR teams. So let's shift a little bit and talk specifically about rapid response teams or medical emergency teams. A 2009 survey, so 10-plus years ago or so, found that 16% of US hospitals reported pharmacist participation on rapid response teams. And just a very rough estimate of the hand raising earlier, I would say the number in this room is probably a little higher than 16%, but certainly always room for improvement. And as you might imagine, data regarding pharmacist participation is really lacking. I was able to find two descriptive studies and one pre- and post-intervention study. I won't go into a lot of detail about the descriptive studies, but the two descriptive studies did have the pharmacist responding fill out forms that tracked things like what interventions they made, what medications the patients received, any questions they were asked, whether those recommendations or interventions made by the pharmacist were accepted or not, and then time spent actually going to the event. The majority of patients did receive some medication, and it was noted in both descriptive studies that they felt one of the biggest roles the pharmacist could provide was facilitation of faster medication turnaround time. And then the time commitment was interesting. One study found about an average 15-minute time commitment, and the other study found about a 21-minute time commitment. So not super significant, especially if it facilitates, you know, improvement in outcomes or medication administration time. We'll go into a little bit more detail about the pre- and post-intervention study now. This was a retrospective study at a 550-bed level one trauma and academic medical center. At the time, pharmacists responded 24-7 to cardiac arrest, but were not a part of the rapid response team. They evaluated 234 events before the pharmacist was involved and 157 events after the pharmacist became involved on the rapid response team. Their primary outcome was time to medication administration, and they found the median time was lower in the post-intervention group, so the group that actually had the pharmacist responding, by about half as much time, 32 minutes versus 64 minutes, which was significant. We also found a higher percentage of cases where medication administration meant their goal turnaround time of less than 30 minutes, again, by a little bit more than half, 54% of the time with the pharmacist present versus 22% of the time without. The authors looked at a number of other secondary outcomes, none of which were found to be statistically significant, but they include the most frequently used medications, which were hydralazine and amiodarone, actually, readmissions to the ICU within 48 hours, the number of events that resulted in an ICU admission, hospital length of stay, and survival to hospital discharge. So in conclusion, pharmacists can play a variety of roles in emergency events, and the benefits of pharmacist participation on CPR teams has been well-documented and is relatively widespread, I think that we can say, certainly in academic medical centers and in smaller hospitals as well. But both participation as well as data available in the literature regarding pharmacist participation on rapid response teams and some of those other code-type event teams that I mentioned earlier are lacking. So all of you who have pharmacists responding to the non-CPR teams, I would say, make it a residency project if you have a residency program and collect data from a, you know, before and after study would be relatively straightforward to do using some of these similar outcomes that the other studies used. That's all I have for today. Thank you very much for your attention. All right, thank you, Allie. We have about 20 minutes for questions, so I'm going to go ahead and open up the floor to the mics, or you can, if you have a louder voice, stand in your place. Yes, go ahead. you can replace it, or it's even a call-out. So, one thing that we look at tracking is repeat number of calls and how many of those repeat number of calls require admission to the intensive care unit. I think that's been really helpful, especially when we're doing our monthly reviews with on the acute care floors, and they can review what was maybe not being addressed, especially that we've now rolled out a formal handoff communication tool. So that's been, I think, a really great metric to track. And then also to partner with leadership on various regards in terms of nursing, respiratory, and the residency program to be able to do specific education in the areas where it's needed on their individual floors. Something that we're looking at at Lurie Children's is not only a watcher program to earlier identify patients on the wards who are at risk, but also to further look at how we can collaborate and make a culture of partnership at the hospital so that when a rapid response team call is happening, the team is familiar with the players, especially when it comes to the floor leadership and the charge nurses. They're comfortable with asking us questions. So we have a two-way partnership that is successful and very open and collaborative. It's not punitive at all. I'm curious. I can understand, obviously, having done this for about 17 years now, the shifts. And I think sometimes we're like, oh, now they're calling us for everything. But yet, then there will be people who are saying, oh, they're uncomfortable. But yet, if they're uncomfortable, the reality is I want them to call. And so I think one of the things is, as you said, so what's the metric? And a lot of times, unfortunately, I don't know that there is truly a metric, although we're exploring that, right? So one of the metrics will be, well, what proportion of them were transferred? And if it went from 80% down to 10%, obviously, that would be a dramatic shift and concerning. If it went from 80 to 50, they say typically at least 50 should stay on the floor. And you kind of have to see where are you. If you're saying, I literally can't take care of my patients because I'm on the floor all the time now, that would be concerning. And I think what's going to be hard is there's probably no number that will equate to knowing if it's right or wrong. And one of the probably more important things is going to be truly assuming that they're it's kind of like the stance that we use in defibrillation, where I assume that they had good intentions, that they're well-trained people, that we're calling for a good reason. And so come from that place and come down, assess the patient. If the patient seems appropriate to stay on the floor, then sort of be asking, so help me understand why you called so that I can try to figure that out. And if we start to see that they called you for a good reason, but they hadn't called their own team first. And that's the trend. They hadn't called their own team first. Then you're like, 10 out of 10 times, they haven't been calling their own team first. I'm still going to come. I'm going to assess the patient. I'm going to make sure they're safe. But we're going to work on making sure they call their own team first. So that's maybe one thing. And maybe we find out that they're not calling their own team first because they're being jerks, or they're stuck in the OR and they haven't learned how to ask the nurse to take the call while they're in the OR, or something like that. So there might be a target there. The second thing might be that they literally are unable to assess if they're critically ill or not. So what's the reason? And so I suspect it won't be a metric. But with curiosity for why they called, you might find the thing that then you can target that gets you back in balance. Thank you. Sure. Go ahead. And one of the... So, nurses have a very soft language. They have expressed concern about patients. The physicians have a very. Yeah, I think that's a great example, I'll respond and then hear if others have something to add. So one of the things we call that hint and hope, where they're saying, I noticed this thing, but they're not saying, he's tachycardic and he's, for instance, we had one where I would stand at the foot of the bed during a sim, and I would say, wow, that heart rate's really fast. Why don't we go ahead and give Tylenol, why don't we do a culture, why don't we do this and why don't we do that? And then the nurses would actually say to me, why don't we get a 12 lead? Should I get some Adenosine ready? And they wouldn't say to me, I think this is SBT, et cetera. And it was fascinating, right? And I would just go, I would purposefully, blindly, no, I'm not going to receive it until they actually say the words. And I, unfortunately, have had the opportunity to debrief a number of real cardiac arrests where someone was in the room who said things like, is this patient DNR? Is this patient a full code? When they met was, I don't understand why we're not doing compressions for this patient, where it was a patient in V-fib that they were all doing 12 leads on and pushing Epi and pushing Amio, but not doing chest compressions. And the team had just sort of like, you know, missed the boat on doing chest compressions. And the person knew, like, I totally don't get why we're not doing chest compressions, but wasn't saying it. Classic hint and hope. So what's interesting when you're teaching someone, you know, I use the example of, you know, so the co-pilot can always literally take over the plane so that you don't run into the mountain. And yet they don't, because they believe the pilot knows more than they do. They somehow, there's this human instinct that somehow they know more. And so they'll hint and hope, but it just doesn't work. And sometimes they'll say, well, I don't want to say it in front of the family. I don't want to make them feel bad. Or, you know, and so it's a huge human instinct to either they want to protect themselves or they want to protect, you know, the family, you know, not having heard that. So it's something, as you said, you literally have to train them. And so that's where the CUS model comes in. You know, I'm concerned, this seems unsafe. And, you know, so I'm concerned. I think that this is, you know, I believe that this is SVT. I don't see P waves. I think we should, you know, consider cardioverting, you know, like that they have to be specific. And they'll be like, really? But what if I'm wrong? So what if you're wrong? So play it out and do the worst case scenario. And then they realize it's not going to hurt anybody, you know, you could save a life. And then ultimately they, that's a good point. It's okay, you know. So we do train them on the very specific language and work through the what is the worst case scenario and help them realize that they can handle the worst case scenario. I literally just did a scenario this past week where someone wouldn't speak up about poor compressions because they didn't want to have the family, you know, hear them saying, you know, that the team was bad. And then I said, okay, so then we don't. And then the patient doesn't wake up at the end. And she's like, oh. I'm like, or maybe worse. They live with a trach and a G-tube. She's like, oh. And she hadn't played it all out. And when we played it all out, then she was like, okay, I said, so now let's learn the language of how to speak out. You know, I see you working really hard with those chest compressions, okay, but we need to hit two inches. So you know, now, you know, I need you to straighten your arms. Like, you know, so what words do we need to do to not accept mediocrity? I just do not accept mediocrity. So how am I going to help you, you know, get there? Easier said than done. I'm not aware of any specific data. Certainly there's data utilizing pharmacy technicians in kind of nontraditional roles to allow, to free up time for pharmacists to provide more clinical services in general. So I would think that that would probably be the focus of where you may kind of focus your efforts, if you will, and really being, of course, you have to have the structure to support the education, mandating that your pharmacy technicians are certified in certain areas, that they've obviously had certain training to allow them to really take more of the distributive functions away from the pharmacists, which then would free up pharmacists' time and resources to not only do day-to-day clinical activities, more rounding, being more visible on the floors to facilitate interactions with various medical teams. But certainly I would think that freeing up resources to participate in some of these code teams would be, could be a goal of that strategy. I'm not aware of any specific data, but I think you could put that hand-in-hand with trying to increase time available for clinical services. Our pharmacists don't routinely attend the emergent intubations, however, those are called overhead, and during certain time periods of the day where anesthesia may be more scattered throughout the hospital and not have as direct access to medications that might be needed, we do have pharmacists who actually come with a resuscitation bag that includes medications. But it's really focused on ensuring that the anesthesiologist will have what they need and it's focused on certain shifts where resources may be more limited. I just want to add, at Memorial Sloan Kettering Cancer Center in the ICU, we do have pharmacists that come for the intubations. But from an RRT perspective, I think it's just not looking at pharmacy or thinking about the pharmacy role in terms of, all right, help us figure out what drugs to give or how to give it, but also sort of engaging them into the patient care. Like I can remember from many RRTs where I'm thinking, I need the expertise of the pharmacists to help me figure out, this clinical presentation right now, is this related to this medication or that medication? Why are these tonic-clonic jerks happening? It's sort of that expertise. It's like there's a lot of, there's not just, obviously if a patient needs, there's a cardiac arrest and you need to give medications. But I think there is also a handful of scenarios where you actually, their expertise at the bedside can help you figure out what may be going on with the patient. Yeah, or even how fast can something be given safely in certain situations. So at Hopkins for the adult team, if a patient is going to be intubated in a non-ICU setting, then a code is called, which means that there would be a pharmacist versus in an ICU setting they would not. And then the DART, so the difficult airway team, they have the pharmacist on that as well. And then for the pediatric team, we only have one team, so the RRT and the code are the same and we always have a pharmacist. Do they bring meds? Yeah, so we have a pharmacy goad bag, which I love. It's one of my favorite things that we ever created. And the reason for that is so that when we arrive, so for instance, if a family drives up to the circle, my theory is they now think they're safe. But the reality of it is while we have what we call the blue box, which is our pediatric box, the black box is the adult box, we have the meds, et cetera, essentially available. But the reality is someone's now dying in front of you and you're going for a blue box. We have, of course, no controlled substances in there, no refrigerated substances in there. And of course, it's hard to draw up epi that fast. And so we have an epi pen in case they're obviously having anaphylaxis, or frankly, if they're coding, then we can give an IM dose of epi. We have our controlled substances that we would be able to give. So we have, for instance, intubated patients that are having laryngospasm right on the front desk of a, you know, essentially, you know, admission table, you know, right there. We have things for seizures, intubation, for cardiac arrest, for status that would be the things that are not going to be, you know, in the blue, you know, cardiac arrest box. Thank you. I think we have time for one more. Go ahead. My name's April, and I'm a nurse practitioner. And I really appreciated all of your presentations today. And so it does seem like in an ideal world, we would have all of the right people there at the bedside on the rapid response teams. And then you would have a highly reliable team consistently responding to all the codes and rapid responses. So is there any work underway from IHI or others to challenge like they did back in, you know, when we first initiated or launched rapid response teams? Is there any work underway now to challenge hospitals to have these types of teams across the board? Because what we see is inconsistency across organizations. Some have dedicated teams. Some don't. Some cobble together, you know, whoever's available. And so there's no consistency when we see there's obvious very effective and powerful patient outcomes as a result of teams like you all have demonstrated today. I think the consensus statement and the consensus guidelines that came out of the international conference from the rapid response system, that is gaining momentum. And I think having published guidelines about what is essential for a hospital to have, what is recommended for a hospital to have in that table that I had on my slide, I think that is a powerful tool now that it's published for hospitals to be able to go back to their home institutions and saying this is an internationally published guideline and they're saying this is essential that we have that. So I would encourage you to look through that article. I think it's very helpful. And even for my own individual practice and how my team is evolving and changing and asking for additional resources, I think having more consensus statements and the gaining force of that society has been really helpful for this initiative. Great. Thank you. So we are out of time. I do want to encourage you all to continue the conversation. Our panelists will be available outside of the hallway for just a little bit briefly. So thank you all to our esteemed panelists today.

emergency response teams

healthcare settings

team leadership

dedicated team

critical care expertise

funding

simulation training

procedural training

communication training

difficult airways

stroke scenarios

debriefing

pharmacists

code events

reduced mortality rates