[ppt]powerpoint presentation - welcome to nhs networks ... · web viewthe confidential enquiry...
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T Pillay SSBCNNOct 2012
Implementing a Newborn Early Warning System
in the SSBC NN
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FIGURE 1 The ambulance corps of Baron Dominique-Jean Larrey, circa 1809.
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Triage: rapid sorting, unwell patients
Illness identification: defining features of illness
Early Warning System: hospital wardsidentify patients at risk of
deterioration
Roland 2012, Arch Dis Paed Ed Pract
Scoring Systems
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Antecedent events of acute deterioration/transfer to ICU:
‘Often early clinical signs missed’
Early Warning Systems Recommended
CEMACH report 2006 NPSA 2007, 2009
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The Confidential Enquiry into Maternal and Childhood
Death Report, Why Children Die–
A Pilot Study 2006
For paediatric care in hospital - recommend a
standardised and rational monitoring system with
imbedded early identification systems for children
developing critical illness - an early warning score
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Standardisation
Improve care for acutely ill
Addresses variability in
detecting clinical Illness early
2012
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Cohort: 170 non-ICU RRT and 16 code events
Test: Retrospective PEWS in last 24 hrs
Outcome: Earliest indicator of deterioration
detected a median of 11 hr 36 min in
85.5% of cases
Sensitivity of Pediatric EWS to Identify Patient Deterioration
Akre et alPediatrics, 2010; 125 : e763-769California, Minnesota
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Sensitivity and Specificity to Identify Patient Deterioration
Skaletzky et alClin Pediatr 2012 May;51(5):431-5. Epub 2011 Dec 8.Miami Children’s Hospital, Miami, FL 33155, USA.
Validation of a modified pediatric early warning system score: a retrospective case-control study.
Cohort: 100 cases 250 controls; ward patients
Test: Retrospective PEWS
Outcome: Sensitivity 62%
Specificity 89%
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Can it make a difference to outcome?
Paediatric EWS Brighton:
• Early identification of children at risk
• Fewer codes
• More timely transfer to ICU
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Which baby will it potentially benefit?
Hospitalised
Not critically ill, but under observation
Babies who are stable, but can deteriorate
At Risk Neonatal Infant
Neonatal Early Warning System
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No defined directive for babies
Benefit?
At Risk Neonatal Infants : ARNI
Post natal ward
Transitional care, SCBU
Neonatal Early Warning System
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• limited information on
• progressive morbidity in early postnatal period in
ARNI
• the triage process, from post natal ward
observations to review, investigations, intervention,
admission to NNU
Neonatal Early Warning System
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• What impact does time to review/intervene have in
ARNI with progressive deterioration?
Neonatal Early Warning System
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• What impact does time to review/intervene have in
ARNI with progressive deterioration?
• Sudden Unexpected Postnatal Collapse/Death
(incidence 0.05/1000 live births)
Neonatal Early Warning System
J-C BecherArch Dis Child FN 2012 F30-4
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• Can it influence provision of care?
• Can it influence outcomes?
Neonatal Early Warning System
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Limitations with Newborn Early Warning Systems
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Neonatal Early Warning System
Roland, Madar, Connolly. Infant 117-120, Vol6, Issue 4, 2012
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Retrospective review : 122 term infants
48% ARNI had observations recorded
52% would have had earlier review with NEWS
Implementation of a Neonatal Early Warning System
Roland D, Madar J, Conolly GInfant 2010; Vol 6, Issue 4 116-121
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Prospective Study : 117 term infants
71.2 % observations recorded
Prompted management decision in 43% of
infants requiring intervention
Facilitates observation of babies assumed to be at risk
Prompts earlier review in those showing clinical deterioration
Considered beneficial by majority of midwives using it
Implementation of a Neonatal Early Warning System
Roland D, Madar J, Conolly GInfant 2010; Vol 6, Issue 4 116-121
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England
Variable implementation eg
Plymouth, Liverpool, Cambridge, Northern Neonatal
Network; not standardised
Scotland
Widespread standardised implementation in NHS,
Orkney, Shetland
Implementation of a Neonatal Early Warning System
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Scottish NHS: widespread use; SCBU and post natal wards, some HDU patients
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Criteria for Newborn EWS Observation
Meconium at delivery
PROM
Maternal pyrexia/infection/chorioamnionitits
SGA
All babies in Transitional care
Poor feeding
Grunting
Hypoglycaemia
Hypothermia
Other, as determined by Midwife/ANNP/Medical team
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Theresa Pilsbury (midwifery) NXH
Claire Cockburn, Nicola Taylor, Pam Smith (NNU) RHH
Anne Clark/Jane Henley Walsall
Gina Hartwell (NNU) MSG
Emma Hubball (midwifery) UHNS
Matthew Nash Grid Trainee
SSBC NN Team
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Positive:
Stopped false calls
Highlighted the 'zig zag' baby
Prompted staff action when they might otherwise not have acted
Empowered midwifery support for post natal babies
Feedback
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Negative:
Parent perception of scoring
Documentation
Lack of common sense approach to duration
/frequency of observations
‘Why do we need a score if we can recognise a
baby becoming ill?’
Cost
Feedback
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Critical thinking
Ease of observation
Easy visualization of problematic baby
Standardized escalation system
Nurses role in EWS
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Does it add value to post natal care provided?
Does it streamline nursing service provision?
Is it cost effective and time – effective?
Does it empower nursing team to think critically?
Does it make a difference to outcome?
Future Questions
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Audit/review of effectiveness:
False positives (hypersensitivity)
False negatives (babies not picked up)
Future Questions
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Fashionable Promoted through National bodies for
Adults/Paediatrics No standardised approach in Neonates
No clear idea as to whether it is indicatedit will make a difference
in At Risk Neonates, not managed in HDU/ICU
Being trialed in SSBC NN
Conclusion