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/PACE Fellow
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) Procedure if PCCU in Moderate Surge
VI) PCCU Consults
VII) PACE vs. CODE BLUE
VIII) Family-Triggered Activation
IX) Equipment
X) Handover / Transfer of Accountability
a) Weekday team handover
b) PACE RN
c) PACE MD
XI) Documentation
a) General
b) New patient record
c) Follow-up record
XII) Quality Assurance and Education
XIII) References
I) General Information
a) Role of PACE
q A Pediatric Medical Emergency Team composed of healthcare providers with specialized training in critical care medicine
q Primary objective is elimination of preventable code blue activations, cardiac arrests and emergent/crash PICU admissions all of which are known to increase both mortality and morbidity
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 – A Code Blue activation is required in these circumstances
2) Follow-up of patients discharged from the PCCU
3) Quality Assurance and Education
o Identification of patient safety issues
o Feedback and 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; however, the team arrives within 5 minutes of the activation in most instances
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 Fellow
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. Currently all of the PACE MDs are staff pediatric intensivists
o Responsible for recommendations made by the PACE team following an activation to a patient’s bedside.
q A PACE MD is separately scheduled during weekdays (Monday to Friday) from 08:00 -4:00pm. After hours and on weekends the PICU Attending cross-covers the role of PACE MD
q PACE Fellow
q A physician who has completed a pediatric resident training program and is enrolled in the McMaster subspecialty training program in pediatric critical care
q A PICU fellow is separately scheduled during weekdays (Monday to Friday) from 07:45am -4:30pm. The PACE Fellow acts as the PACE team leader during new activations and rounds with PACE RN on patients requiring PACE follow-up. The PACE Fellow remains at all times responsible to the PCCU /PACE Attending Physician with whom they must and review all new activations and follow-up activity.
q The PACE Fellow or PACE MD must 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.
q 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 or PACE fellow.
q The PACE Fellow will attend morning and afternoon rounds and attend to any urgent/emergent patient care issues arising in the unit or from new consults to ensure the PICU Fellow and PICU rounds can remain as uninterrupted as possible. If not engaged in PACE activity, the PACE fellow is expected to be present in the PICU to assist the PICU team and participate in PICU educational activities.
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 activities 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 a maximum 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
o Engages in outreach activity to the different clinical areas of the Children’s Hospital and includes the following roles:
q Assistance in transition of long-term/complex PICU patients form ICU to the ward by providing additional nursing follow-up visit to ensure the ward RNs are comfortable taking over the needs of these patients “stepping down” from the PICU
q The PACE nurse will independently round the wards at approximately 0800 + 1600 , 2100 + 0300 to determine the ward acuity and to identify at risk patients using the pace rounds check-list. The PACE nurse will ensure the ward charge nurses have the PACE nurses name and pager to call as a resource.
q The PACE nurse will be a liaison between PCCU and the ward and will share round information with the PCCU charge nurse and the staff intensivist to identify at risk patients.
q The PACE nurse will independently respond to pages regarding education, collaboration, and best practice. The PACE nurse will not assist with coverage, transfers, pt. care etc.
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 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
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 and PACE Fellow will see the patients initially and complete the appropriate documentation
q Once the patients have been assessed 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 applies only 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 or delegate will assume responsibility for PACE documentation.
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 fellow or 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 or delegate will be responsible to complete PACE documentation
q Subsequent PACE RN’s will perform data entry from the completed documentation into the PACE database
V) Procedure if PCCU in Moderate Surge*
q This section applies only to situations where the PCCU is in moderate surge.* In this situation, the PACE RN may be assigned increased clinical responsibilities in the PCCU that may affect his/her ability to respond to a PACE activation for patient safety reasons. As per the PACE mandate to ensure a consistent response by all team members to a new activation, every attempt should be made to facilitate the PACE RN participation in the PACE response to the activation; however, if this would lead to a critically unsafe situation in the PCCU, the following steps should be taken:
1) As soon as this potential situation is recognized, a clear plan should be communicated to the other members of the PACE team (PACE MD, PCCU Fellow, PCCU resident, and RT) to determine who will bring the PACE equipment bag to the activation and complete the documentation.