High Dependency Care Audit for Children & Young

People in Scotland – Interim Report

Background to the High Dependency Care (HDC) Audit• The Kerr Report recommended:

“that the age for admitting children & young people to acute care in paediatric facilities is up to their 16th birthday”.

• Delivering for Health:– “continued provision of paediatric intensive care and high

dependency care (HDC) is an immediate issue for NHSScotland in the light of trends in activity and case mix that may not be sustainable within current provision.”

• SEHD commissioned NSD to conduct audit, to assess demand across Scotland and the current capacity to provide HDC:– quantity – high dependency care audit;– quality – assessing paediatric services against national

standards (West Midland Guidelines).

HDC Audit - Methodology

• Aim to identify where children with HDC needs are currently managed, how many, levels of HDC care and the number transferred.

• Development of a set of national high dependency care criteria and classification standards.

• 12-14 month prospective audit – in all hospitals across Scotland.

• Include all children up to their 16th birthday.

• Pilot conducted in wards within DGH, Tertiary Hospitals and Adult Hospitals.

HDC Audit – roll out began in October 2006, all hospitals were participating by end of

Nov. Health Board Children’s

WardsAdult Wards

Ayrshire & Arran 2 4

Borders 1 7

Dumfries & Galloway 1 5

Fife 3 13

Forth Valley 2 16

Greater Glasgow & Clyde

12 142

Grampian 7 9

Highland 1 19

Lanarkshire 2 13

Lothian 12 36

Orkney 0 3

Shetland 0 3

Tayside 6 10

Western Isles 0 4

Total 49 284

12 hr episodes: day / night; changes in care

Post-operative airway obstruction

Upper airway obstruction needing close observation. INCLUDES post-tracheostomy decannulation (first 24 hours), post-op adenotonsillar bleed, post major upper airway surgery.

A01

Airway obstruction Upper airway obstruction needing close observation e.g. requiring oxygen or nebulised adrenaline within the last 12 hours.

A02

New tracheostomy New tracheostomy before the first tube change (less than 7 days). A03 Airway intervention INCLUDES stable tracheostomy (more than 7 days), nasopharyngeal airway, prongs, stents, guedel airway, Replogle

tube. EXCLUDES intubation. A04

Ventilated/Assisted respiration

Ventilated or assisted respiration (e.g. bag and mask) other than during recovery from anaesthetic. INCLUDES acute and/or new BiPAP & CPAP.

A05

Stable long term ventilation

Stable long term ventilation. INCLUDES long term CPAP/BiPAP/PEEP/CNEP A06

O2 more than 40% / 2litres

Oxygen therapy more than 40% or 2 litres/min via headbox, facemask, nasal CPAP or O2 via mask with reservoir (whatever flow rate)

A07

Recently extubated - prolonged ventilation/Intensive care step down

Patients recently (within 24 hours) extubated following prolonged ventilation (more than 5 days intensive care), step down as arranged with PICU.

A08

Vasoactive, inotropic, anti-arrhythmic drugs

Needs IV vasoactive drugs to support cardiac output or to control BP. INCLUDES continuous IV antihypertensives or inotropes and bolus IV drugs.

C01

Shock/hypovolaemia Intravenous fluid resuscitation over 20ml/kg within last 12 hours and/or inotropes OR circulatory instability due to hypovolaemia.

C02

Fluid Output Hourly monitoring of fluid intake and outputs e.g. urine/drains/CSF/nasogastric loss C03 Continuous IV drug infusions

Continuous IV drug infusion EXCLUDES Antibiotics and anti-virals and analgesia C04

Invasive monitoring Continuous invasive cardiovascular monitoring e.g. central venous, arterial line or Swan Ganz catheter. C05 Severe haematological problem

Symptomatic anaemia/thromobocytopenia/coagulation problem requiring close observation OR frequent infusions of blood products (more than 3 in 12 hours).

C06

Acute hypotension/hypertension

Acute hypo/hypertension (blood pressure =15% change from normal values) requiring frequent ( ? 1 hourly) BP monitoring.

C07

Cardioversion Has required cardioversion or DC countershock within the last 12 hours. H01 Acute or external pacing

Acute or external cardiac pacing. H02

CPR Cardiopulmonary resuscitation (within the last 12 hours). H03 Post-cardiac surgery (non ICU)

Post Cardiac Surgery (first 24 hours). H04

BMT/severe neutropenia

Any child post bone marrow transplant and/or severe neutropenia (neutrophils below 0.5 or falling). I01

Sepsis Suspected septicaemia. INCLUDE all who require at least hourly observations, including meningococcal I02 Acute renal replacement therapy/Hourly cycle PD/Acute renal failure

Acute renal replacement therapy (haemodialysis, haemofiltration) OR hourly cycle peritoneal dialysis (EXCLUDES CCPD) OR acute renal failure (urine output less than 1ml/kg/hour). EXCLUDES chronic renal failure.

K01

Diabetic ketoacidosis (DKA)

Diabetic ketoacidosis with continued deterioration in conscious level after the start of therapy. K02

Fluid/electrolyte derangement/ severe metabolic derangement

Potential/actual severe metabolic derangement, fluid or electrolyte derangement. INCLUDES frequent U&E monitoring, multiple electrolyte supplements (more than 2 in 12 hours), regular blood gas/glucose monitoring and/or frequent changes to fluid regimes and hourly urine measurement.

K03

GCS less than 12 GCS less than 12. N01

Airway / Circulatory Classifications

Co-ordination of HDC Audit

• Each hospital has a designated co-ordinator and deputy.

• Key to ensuring the quality of the data returned to NSD:– interpretation of HDC criteria – peer review;– link with NSD regarding queries on the audit

forms;– meet regularly to discuss issues.

• Completed forms returned on a weekly basis from paediatric wards and monthly basis from adult wards

Audit forms should contain – the patient’s complete journey

Each form should contain the following: • hospital & ward;

• patient details – CHI, DoB, Postcode,

• type of admission – emergency / elective;

• date & time per patient – when HDC commenced & ended, not shifts.

• admission from – where was the patient prior to coming to the hospital;

• primary journey – how did the child get to the hospital;

• secondary journey – if child was transferred from another hospital – how was the child transferred;

• end destination – when HDC ended where did the child go;

• HDC criteria – for complete 12 hr period.

BRANNIGAN

BRANNIGAN

HDC Audit progress• Database Issues:

– delays developing database;– backlog of data entry;– quality of initial audit forms received – still

working on clearing the outstanding queries;– delay in feedback to wards/hospitals.

• Data presented is not complete due to backlog/queries.

• Staffing issues within NSD.

• To end of December information on 1369 children has been received. (Still adding to database for Jan/Feb - to date 1687)

Number of Children included in the HDC Audit

Hospital October November December Total

Aberdeen Royal Infirmary 1 2 0 3

Balfour Hospital 0 0 1 1

Belford Hospital 7 5 3 15

Borders General Hospital 8 8 2 18

Caithness General Hospital 3 6 2 11

Crosshouse Hospital 21 25 0 46

Dr Gray's Hospital 14 6 3 23

Dumfries & Galloway Royal Infirmary 1 19 8 28

Gilbert Bain Hospital 2 1 2 5

Ninewells Hospital 24 42 49 115

Perth Royal Infirmary 0 3 2 5

Queen Margaret Hospital 0 3 2 5

Raigmore Hospital 15 18 11 44

Royal Aberdeen Children's Hospital 46 88 39 173

Royal Alexandra Hospital 0 9 3 12

Royal Hospital for Sick Children (Edinburgh) * 58 68 49 175

Southern General Hospital 0 4 2 6

Stirling Royal Infirmary 38 29 14 81

St John's Hospital at Howden 4 4 4 12

Victoria Hospital 14 30 4 48

Wishaw General Hospital 53 36 13 102

Yorkhill NHS Trust * 0 237 204 441

Total Number of Children Included in Audit 309 643 417 1369

* Significant amount of outstanding data entry

HDC Audit – planning tool / issues impacting on children’s services

• Capacity:– no of HDC episodes; no. of children; episodes per

child;

• Location:– where do children receive HDC; type of hospital,

regional location.

• Demand:– proportion emergency / elective admissions.

• Staffing:– proportion day / night HDC

• Patient Pathway:– how many children are transferred to another

hospital;– how do children arrive at hospital;– where do they go after HDC.

Breakdown of HDC for children in audit to date.

HDC care provided in Short Stay, Paediatric Ward, HDU.

Treatment CodeNo. of Patients Categories

Post-operative airway obstruction 12  

Airway obstruction 12  

Airway intervention 13

AirwayVentilated/Assisted respiration 13

Stable long-term ventilation 3  

O2 more than 40% 63  

Recently extubated - prolonged ventilation/Intensive care step down

1 

Vasoactive, inotropic, anti-arrhythmic drugs 1  

Fluid balance 42  

Shock/hypovalaemia 4

CirculatoryMultiple IV drugs or continuous infusion 33

Invasive monitoring 9  

Severe haematological problem 5  

Acute hypotension/hypertension 1  

Cardioversion 1 Cardiac

CPR 1  

BMT/severe neutropenia 6 Infection

Septicaemia 10  

Acute renal replacement therapy/Hourly cycle PD/Acute renal failure

1 

Diabetic ketoacidosis (DKA) 7 Renal

Severe metabolic/fluid/electrolyte derangement 10  

Treatment CodeNo. of Patients Categories

GCS 8-12 14  

Prolonged/recurrent seizures 9  

Complex anti-convulsants 6 Neurology

Post - craniotomy 1  

Hourly neuro observations 50  

Apnoeas/cyanotic episodes 8  

Deterioration to ventilation 7  

Severe asthma/bronchodilators 34 Respiratory

ECG and Sa02 monitoring 30  

2+ chest drains & hourly replacement 1  

Arrhythmias 2  

Sedation or GA for ward procedure 49  

Complex pain control 28  

Frequent sampling/dressings 10  

End of life care 3 Other

Major trauma 3  

Previous rapid deterioration resulting in PICU admission 3  

Central lines 1  

Minor surgery, same day 1 Neonates

Morphine 2  

Breakdown of HDC for children in audit to date.

HDC care provided in Short Stay, Paediatric Ward, HDU.

Where children who require HDC were admitted from:

  Oct Nov Dec Jan Feb

  % % % % %

A & E 29 25 30 22 54

Same Ward 0 1 5 0 0

HDU (transferred from HDU to Wd still requiring

HDC) 6 1 6 0 0

Home 29 48 43 31 8

ICU 0 0 0 0 0

Other Ward 19 19 19 46 38

Other Hospital 12 5 3 0 0

PICU 0 0 0 0 0

Short Stay 5 1 5 1 0

Patient Journey

HDC Audit – implications for children’s nurses

• Aim is to produce report Spring 2008; supporting the planning of local, regional and national planning of critical care services.

• Assessment of paediatric facilities, will be included in final report.

• Provide evidence to support local needs analysis:– training – differing between hospital

environments;– staffing levels;– facilities;– equipment– epidemiological data of patient base

(Data Warehouse linkage).

HDC Audit – implications for children’s services

• Ethos of Delivering for Health is to provide services as locally as possible.

• Current paediatric service provision – centralisation of paediatric intensive care (2) and high dependency units (4).

• This audit will identify the number of children with high dependency care needs across all hospitals and wards – linking to the development of a managed critical care network.

Acknowledgements to -Julie AdamsProject Manager National Services Division