national clinical guidelines a system to support clinical ... · re s p irat or y r at e ... •...

Dr John Fitzsimons

Consultant Paediatrician and Clinical Director for Quality Improvement

HSE

Wednesday November 26th 2014

National Clinical Guidelines

– a System to Support Clinical Decisions

The National Paediatric Early Warning Score (PEWS) System

More than a number

National Clinical Excellence Symposium

Dublin Castle, November 26th 2014

Dr John Fitzsimons on behalf of the PEWS Working Group

PEWS Paediatric Early Warning Score

PEWS Paediatric Early Warning Score System

“Brighton” PEWS

Drogheda PEWS 2010

Version 4

PTO

Paediatric Observation Chart & PEWS

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!OLOLH Drogheda

PEWS

Name: Hospital Number: Date of Birth:

1. Record observations. 2. Add up shaded boxes (1 point each). 3. Enter Total PEWS 4. Act on Total PEWS (PTO)

Date

Time

! if concerned about patient

Temperature

Temperature is not used

To calculate PEWS

40

39

38

37

36

35

Heart Rate

Blood Pressure

BP is not used to calculate

PEWS

140+

130

120

110

100

90

80

70

60

50

0-49

Heart rate (number)

Respiratory Rate

40+

30

20

10

0

Respiratory rate (number)

Respiratory Distress

Mod-Severe

Mild

None

Oxygen saturation %

! if receiving Oxygen

Oxygen flow rate

! if Stridor / Apnoea

Consciousness normal (A)

Conscious decreased (VPU)

BO PU

Blood Sugar

Pain Score (0-10)

Total PEWS 0-2

3-4

5-7

Initials

Weight:

_____

KG

Version 4

PTO

Paediatric Observation Chart & PEWS

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PEWS

Name: Hospital Number: Date of Birth:

Please record call when PEWS 3 or more Please record review & action taken

Date Time PEWS Print Name (nurse in charge)

Date Time Print Name

(doctor)

Action

PEWS ACTION TO BE TAKEN MONITORING

Continue monitoring 4 Hourly

Nurse in Charge review 2 Hourly

Nurse in Charge & SHO review

Hourly

Nurse in Charge & SHO review & Registrar review

Hourly

Paediatric & anaesthetic registrar review.

Inform Consultant

Continuous

Remember: If you feel you need more help at any time, call for help – regardless of PEW Score

OUR STORY SO FAR…

A national Paediatric Early Warning Score (PEWS) System

Irish PEWS So Far…

• Jan 2014 Project initiated

• Feb 2014 Working Group Established

Project aims agreed

• Mar 2014 PEWS literature review commissioned by NCEC

Call for international examples of PEWS in practice

• April 2014 Review of international PEWS systems

• May 2014 PEWS literature review awarded to DCU

Irish PEWS So Far…

• June 2014 Parameters & cut offs selected

• Aug 2014 Draft PEWS literature completed

• Sept 2014 PEWS co-ordinator appointed

Parameters finalised – Version 1

Testing on draft observation charts begins (add 5th)

• Oct 2014 Pilot sites selected

• Nov 2014 Version 5

Compass adapted

Project Aims

• To design and support the implementation of a national PEWS system as per the National Clinical Excellence Committee guidelines for all children in hospital.

• To trial the PEWS system in ED settings

Current Working Group Claire Browne Paediatric Programme Manager Suzanne Dempsey Director of Nursing, Temple St. Demot Doherty Paediatric Anaesthetist and Intensivist John Fitzsimons (Chair) Paediatrician, Drogheda & QPS Mary Gorman Resuscitation Officer, Crumlin Rachel MacDonell (PEWS Co-ordinator) Resuscitation Officer, Crumlin Ciara Martin Paediatric ED consultant, Tallaght Alf Nicholson Paediatrician, Temple St. & National lead Marina O’Connor ADON, Drogheda Carmel O’Donnell Nurse Education Crumlin Previous Members Ethel Ryan Paediatrician & Neonatologist, Galway Anthea Savage Resuscitation Officer, Temple St Grace Turner Paediatric Programme Manager

The ideal PEWS would….

• Be easy to use

• Be sensitive and specific

• Improve prediction and situation awareness

• Prompt and direct early action

• Be reliable & reproducible

• Be appropriate across all care environments(pre-hospital, ED, Ward)

• Be used in every hospital that cares for children

• Integrate with other EWS’s and communication tools

• Be easy to evaluate

• Be easily adapted to electronic format

PEWS would also help with latent deteriorations…

• Sepsis

• Cardiomyopathy

• End stage respiratory failure

With a little help from our friends…

Don’t Loose Situation Awareness!

Situation Awareness

Perception Gather the information

Comprehension Recognise and Understand

Projection Anticipate/Predict/Mitigate/Escalate

Loss of Situation Awareness?

PEWS Project Overview

Design • Project team

• Detection & Response system

• Education

Test • Can it work?

• Findings from review

Pilot • Does it work?

Spread

Evaluate

Train the trainers

Does it improve care?

Working Group At Work

DCU Systematic Review

• Systematic review of 11 clinical guidelines & 70 research articles

• Grey literature review & interviews

• Review of detection & response systems as well as implementation & economic impact.


“positive directional trends in improving clinical based outcomes”

“there is no consensus and limited evidence about which PEW system is most useful or ‘optimal’ for paediatric contexts”


“The consequence of not investigating PEW systems as complex interventions is that... we are still unclear on what the true “active ingredients” of the PEW systems are”

Triggers

Baseline Observations Score

1.Nurse or family concerns 0, 1

2.Heart rate 0, 1, 2, 3

3.Respiratory rate 0, 1, 2, 3

4.Respiratory effort 0, 1 or 3

5.Oxygen use 0, 1, 2

6.AVPU 0, 1 or 3

Add-on Observations if PEWS > 3 (Prompting & Amplifying)

7.SpO2 0, 1, 2, 3

8.Blood Pressure 0, 1 or 3

9.Capillary refill time 0 or 1

5 Age Groups

1. 0-3 months

2. 4-11 months

3. 1-4 years

4. 5-12 years

5. 12+ years

PEWS Chart Design

Front Page

• Observation Chart

- Immediate triggers

- Aggregate scores

- Limited weighting

• Room for trigger modifications

Back Page

• Escalation plan

• ISBAR Prompts

• Sepsis plan

• GCS & Neuro Chart

• Pain chart

• Room For local additions

Back Page

Age Groups

Paediatric Sepsis 6

Get 3 Give 3 • IV or IO access and take bloods - Blood Culture & PCR - FBC - Glucose & treat if low - Blood Gas - Lactate • Urine output measure

• Early Senior input

• High flow Oxygen • IV fluids - Aim to restore circulating volume - Titrate 20mls/kg isotonic fluid over 5-10 mins. - Repeat if necessary. - Caution for fluid overload. or hepatomegaly. • Broad spectrum IV Antibiotics

ISBAR

Identify

Situation

Background

Assessment

Recommendations




• Education




Spread

Evaluate

Train the trainers


Model for Improvement

Aim

Measures

Ideas

Execution


Design •Detection & Response system •Project team reviews •DCU report




Spread

Evaluate

Train the trainers


Pilot Plan

• Four paediatric sites selected: OLCH Crumlin, CUH Temple St, University Hospital Limerick & Portiuncula.

• Training using adapted Compass training programme

• Train the trainers in December 2014

• Training of local staff & launch in January 2015

• Plan to run for 6 weeks and then to analyse before finalising the PEWS observation charts and other system elements.

Compass Training

• Paediatric version available from Australia. Only slight modifications from Adult version.

• Kept structure (mostly) but adapted the content to our needs

• Main purpose is to introduce the PEWS observation chart and the other system elements

• Refresher in paediatric resuscitation with ABCDE approach to assessment.




• Education




Spread

Evaluate

Train the trainers


Challenges ahead

• How else might we improve:

- Safety culture

- Situation awareness

- Communication

- Team work

• Measure of outcomes (hard & soft) – need for better data nationally.

Special thanks

• To Rachel MacDonell, Anthea Savage

• To Claire Browne & Paediatric Programme

• To the DCU team

• To the NCEC team

Thank You

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