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Pediatrics. 2012 Apr;129(4):e874-81. doi: 10.1542/peds.2011-2784. Epub 2012 Mar 5.

Development of a pragmatic measure for evaluating and optimizing rapid response systems.

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  • 1Division of General Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA. bonafide@email.chop.edu



Standard metrics for evaluating rapid response systems (RRSs) include cardiac and respiratory arrest rates. These events are rare in children; therefore, years of data are needed to evaluate the impact of RRSs with sufficient statistical power. We aimed to develop a valid, pragmatic measure for evaluating and optimizing RRSs over shorter periods of time.


We reviewed 724 medical emergency team and 56 code-blue team activations in a children's hospital between February 2010 and February 2011. We defined events resulting in ICU transfer and noninvasive ventilation, intubation, or vasopressor infusion within 12 hours as "critical deterioration." By using in-hospital mortality as the gold standard, we evaluated the test characteristics and validity of this proximate outcome metric compared with a national benchmark for cardiac and respiratory arrest rates, the Child Health Corporation of America Codes Outside the ICU Whole System Measure.


Critical deterioration (1.52 per 1000 non-ICU patient-days) was more than eightfold more common than the Child Health Corporation of America measure of cardiac and respiratory arrests (0.18 per 1000 non-ICU patient-days) and was associated with >13-fold increased risk of in-hospital death. The critical deterioration metric demonstrated both criterion and construct validity.


The critical deterioration rate is a valid, pragmatic proximate outcome associated with in-hospital mortality. It has great potential for complementing existing patient safety measures for evaluating RRS performance.

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