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ObjectiveTo assess the value of the Emergency Department–Pediatric Early Warning Score (ED-PEWS) for triage of children with comorbidity.DesignSecondary analysis of a prospective cohort.Setting and patients53 829 consecutive ED visits of children InterventionED-PEWS, a score consisting of age and six physiological parameters.Main outcome measureA three-category reference standard as proxy for true patient urgency. We assessed discrimination and calibration of the ED-PEWS for children with comorbidity (complex and non-complex) and without comorbidity. In addition, we evaluated the value of adding the ED-PEWS to the routinely used Manchester Triage System (MTS).Results5053 (9%) children had underlying non-complex morbidity and 5537 (10%) had complex comorbidity. The c-statistic for identification of high-urgency patients was 0.86 (95% prediction interval 0.84–0.88) for children without comorbidity, 0.87 (0.82–0.92) for non-complex and 0.86 (0.84–0.88) for complex comorbidity. For high and intermediate urgency, the c-statistic was 0.63 (0.62–0.63), 0.63 (0.61–0.65) and 0.63 (0.55–0.73) respectively. Sensitivity was slightly higher for children with comorbidity (0.73–0.75 vs 0.70) at the cost of a lower specificity (0.86–0.87 vs 0.92). Calibration was largely similar. Adding the ED-PEWS to the MTS for children with comorbidity improved performance, except in the setting with few high-urgency patients.ConclusionsThe ED-PEWS has a similar performance in children with and without comorbidity. Adding the ED-PEWS to the MTS for children with comorbidity improves triage, except in the setting with few high-urgency patients.

Most children in hospital who are clinically deteriorating are monitored regularly, and their treatment is escalated effectively. However a small, but significant, number of deteriorating children experience suboptimal outcomes because of a failure to recognise and respond to acute deterioration early enough leading to unintended harm. Tragically this occasionally can have fatal consequences. Investigations into these rare events highlight common themes of missed early signs of deterioration in children, prompting regulatory agencies to suggest paediatric early warning systems (PEWS) to aid clinical practice. In England, track and trigger tools (TTT), which are one facet of PEWS have been widely rolled out but in a heterogeneous fashion. The evidence for TTT is mixed but they are complex interventions and current outcomes do not fully define the entirety of their potential impact. This article explains the rationale behind the decision of the NHS England and NHS Improvement, Royal College of Paediatrics and Child Health and Royal College of Nursing to implement a standardised inpatient PEWS as part of a system-wide paediatric observations tracking system in England and how this fits into a wider programme of activity.

BackgroundThe value of routine blood pressure measurement in the emergency department (ED) is unclear.ObjectiveTo determine the association between hypotension in addition to tachycardia and the Shock Index for serious illness.DesignObservational study.SettingUniversity ED (2009–2016).Participants, methods and main outcomesRoutine data collected from consecutive children ResultsWe included 10 698 children with measured BP. According to three age-adjusted clinical cut-offs (Advanced Paediatric Life Support, Paediatric Advanced Life Support and Paediatric Early Warning Score), hypotension was significantly associated with ICU admission when adjusted for tachycardia (range OR 2.6–5.3). Hypotension showed low sensitivity (range 0.05–0.12) and high specificity (range 0.95–0.99) for ICU admission. Combining hypotension and tachycardia did not change the predictive value for ICU admission. Similar results were found for hospitalisation. Shock index was associated with serious illness. However, no specific cut-off value was identified in different age groups.ConclusionsHypotension, adjusted for tachycardia, is associated with serious illness, although its sensitivity is limited. Shock index showed an association with serious illness, but no acceptable cut-off value could be identified. Routine BP measurement in all children to detect hypotension has limited value in the ED. Future studies need to confirm which patients could benefit from BP measurement.

The term paediatric early warning systems (PEWS) has emerged to describe an array of interventions needed to improve recognition of children who require review/escalation of care. In 2005, 21.5% of National Health Service (NHS) trusts in the UK that care for children used a PEWS1; by 2013, 85% of units were using a PEWS and 18% had an RRT (Rapid Response Teams) in place.2 The PEWS in use were extremely variable: 36 different parameters were used in various combinations in 2005, growing to 47 in 2013. In 2018, NHS England and NHS Improvement (NHSE/I), the Royal College of Paediatrics and Child Health and the Royal College of Nursing brought together a national PEWS Programme Board with the aim of producing a national PEWS for England. This letter describes the …

The national implementation groups of early warning systems in the UK and Ireland have identified a need to understand implementation, adoption and maintenance of these complex interventions. The literature on how to implement, scale, spread and sustain these systems is sparse. We describe a successful adoption and maintenance over 10 years of a paediatric early warning system as a sociotechnical intervention using the Nonadoption, Abandonment, Challenges to the Scale-Up, Spread, and Sustainability Framework for Health and Care Technologies. The requirement for iterative processes within environment, culture, policy, human action and the wider system context may explain the possible reasons for improved outcomes in small-scale implementation and meta-analyses that are not reported in multicentre randomised control trials of early warning systems.

BackgroundPaediatric early warning scores (PEWS) are widely used as an adjunct to support staff in recognising deterioration in hospitalised children. Relatively little is known about how staff use these systems.ObjectiveTo examine the completeness and accuracy of PEWS recording in hospitalised children in a tertiary specialist children’s hospital.DesignThis is a secondary analysis of retrospective, case-controlled study data. Case patients suffering from a critical deterioration event were matched with controls present on the same ward at the same time and matched for age. Data were extracted from the PEWS chart for the 48 hours before the critical deterioration event for case patients and the corresponding 48 hours period for the control. Observation sets were assessed for completeness and accuracy of PEWS scoring.ResultsIn total 297 case events in 224 patients were available for analysis. Overall 13 816 observations sets were performed, 8543 on cases and 5273 on controls. Only 4958 (35.9%) of observation sets contained a complete set of vital sign parameters and a concurrent PEWS. Errors were more prevalent in the observation sets of case patients versus controls (19.5% vs 14.1%). More errors resulted in the PEWS value being underscored rather than overscored for all observation sets (pConclusionFailure to record complete and accurate PEWS may jeopardise recognition of children who are deteriorating. Technology may offer an effective solution.

A 3-year-old boy presents to his local district general hospital with a 1-day history of fever and shortness of breath. He is admitted to the paediatric ward for ongoing observation and management. The nursing staff calculate a paediatric early warning score (PEWS), based on physiological parameters, with each set of nursing observations. The student nurse on the ward notices that your chart is different from the one used by the paediatric ward on her last placement. She asks you how accurately paediatric early warning scoring systems predict serious clinical deterioration, particularly cardiopulmonary arrest (CPA), paediatric intensive care admission or paediatric high-dependency care admission. In paediatric inpatients, can a paediatric early warning trigger or scoring system predict serious clinical deterioration? Medline 1950 to present from PubMed Cochrane Library Issue 9, September 2014 Search terms used: ((‘pediatrics’[MeSH Terms] OR ‘pediatrics’[All Fields] OR ‘paediatric’[All Fields]) OR (‘pediatrics’[MeSH Terms] OR ‘pediatrics’[All Fields] OR ‘pediatric’[All Fields])) AND (early[All Fields] AND warning[All Fields]) AND ((‘Sentinel Event Alert’[Journal] OR ‘alert’[All Fields]) AND (‘standards’[Subheading] OR ‘standards’[All Fields] OR ‘criteria’[All Fields])) No limits were placed on the search. Studies conducted on paediatric inpatient populations, aged 0–16 years, in developed countries were included. One systematic review, 12 papers validating PEWS in paediatric inpatients were found. Five …

ObjectiveThe primary objective of this study was to determine the level of inter-rater reliability between nursing staff for the Paediatric Observation Priority Score (POPS).DesignRetrospective observational study.SettingSingle-centre paediatric emergency department.Participants12 participants from a convenience sample of 21 nursing staff.InterventionsParticipants were shown video footage of three pre-recorded paediatric assessments and asked to record their own POPS for each child. The participants were blinded to the original, in-person POPS. Further data were gathered in the form of a questionnaire to determine the level of training and experience the candidate had using the POPS score prior to undertaking this study.Main outcome measuresInter-rater reliability among participants scoring of the POPS.ResultsOverall kappa value for case 1 was 0.74 (95% CI 0.605 to 0.865), case 2 was 1 (perfect agreement) and case 3 was 0.66 (95% CI 0.58 to 0.744).ConclusionThis study suggests there is good inter-rater reliability between different nurses’ use of POPS in assessing sick children in the emergency department.

ObjectivePaediatric early warning scores (EWS) were developed to detect deterioration in paediatric wards or emergency departments. The aim of this study was to assess the relationship between three paediatric EWS and clinical deterioration detected by the nurse in paediatric intermediate care units (PImCU).MethodsThis was a prospective, observational, multicentre study at seven French regional hospitals that included all children ResultsA total of 2636 children were included for 14 708 observations to compute a posteriori the EWS. The discrimination of the three EWS for predicting calls to physicians by nurses was good (range: 0.87–0.91) for the derivation cohort and moderate (range: 0.71–0.76) for the validation cohort. Equations for probability thresholds of calls to physicians, taking into account the time t, the score at time t and the score at admission, are available.ConclusionThese three EWS developed for children in paediatric wards or emergency departments can be used in PImCU to detect a clinical deterioration and predict the need for medical intervention.

Objective: To develop and test the predictability of a paediatric early warning score to identify children at risk of developing critical illness. Design: Prospective cohort study. Setting: Admissions to all paediatric wards at the University Hospital of Wales. Outcome measures: Respiratory arrest, cardiac arrest, paediatric high-dependency unit admission, paediatric intensive care unit admission and death. Results: Data were collected on 1000 patients. A single abnormal observation determined by the Cardiff and Vale paediatric early warning system (C&VPEWS) had a 89.0% sensitivity (95% CI 80.5 to 94.1), 63.9% specificity (95% CI 63.8 to 63.9), 2.2% positive predictive value (95% CI 2.0 to 2.3) and a 99.8% negative predictive value (95% CI 99.7 to 99.9) for identifying children who subsequently had an adverse outcome. The area under the receiver operating characteristic curve for the C&VPEWS score was 0.86 (95% CI 0.82 to 0.91). Conclusion: Identifying children likely to develop critical illness can be difficult. The assessment tool developed from the advanced paediatric life support guidelines on identifying sick children appears to be sensitive but not specific. If the C&VPEWS was used as a trigger to activate a rapid response team to assess the child, the majority of calls would be unnecessary.

Methods Using the science and approaches of quality improvement the Health and Social Care Safety Forum have engaged with all paediatric units in Northern Ireland in an on-going quality improvement collaborative. Results A Regional Collaborative has now been in place since August 2013. An advisory group has been established to provide focus and drive, this is chaired by a consultant paediatrician and a senior nurse acts as vice chair. To date there have been five learning sessions held with continuing support and engagement from frontline clinical staff. Communication – All paediatric units now hold safety briefings and have a structured handover in place. The collaborative has also coproduced with parent representatives a parent safety poster, video and is working with Parent Action to coproduce a parent checklist. The collaborative is building on the initial “what matters to me” approach tested in one Trust using “Daisy” the cow as a mascot. This has received multiple awards and commendations. The roll out is being supported by the “Daisy Chain” graphic, highlighting the NI linkages with local mascots to support ownership. Reduction in medication errors – including prescribing and administration errors. Development of a regional drug kardex, currently out for testing. Early detection and rescue of the sick child – the collaborative have agreed a set of regional, age bracketed early warning score charts and an agreed escalation protocol. These are currently out for testing and regional audit is underway. QI training- fundamentals of QI, human factors, situational awareness and linking with NI paediatric training schedule Conclusion The value of a regional paediatric quality improvement collaborative is that it brings clinicians, managers and parents together with a set of core aims. The collaborative gets results by engaging frontline teams in identifying the key challenges faced, generating the potential solutions and then by using the methodology, testing these in real time to see what works and importantly what doesn’t work before scaling up change.

Context This safety improvement project took place in a district general paediatric department that sees 17,000 children annually in AE around 60 of these requiring high dependency (HDU) care. This project focused on identifying areas for improvement in the care of this sickest group of patients. Problem Children who deteriorate on the ward requiring HDU care are, by definition, the sickest children, and so analysis of their care is essential to identify missed opportunities to prevent deterioration and reduce morbidity. We identified a need for a formal pathway to identify areas for improvement and to subsequently disseminate learning to clinical staff. Assessment of problem and analysis of its causes To review the care of all children who deteriorated on the ward requiring HDU care (or transfer out to PICU) we used an adapted version of the RECALL (Rapid Evaluation Cardio-respiratory Arrest with Lessons for Learning) tool. This provides a structured template to review the medical and nursing notes and identify areas for improvement. It focuses on assessment (recording of paediatric early warning score (PEWS)), escalation in response to deterioration, clinical reviews at appropriate points, interventions implemented and additional information (staffing levels, parental concerns). 37 children required HDU care in the six-month study period. The RECALL tool highlighted areas of good practice in care including accurate use of the Paediatric Early Warning Score (PEWS), and appropriate management plans acted on in a timely manner. However, it also identified areas for improvement, for example, children scoring 3 on PEWS not reported to nurse In charge or doctors, a discordance between nursing documentation and the clinical situation, and delayed medical reviews. Intervention The issues identified in the analysis were recurring themes and similar missed opportunities were identified more than once. To disseminate these lessons and also feedback areas of good practice we created a paediatric risk newsletter to be distributed regularly across the medical and nursing teams. We also commenced monthly “safety meetings” to discuss lessons learnt from the previous month. Study design This study was a retrospective analysis of the HDU data using the “RECALL structured template. Strategy for change A monthly safety newsletter incorporating the results of the RECALL analysis is disseminated electronically via secure email as well as in paper form to help us reach all staff. The newsletter allows rapid dissemination of learning. Furthermore, the monthly safety meetings have been valuable to ensure the safety lessons learnt remain at the forefront and encourages staff to remain involved with contributing to patient safety. Measurement of improvement The RECALL tool is being continually used to analyse patient care, allowing us to identify recurring themes that need to be addressed and measure the effect of changes made. These are reviewed regularly at risk meetings and displayed on a new safety noticeboard on the ward. Effects of changes Using the RECALL tool has resulted in measurable improvements. wHowever, new themes are continually identified, highlighting the need for continual vigilance and intervention to improve patient safety. Lessons learnt The RECALL tool is useful to identify improvements required in patient care, however a strategy is required to disseminate these lessons to frontline staff and engage them in continual improvement. A newsletter is a useful way of disseminating information to staff, however we have learnt that on its own it is not sufficient. We are therefore integrating a weekly learning point into the daily morning safety huddles and basing simulation scenarios on recent clinical cases. Message for others Quick prospective analysis of patients’ care using the RECALL tool is a simple way to identify missed opportunities to prevent deterioration. When recurring themes are identified staff education is critical to improve care. A newsletter is an efficient way of disseminating information.

Context This project was performed in the Maternity and Neonatal unit of a tertiary hospital in Scotland. Involvement was from midwifery, quality improvement, e-health and neonatal staff Problem Infants were not routinely screened for risk factors associated with acute deterioration in the postnatal period. There is a risk of serious harm which could be more quickly acted upon. Assessment of problem and analysis of its causes The postnatal period is extremely busy for staff. Midwives are looking after many mothers and infants and need to prioritise cases. The neonatal unit noted that the risk assessment of infants in our centre was largely ad-hoc. A standardised approach has been suggested by the International Liaison Committee on Resuscitation (ILCOR). A tool for assessing every infant was needed for those carrying out the assessment. Intervention Doctors created a checklist to be completed for each infant. Recognised risk factors trigger a Neonatal Early Warning Score Chart which creates a score based on observations over time. The risk assessment tool was initially a sheet of paper for completion before transfer from the labour ward to the postnatal wards. A simplified electronic version of the tool was then implemented and joined to an assessment performed on every infant within an hour of birth. The questions were made mandatory and required username and password input for completion. Study design Not formal research. Snapshot audits performed and cycles of intervention and re-audit implemented. Strategy for change The change was implemented over a 6 month period. Doctors, Midwives, E-health and quality improvement team members were all involved. The paper version of the tool was distributed to the wards and discussed at morning handovers and safety briefings. An e-learning module was created and posters presented throught the department. The results of "snap shot" audits were fed back to the "Safety Lead" Midwife for dissemination. An electronic version of the tool was created and the change in procedure was explained at the same daily meetings over several occasions Measurement of improvement The acute effect of the interventions has been a measure of 9Risk assessment tool9 use and completion rate. This was performed by analysis of 20 neonatal patient records in each snapshot looking for the presence of the risk assessment tool, whether it had been completed correctly and reasons why if this was not the case. Outcomes from the electronic version are under review currently showing improved completion rates and static quality. Effects of changes Initially the tool had a poor implementation rate and was often incomplete. The worst performance was for the legal aspects of the document. This was improved with practical measures but lacked accountability. An electronic version of the assessment automatically generated all the legal documentation and identified the assessor. There are still occasions when time constraints delay the time of the assessment but these are far less common. One of the big challenge was creating an audit model that was sustainable and could evolve over time to ensure progress in other associated areas of postnatal care. Lessons learnt The project was refined with key input from all departments which lead to a more sustainable project. Projects that combine jobs and reduce paperwork are the most likely to succeed. Everything takes longer than you think. Next time I would get all members together before the project to discuss challenges and feasibility of the planned changes. Message for others The implementation of a universal newborn screening tool is achievable. Use of an electronic version is recommended. This should lead to earlier recognition of the unstable neonate.

Context Effective triage of paediatric patients is challenging due to normal physiologically parameters varying with age. Paediatric Early Warning Score (PEWS) is an adapted tool that can be used to identify sick patients by stratifying them into four age categories and assigning a numerical score. PEWS of 3+ warrants prompt senior review (ST3+) within 30 min whilst PEWS of 2 warrants prompt review (but not necessarily senior) within 30 min. PEWS of 0 or 1 are less unwell and therefore able to wait. Problem Due to service reconfiguration a new Paediatric Assessment Unit (PAU) was opened in Autumn 2014 but concerns were raised that a PEWS based initial triage was not being implemented correctly. Assessment of problem and analysis of its causes Dual approach using both quantitative and qualitative data was used to assess the issue. 43 of 55 patients’ notes were reviewed over one week in October 2014. All patients had triage observations documented but 18 (42%) did not have PEWS calculated. Of the 25 (58%) which had PEWS documented only 18 (72%) were correct. Overall only 41% of patients had the correct PEWS assigned at triage. Regarding escalation only 62% of patients with higher PEWS followed the protocol for prompt medical review of appropriate seniority. Discussions with members of staff working in PAU highlighted many contributing factors including time pressure and unfamiliarity with PEWS escalation policy. Intervention An interactive departmental MDT teaching session held in early January 2015. Attendees were presented with a series of patients of different ages and asked to triage based on their initial observations. The correct PEWS were given and the appropriate escalation discussed. This acted as a platform for open discussion across the MDT around potential solutions. One point identified was the high level of accurate PEWS documentation when using the inpatient observation charts. These are stratified for age and colour coded so that abnormal values are visually highlighted as recorded. As a direct result of this meeting inpatient PEWS charts were incorporated into the triage process. Study design Retrospective study that reviewed patient notes after attending PAU. Strategy for change Our strategy throughout the process has been focused on empowering PAU staff and engaging with them in order to maximise the effectiveness of the triage process. Measurement of improvement All PAU patients over one week in April 2015 were included and their notes reviewed for triage observations, PEWS and time of medical review. These values were compared to the baseline data collected in October 2014 to measure improvement. Effects of changes Repeat cycle of 51 patients showed 39 (76%) had PEWS documented of which 34 (87%) were correct. This meant that now 66% of all patients were assigned the correct PEWS on triage compared to 41% originally. 83% of high PEWS patients were escalation appropriately up from 62% at baseline. Lessons learnt Key learning points included the effectiveness of an interactive teaching scenario to break the ice in an MDT audience in order to maximise constructive discussion from all parties. Another was that change does not necessary require new resources to be designed specifically but to reconsider the use of available tools. This not only minimises cost but also enables quick implementation, as staff are already familiar with the resource. Message for others Paediatric triage is a challenging process due to multiple contributing factors. An MDT approach to education and brainstorming solutions can be pivotal in shifting culture and improving effectiveness of such a dynamic process.

Context According to the British Association of Perinatal Medicine Categories of Care 2011, a baby receiving transitional care (TC) must be resident with the mother. Problem TC admissions and neonatal intravenous antibiotic administration (n-IVAB) on the neonatal unit (NNU), which was geographically remote from the postnatal ward, resulted in mother-baby separation soon after birth and suboptimal documentation. Assessment of problem and analysis of its causes Three audits over four months in 2012 showed that: 3–10% of admissions to NNU represented between 23–62 TC bed days per month There were 905 episodes of n-IVAB administration Only 30% of TC babies had complete/accurate documentation, 59% had an incomplete/inaccurate record and 11% were not recorded at all Engaging staff Audit results were presented to the stakeholders in a combined meeting across Maternity, Neonatal, Divisional Management, Pharmacy and Estates Departments Strategy for change Agreed criteria for admission to the TCW Introduced a proforma to allow accurate documentation for each TC admission, management and discharge plan Intervention Delineated a transitional care ward (TCW) within the postnatal ward Provided 24 h TCW cover with allocated neonatal nurses administering n-IVAB and undertaking neonatal observations Adopted the Neonatal National Early Warning Score (nNEWS) for recording observations on TC babies Initiated midwifery training in checking neonatal drugs and providing opportunities for practice development in neonatal care Measurement of improvement Following implementation, a 4 week pilot showed 34 TCW admissions and 183 episodes of n-IVAB administration on TC, matching previous TC activity and now no longer required to be undertaken on NNU. Effects of change All TC babies are now managed on TCW, preventing mother-baby separation and allowing improved quality of care via a new neonatal/maternity working partnership. Lessons learnt Service improvement to an inefficient but established NHS system has proved challenging because of changes required to the physical working environment and the impact on staff of new working patterns and documentation. Message for others The implementation of a neonatal TCW has been achieved by motivating buy in from diverse stakeholders, excellent interpersonal skills and a solution-based approach focussed on keeping TC babies together with their mothers to improve quality of care.

Aim Following an audit in 2012, which identified variability in the recognition and escalation of deteriorating patients, Safety Huddles were introduced, utilising a Childrens’ Early Warning Score (CEWS), to enhance situation awareness. Huddles are scheduled, regular multi-professional meetings, no longer than ten minutes, held in the clinical environment alongside an interactive electronic patient board. The sickest and most at risk patients (CEWs > 2) are identified, prompting immediate and appropriate escalation. Four additional risk factors (family concerns, high risk therapies, clinicians’ gut feeling and communication concerns) further identify patients as ‘watchers’. Huddles provide: - Optimum safety through elimination of avoidable harm - Greater empowerment and accountability of all staff through shared decision making Our aim was to evaluate the attitudes and understanding of front-line staff regarding the purpose and effectiveness of Huddles, 18 months on. Methods A voluntary, anonymous online survey was disseminated to staff across 3 clinical areas (2 wards, 1 outpatients). Ethical approval was not required. Results 41 responses were returned. Respondents included 2 consultants, 4 registrars, 24 nurses, 1 nursing student, 1 healthcare assistant, 2 pharmacists and 5 interpreters. The majority rated their understanding regarding the purpose of the Huddle as “good” (51%) or “excellent” (41%). 88% described the Huddle as an “important aspect” of their work, 98% no longer requiring reminders to attend. Subjectively, the Huddle led to improvements in: Team Communication (95%), Patient/carer involvement (63%), Staff support (80%), identification of deteriorating patients (93%) and timely escalation (90%). 83% felt better informed about patients not specifically allocated to their care. 50% felt Huddles should occur with increased frequency. Crucially, 93% felt enabled to have their concerns heard. Problems identified included punctuality of start times and occasional non-attendance of doctors, which subjectively lessened the value of the Huddle. Conclusion Huddles are regarded as useful by the vast majority of staff and are an inclusive, empowering, non-hierarchical method of information sharing regarding patient safety. Our findings have been shared with all staff and suggested modifications are being considered. Huddles are now being introduced across UK 12 sites as part of the SAFE collaborative of RCPCH.

Aim The aim of this abstract is to describe the process of engaging and supporting those working in the paediatric service across an entire health system in a Quality Improvement (QI) programme and to describe its outcomes to date. Methods Using the Institute for Healthcare Improvement “breakthrough collaborative” methodology, the Northern Ireland Health and Social Care Safety Forum engaged with all paediatric units to agree areas for quality improvement and to develop these into a regional driver diagram. The areas for improvement agreed upon were: Communication – focusing on handovers, structured communications tools e.g. IPASS and SBAR, the use of safety briefings and the quality of ward rounds. The collaborative has also worked with parent representatives to develop a parent safety poster for use in all paediatric units in Northern Ireland. Reduction in medication errors – including prescribing and administration errors Early detection and rescue of the sick child – the collaborative have agreed a set of regional age bracketed early warning score charts and an agreed escalation protocol. Management and Leadership – Optimising the flow of children in the acute setting The initial three learning sessions were held over a 12 month period with action periods between. Each Trust sent a core multidisciplinary clinical team to the learning sessions and reported progress in an “all teach, all learn” environment. The Model for Improvement was used to test and implement changes. Results Figure 1 Regional Driver Diagram and participating units Figure 2 – Examples of Improvement work undertaken as part of the collaborative Early detection of deterioration Figure 3 – parent safety poster Conclusion The value of a regional paediatric quality improvement collaborative is that it brings clinicians, managers and parents together with a set of core aims. The collaborative gets results by engaging frontline teams in identifying the key challenges faced, generating the potential solutions and then by using the methodology, testing these in real time to see what works and importantly what doesn’t work before scaling up change.

Aim To look at the effect of the consultant delivered care in comparison to the registrar delivered care on the clinical services, patient care, satisfaction and staff opinion. Method All the patients attending our paediatric assessment unit between 1130 am and 2100 were assessed on three consecutive days for two weeks. The parameters compared were the length of time taken to make a clinical decision from the time the patient was seen, investigations performed, any readmissions, patient outcome, any significant incidents, patient satisfaction and nursing staff opinion. Results A total of 51 patients were analysed. 21 of them were seen by the consultants and 29 were seen by the registrars. The time taken for Consultants to make the clinical decision and management plan varied from 15 to 100 minutes with a median of 30 minutes and mean of 39.6 minutes. The registrars took 90 to 480 minutes for the clinical decision with a median time of 250 minutes and mean of 233 minutes. 4 (19%) and 16 (55%) patients seen by consultants and registrars had investigations respectively. 2 patients, seen by registrars, with Paediatric Early Warning Score of more than 4 were admitted after 280 min. One of these patients needed HDU admission and was transferred to specialist hospital. Another patient was diagnosed to have sepsis and had acute deterioration. 16 (76%) patients were discharged home and 5 (24%) patients were admitted by consultants. In the group seen by registrars or speciality trainees, 10 patients (34.5%) were sent home, 17 were admitted (59%) and 2 were transferred out. There was one readmission from the group seen by the speciality trainees Patients’ satisfaction survey was similar in both groups. Nursing staff in POAU felt there was quicker decision making and more precise plans when seen by the Consultants. Conclusion The consultants made faster decision, performed less investigations and discharged more patients home with no readmissions or clinical incidents.

Background This preliminary audit aimed to assess the feasibility of referring children presenting to a UK District General Hospital Emergency Department (ED), seeing 27500 children per year, to their own Primary Care General Practitioner (GP) following an initial assessment in the ED. Method One hundred and fifty-two patients were assessed by a Consultant in Paediatric Emergency Medicine in the ED during the triage process. Those fulfilling the audit inclusion criteria were referred directly from triage to their own off-site Primary Care GP for a same-day assessment. Results Only ten patients (6.6%) fulfilled the inclusion criteria for referral to Primary Care and seven (70%) of these were accepted, none of whom were referred back to the hospital acutely by their GP. The median time spent in the ED for the 152 patients assessed in the audit was 1 hour 12 minutes and for the 10 patients referred to Primary Care was 31 minutes. Conclusions Only a small number of children assessed in the audit were suitable for referral to Primary Care. The assessment and referral process was not a good use of Emergency Department resources. The absence of a valid and reliable screening tool or early warning score to predict the safe discharge of children from an ED reduced the number of children that could be referred directly to primary care from the ED. Further multi-centre work is required to evaluate a clinical decision-making framework to enable the accurate assessment of children for their safe discharge or referral from an ED.

This study was designed to determine the impact of the internship experience on the BSTP. The survey evaluated job allocations, intern education, clinical skills development, and exposure to patient care. A combination of binary responses (yes, no) and Likert scoring (cuing at 1 never/disagree, and at 6 always/strongly agree) were used to code responses. Thirty five trainees responded (all those present at a study day), representing 60% of all trainees. These trainees undertook approximately 130 rotations, with 12 (34%) undertaking a paediatric rotation. Relating to intern education; only 10 (28%) of trainees had a mentor. Education was frequently provided as scheduled (Likert mean (LM) 3.82). The preferred method of teaching was bedside delivered. Interns strongly agreed that time management (LM 5.0, Positive skew (PS) 82%) and communication skills (LM 4.9, PS 71%) were clinical skills developed during intern year Relating to exposure to patient care; Interns were frequently out of their comfort zone in dealing with patients (LM 4.3, PS 41%). Most said they had never been debriefed after attending an emergency situation (LM 1.7, PS 3%). An elevated Early Warning Score (EWS) in Irish hospitals precludes intern assessment however this rule is frequently ignored (LM 4.9, PS 80%). Interns infrequently clerked patients in the emergency department (LM 2.6, PS 14%), although many agreed that interns should be clerking patients (LM 4.4, PS 55%) This survey highlights the variability of the internship experience in Ireland, and highlights some areas where direct improvements could be made.

Background Our institution is the only tertiary paediatric oncology centre serving a low-income country with a population of over 35 million. Outcomes are limited by social factors, material resources and shortages of qualified health care workers. Many children do not benefit from available chemotherapy drugs due to high mortality from treatment-related toxicity. Objectives To improve in-patient supportive care Methods At the beginning of the intervention (July 2011) discussion among medical, nursing, and pharmacy staff identified sepsis as a top preventable cause of morbidity and mortality among paediatric in-patients. Monitoring of vital signs, safe systems for fluid and drug prescribing and administration, and a standardised approach to managing neutropaenic fever were identified as key areas for intervention. Several tools were designed and implemented to address these concerns, including a paediatric observation chart, modified Paediatric Early Warning Score, drug and fluid prescription charts, and local clinical guideline for management of febrile neutropaenia. Implementation of bedside charts and compliance with sepsis guideline were audited on ward round spot audits conducted on average twice per week over the course of three follow-up visits (April 2012 – July 2013). Results Previous to these interventions no children had observations charted at the bedside and vitals were rarely documented in notes. Post implementation of bedside charts, over 90% of children seen on ward rounds had bedside observation, drug, and fluid charts. Vitals were recorded on average once per day, more often in children on the febrile neutropaenia protocol. Pulse, oxygen saturation and blood pressure were documented at least once per day in 75–95% of instances, and respiratory rate 90% of instances where the drug in question was an antibiotic. Over 95% of neutropaenic children with a documented episode of fever in the preceding 12 h had appropriate antibiotics prescribed and administered as per local guideline. Conclusion Our experience demonstrates that these simple interventions are sustainable and have improved the standard of patient care. This has been associated with earlier recognition and treatment of patients with febrile neutropaenia.

Introduction Early Warning Scores are associated with an increase in early detection of illness (true positive), high scores without clinical deterioration (false positive) and clinician over-ride or alarm fatigue that leads to missed detection (false negative). Aim: To establish the prevalence of false positive and false negative alerts generated by the Paediatric Early Warning Score (PEWS) Methods Data collection occurred on three different days selected purposefully for when the hospital would have the maximum number of patients and a representative case mix of medical and surgical patients. The PEWS score and physiological parameters for the patients were entered on a secure database. For patients with high PEWS (>/= 9), notes were reviewed and nursing staff were contacted for clarification of the action taken and bedside management and escalation plan. This is similar to routine Trust wide safety audits. Results: 248 patients’ PEWS charts from 300 inpatient beds were reviewed over 3 days. 87% of the patients had observations in their PEWS chart, with a physiological value against their PEW score. PEWS were scored more >9 in 2%, 5–8 in 13% and 1–4 in 85% of patients. Majority of the patients with high PEWS were from the cardiac, respiratory and post-operative units. In 46 and 57% of the patients with PEWS >/= 9 and 4–8 respectively, inappropriate response was taken. During this period 4 of the patients were admitted to the PICU from the wards. Conclusion 2% of patients had score >/= 9 and so even if these are false positives it is a small burden. Clinicians do override the PEWs recommendations. Is this due to poor calibration of the score or clinician disbelief?

Aim Our aim is to evaluate if Paediatric Illness Severity Assessment (PISA) and PEWS can be used as a combined tool for safe discharge of patients from Paediatric Observation and Assessment unit (POAU). Method We reviewed the PISA and PEWS scoring on patients attending our POAU over a busy winter on three randomised days. All patients routinely had PEWS assessed by nursing staff at the time of admission, discharge and as needed in between these two. PISA was calculated from the clinical notes. The combined tool was used to assess whether patient needed admission or discharged home. If discharged home, data was collected if there were any complications or readmissions. Results A total of 52 patients were studied. Their age range varied from 1 day to 15 years. 37 patients were discharged home and 15 were admitted to the hospital. All of the children who were discharged had an initial PEWS score of or less than 4 or had good response with the PEWS score dropping to 0 to 2 with intervention, while their PISA grading suggested mild or moderate risk. There were no major complications in those who were discharged home. One patient was readmitted, which the parent was already cautioned. 5 patients who were admitted to the hospital had PEWS score of 0 to 2 but their PISA grading was moderate to severe risk, indicating the need for hospital admission. All those with an initial PEWS scoring above 4 or those with persistent score above 3 needed hospital admission and their PISA grading suggested moderate risk. The combined PISA and PEWS tool, in our study, when used for discharge, had a sensitivity (the probability of the child being discharged) of 100% and specificity of 97.3% with a PEWS scoring below 2 and PISA grading of mild risk. Conclusion The Combined tool with PISA and PEWS provides clinical guidance in safely discharging patients home from the observation and assessment unit. We recommend performing a prospective study to validate this combined tool in a larger study population.

Background and Aims Structured observations and examination are crucial. However, paediatric early warning scoring systems is a relatively new concept. We aimed to investigate the feasibility of a modified version of the Brighton paediatric early warning score (PEWS) in our department. Methods The PEWS consists of respiratory, circulatory and behavioural parameters with 0–3 points assigned for each category. Persisting postoperative vomiting and continuous inhalation medications give 2 extra points each. Hence, a score of 0 to13 can be assigned, score 0 being most favorable. All acutely referred children in April/May 2011 were scored. Patients were retrospectively categorized into diagnose groups. We included patients with score 0 (n=89) and those with scores ≥4 (n= 49). Results The 0 group: Sixty percent of patients considered to be well enough to be sent home without admittance to the ward had a PEWS of 0. Only 10% of patients that were admitted had a PEWS of 0. Allergic reactions (excl. anaphylaxis), arthritis, vasculitis, abnormal head circumference, psychosomatic disorders, constipation and upper respiratory tract infection typically gave low PEWS. The ≥ 4 group: Diagnoses like asthma, bronchiolitis and other lower respiratory tract infections gave almost invariably high PEWS. In addition, cardiological conditions gave PEWS ≥4. PEWS scoring varied with age as 18/35 (60 %) of 0–2 year olds scored ≥ 4, 11/20 (55 %) at 2 years and only 17/83 (20 %) of patients >3 years scored ≥4. Conclusions The modified PEWS may be a useful method to detect high-risk patients in our department.

Background Akershus University Hospital is the largest acute care hospital in Norway. It employs 6.200 people to serve 460.000 inhabitants, of which 115.000 are children. Currently, our Department is experiencing an increased admission of critically ill children, which let physicians and nurses feel overwhelmed and insecure. Our project aimed to improve knowledge, communication and documentation to meet today’s standards for quality of care. Methods Based on the Acute-Life-Threatening-Events-Recognition-Treatment (ALERT TM ) courses, the Airway-Breathing-Circulation-Disability-Exposure (ABCDE) algorithm, and the Identify-Situation-Background-Assessment-Recommendation (ISBAR) tool, we have developed an interactive platform for physician and nurses to improve clinical communication and to standardize assessment for intensive care patients. Furthermore, we have introduced the Brigthon Paediatric Early Warning Score (PEWS) to detect children with the highest risk for cardio-respiratory failure. Results Our healthcare providers have benefited from this program. For example, they gained useful skills to create efficient work flows and improve team communication. For half an hour every other week, we play a scenario where 2 physicians and 2 nurses practice the ABCDE algorithm, ISBAR tool and the PEWS in a simulated patient. We have implemented training courses (Casetrening) to help them use the various assessment tools. Our main focus is to provide high quality of care, patient safety and efficient clinical operations. However, we understand that it takes an ongoing effort to introduce a systematic method in practice. Conclusion We have introduced a program for physicians and nurses to increase clinical competence and patient care with a high potential for further development.

Objectives To assess if the antibiotic regimens being instituted are according to the NUH febrile neutropaenia guideline. To determine if gentamicin levels are being taken appropriately and are within recommended limits. To assess if the Paediatric Early Warning Score (PEWS) or the C reactive protein (CRP) is able to distinguish at admission those children who are more likely to have an unfavourable outcome. To determine the percentage of children who receive antibiotics within 1h of presentation. Methods Patients admitted to NUH with febrile neutropaenia between August and November 2010 were identified from clinical notes. PEWS data and CRP values were collected at admission, 24 and 48 h from nursing observation charts and the NUH results system (NotIS) respectively. Antibiotic levels were retrieved from NotIS. The door to antibiotic time was calculated from the admission time recorded on nursing admission notes and the time at which the first dose of antibiotic was documented on the drug chart. Results Data were collected from 20 patients aged 1.3–16.6 years (median 9.4 years). 13 patients (65%) were started on first line antibiotics in line with the NUH febrile neutropaenia guideline. Two patients were incorrectly given gentamicin as they were receiving nephrotoxic chemotherapy regimens. Gentamicin levels were available for 17 patients. 14 patients (82%) had levels taken correctly of which eight patients (57%) were within the specified range and 5 (36%) had low post dose levels. Median PEWS scores was 4 (20 patients) and CRP was reported on admission for eight patients (mean 10). Five patients had positive blood cultures but none were admitted to intensive care or died. The door to antibiotic time was determined in 11 patients and was less than 1 h in five patients (45%, mean 94 min). Conclusions The majority of patients received first line antibiotics in accordance with the NUH febrile neutropaenia guideline. Since this review was completed the Trust has switched to once daily dosing of gentamicin and there has been a new guideline publicised. As a consequence of this change it is imperative that pre dose levels are measured correctly but post dose levels are no longer required. This review did not demonstrate any correlation between CRP or PEWS score and positive blood cultures or length of stay however larger studies are needed to investigate this further. In nearly half of patients the door to antibiotic time could not be determined from the medical or nursing notes. This highlights the need for a more robust system to be in place to record the time that patients present to hospital.