Academic Center to Community PICU: An Interdisciplinary Approach to Improve Escalation of Care

Introduction: Inconsistent intrahospital communication regarding clinically deteriorating patients may lead to increased morbidity and mortality. The Institute for Healthcare Improvement and Society of Critical Medicine advocate for the inclusion of rapid response team (RRT) systems at all hospitals. Our enterprise includes two large, academic children’s hospitals with established escalation of care pathways and one community pediatric intensive care unit (PICU) with variable use of an escalation pathway. We aim to increase adherence to the pediatric escalation of care pathway at the community hospital from 24% to 75% by February 2025.


Methods: We used the Model for Improvement to implement a series of planned sequential interventions including focus groups with key multidisciplinary stakeholders, an updated escalation of care pathway, interdisciplinary simulations, electronic medical record (EMR) integration, and educational presentations. Our outcome measure was the percent adherence to the pediatric escalation of care pathway. We used the number of PICU consult orders, RRT activations, and PICU evaluation notes as process measures, and the number of transfers from the floor to the PICU with no ICU level intervention within 24 hours and the number of code activations as balancing measures. Data were collected via EMR review and analyzed with Shewhart “p” charts. Special cause variation was detected with Associates for Process Improvement rules.


Results: From July 2023 to June 2024, adherence to the escalation of care pathway was 24% (n = 53). Post-intervention, from July 2024 to January 2025, adherence increased to 78% (n=55). During this entire time period, there were 58 PICU consult orders, 2 RRT activations, and 85 PICU evaluation notes. 5 patients were transferred from the pediatric floor to the PICU who did not require ICU-level interventions. Pareto charts demonstrated a notable improvement in adherence to the pathway among patients with sickle cell anemia and pain.


Conclusions: An interdisciplinary approach utilizing education, electronic medical record enhancements, and simulation can improve adherence to a formal escalation of care pathway. Adapting standardized practices from a large, academic medical center to an affiliated community hospital requires flexibility and site-specific adjustments.