Roles and Responsibilities
Table of Contents
I) General Information
a) Role of PACE
b) Areas of PACE coverage
c) Activation triggers and calling criteria
II) Activation of PACE
a) General
b) Team Member Roles
o PACE MD
o PACE RN
o RRT
o PCCU resident
c) Responsibility of Bedside Team after calling PACE
d) Communication with the most responsible team
III) PACE Follow-up
a) Follow-up of a PACE activation
b) Follow-up post PCCU Discharge
IV) Procedure if no PACE RN on duty
a) Activations
b) Follow-up
V) PCCU Consults
VI) PACE vs. CODE BLUE
VII) Family-Triggered Activation
VIII) Equipment
IX) Handover / Transfer of Accountability
a) Weekday team handover
b) PACE RN
c) PACE MD
X) Documentation
a) General
b) New patient record
c) Follow-up record
XI) PACE MD Coverage
a) Weekdays
b) Weekends, Weeknights and Holidays
XII) Quality Assurance and Education
XIII) References
I) General Information
a) Role of PACE
q Medical emergency team composed of healthcare providers with specialized training in critical care medicine
q Primary objective is reduction / elimination of preventable code blue activations, cardiac arrests and emergent PCCU admissions
q 3 clearly defined roles of PACE within the Children’s Hospital:
1) Rapid response to patients with evolving critical illness
o Will respond to a patient’s beside as soon as possible up to a maximum of 15 minutes from the activation
o Will bring equipment and resources for management of a variety of acute illnesses
o Will not bring equipment for resuscitation or intubation
2) Follow-up of patients discharged from the PCCU
3) Quality Assurance and Education
o Identification of patient safety issues
o Education to frontline caregivers
o Improve knowledge translation of best practices
b) Areas of PACE coverage
o All inpatient pediatric wards
o Radiology, including MRI
o PACU
o Admitted pediatric patients in the ED
o All outpatient pediatric clinics
PACE will not respond to:
o OR
o NICU including the Level I and II nurseries
o Non-admitted patients in the ED
c) Triggers of PACE activation:
1) A bedside caregiver is concerned about the condition of the patient and/or because the patient has consistently exceeded calling criteria for PACE activation (see below)
2) A family member of the patient is concerned about the condition of the patient (see the family-triggered activation section for more information)
q PACE calling criteria:
II) Activation of PACE
a) General
q PACE activations should be called to paging at extension 75030
q Members of PACE who receive direct phone calls from clinical areas requesting PACE involvement should re-direct callers to call paging and ask for PACE
q PACE team members will be paged simultaneously and expected to respond directly to the patient location within a maximum of 15 minutes
q The page will direct the team to the location using the following format:
“PACE / Ward or Clinic / Room number”
q The following pediatric critical care healthcare providers will receive the PACE activation page:
o PACE MD
o PACE RN
o Wards RRT
o PCCU Resident
q A rapid critical care assessment of the patient should be performed by the PACE team members within the first few minutes of arrival to determine whether there are active critical care issues requiring immediate attention
q If the patient is assessed to be stable and without need for urgent management then the PCCU resident and Ward RRT should return to their previous clinical duties. The PACE MD and/or the PACE RN will complete further recommendations and documentation.
b) Team Member Roles
q PACE MD
o A physician with advanced pediatric critical care training, usually a staff physician or fellow
o Responsible for recommendations made by the PACE team following an activation to a patient’s bedside.
o The PCCU fellow may fill the in-house response of the PACE MD on weekends, weeknights and holidays as the “Acting PACE MD”; they will at all times remain responsible to the PCCU /PACE Attending Physician.
o The PACE MD will communicate directly with the attending physician most responsible for the patient to advise them of the change in the patient’s condition if a significant change to the care plan for the patient is required, such as PCCU admission.
o For less urgent issues, communication with the attending MRP can occur through an in-house member of the patient’s most responsible team at the discretion of the PACE MD.
q PACE RN
o A pediatric critical care RN with > 3 years of critical care experience and additional Pediatric Critical Care Response Team training.
o Is a dedicated role and should not be engaged in an activity in the PCCU such that that he or she is not able to transfer responsibility to another RN and respond to a PACE call within 15 minutes.
o Responsible for bringing the PACE documentation records and the equipment bag located in the PCCU to all activations
o Responsible for re-stocking the equipment bag after each use and to check the contents of the PACE equipment bag on a daily basis.
Ø See the appendix for a list of equipment contained in the PACE equipment bag.
o Responsible to enter data from the documentation record into the APCE database following the activation
q Ward RRT (pager 1362)
o Registered Respiratory Therapist (RRT) responsible for covering the inpatient pediatric areas
o A non-funded member of the PACE activation
o Assistance with basic airway stabilization, nebulized therapy, oxygen therapy, short-term ventilatory support, etc.
o The RRT should return to his or her pervious clinical duties if the PACE team determines that the patient is stable without active critical care or respiratory issues requiring urgent intervention
q PCCU Resident
o The pediatric resident on-call for PCCU and a non-funded member of the PACE activation
o Will respond to all PACE activations as potential urgent PCCU admissions and respond to the patient’s bedside within 15 minutes.
o Should work collaboratively with the rest of the team and may perform roles such as physical examination, assessment of recent laboratory or radiographic investigations, obtaining a relevant history from the most responsible team and assisting in the prescription of urgent interventions.
o The PCCU resident should return to his or her pervious clinical duties if the PACE team determines that the patient is stable without active critical care issues requiring urgent management
c) Responsibility of Bedside Team after calling PACE
q Healthcare providers activating PACE are required to remain at the patient location to advise the PACE team members of the situation that lead to the activation and participate with the assessment and management
q A physician representative of the most responsible team (in-house resident, fellow or nurse-practitioner) must be present during a PACE activation. If they have not already been informed of the PACE activation, then they will be paged on arrival of the PACE team
d) Communication with the Patient’s Most
Responsible Team (MRT)
q The most responsible house staff (resident, fellow, or NP) for the patient must be notified of the PACE activation and requested to be in attendance
q As a rule, PACE should not be activated before members of the most-responsible team have been made aware of the change in the patient’s clinical status unless there is difficulty contacting a member of the MRT (i.e. not returning pages, tied up in a procedure, etc).
q The attending MRP should be notified by the unit clerk, ward RN or PACE team of the PACE activation by text page using the format:
“PACE called / Ward / Room #/ Patient initials”
q The MRP will receive a page from either the PACE team or their in-house delegate advising them of the situation once the patient has been assessed.
q Medical responsibility will remain with the patient’s most responsible team (MRT). All suggestions should be agreed to by the MRT before they are carried out unless the patient requires urgent intervention.
III) The PACE Follow-Up
a) Follow-up of a PACE activation
q Decisions on when / if a patient needs further PACE follow-up after an activation are at the discretion of the team based on the resources of the inpatient unit and the clinical status of the patient.
q Follow-up visits are the primary responsibility of the PACE RN although other members may participate in the follow-up if they choose
q If patient is found to have clinically deteriorated at the time of the follow-up, the remainder of the PACE team should be activated through paging
q Less acute concerns arising from a follow-up should be directed to the PACE MD
b) Follow-up of PCCU Discharge Patients
q All patients admitted to the PCCU who are discharged to an inpatient area are followed by the PACE team for 48 hours.
q The PACE RN scheduled for the day should update the list of active patients by screening the PCCU admission/discharge logs for patients discharged over the preceding 24 hours
q The minimum expectations for follow-up of patients discharged from the PCCU are that they be seen once a day over the 2-day period.
q Criteria for PACE discharge after 24 hours (single follow-up):
o The patient is likely to be discharged from the hospital within 24 hours of PCCU discharge
o The patient’s discharge from the PCCU was delayed by > 24 hours
o The patient’s clinical status has returned to their normal baseline; however their discharge from hospital is delayed for other reasons (social concerns, waiting for follow-up imaging or consultation, etc)
o Patient’s who meet criteria for discharge after 24 hours may be done so at the discretion of the PACE RN
q The PACE RN will see the patients initially and complete the appropriate documentation
q Once the patients have been assessed by the PACE RN, they should be reviewed together with the PACE MD
q Patients in whom the PACE makes recommendations should have these communicated to a member of the MRT
q Clinical issues requiring more urgent attention require notification of the patient’s MRP.
IV) Procedure if No PACE RN on duty
q This section only applies to situations where there is no PACE RN on duty due to illness or other unforeseen circumstances
a) New activations
q The remaining in-house members of the PACE should respond to activations as per the usual practice.
q The PACE MD will assume responsibility for PACE documentation.
q If the PACE MD is off-site then documentation should occur through notation in the patient’s chart and documentation using the PACE forms may be deferred.
q Responsibility for bringing the PACE equipment bag should be decided by a conversation between the PACE MD and remaining in-house members of the PACE response. If at the time of the activation, the remaining PACE team are not in the PCCU and are geographically closer to the patient location, it may be faster to assess the patient quickly before diverting to the PCCU to obtain the PACE equipment bag.
q If the patient is at risk of further deterioration and is planned to remain on the ward, then consideration should be made to having the PCCU resident follow the patient through formal PCCU consultation in lieu of PACE RN follow-up
b) Follow-up
q Patients due for follow-up either from a previous PACE activation or due to PCCU discharge will be seen by the PACE MD
q The PACE MD will be responsible to complete PACE documentation
q Subsequent PACE RN’s will perform data entry from the completed documentation into the PACE database
q If a patient is due for follow-up after hours when the PACE MD may not be in house and the patient is at risk for PCCU admission then consideration should be made to have the patient followed by the PCCU resident through formal PCCU consultation
V) PCCU Consults
q All urgent/emergent PCCU consults on admitted patients should be referred to the PACE team
The following guidelines have been provided to ensure that communication of requests for PCCU consultation and admission are clear:
1) This guideline should be applied only to patients who have been admitted to the Children’s Hospital. PCCU consultations for non-admitted patients in the Emergency Room should continue to occur via direct communication between the Emergency Department Staff Physician and the Attending Pediatric Intensivist.
2) Communication to the PACE MD by the Attending MRP must continue to occur but should not delay activation of the team. This communication can occur at the bedside; otherwise this can occur by phone.
3) Physicians who wish to speak directly with a Pediatric Intensivist for advice without requiring patient assessment should page the intensivist on call. If it is determined that the patient requires a critical care assessment or PCCU admission, the Pediatric Intensivist will recommend to the Attending MRP to activate PACE directly.
4) This guideline is not intended to be used for planned admissions to the PCCU. Admission for these patients should continue to be coordinated through direct communication with the Pediatric Intensivist on service.
VI) PACE vs. CODE BLUE
q A CODE BLUE is a distinct response from a PACE activation
q A CODE BLUE should be activated if without immediate assistance or within several minutes, the patient may experience a respiratory or cardiac arrest
q The PACE team should be activated if it is unlikely for the patient to progress to respiratory or cardiac arrest within 15 minutes but the patient is exhibiting signs of critical illness
q PACE will not bring resuscitation medications, definitive airway equipment, or electrical therapy. If these are required, a CODE BLUE should be activated.
VII) Family-Triggered Activation
o Family members or parents of an admitted patient to the Children’s Hospital may activate PACE directly by calling 75030 if they feel that their child needs help immediately because of a change in the clinical condition.
o Family members are directed to address concerns to their bedside RN and most responsible medical team first before calling PACE
o Posters explaining the role of the PACE team and how to access PACE have been placed in every inpatient room in the Children’s Hospital.
VIII) Equipment
o The PACE RN is responsible for bringing the PACE equipment bag stored in the PCCU.
o A detailed equipment list can be found as an appendix to this document.
o The contents of the equipment bag should be verified and initialed once per shift by the PACE RN using the equipment checklist found in the PCCU
o It is the responsibility of the PACE RN to re-stock the equipment bag after every use
IX) Handover / Transfer of Accountability
a) Weekday Team Handover
o The PACE MD, PACE RN, Pediatric Intensivist and PCCU Charge RN should meet prior to sign out of the PACE MD at 4pm to discuss any active PACE patients who may be at risk of PCCU admission and to identify any patients scheduled for a late discharge from the PCCU who may require overnight follow-up by the PACE RN