Abstract
Compared with adult-focused systems, paediatric rapid response systems face slightly different challenges. Detecting early signs of clinical deterioration is more challenging given the widely varying normal ranges of vital signs in children from infancy to late adolescence. In addition, cardiac arrest and death are far less common in hospitalized children than in adults, which is a good thing, but makes identifying meaningful outcome metrics of rapid response system performance more complicated. In this chapter, we describe the distinguishing features of paediatric rapid response systems, with a special focus on the recognition of clinical deterioration on general inpatient units and selection of outcomes following rapid response system implementation.
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Keywords
- Business
- Plan
- Canvas
- Cost
- Cost-effective
- Crisis resource management
- Deflator
- Diffusion curve
- Economics
- Electronic medical record
- Entrepreneur
- Executive
- Financial analysis
- Governance
- Learning curve
- Legal
- Marketing
- Model
- Mortality
- Non-technical skills
- Outreach
- QALY
- Rapid response team
- Risk
- Simulation
- Standards
- Telemetry
- Track and trigger
- Training
- Value
Why Write a Business Plan?
Rapid Response Systems have been introduced widely. How often without writing a business plan? Historically, this may have led to slow adoption. Turf wars may have been avoided by better marketing of the concept to sceptical clinicians and hospital executives . The consequences today may be underfunding, neglect of essential elements, and a poor appreciation of financial and clinical risks.
Writing a Business Plan allows better definition of the innovation and associated opportunity costs. While many health services are not-for-profit organisations and are therefore primarily motivated by service delivery to patients, they are equally “not-for-loss” and must remain financially viable to deliver their mission. Constructing a Business Case is an important step to secure funding for the service in a competitive environment.
An operational plan is essential to avoid constant “fire-fighting”. Foresight at the planning stage may save a lot of time later. Implementation of a new service requires ready solutions to such issues as communication pathways and supporting information technology, way-finding within facilities, handling concurrent emergencies, and coverage of specialized areas such as the Radiology Department and Post-anaesthesia Care Unit.
Risk needs to be managed. This issue falls within the Governance “limb” of the Rapid Response System. It includes a consideration of medico-legal indemnity, clinical credentialing of practitioners, and governing policies. Data will need to be collected for audit and Quality Assurance purposes.
Finally, the marketing plan is crucial, not only in “selling” the benefits of a Rapid Response System to hospital administrators, but also in approaching the diffusion strategy. Adoption of a seemingly radical new innovation throughout a conservative healthcare organisation requires advocacy, education and persistence.
The Business Model Canvas
A Business Model Canvas is useful to display the outline of the plan in a semi-graphical format all on one page ( [1]) (Refer Fig. 12.1). This allows capture of important elements and relationships in a way that is visually easy to understand and convey to others. This step facilitates brainstorming and can be helpful in testing the viability of the service plan.
Key partners in a Rapid Response System include ward-based clinicians, critical care units (ICU, CCU, ED), specialties such as anaesthesia, hospital administration and of course the patient and his or her family. Patient-centred care demands that the plan is designed around the needs of the deteriorating patient as distinct from the convenience of clinicians. At this stage, it is imperative to describe how the patient and family members can directly activate the afferent limb and achieve an escalation in care.
Will the Track and Trigger System be based on a weighted score or single variable threshold? To what extent will clinicians be empowered to raise concerns independent of the Track and Trigger System? How will emerging technology in vital signs telemetry [2, 3, 4] be incorporated to enhance the sensitivity and specificity of the afferent limb?
What will the attending team actually do—will they assess and triage or undertake more complex and prolonged resuscitation? What are the implications, particularly in terms of resources? The decision may depend upon availability of ICU beds, proximity of the patient to ICU or CCU, distances encountered in retrieving patients from remote locations within the hospital complex, response times and the expertise of the clinicians responding.
Relationships are important to capture especially with strategic customers such as the admitting medical or surgical specialists. Rapid Response Systems operate on behalf of the treating specialist or home unit. They also operate on behalf of the hospital that shares a duty of care to the patient. It is imperative that all stakeholders caring for the patient share in open communication and are made aware by the Rapid Response System that a patient is in fact deteriorating. They must have confidence that the patient is receiving satisfactory attention.
Are we going to provide a comprehensive service to all patients or will we fragment the service to provide specialised responses according to case-mix? There may be merit in differentiating the afferent and efferent limbs to respond specifically to obstetric patients, paediatric patients, and surgical and medical patients.
Capturing all the costs including those pertaining to education and data collection is essential. What expertise and clinical resources do we already have at our disposal? What additional training will be required and how will the investment in education be retained given the reality of an itinerant medical and nursing workforce in many hospitals? How will the Rapid Response System be funded—fee for service, block funding under Activity Based Funding [5], Bundled Payments for Care Improvement [6] or a levy imposed on clinical units? The answer will largely depend on the public and private models of remuneration dictated by State and Federal jurisdictions.
Once the Canvas is complete it is worthwhile garnering broad feedback from all stakeholders. At this stage “critics” are your allies in determining weaknesses of the proposed system and may help in planning a better, more sustainable service .
Gap Analysis
When approaching this task a useful starting point is a Gap Analysis between the realities of what we have and compliance with the National Standards [7, 8, 9] or Guidelines [10] and Best Practice as described in the literature [11].
The traditional emphasis of hospital Resuscitation Committees has been focused on Cardiac Arrest. However in-hospital cardiac arrest still carries a high mortality , whereas mortality gains will likely derive from earlier intervention [12–14] (Refer Fig. 12.2). The dramatic reduction in reported rates of in-hospital cardiac arrest has been accompanied by disproportionately modest declines in adult hospital mortality [15, 16]. Perhaps the system needs to intervene earlier?
Considerable resources are devoted to ACLS Training . Comparatively little educational resource is expended on training doctors and nurses to respond to patients who are becoming critically ill in the pre-arrest phase [17]. Simulation of a broad range of clinical scenarios may hold the answer. A change in focus beginning with the clinical leadership of the resuscitation Committee is needed.
There is still to be defined a minimum data set for measuring performance of Rapid Response Systems, although a consensus is evolving [18]. Key Performance Indicators are difficult to define for a service that must respond to a broad array of patients and range of conditions. Collection of data will not occur without allocation of resources and appropriate information technology infrastructure to underpin the incident reporting system. Thankfully, many hospitals are implementing real-time on-line electronic reporting systems to facilitate this aim [19].
Reliability of Vital Signs recording and interpretation is still in the domain of humans. Accordingly it is prone to human error. An appreciation of human factors science [20] is valuable in planning a Rapid Response System. For example, the weighted score Track and Trigger System requires careful calculation of an aggregate score from multiple vital signs observations and has been shown to suffer from inaccuracy [21, 22]. Simpler single variable systems may lack sensitivity and specificity. Technological solutions relying upon new telemetry devices integrated with an Electronic Medical Record (EMR) may offer a way forward. However, barriers to adoption may include cost and clinician resistance.
Multi-disciplinary teams would seem intuitively more appropriate. They replicate the model of how care is delivered to patients in hospitals and allow training of doctors and nurses in non-technical team skills (NTS) [23] or crisis resource management (CRM) [24, 25]. Many systems in Australia and New Zealand are medical based [26]. The UK has adopted a nurse-led Critical Care Outreach System . Neither approach has proven superior [27]. Local resources may dictate the optimal model.
Critical Care Outreach and follow-up of patients after discharge from ICU may offer additional benefit to an at-risk group of patients [28–30]. Defining high-risk groups of patients and rounding by critical care nurses may constitute a more proactive approach to Rapid Response Systems. Most existing Rapid Response Systems are reactive.
Notification of treating specialists should be mandatory. Apart from the obvious medico-legal implications, early involvement of the primary clinicians responsible for the patient in the event of clinical deterioration may lead to better outcomes [31]. Many existing systems suffer from a communication block at this critical juncture and fail to observe and maintain the principle of continuity of care. Clinician disengagement can be an unintended by-product.
Rapid Response Systems were initially intended to provide education and debrief to the staff members working on hospital wards [32]. It was envisaged that they would be supportive, enlightening and empowering. The frequent reality has been a failure to provide education and support post incident owing to a lack of resources and the imperative for the Rapid Response Team to return to other pressing duties. The result may be further clinician disengagement and disempowerment.
Standardisation is difficult when best practice remains to be defined. Nevertheless, it is desirable that unwarranted variation in the delivery of care should be avoided. Supporting protocols for the management of many predictable clinical emergencies are essential to underpin the operation of an effective Rapid Response System. Examples would include seizure, chest pain and sepsis protocols. This policy work cannot be overlooked and gaps need to be addressed in the planning stage .
Finally, many Rapid Response Systems are under-resourced or receive no dedicated resources whatsoever. In Australia only 25% of Rapid Response Systems received additional funding [33]. It is implausible that a clinical system could be expected to deliver dramatic improvements in patient outcomes at no cost. How should resources be allocated efficiently?
Hospitals are not free markets and do not subscribe to the principles of allocative efficiency. More likely, resources are distributed according to traditional models of care and medical hierarchies. The point is that good patient care need not cost more and may in fact cost less. However, paying for a service twice by grafting a Rapid Response System on top of a traditional model of service delivery (home units composed of ward nurses, physician/surgeon, advanced trainee, resident and intern) inevitably leads to duplication and waste.
Many of these issues would be endemic to RRS’s throughout the US, UK, Australia and New Zealand.
The Financial Plan
Perhaps the most neglected area in planning for a Rapid Response System is a detailed financial plan. The starting point should be to build a comprehensive model of how the system will operate. It is important to be inclusive. Costs can be broken down per Rapid Response Team attendance, and according to system costs and establishment costs. System costs include training , research, data collection, quality assurance, governance and administration.
With the introduction of any new service there will be learning curve effects over time. Rapid Response Systems must change with the rapid pace of innovation in hospitals. They are dynamic systems. As the service grows economies and eventually diseconomies of scale can become apparent.
Various financial inputs can be considered for inclusion in the model. My suggestion is be inclusive. Underselling the cost will guarantee that the Rapid Response System is underfunded. Refer to Table 12.1 that details establishment costs, salaries and wages, team composition and governance positions for a typical 400-bed general hospital.
Money has a time value. Services should be costed over 5 years by employing an appropriate deflator for healthcare. In Australia between 2000 and 2011 the Government Final Consumption Expenditure (GFCE) Deflator for Hospitals and Nursing Homes has historically tracked from 2.7 to 4.4% per annum [34]. From 2008 to 2013 the average growth in recurrent expenditure by Australian public hospitals was 5.1% (adjusted for inflation) [35]. The long-term average US healthcare inflation rate is 5.44%, although by 2014 it had fallen to 2.61% per annum [36]. These figures are influenced by innovation in medical technology and pharmacotherapy.
Rapid Response Systems are principally dependent upon labour costs. An alternative approach may be to project increases based on the average rate of salary growth. This treatment would result in a more modest estimate of recurrent costs. It should be born in mind that in the near term it is likely that there will be broader implementation of new telemetry and central monitoring systems integrated with hospital-wide Electronic Medical Records . Technology costs at establishment of the Rapid Response System and depreciation of equipment over time will then assume a greater component of overall expenditure.
Businesses have a lifecycle that includes early investment and sunk costs before eventually maturing and paying a dividend (Refer Fig. 12.3). A problem with how Rapid Response Systems have been implemented is that often the upfront investment in training and governance has not been made. Neither has there been acknowledgement of the ongoing costs of operation over time.
Benefits may not be immediately apparent. Evidence suggests that approximately 2 years may be required for maturation of the service after which an improvement in hospital mortality may be observed [16]. This may be due to achieving efficiencies of scale, overcoming cultural barriers and the learning curve effect.
A sensitivity analysis allows prediction of costs by varying basic assumptions in the elements of the model from simple to more sophisticated. The more inclusive we can be at this stage the less likely we are to be confronted in the fullness of time by hidden costs. Scenario planning should test assumptions pertaining to the worst case, best case and most likely outcomes.
The Lean Model
A lean model has no funded governance or training positions and is purely medical in its composition. Patient caseloads for Registered Nurses are more strictly defined and regulated. Medical staff based in the ICU, Emergency Department and general wards can be temporarily redeployed to the Rapid Response Team .
The efferent limb may consist of only one junior medical officer based in the ICU. Nursing assistance is co-opted from the hospital medical or surgical ward where the patient is located. The average time spent at the patient bedside can be estimated to be 30 min [37]. This is consistent with a rapid assessment and triage model of care.
Conservatively, we may assume a 2% per annum growth in the number of calls, provided that the hospital is not expanding the inpatient bed platform and acuity remains stable.
Since the Global Financial Crisis, wages and salaries have grown at a more modest pace of 2.3% per annum [38].
Hospitals must comply with ILCOR Guidelines [39] for managing cardiac arrest and maintain appropriate resuscitation equipment in close proximity to inpatient areas. Accordingly, there may be little need for investment in specialised resuscitation equipment beyond what is already available.
The system may receive oversight from the hospital Resuscitation Committee. Training for medical responders may be confined to Advanced Cardiac Life Support. High-fidelity simulation training is not provided in this model. Debrief of clinical incidents is by exception.
Even this anaemic model still attracts a cost over 5 years (Refer Table 12.2). The key determinants of cost are the number of calls per annum, time spent per call and hourly rates of pay for junior medical staff.
This model is inexpensive and feasible to implement in smaller institutions and private hospitals that do not employ many senior medical staff. Its viability is critically dependent on a low rate of medical emergency calls since the medical officer may also be responsible for supervising the intensive care unit, especially after-hours.
The response relies on accurate and timely medical assessment with escalation to other services if more complex and sustained intervention is required. Clearly, this is not a team-based approach and either additional personnel will need to be summoned to the bedside of a critically ill patient or the patient will require expeditious transfer to a Coronary Care Unit , High Dependency Unit or Intensive Care Unit. The junior doctor who responds to medical emergencies must be supervised and supported by senior medical staff possessing advanced airway management and resuscitation skills.
Specialised training , research and collection of detailed data for Quality Assurance purposes are not funded components of this model. The focus of the service is clinical. Performance of the system depends less upon the first responder and more critically upon the escalation to and coordination of hospital-wide expertise.
While a figure of AUD $13,000 (US $10,000) per annum to cover operational costs is very low, it is essential that the unfunded system costs including training, governance and Quality Assurance are supplemented in some way. This may require recruitment of more experienced (and expensive) medical personnel who are responsible for their own medical education and professional development. The goodwill of dedicated clinicians and administrators may be harnessed to provide a measure of oversight, reporting and quality control.
The Optimum Model
A more robust model consists of a multi-disciplinary team of doctors and nurses possessing specialised skills and training in responding to medical emergencies. This team could include an Intensivist . The team may be tasked principally with the responsibility of responding to deteriorating patients outside the ICU. In this model greater emphasis is placed upon the performance of the dedicated (possibly stand-alone) first responders and their more definitive management of the patient at the bedside. The broader resources and expertise of the hospital are accessed only by exception when necessary.
The governance of the system assumes a higher priority with the provision of a dedicated Medical Director and Quality Assurance Officer. Data is routinely collected for benchmarking against Key Performance Indicators (KPI’s) . Training in technical and non-technical skills is well resourced and relies heavily upon high-fidelity simulation . Weekly dedicated training time is funded.
The growth in medical emergency calls may be increasing at higher rates than previously expected [40–42]. It is likely that this call rate will plateau as local Rapid Response Systems mature. However, increasing patient acuity, aggressive intervention and an aging population make it more likely that many institutions are still on the steep part of the growth curve. An annual increment in medical emergency calls of 10–15% may be more applicable to some healthcare services [43].
Expert team-based responses offer greater scope to manage the deteriorating patient for longer periods on the hospital ward. This may prevent the need for transfer of the patient to a higher acuity service such as the ICU. More complex management may require an hour or more time spent at the patient bedside. Obviously, the Rapid Response Team must be free of other duties to devote greater time exclusively to the deteriorating patient on the hospital ward.
Establishment costs could include a dedicated resuscitation equipment trolley. The team would have the facility of bringing to the bedside procedural equipment and a broader range of pharmaceuticals than would normally be maintained on the ward cardiac arrest trolley.
The Rapid Response System could avail new technology in remote telemetry and central monitoring of vital signs. This offers the promise of improved reliability of Track and Trigger Systems from automated collection of near continuous observations [44]. It does represent an additional sunk cost in setting up the telemetry and depreciation of equipment.
This more complex model is not dependent on labour costs alone, although they still account for the greatest proportion of recurrent spending. Provided there are enough calls to justify the service it is less sensitive to the absolute number of calls per annum or the time spent at the bedside. By contrast, the principle costs are fixed and relate to leadership positions, a stand-alone team who do not have alternate duties, investment in training and technology.
Since we are not dealing with labour costs alone, it may be more appropriate to apply a general measure of healthcare inflation to this elaborate model. The costs of a fully fledged model over 5 years can be quite confronting (Refer Table 12.3). We should not shy away from presenting this reality to hospital administrators. Rather, we should make them aware of the real costs, and the real deficiencies in existing services .
Cost Benefit Analysis
We are not at the point where we can confidently bank the cost savings from improved patient outcomes due to implementation of the Rapid Response System.
Prevention of critical deterioration in paediatric patients has been shown to result in cost savings that can plausibly offset the operation of a multi-disciplinary medical emergency team [45]. There is some evidence that Rapid Response Teams that share personnel with traditional cardiac arrest teams are most cost effective [46]. Ideal team composition and overlap of personnel with the Code Blue Team remains an area for further research.
The alternative to implementing a Rapid Response System is to rely upon the traditional cardiac arrest (Code Blue) team to salvage deteriorating patients. The health system costs of in-hospital cardiac arrest are high for paediatric [47] and adult patients [48]. The cost per Quality Adjusted Life Year (QALY) saved following cardiopulmonary resuscitation adjusted to 2011 US Dollars is approximately $100000 [46, 49]. This figure does not take into account the average costs of training the Rapid Response Team (US $118000) [50] versus the Code Blue Team (US $279000) [51] adjusted to today’s prices [46], respectively.
Perhaps a case can be made for improved staff retention rates, reduced parent medical unit overtime, more efficient use of our ICU’s [52] and avoidance of litigation. But we must acknowledge the propensity for cost shifting and possibly an increase in admission rates to Intensive Care [53] and high dependency units.
Consider an estimated cost of AUD $1.5 million (US $1.05 million) for a fully fledged Rapid Response System over 5 years. Based on a benchmark of $50000 US per QALY saved [54], even a service that rescues 30 people, extending their quality of life by just one year, would represent acceptable value.
Recent meta-analyses have demonstrated an overall reduction in paediatric and adult hospital mortality since the advent of Rapid Response Systems that may be attributable to their effect [15, 16, 55, 56]. The point estimate for adult hospital mortality in the meta-analysis performed by Winters et al [55] was 0.88 (CI 0.82–0.96).
Medium sized hospitals average 5900 patient separations per annum, while large institutions exceed 15,000 separations per annum [57]. Mortality in US Hospitals has fallen gradually from 2.5% to 2.0% over the decade from 2000 to 2010 [58]. A 10–12% reduction in mortality over the last decade deriving from the implementation of Rapid Response Systems suggests that the number of lives saved in our worked example could be as many as 90 over 5 years. When compared to the cost-benefit analyses for ECMO [59] and solid organ transplantation [60], the Rapid Response System can be argued to be value for money.
In the discipline of Economics there is a “sweet point” at which a service or production line is most efficient [61] (Refer Fig. 12.4). This frequency of Rapid Response Team calls needs to be defined for each institution relative to size and resources. Too few calls may be ineffective. Endless growth may result in cost blowouts and degradation of overall clinical performance. In the final analysis, it may be that safety and quality cannot readily be reduced to a dollar value .
Risk Management
Just because Rapid Response Systems enjoy strong face validity and seem like a good idea does not mean that they cannot do harm. Any Business Plan must include a treatment of risk. Indemnity for the Rapid Response Team particularly in the private sector is a controversial subject. Without a strong governance framework how can there be accountability? Most of these risks attract cost and can have a dollar value set beside them in a comprehensive plan.
These systems should be corporately owned. That is to say they should be regarded as essential infrastructure underpinning hospital safety and quality of care. They need strong identifiable leadership and should report to the Hospital Executive . It is imperative in the design phase that the “followership” among rank and file clinicians not be given an opt-out. A fundamental question to ask is; who is the team?
Does the responsibility for responding to deteriorating patients reside solely with the members of the Rapid Response Team ? What contribution should be made by ward-based clinical teams? How should Anaesthetists, Intensivists, Emergency Physicians and treating medical specialists be engaged? The choice is between many hands and just a few.
The implications of this decision are profound (Refer Fig. 12.5). Hospitals can adopt an approach to patient safety that makes it everyone’s responsibility and incur relatively few emergency calls. Or we can delegate the sick and inconvenient to be cared for by the Intensive Care Unit doctors and nurses .
Marketing and Implementation
Today we are not in the position of having to “sell” a Rapid Response System to the Hospital Executive . They have already bought the concept. Compliance with National Standards means that implementation of a Rapid Response System is part of business as usual.
Introducing any new product or service has a characteristic Diffusion Curve [62]. Today, we are way over to the right of this curve. The majority conservatives have accepted the place of Rapid Response Systems. Stakeholders want solutions and convenience (Refer Fig. 12.6). Clinicians, administrators and patients want a mature service that works seamlessly. In other words, free from bugs!
At the other end of the bell curve medical sceptics will resist acceptance of the Rapid Response System while awaiting further proof of efficacy or optimal design.
Pitching the Plan to Executive
At the completion of the Business Plan a crucial step will be “pitching” the proposal to the administration for the first time. Hospital Executives are not “Angel Investors” looking to donate funds to an enthusiastic entrepreneur with a great idea. Care should be exercised in offering a compromise model because that is probably what will be seized upon as a cheaper option. Thereafter, the journey towards better outcomes for deteriorating patients will be fixed on a lesser path.
The temptation to make ambit claims should also be avoided. Maintaining credibility is essential in winning support for a service innovation. A comprehensive Business Plan including an Executive Summary and supporting appendices is a firm foundation for arguing the case in favour of Rapid Response Systems .
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Townsend, S.C. (2017). Making the Business Case for a Rapid Response System. In: DeVita, M., et al. Textbook of Rapid Response Systems. Springer, Cham. https://doi.org/10.1007/978-3-319-39391-9_12
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DOI: https://doi.org/10.1007/978-3-319-39391-9_12
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