A Multidisciplinary QI Initiative to Improve the MSKCC’s Pediatric Emergency Escalation System

Introduction: Recently, on our pediatric platform at a quaternary oncology referral center, we have experienced an increase in the number of hospitalizations of medically complex patients, including those who are technology supported (e.g. tracheostomy). These patients are at risk of rapid deterioration requiring provider prompt activation of escalation of care (EOC)- rapid response team (RRT) or PICU consult. Our baseline Adverse Event data have shown a significant delay in EOC activation leading to an increased number of Preventable Adverse Events (PAE).On our pediatric platform of medical surgical unit and ambulatory cancer center, we aimed to 1) reduce the number of PAEs to zero related to EOC and 2) improve healthcare providers’ comfort with escalating care by 20% by August 2025.


Methods: Using the Model for Improvement, a series of sequential interventions were implemented. Our outcome measures were the number of PAEs related to EOC and self-reported comfort with escalation. We utilized the following process measures: number of consults, number of RRTs, number of medical codes outside the PICU, number of cases reviewed by the committee, number of repeat EOCs on the same patient within 48 hours if not initially transferred to the PICU. Balancing measure of increase of PICU transfers from EOC activations. Data were collected via electronic medical record (EMR) review and analyzed using statistical process control charts. We applied API rules to detect special cause variation.


Results: Baseline data for 2023-24 academic year demonstrated that there were 2 PAEs related to EOC and 60% of staff felt somewhat comfortable or extremely comfortable (n= 31). In 2024-2025, there was 1 PAE related to EOC and 88% of staff reported being comfortable or somewhat comfortable (n= 32), an increase of 28%. We reviewed 85 EOC as a review committee. There was 1 medical code outside the PICU. We reduced the number of repeat EOC on the same patient from a rate of 0.37 to 0.02 to eventually 0.01. There was no increase in activations that did not lead to PICU transfer.


Conclusions: We demonstrated a successful multifaceted approach to increasing provider’s comfort level to activate EOCs for pediatric oncology patients who are showing early signs of deterioration.