identification of the deteriorating child: paediatric ... · identification of the deteriorating...
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Identification of the Deteriorating Child: paediatric early warning & telemetry
Heather Duncan
Declaration Unlicensed medical devices
"…as the physicians say it happens in hectic fever, that in the beginning of the malady it is easy to cure but difficult to detect, but in the course of time, not having been either detected or treated in the beginning, it becomes easy to detect but difficult to cure."
The Prince Niccolò Machiavelli
1. identification/ afferent limb
2. response/ efferent limb
3. effectiveness and outcomes
Challenges
P
E
W
S
21% Duncan ADC 2007
85% Roland ADC 2007
PEWS 10 PEWS 3
Inaccurate routine observations improve
with simulation
Identification
Bonafide Pediatrics 2013
Flemming Lancet 2011
Scatter plot array showing the distribution of HR and RR in the study sample in comparison with
existing EWS point ranges.
Bonafide Pediatrics 2013
Identification
Family concerns High-risk therapies Elevated early warning score Watcher/clinician gut feeling Communication concerns
Bonafide Pediatrics 2012
Age <1 year
Epilepsy
Congenital/genetic conditions
History of transplant
Enteral tube
Hemoglobin <100 g/L
Blood culture drawn in the preceding 72 hours Bonafide J Hosp Med 2012
Antibiotics
Glycopeptides
Anaerobics
third- & fourth-generation Cephalosporins
Aminoglycosides
Systemic corticosteroids
Benzodiazepines
Loop diuretics
Narcotic analgesics (full opioid agonists)
Antidotes to hypersensitivity reactions Huang J Hosp Med 2013
Patients at Risk
RRS Outcomes
• Mortality
• Acute life-threatening events
– Cardiac arrest, respiratory arrest & other ALTEs
• Serious Adverse events
• Avoidable Harm
– Predictable
– Preventable
• Failure to rescue
Critical deterioration = ICU transfer & within 12 hours Non-invasive ventilation or Intubation or Vasopressor infusion
Brady Pediatrics. 2013
RRS Outcomes Conclusions: Chapman ICM 2009
Evidence supporting validity, reliability & utility of paediatric alert criteria is weak
Studies are needed to determine which physiological parameters should be included
Conclusions: Chan Arch Intern Med 2010
In children, RRT was associated with 37.7% reduction in rates of cardiopulmonary arrest and 21.4% reduction in hospital mortality rates
….studies frequently found evidence that reduction in cardiopulmonary arrest were prevented out of proportion to deaths, raising questions about mechanisms of improvement
CPR
Mortality
Chan Arch Intern Med 2011
Systematic Literature Review & Meta-analysis Less CPR – same mortality?
Rate of MRT preventable codes outside of the ICU by month.
Brady P W et al. Pediatrics 2013
Change in Adverse Events over time
Kirkendall Pediatrics 2012
BCH Hospital Mortality p=0.001,year to year, Odds ratio 0.92 (95%CI 0.89-0.96)
Joffe Arch Pediatr Adolesc Med 2011
23 – 44 % reduction in Hospital Mortality without a RRT
What about PIC?
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Nu
mb
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Inci
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nts
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All PIC Incident Reports and Incident Severity
All Incident Reports
All Incidents with Score > 6
Linear (All Incident Reports)
Linear (All Incidents with Score > 6)
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5 5
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Car
dia
c A
rre
sts
>1m
in (
n)
CARDIAC ARRESTS picu cardiac arrests >1min
Potentially Preventable CA>1min
15% cardiac arrests predicted by clinicians 81% predicted by adaptive models 85% predicted by both
Young Lives, BCH
PICU Cardiac Arrests > 1 min
Cardiac arrest
“better for patients, parents, siblings & hospitals”
“different models of care PIC, wards, home”
“why aren’t you doing it already…?”
Wireless monitoring
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eTi
me
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:54
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:11
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:28
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:45
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:36
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:53
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:27
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:44
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:34
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:25
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:07
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:31
HeartRate
Normal transmission
HR from PEWS
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me
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AMP2P_RespRate
RR from PEWS
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70
90
Dat
eTi
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SpO2
SpO2 from PEWS
1. identification/ afferent limb
-Use any tool well
2. response/ efferent limb
- Reduces CPR > death
3. effectiveness and outcomes
-Use any measure well
Summary
Early Warning Systems
There's no use trying to change human nature
It's been the same for a very long time
Instead, go after the tools
New tools make new practices
Better tools make better practices
Buckminster Fuller
THANK YOU Acknowledgements:
Paediatric Early Warning Group
PIC Research Team, Raje Matam, David Lowe, Nikki Kidd
PIC Risk Team, Jeff Martin, Caron Eyre