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Paediatric tracheostomy is most commonly performed in children on the paediatric intensive care unit (PICU) to facilitate long-term ventilation. We sought to identify trends in UK tracheostomy practice in PICUs. Data were analysed from 250 261 admissions, including 4409 children tracheostomised between 2003 and 2017. The incidence of tracheostomy in 2017 was approximately half that in 2003 (incidence rate ratio=0.48, 95% CI 0.40 to 0.57). The percentage of patients tracheostomised during a PICU admission, as a proportion of all admissions, was 2.44% (n=319) in 2003 and reduced to 0.97% (n=180) in 2017. Nevertheless, we identified great variability in practice between different PICUs with tracheostomy rates between 0.0% and 4.0% of all admissions. Risk-adjusted PICU mortality was comparable between tracheostomised children and all admissions to PICU.

AimDifferences in the gaze behaviour of experts and novices are described in aviation and surgery. This study sought to describe the gaze behaviour of clinicians from different training backgrounds during a simulated paediatric emergency.MethodsClinicians from four clinical areas undertook a simulated emergency. Participants wore SMI (SensoMotoric Instruments) eye tracking glasses. We measured the fixation count and dwell time on predefined areas of interest and the time taken to key clinical interventions.ResultsPaediatric intensive care unit (PICU) consultants performed best and focused longer on the chest and airway. Paediatric consultants and trainees spent longer looking at the defibrillator and algorithm (51 180 ms and 50 551 ms, respectively) than the PICU and paediatric emergency medicine consultants.ConclusionsThis study is the first to describe differences in the gaze behaviour between experts and novices in a resuscitation. They mirror those described in aviation and surgery. Further research is needed to evaluate the potential use of eye tracking as an educational tool.

ObjectiveTo understand the impact of the National Institute for Health and Care Excellence (NICE) bronchiolitis guidelines on the management of children referred to paediatric intensive care unit (PICU) with bronchiolitis.Design and settingData were collected on all children referred to a regional PICU transport service with the clinical diagnosis of bronchiolitis during the winter prior to the NICE consultation period (2011–2012) and during the winter after publication (2015–2016). Management initiated by the referring hospital was assessed.ResultsThere were 165 infants referred with bronchiolitis in epoch 1 and 187 in epoch 2. Nebuliser use increased from 28% in epoch 1 to 53% in epoch 2. Increased use of high-flow nasal cannula oxygen and reduction in continuous positive airway pressure use were observed. The use of antibiotics did not change between epochs.ConclusionThe use of nebulised therapies has increased in the management of severe bronchiolitis despite national guidance to the contrary.

IntroductionPaediatric Intensive Care Unit Nurses (PICU RNs) manage the code cart during paediatric emergencies at the Children’s Hospital at Dartmouth-Hitchcock. These are low -frequency, high-stakes events.MethodsAn uncontrolled intervention study with 6-month follow-up. A collaboration of physician and nursing experts developed a rolling-refresher training programme consisting of five simulated scenarios, including 22 code cart skills, to establish nursing code cart competency. The cohort of PICU RNs underwent a competency assessment in training 1. To achieve competence, the participating RN received immediate feedback and instruction and repeated each task until mastery during training 1. The competencies were repeated 6 months later, designated training 2.ResultsThirty-two RNs participated in training 1. Sixteen RNs (50%) completed the second training. Our rolling-refresher training programme resulted in a 43% reduction in the odds of first attempt failures between training 1 and training 2 (p=0.01). Multivariate linear regression evaluating the difference in first attempt failure between training 1 and training 2 revealed that the following covariates were not significantly associated with this improvement: interval Paediatric Advanced Life Support training, interval use of the code cart or defibrillator (either real or simulated) and time between training sessions. Univariate analysis between the two trainings revealed a statistically significant reduction in first attempt failures for: preparing an epinephrine infusion (72% vs 41%, p=0.04) and providing bag-mask ventilation (28% vs 0%, p=0.02).ConclusionsOur rolling-refresher training programme demonstrated significant improvement in performance for low-frequency, high-risk skills required to manage a paediatric code cart with retention after initial training.

Sepsis is the leading cause of child's death, yet it is well known that the rapid initiation of simple, timely interventions reduces morbidity and mortality. This paper shares our findings on the barriers doctors in training have identified to delivering such care. We also share the results of a pilot paediatric intensive care unit outreach teaching programme designed to directly address these highlighted concerns.

Oliver discusses some ethical issues that arise from changing pathways of care to manage demand.1 We present another altered treatment paradigm from the first wave of covid-19 that required novel ethical decision making. Similar to Massachusetts General Hospital for Children,2 Alder Hey Children’s NHS Foundation Trust accommodated adults in its paediatric intensive care unit. Fortunately, few local children with covid-19 were admitted to hospital, so the trust offered to relieve pressure on adult services. Anticipating …

AimTo perform a retrospective analysis of tenfold medication errors between the 1st January 2017 and the 31st December 2018 and identify contributing factors.MethodInformation from all tenfold medication errors reported to the Ulysses system between 1st January 2017 and 31st December 2018 which met the criteria was inputted into a data collection sheet. Information gathered included the age of the patient, the time the error occurred, the location within the hospital, the point in the medication process the error occurred, the drug involved and the NCC-MERP category of harm assigned to the error. Reports were excluded if they were repeated entries or if they did not meet the criteria for a tenfold medication error. The total number of medication errors reported per month and the total number of admissions per month was also identified. Once data collection was complete, these errors were qualitatively analysed and compared with those of a previous audit using errors reported from 1st January 2013 to 31st December 2014.ResultsTenfold errors were most likely to be reported in the Critical Care areas (34.4% of tenfold errors being reported over the two-year period). Prescribing was the most common origin of error accounting for 54.3% of tenfold errors in 2017 and 51.7% in 2018. The most common category of harm assigned was category B (no harm – error did not reach patient) with a total of 40.6% of the errors reported. The age group with the highest number of errors reported was 29–364 days with 39.3% tenfold medication errors reported over the two-year period. Morphine was the most common drug involved accounting for 13.8% of errors reported.ConclusionThe findings from this report mirror the results from the previous audit performed in 2014 in respect to error origin and patient age. Tenfold prescribing errors have more chance of being intercepted before reaching the patient due to there being more steps in the process before administration, therefore it is less likely that errors that originate at prescribing will reach the patient. Tenfold administration errors were more likely to reach the patient and therefore to cause harm. Morphine was the most reported drug in both 2017/18 and the 2013/14 audit suggesting that more work needs to be done on the safe use of opioids. Critical Care was the location with the highest number of errors reported, patients in this area often require complex medication regimes increasing the likelihood of being involved in a medication error.1ReferenceBower R, Coad J, Manning J, et al. A qualitative, exploratory study of nurses’ decision-making when interrupted during medication administration within the paediatric intensive care unit. Intensive Crit Care Nurs 2018;44:11–17.

Gerald Wilson Black (“Gerry”) completed his medical degree at Queen’s University Belfast. After a research fellowship in the department of anesthesiology, University of Pennsylvania, USA, he was appointed as consultant paediatric anaesthetist to the Royal Belfast Hospital for Sick Children (RBHSC) in 1960, in which capacity he served until his retirement in 1990. Much of his work involved the perioperative care of newborn infants and, recognising the need for more intensive medical and nursing care for critically ill children, he pioneered the development of paediatric intensive care in Northern Ireland. The paediatric intensive care unit in RBHSC, of which he was in administrative charge, was one of the first in the UK. He was recognised internationally as a leading authority in volatile anaesthetics and considered to be one of the outstanding anaesthetists of his generation. For many years Gerry was involved in the investigation of the sympatho-adrenal, metabolic, and circulatory effects of the various inhalation anaesthetics. A close relation was found …

Objective To determine if standardised chart review applied to records of patients discussed at a paediatric intensive care unit (PICU) morbidity and mortality conference (MMC) yields additional or different information regarding safety event occurrence and characteristics. Design Retrospective record review. Setting Single tertiary referral PICU in Baltimore, Maryland, USA. Participants 96 patients discussed at the PICU MMC over 14 months (November 2011–December 2012). Main outcome measures Safety events and their characteristics (medical error category, severity and preventability). Results A total of 275 safety events were identified through the MMC and/or chart review. The MMC identified 131 (48%) events, 53 (19%) of which were identified through the MMC alone. After chart review was performed, an additional 144 (52%) events were identified. 78 (28%) events were identified through both. High severity adverse events potentially contributing to permanent harm or death were more likely to be identified through both the MMC and chart review (47%) compared with either alone. The MMC alone identified more near-misses (21%) and preventable events (96%) compared with chart review alone or both MMC and chart review. Although chart review alone helped to identify many healthcare-associated infections, medication errors and sedation/pain control issues not elicited through the MMC, the MMC alone identified more communication errors and workflow problems. The MMC alone also identified 40% of all diagnostic errors, which would not have been discovered otherwise despite chart review by itself identifying 50% of such misdiagnoses. Conclusions Standardised chart review applied to records of patients discussed at a PICU MMC identified significantly more safety events not initially discovered through the MMC. However, the MMC was superior to chart review in identifying broader problems such as communication errors, workflow issues and certain diagnostic errors not captured by chart review, which can potentially affect many aspects of care.

AimInfusion pumps are commonly used to administer medicines by intravenous infusion. Traditionally, pumps are programmed by simply entering the required number of millilitres (mL) per hour, and there has been no mechanism whereby the pump can alert the operator to a programming error e.g. the wrong mL/hour rate being entered.More recently, ‘smart’ infusion pumps have become available which have in-built drug libraries. For each drug, defined dosing limits are set. Users are required to reconfirm the selected infusion rate when ‘soft’ limits are overridden and the infusion cannot be commenced if ‘hard’ limits are exceeded. Soft and hard limits can also be set for the administration of boluses from continuous infusions. This study aimed to evaluate the introduction of smart syringe pumps into a UK PICU by objective assessment of compliance with drug library use, and by obtaining direct feedback from nursing staff.MethodsData was collected over a 4 week period, immediately following the introduction of new Alaris CC smart syringe pumps. Objective assessment of drug library use utilised a piloted data collection form. One form was completed for each infusion running at the time of daily data collection. The prescription, syringe label, and programmed pump parameters were checked for each infusion and any discrepancies noted. Where the drug library was not being used, reasons for non-use were recorded. Nursing views on the benefits and potential risks of the new smart syringe pumps were determined through individual and group interviews, each following the same pre-prepared format.Results79 individual drug infusions were observed. 4 (5%) were being given without using the drug library, i.e. just in terms of mL/hour; in all cases, the explanation was the fact that the drug was not included in the library. 73 (92%) of the infusions observed were continuous, the remainder intermittent. 13 nurses were interviewed: the unanimous view was that the new smart pumps improved patient safety. One nurse described a situation where the smart pump had prevented a 10-fold paracetamol overdose. Many nurses commented that pre-defined sedation boluses were a definite patient-safety benefit, both in terms of preventing incorrect dosing or the bolusing of the wrong drug. Nurses, in general, felt that the safety benefits of smart pumps applied equally to intermittent and continuous infusions. Nurses found the drug libraries easy to use, and whilst infusion set-up may take marginally longer with the drug libraries than without, this was offset by patient safety benefits. It was noted that the longer time taken to programme the pumps may diminish as familiarity increases. A small number of minor issues with the drug library were identified through nursing feedback, though none of them were patient-safety critical. This has allowed the drug library to be modified before the same pumps are also introduced to general wards across the Children’s Hospital.ConclusionThe drug libraries in the new smart syringe pumps were being routinely and correctly used throughout the study period. Nursing staff had embraced the new technology, seeing clear patient safety benefits.

ObjectivesTo provide an in-depth insight into the experience and perceptions of bereaved parents who have experienced end of life care decision-making for children with life-limiting or life-threatening conditions in the paediatric intensive care unit (PICU).DesignAn in-depth qualitative interview study with a sample of parents of children with life-limiting or life-threatening conditions who had died in PICU within the previous 12 months. A thematic analysis was conducted on the interview transcripts.SettingA PICU in a large National Health Service (NHS) tertiary children’s hospital in the West Midlands, UK.Participants17 parents of 11 children who had died in the PICU.ResultsFive interconnected themes were identified related to end of life care decision-making:(1) parents have significant knowledge and experiences that influence the decision-making process.(2) Trusted relationships with healthcare professionals are key to supporting parents making end of life decisions.(3) Verbal and non-verbal communication with healthcare professionals impacts on the family experience.(4) Engaging with end of life care decision-making can be emotionally overwhelming, but becomes possible if parents reach a ‘place of acceptance’.(5) Families perceive benefits to receiving end of life care for their child in a PICU.Conclusions and implicationsThe death of a child is an intensely emotional experience for all involved. This study adds to the limited evidence base related to parental experiences of end of life care decision-making and provides findings that have international relevance, particularly related to place of care and introduction of end of life care discussions. The expertise and previous experience of parents is highly relevant and should be acknowledged. End of life care decision-making is a complex and nuanced process; the information needs and preferences of each family are individual and need to be understood by the professionals involved in their care.

Objective Advance Care Planning (ACP) is nationally a core element of adult and paediatric palliative care strategies. It is defined as a process of discussion between an individual, their care providers and those close to them, about future care. Formal procedures and processes can help with some of the most difficult elements of communication related to ACP. The majority of children who die do so in a Paediatric Intensive Care Unit (PICU). This survey aimed to identify and compare paediatric ACP documents that are in use within UK hospitals with a PICU. Design Email survey of lead clinicians from UK PICUs (n=28). Results 24 (86%) questionnaires were returned. 14 (58%) responded that formal ACP documents were currently in use within their hospital trust. Of the remainder, 2 (8%) detailed plans to launch local ACP documents in the near future, 1 (4%) had a ‘Children and Young Persons Deterioration Management (CAYPDM) Document’ and 3 (12%) listed rapid discharge and extubation pathways. 6 (25%) provided details of the document in use. They varied widely in terms of their presentation, content and intended use with some having been developed locally and others having been adopted across regions. Conclusions There is variation around the UK in the existence of formal ACP documents for paediatric patients with palliative care needs, as well as variation in the type of document that is used. Consideration of a national policy should be informed by further review and evaluation of these documents, as well as current practice in ACP.

A healthy 5 year-old girl was admitted to Paediatric Intensive Care Unit with respiratory failure secondary to varicella pneumonitis. Shortly after arrival, she required manual ventilation with high pressures via an anaesthetic circuit. She was subsequently stabilised on high-frequency

Objective To describe and quantify the clinical and logistic activities of a resident pharmacist in a paediatric intensive care unit (PICU) and to identify the key areas for improvements in training. Methods A prospective quasi-experimental cross-sectional study was conducted in an 11-bed PICU over a 3-month period. Pharmacist recommendations (clinical interventions) were made on patient care during the validation stage of medical orders. All interventions performed were recorded in a database and included the following information: reason for the intervention, clinical significance and acceptance by the physician. A record was also kept of the number of interventions per patient-day and the number of drugs whose profiles for dispensing from an automatic cabinet automatic dispensing system (ADS) were modified. Results There were 40 interventions (13% recommendations issued in the absence of error, 59% concerned drug safety issues, 20% related to efficacy and 8% to the indication), of which 72.5% were classified as significant or very significant; 95% were accepted by the physician. There were 4.0 interventions per 100 patient-days. No single drug was involved in more than 5% of interventions. The profiles of 16.6% of the drugs included in the ADS were modified. Conclusions The action of the pharmacist enabled prevention of prescription errors of critically ill paediatric patients. It is necessary to broaden and systematise clinical training in this discipline in order to identify a larger number of negative outcomes associated with medications.

OBJECTIVE: To identify patient safety factors in pre-hospital and hospital management of critically ill children dying in a paediatric intensive care unit (PICU). DESIGN: Retrospective case notes review. SETTING: Single tertiary regional PICU in London. PARTICIPANTS: 47 patients (7%) who died from a total of 679 children admitted during 2007 and 2008. Median age was 1.1 years and median predicted mortality from the Paediatric Index of Mortality 2 score was 39%. MAIN OUTCOME MEASURES: Adverse events contributing to death (AEds) and critical incidents (CIs). AEd was defined as an unintended injury or complication caused by health care management, contributing to death. CI was defined as an undesirable event in healthcare management, which could have led to harm or did lead to harm of the patient but did not contribute to the patient's death. RESULTS: 22 AEds occurred in 17 of 47 (36%) cases. Two AEds occurred in primary care, 20 in pre-PICU hospital care, and none in PICU. AEds were mainly problems in diagnosis and management of critical illness. 37 CIs occurred in 28 of 47 (60%) cases. Two CIs occurred prior to hospital admission, 17 occurred in pre-PICU hospital care, 1 during inter-hospital transport and 17 in PICU. CIs were predominantly medical management and procedure related. Individual, team and organisational factors caused the majority of AEds and CIs. CONCLUSION: Adverse events in pre-PICU hospital care were common in children who subsequently died in PICU. CIs occurred throughout the patient journey. Interventional studies of healthcare organisation and delivery are necessary to identify appropriate strategies to improve patient safety.

Objective To test the predictability of the Melbourne criteria for activation of the medical emergency team (MET) to identify children at risk of developing critical illness. Design Cohort study. Setting Admissions to all paediatric wards at the University Hospital of Wales. Outcome measures 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 Melbourne Activation Criteria (MAC) had a sensitivity of 68.3% (95% CI 57.7 to 77.3), specificity 83.2% (95% CI 83.1 to 83.2), positive predictive value (PPV) 3.6% (95% CI 3.0 to 4.0) and negative predictive value 99.7% (95% CI 99.5 to 99.8) for an adverse outcome. Seven of the 16 children (43.8%) would not have transgressed the MAC prior to the adverse outcomes. Four hundred and sixty-nine of the 984 children (47.7%) who did not have an adverse outcome would have transgressed the MAC at least once during the admission. Conclusion The MAC has a low PPV and its full implementation would result in a large number of false positive triggers. Further research is required to determine the relative contribution of the components of this complex intervention (Paediatric Early Warning System, education and MET) on patient outcome.

Objective In the UK, the number of patients waiting for an organ transplant has increased by 30% since 2001. Non-heart beating organ donation (NHBD) programmes are advocated as a means of increasing the number of potential donors. Such programmes remain in their infancy within paediatrics. We examined all deaths in our paediatric intensive care unit (PICU) between January 2005 and December 2008 to establish the number of potential NHB donors. We further obtained data from UK NHS Blood and Transplant detailing all paediatric patients that became heart beating and NHB donors in the UK over the same period. Design (A) Data obtained from UK NHS Blood and Transplant detailing the number of organ donors within the unit and within the UK. (B) Retrospective review of our paediatric intensive care mortality database and patient notes to identify patients aged 1–16 years who died in the PICU over the same period. Assessment of patient suitability for NHBD was made according to predetermined exclusion criteria. Results During the study period, 126 children died in the PICU. Three children were referred for heart beating organ donation (two proceeded to be donors). Nine children were referred for NHBD (three proceeded to be donors). Of the remaining 114 patients, 39 (34%) were aged >1 year and died following active withdrawal of treatment. Of these 39, 27 (69%) had relative contraindications, leaving 12 patients that might have been considered as potential NHB donors. If a 50% conversion rate is used, six children may have been realised as actual NHB donors. Conclusion If this situation were replicated in the PICUs throughout the UK, it would represent a significant increase in the number of organs available for transplantation.

Little is known of the incidence of adverse events in the paediatric intensive care unit (PICU). Perceived incidence may be dependent on data-collection methods.To determine the incidence of adverse events by voluntary reporting and systematic enquiry.Adverse events in PICU were recorded contemporaneously by systematic enquiry with bedside nurses and attending doctors, and compared with data submitted voluntarily to the hospital's quality and safety unit. Events were classified as insignificant, minor, moderate, major and catastrophic or lethal, and assigned origins as medical/surgical diagnosis or management, medical/surgical procedures, medication or miscellaneous.Among 740 patients, 524 adverse events (mean 0.71 per patient) occurred in 193 patients (26.1%). Systematic enquiry detected 405 (80%) among 165 patients and were classified by one investigator as insignificant 30 (7%); minor 100 (25%); moderate 160 (37%); major 103(25%) and catastrophic 12 (3%). The coefficient of agreement (kappa) of severity between the two investigators was 0.82 (95% CI 0.78-0.87). Voluntary reporting detected 166 (32%) adverse events among 100 patients, of which 119 were undetected by systematic reporting. Forty-nine events (9%) were detected by both methods. The number and severity of events reported by the two methods were significantly different (p0.0001). Voluntary reporting, mainly by nurses, did not capture major, severe or catastrophic events related to medical/surgical diagnosis or management.Neither voluntary reporting nor systematic enquiry captures all adverse events. While the two methods both capture some events, systematic reporting captures serious events, while voluntary reporting captures mainly insignificant and minor events.

AimsHealth information technology (HIT) is increasingly being promoted as a medication error reduction strategy. Electronic prescribing and smart-pump technology are examples of HIT widely advocated in the hospital setting. In critical care, the risks associated with paediatric infusions have been specifically addressed with calls for the use of standard concentration infusions (SCIs) in conjunction with smart-pump technology. Evidence on the benefits of HIT in the paediatric setting remains limited. This study aims to assess the impact of both electronic prescribing and a smart-pump drug library of SCIs on medication errors in paediatric critical care.MethodsA retrospective, observational study based on an interrupted time series design was conducted in the 23-bed paediatric intensive care unit (PICU) of a tertiary children’s hospital. 3400 randomly selected medication orders were reviewed over 4 epochs: pre-implementation of either technology (Epoch 1); post-implementation of SCIs (Epoch 2); immediate post-implementation of electronic prescribing (Epoch 3); and 1 year post-implementation of both (Epoch 4). Orders prescribed during the study period were included provided they had undergone clinical pharmacy review. Intravenous fluids, epidural/regional blocks, total parental nutrition, chemotherapy and patient/nurse controlled analgesia were excluded. Medication error rates were calculated applying pre-specified definitions and inclusion criteria.1 Novel technology-generated errors were identified and defined using a modified Delphi process. Errors were graded for severity using a combination of two validated grading tools.2,3ResultsOverall medication error rate based on all orders were similar in Epoch 1 and 4 (10.2% vs 9.7%; p=0.66). Altered error distribution was however evident. Incomplete and wrong unit errors were eradicated, but duplicate orders increased. Dosing errors remained the most common. 77% of pre-implementation errors were considered likely to be removed by the new technology. 24% of post-implementation errors were considered to be novel technology-generated errors. Examples included incorrect formulation selection and errors on altered electronic orders. In Epoch 2, the implementation of SCIs prior to electronic prescribing significantly reduced infusion-related prescribing errors (31.4% to 12.6%; pConclusionThe overall medication error rate in PICU was largely unchanged by the introduction of electronic prescribing. Some errors disappeared but new errors directly attributable to the implemented technologies emerged. In the complex PICU environment, dosing errors remain common. A significant reduction in infusion-related errors was found as a consequence of the introduction of SCIs and smart-pump technology. The introduction of electronically-generated standard infusion orders brought further benefits. The results of this study show that the benefits of HIT in the paediatric setting cannot be assumed and highlight the need for further studies with increasing use of HIT in paediatric settings.ReferencesGhaleb MA, Barber N, Dean Franklin B, et al. What constitutes a prescribing error in paediatrics?BMJ Qual Saf2005;14(5):352–7.Dean BS, Barber ND. A validated, reliable method of scoring the severity of medication errors. Am J Health Syst Pharm1999;56(1):57–62.National Coordinating Council for Medication Error Reporting and Prevention. Taxonomy of medication errors1998. http://www.nccmerp.org/about-medication-errors

Background: With more liberal visiting hours in paediatric intensive care practice, parents’ presence at the bedside has increased. Parents may thus become involved in critical incidents as contributors or detectors of critical incidents or they may be affected by critical incidents. Methods: Voluntary, anonymous, non-punitive critical incident reporting system. Parents’ involvement in critical incidents has been evaluated retrospectively (January 2002 to August 2007). The reports were analysed regarding involvement of parents, age of child, unit (paediatric intensive care or intermediate neonatal nursery), critical incident severity, critical incident category, actual or potential harm to patient and/or parent (minor, moderate, major), delay between the critical incident and its detection, and implemented system changes. Results: Overall, 2494 critical incidents have been reported. There were 101 critical incidents with parental involvement: parents as contributors to critical incident (18; 0.7%), parents discovering a critical incident (11; 0.4%), parents affected by critical incident (72; 2.9%). The most vulnerable categories regarding contribution and detection were drugs, line/drain disconnection, trauma and hygiene. Ten critical incidents precipitated by parents were of moderate severity and seven of potential major severity (six line/drain disconnections). The majority of the events (six) detected by parents were of potential moderate severity and four were of major severity. Conclusion: Because of their presence at the bedside, parents in the paediatric intensive care unit are inevitably involved in safety issues. It is not the parents’ duty to guarantee the safety for their children, but parents should be encouraged to report anything that worries them. Only an established safety culture allows parents to articulate their concerns.

Between January and October 2014, Great Ormond Street Hospital Paediatric Intensive Care Unit (PICU) was spending an average £23,392 on blood tests per month. Blood tests should be requested based on previous results and the patient9s clinical condition, medication and nutritional status. However, more blood tests were being ordered than clinically indicated: an audit in October 2014 showed liver function tests (LFTs) were requested daily on most patients, even with previous normal results. A driver diagram identified three primary drivers for blood test requesting: decision-making, situational awareness and computer-based ordering. Decision-making for routine blood tests was the responsibility of the bedside nurses on each night shift. The communication between the nurses and doctors was an identified secondary driver. The project9s primary aim was to reduce unnecessary LFTs requests on PICU over 6 months by implementing a blood test request form, a table of common investigations to facilitate and document discussion between the nursing and medical teams. The secondary aims were to reduce other unnecessary blood test requests, including full blood counts (FBC), coagulation screens and CRP. This project was conducted in three phases: construction, testing and implementation of the blood test form. PDSA cycles were used within each phase. Two PICU nurse champions were engaged to provide bedside support, education and feedback. In the 8-month period following implementation, there was a significant sustained reduction in LFTs requests. A similar pattern of sustained reduction also occurred for FBC, coagulation screens and CRP requests. This sustained reduction in blood tests requested equated to a saving in excess of £36,000. This project was successful: the reduction in the number of inappropriate blood tests had clear financial benefit for PICU and reduced blood loss for patients. Early engagement and support from key stakeholders avoided conflict, guaranteed data sharing and aided engagement of bedside nurses.

Children with bacterial meningitis often have a full blood count (FBC) measured urgently on admission. We investigated whether urgent FBC gave results that aided immediate management or predicted outcome in children with meningitis. FBCs were measured on admission during 190 episodes of bacterial meningitis in children admitted between 1984 and 1991. Significant anaemia was found in seven children, but immediate transfusion was only necessary in the three subjects who were in the Paediatric Intensive Care Unit (PICU). A white blood count of less than 5 x 10(9) L-1 was significantly associated with death (P < 0.02), but a Glasgow Coma Score of less than 8 predicted death more accurately (positive predictive value of 40%). FBC yielded immediately useful information only in the 15% of children who were admitted to PICU. Conscious level was a better predictor of outcome than FBC. We recommend that urgent FBC should be performed in children with meningitis admitted to a PICU; in other children with meningitis FBC can be analysed during normal laboratory hours.

Tom Brick and Christine Pierce describe a successful new programme in the intensive care unit at Great Ormond Street Hospital, which allows senior trainees to step up to a consultant role.

Aims Whilst patient turnover in the Paediatric Intensive Care Unit (PICU) is high with an average stay of 2 days, improvements in life-sustaining treatments have resulted in increasing numbers of children who are hospitalised for long periods of time. A child’s admission to the PICU induces high levels of stress and anxiety in parents. A growing number of research studies have explored the needs of family members of critically ill children. However, little is known about the experience of parents who have a child in the PICU for a prolonged period of time. Methods Semi-structured interviews were conducted with 17 members of staff (3 consultants, 7 nursing staff and 7 allied-health professionals) and 27 parents whose child had a long-stay in one of three units providing intensive care at a tertiary paediatric hospital. Framework Analysis was used to analyse the data. Results Every family is different in how they cope and adapt to being in the PICU for a prolonged period of time. Despite differences, a number of things characterised long-stay parents’ experiences of being in the PICU. Parents adjusted to being in the PICU, developing routines which supported coping. Long-stay parents were grateful for any opportunity to be involved in their child’s care and relied upon the nursing staff to facilitate this. Their exposure to the PICU resulted in increased knowledge of their child’s condition and the environment. This knowledge led to heightened sensitivity to, and awareness of, the care provided by staff; both the good and bad. Moving on from the PICU can be particularly difficult for long-stay parents who have become accustomed to life in the PICU. Conclusion Long-stay families will likely become more familiar with the environment, more knowledgeable about their child’s medical needs and more familiar with the staff looking after their child than average-stay parents in the PICU. They are likely to seek a greater involvement in their child’s care and may be more critical of the care provided by staff. This has implications for staff working in the PICU.

Aims To meet the emotional and psychological needs of the child and the family admitted to hospital, as well as their medical needs. Method From October 2014, each child admitted to the Paediatric Intensive Care Unit (PICU) had a specially designed laminated “What Matters to Me (WM2M)” card displayed at the bedside, completed by both the parents and (where possible) the child. This was a simple way to formally transfer more personal information, including likes and dislikes, from one member of staff to another. On the reverse, there was a feedback questionnaire to grade the use of the cards from “very good” to “very poor”, as well as an area for any other comments. Results Across the initial 18 weeks of use, 85.7% of patients received a WM2M card. Feedback was taken from parents, patients and nursing staff. 54.8% of the WM2M cards had feedback completed. A total of 39.5% found the cards “very good” (26.3% of these were parents/patients and 13.2% nursing staff). 60.5% found the cards “good” (28.9% of these were parents/patients and 31.6% nursing staff). No one selected “poor” or “very poor”. Other wards began to take on the project after hearing staff and families commenting on the cards. This also included patients going to theatre. Furthermore, The Institute for Healthcare Improvement (IHI) presented a short presentation on the project after they heard about the cards, during a keynote speech at their 26 th Annual National Forum in Orlando Florida. Conclusions Instead of asking our patients “What’s the matter with you?” we also ask them “What matters to you?” This is what the IHI call “flipping healthcare”. Children are to be recognised as NHS consumers in their own rights. There should be less barriers to accessing their views and experiences 1 of which we hope our WM2M cards have help to do.

Background and aims Long-stay patients in paediatric intensive care units (PICU) are associated with disproportionately high healthcare resource utilisation and unfavourable outcomes. Increase in long-stay admissions and bed-occupancy have been reported elsewhere but not in the UK. Methods We performed a retrospective analysis of PICU admissions over the last 19 years. Long-stay admissions [length of stay ≥ 28 days] were analysed over 4 different study-periods [1996–2000, 2001–2005, 2006–2010 and 2011–2014]. Chi-square test for trends used for significance tests for trends in proportions. Results 22,059 admission episodes accounted for 108,522 bed-days. 521 long-stay episodes accounted for 30,052 bed-days. Proportion of long-stay admissions and bed-days increased from 1.2% and 19% respectively in 1996–2000, to 3.6% and 36% in 2011–2014 [p Conclusions We found an increasing trend in proportion of long stay patients and bed occupancy. If nationwide figures confirm this trend, PICU capacity planning for the future should take this into account.

Aims To describe the practice of high flow nasal prong (HFNP) therapy in infants Methods Retrospective chart review from the local database (Carevue) of infants Results Total of 74 patients received HFNP therapy during this period. Out of these, 26 (35%) patients were infants Conclusion HFNP therapy was successful in the vast majority of patients, particularly in those without risk factors. HFNP therapy has changed ventilatory practice in infants

Background Omitted or missed doses are common to all patients within an acute setting and are the second most common medication related incident in paediatrics.1 Literature reported rates varying from 2.4% to 13%.2 The National Patient Safety Agency (NPSA) published a report highlighting potential harm from omitted and delayed medicines.3 Five recommendations were made to reduce harm. A missed dose was defined by the NPSA, as a dose given more than one hour later than the prescribed time; omissions as no documentation for not administering the dose. In response to this report the Paediatric Intensive Care Unit (PICU) at Birmingham Children9s Hospital produced a core time critical list of medicines. Aims To assess the compliance with the NPSA9s recommendations and the local resultant core critical list. To determine which medicines were missed most frequently, and establish whether a correlation existed between delays/omissions and specific times of the day. Method PICU was visited at the same time twice daily for four weeks. Data collected included prescribed doses per patient, omissions and delayed doses. Drug name, formulation, length of delay, reasons for omission and prescribed time was recorded for all omitted or missed doses. Bedside nurses were surveyed for reasons in delays or omissions and measures which may help reduce incident frequency. Results Data from 236 patients were included with 3363 doses. Of these doses 116 (3.45%) were missed or omitted. A previous audit found a rate of dose omission as 6.5%. Antibiotics (40%) and 28% anti-hypertensive drugs were the most common omissions or delays. Forty seven (40.5%) doses were delayed by more than three hours. Eight (6.8%) of the time critical medicines did not have a specific prescribed time defined. Intravenous medicines were more often delayed or omitted (58%) in comparison to enteral (38%). Omission and delay rates were higher during the 7am to 7pm shift, with peaks at peri-handover times. No omission or delay incident reports were completed as per the NPSA recommendations during the study. Bedside nurses suggestions for reducing missed/omitted dose frequency included increasing the availability and variety of prefilled syringes prioritising support and assistance when intravenous access is problematic. Further recommendations following the audit include assigning specific times for all medicines on PICU, avoidance of handover and shift change times for medicine administration and re-audit following implementation of changes. Conclusion This study reflects the literature with antimicrobials the highest medicine class delayed or omitted. Avoiding administration times around handovers and ward rounds as well as ready to administer medicines, may assist with further reducing omissions or delays in administering medicines.

Background and aims In a regional Paediatric Intensive Care Unit (PICU) the research team have been recruiting to three multi-centre randomised controlled trials. The team were interested to explore parent’s preference for the research nurses wearing a uniform whilst recruiting to these trials. Method 62 questionnaires were given out to non-research PICU staff (nursing, administrative and medical staff). Multiple choice questions asked what they would prefer to see research nurses wearing when approaching parents about research. 24 questionnaires were given out to parents who had been approached about research trial participation in PICU. Multiple choice questions asked whether they would prefer to be approached for consent by a research nurse wearing a clinical nurse uniform, alternative uniform or their own clothes (pictorial representations given). Results Parental questionnaire return rate was 67%. Responding parents favoured (62%) a uniform with reasons given including ease of identification, trust and professionalism. From the options provided, only 6% chose the ‘own clothes’ option. 32% reported no preference. 31% of parents felt that what the nurse was wearing was likely to have influenced their decision to give their consent, no information was given as to whether this would be in a positive or negative way. Staff questionnaire return rate was 73%. 67% preferred a uniform, 22% an ‘own clothes’ option and 11% reporting no preference. Conclusion The results display a preference towards research nurses wearing a uniform, however there is no agreement as to what that uniform should be. Further research would be needed to conclude whether the wearing of a uniform influences parental decision to consent for their child to participate in research trials and before any recommendations can be made for practice.

Aims On our paediatric intensive care unit (PICU) doctors induction traditionally consisted of a series of lectures and small group work. In order to make introduction more interactive and enhance learning, we decided to set up a one day simulation based induction course. Methods Learning needs were identified from informal survey of current trainees and PICU consultants. Four simulation scenarios were designed to encompass the learning objectives established from the learning needs survey and key competencies needed for PICU. Scenarios involved patients transferred to PICU for stabilisation, or deteriorating patients on the unit. 30 min simulations and were followed by 1 h debrief and tutorial. Tutorials focused on medical management and practicalities such how to set up a ventilator or give inotropes. Simulations ran with 2–3 trainees and 2 PICU nurses per scenario, and were set up in a cubicle with standard equipment, using high fidelity manikins. Due to anticipated inexperience, trainees were offered “time out” and “ask the audience” options during the scenarios to enable them to draw on the knowledge of their peers. Results 10 trainees completed the simulated induction course. When asked to use a 5 point likert scale, 90–100% of trainees either agreed or strongly agreed to all but one of the 9 statements related to the course meeting learning objectives and knowledge needs. High frequency oscillation was the single area that was identified by trainees as not being covered in desired depth. Free text feedback was overall very positive. Suggestions for improvement would be to provide a specific ventilation workshop to enable this subject to be covered in greater depth, plus a written handout to supplement the day. We are waiting to see how the induction evaluates in the GMC survey, compared to traditional induction. Conclusion We ran a pilot PICU simulation induction which was well received by trainees, and met all but one learning objective. The course could be easily adapted to address this objective and could be tried in other Paediatric Intensive Care Units.

Bronchiolitis is a common cause of respiratory illness in children resulting in significant pressures on health services. Hospitalisation occurs in up to 3.5% of cases and 10% of these will require admission to the paediatric intensive care unit (PICU). Aim To review the patient characteristic’s for all infants (less than 1 year old) who were admitted to the regional PICU requiring invasive ventilation for bronchiolitis, over the 10 year period from 1st January 2003 to 31st December 2012. Method Data was retrospectively collected for all infants admitted to the regional PICU from PICANet data, the retrieval database and discharge letters were then reviewed. A range of data was collected including gestational age, age at presentation, presence of apnoeas, length of ventilation, length of stay, Respiratory syncytial virus status, use of inotropes and pre-existing diagnoses (particularly congenital heart disease and chronic lung disease). Results 256 infants were invasively ventilated, there were 4 deaths (all had significant co-morbidities). 82% of admissions were between November and January. There was a male predominance and two thirds of the infants ventilated were less than 2 months at presentation. The Mean length of PICU stay was 8 days and mean number of days ventilated 6. 16% of patients required inotropic support. Interestingly 43% of infants with congenital heart disease who were ventilation for bronchiolitis required inotropes. As found by previous studies, apnoea was a common feature, this was associated with prematurity (64% of infants Conclusion This study highlights high seasonal pressure on PICU of bronchiolitis and that apnoeas are a significant risk factor for PICU admission. It also shows that although bronchiolitis is commonly thought to be a single organ disease, it can have cardiovascular consequences.

Aims To describe the characteristics of children resident in England and Wales admitted to a paediatric intensive care unit (PICU) who required prolonged invasive ventilation over the last decade and to compare their demographic and clinical characteristics to those who required a shorter period of invasive ventilation. Methods Clinical and demographic information on all children resident in England and Wales admitted to a PICU were analysed. Prolonged invasive ventilation (PIV) was defined as receiving invasive ventilation for more than 21 days during a single admission via endeotracheal tube or tracheostomy including jet or oscillatory ventilation. The cut-off of 21 days was chosen as it has been previously used in adult studies of prolonged ventilation during intensive care stay. Results 99,818 of 147,709 admissions (67.6%) received invasive ventilation; of these 2,980 (3.0%) required PIV. As a percentage of all invasive ventilation, PIV has increased slightly over the previous decade from 3.1% in 2004 to 3.4% in 2013. PIV was most common in the under 1s (3.6%) and was similar in males (2.9%) and females (3.0%) (chi-squared p = 0.35). Children receiving PIV account for over a quarter (26.5%) of all invasive ventilation bed days, median length of ventilation was 32 days (IQR: 26–48 days) and median length of stay was 37 days (IQR: 28–57) in those receiving PIV. Overall, those receiving PIV had a higher Paediatric Index of Mortality (PIM) score on admission (4.1% vs. 2.5% with a score >30%, chi-squared p Conclusion Children receiving PIV are only a small percentage of all admissions requiring invasive ventilation but account for over a quarter of all invasive ventilation bed days. A higher percentage of under 1s who receive invasive ventilation require PIV and it is associated with a higher in-unit mortality overall.

The nature of paediatric intensive care medicine is such that when the battle with a disease process cannot be won, focus needs to be placed on achieving a dignified death. If the situation permits, families will often opt for a peaceful passing away in familiar surroundings, at home or in a hospice. We focus on the common practical considerations that need to be addressed in order to facilitate the return home; as well the necessary planning to conform to legal requirements following a child’s expected death outside the hospital setting. We look into what medications might be needed for symptom control and what the challenges of prescribing these in the community might be. We shall also look into the importance of assessing the home environment and social support in advance, as well as what the logistics of transporting the patient out of hospital are. Furthermore we touch upon who needs to be involved in the on-going medical care of the child, as well as possible contingency plans, should the child survive at home. Finally we shall explore what the role of the intensive care physician is in facilitating what is required by law; including confirmation of death, discussions with the coroner, and transport to the mortuary. Good, advance planning enables clinicians to minimise the invasion of the family’s privacy during these delicate moments, and helps make a child’s death as dignified as possible.

Background Parenteral nutrition (PN) is important for providing sufficient food for neonates, especially premature infants. Individually prescribed PN addresses specific patient requirements. 1 Due to the diversity and complexity of PN prescribing, medicines errors may occur. 2 Purpose To identify the incidence, type and severity of prescribing errors in PN in a paediatric intensive care unit (PICU). In this context the role of a clinical pharmacist should be checked as a member of an interdisciplinary team. Material and methods The occurrence of prescribing errors in PN in a PICU in a university hospital was analysed retrospectively between March 2012 and July 2013. First the errors were categorised in seven pre-defined categories. Afterwards the potential severity of each individual error was assessed independently by three medical experts from three different Level III neonatal units, not involved in any treatment regimen and blinded for patient outcome, based on the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index for Categorising Medicines Errors. 3 Results 118 prescribing errors were identified from 2,889 PN orders. Each error had been discussed and eliminated before preparing the PN, so no errors reached the patient. The majority of errors constituted the category ‘concentration range’; 65%. Nearly 11% of the errors occurred in the categories ‘dose’ and ‘indication’. Error rates of 5% and lower were due to ‘choice of drug’, ‘compatibility’, ‘patient data’ and ‘osmolarity’. (By using the NCC MERP Index, the three experts classified the errors into several categories.) Conclusion These results underline that clinical pharmacists can prevent minor as well as major adverse drug events. Physicians as well as clinical pharmacists have to be aware of these risks and have to implement strategies to enhance medicines safety in PN treatment. Reference 1,2,3 Literature available from the author No conflict of interest.

Aim To study the outcome of children brought in to the Emergency Department (ED) by ambulance. Method All children (below16 years) who were brought in by ambulance over a period of one year to our ED were included in the study. Data was retrospectively analysed from electronic hospital records. Final diagnosis was obtained from the coding system used locally. Results Our ED sees about 20,000 children per annum. A total of 1,828 children were brought in by ambulance between the period 01/09/2011 to 30/08/2012. Only 568 (34.88%) children were admitted as inpatients. A total of 1,191 children were discharged home from the ED. Diagnosis was available for 1,628 children. Out of these children (1,628) where diagnosis was documented in the ED notes, trauma was the most common reason for being brought in by ambulance – 502 (30%) out of 1628, 115 out of these were discharged. The commonest medical reason for which children were brought to ED was respiratory problems (about 22%). Out of which 55% were discharged. Out of 107 children brought for febrile seizure 83 (78%) were discharged from ED. Seventy five children were diagnosed to have an upper respiratory tract infection. In total, only 50 children were admitted to paediatric intensive care unit (PICU). Out of the 200 where diagnosis could not be found in ED records, 30 (15%) were admitted and 56 were discharged, 46 children were referred to the GP in ED and 12 patients did not wait to see a doctor. The number of children brought in by ambulance increased after 17:00 and decreased after 22:00. Conclusion The majority of children brought in by ambulance were discharged home from ED. Targeted intervention aiming at certain paediatric diagnoses may help to prevent inappropriate ambulance transfer to ED and create significant cost savings. List of figures Figure 1 Outcome of children brought in for medical reason. Figure 2 Outcome of children brought in for trauma.

Commentary on: Mehta NM, Bechard LJ, Cahill N, et al. Nutritional practices and their relationship to clinical outcomes in critically ill children: an international multicenter cohort study. Crit Care Med 2012; 40: 2204– 11.[OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4] Adequate nutritional support is a keystone to prevent vulnerable critically ill children from becoming undernourished. However, there is often a marked discrepancy in prescribed and delivered energy and protein intake. Several barriers explaining these inadequate nutritional practices have been identified. Consequently, cumulative energy and protein deficits develop, which result in anthropometric deterioration as shown in a cohort of 293 paediatric intensive care unit (PICU) patients.1 So far, multicentre studies describing nutritional practices in PICUs in large cohorts of critically ill children have been lacking and the association between nutritional practices and clinical outcome has not been described. In a prospective multicentre cohort study, Mehta and colleagues studied nutritional practices in 500 children admitted into 31 participating PICUs. This study … [1]: {openurl}?query=rft.jtitle%253DCritical%2Bcare%2Bmedicine%26rft.stitle%253DCrit%2BCare%2BMed%26rft.aulast%253DMehta%26rft.auinit1%253DN.%2BM.%26rft.volume%253D40%26rft.issue%253D7%26rft.spage%253D2204%26rft.epage%253D2211%26rft.atitle%253DNutritional%2Bpractices%2Band%2Btheir%2Brelationship%2Bto%2Bclinical%2Boutcomes%2Bin%2Bcritically%2Bill%2Bchildren--an%2Binternational%2Bmulticenter%2Bcohort%2Bstudy%2A.%26rft_id%253Dinfo%253Adoi%252F10.1097%252FCCM.0b013e31824e18a8%26rft_id%253Dinfo%253Apmid%252F22564954%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1097/CCM.0b013e31824e18a8&link_type=DOI [3]: /lookup/external-ref?access_num=22564954&link_type=MED&atom=%2Febmed%2F18%2F4%2F151.atom [4]: /lookup/external-ref?access_num=000305767800026&link_type=ISI

Background and Aims Unplanned Extubations (UE’s) are potentially life threatening events 1 . They can result in traumatic reintubations which in turn can lead to tracheal damage. The monitoring and prevention of these incidents is of paramount importance to the safety of children in the paediatric intensive care unit (PICU). Methods A previous audit of UE’s had been conducted between August 2010 and April 2011 as we had noticed a sharp increase in incidence. Although the rate of 0.56/100 ventilator days was within the expected range of 0.11–2.27/100 ventilator days 1 , we identified staffing levels and sedation as key areas which appeared to have some causal effect on these numbers. Following the audit, staff were made aware of the increase in UE’s and the importance of prevention was highlighted. Results Between May 2011 and March 2012. all incident forms were examined and those relating to ‘accidental extubations’ or ‘tube displacement’ were examined in more detail. During this time period it was noted that the UE rate was 0.65/100 ventilator days. Conclusion Despite reviewing the sedation policy and staffing levels, the UE rate remains unchanged. It is possible that the heightened awareness of staff has increased the reporting rate but there is no evidence of this. Although our UE rate remains low we will continue to examine each case individually and review practice as necessary. 1. da Silva et al 2010. Pediatr Crit Care Med. Unplanned extubation in pediatric critically ill patients.

Background and aims CO monitoring has an important role for management of ACF in PICU. This monitoring device tracks the changes in CO induced by volume expansion or inotropic drugs. In this way CO can be measured noninvasively using aortic blood flow (ABF), continuously at the descending thoracic aorta with OD or discontinued in ascending thoracic aorta with TTE. The aim of this study is to compare the CO obtained by TTE and OD in the management of ACF in PICU. Methods A prospective and comparative study conducted in PICU between march 2012 and march 2014. We investigate 16 mechanically ventilated children less than 1 year who had tachycardia, hypotension, oliguria, delayed capillary refilling or haemodynamic instability despite vasopressor drugs, we compare the measurements of the CO and strong volume (SV) obtained by OD ‘ATYS-WAKI 2’ and TTE ‘SCHIMADZU SDU 2200 PRO’ before and after volume expansion (VE). Results 32 paired (CO and SV) measurements were obtained: a strong correlation was found between CO obtained by OD and by TTE before and after VE (Index of Pearson: R 2 = 0,983, R 2 = 0.977). The same correlation between the SV obtained by OD and by TTE was observed before and after VE respectively (Index of Pearson: R 2 = 0.982, R 2 = 0.983). Conclusion OD is an appropriated, very simple and noninvasive method to measure CO. This technique remains reliable and reproducible comparative to TTE to guide VE.

Background and aims Admission of a child to a paediatric intensive care unit (PICU) is a very stressful event for the child, but also for the parents. This might not only lead to suffering during admission, but also might have lasting effects. Little is known about the long term effects. In a previous study done during the stay of a child in a PICU we saw that a child’s admission to a PICU causes suffering of parents. In this study we evaluated if there are still feelings of suffering in parents four years after PICU admission. Methods A structured audio taped interview with 15 parents of children four years after admission of the child to a 20 bed level III PICU of a university teaching hospital to assess whether parents still have feelings of suffering and to identify aspects of suffering. Results Four years after PICU admission about 50% of the parents indicated that they still have feelings of suffering. Parents of 6 children didn’t suffer themselves. Parents describe mainly physical and psychosocial causes for the suffering. Reasons for suffering are experiencing changes in the physical and mental situation of the child. Also, the uncertainty of the future, effects on the family and problems in the organisation of healthcare contribute to the suffering. Conclusions A child’s admission to a PICU causes long term suffering in the parents. Caregivers in paediatrics need to be aware of these phenomena and should give attention to these aspects in the follow up support.

Aim The aim of the EMPATHIC-30 Poland study was to implement a validated parent satisfaction questionnaire. Material and method The EMPATHIC-30 questionnaire was used with a written permission of author. The study has been performed at the 10 beds PICU. Inclusion criteria were all parents whose child was admitted to the PICU for at least 24 h and not died in this unit. Results During 4 months 62 children (including 10 deaths) have been discharged from the PICU. There were 2 parents who refused to take part in the study, another 3 parents were not present during hospitalisation. Twenty five questionnaires have been collected (response rate 53%). Among patients there were 18 infants and toddlers, 3 children and 4 adolescents. Mean length of stay in the PICU was 11 days, 60% of admissions were unplanned. Questionnaires were completed mainly by mothers (84%). Not satisfactory opinions have been given manly for understandable information on examinations and tests (12%) and on possibility to stay close to the child during intensive procedures (16%). All of parents declared that the team worked efficiently and the team showed respect for the patients but only 72% of parents responded that during stay in the PICU the staff regularly asked for parent’s experiences. Conclusions The EMPATHIC-30 empowers parents to provide feedback on their experiences in paediatric intensive care and may facilitate health care professionals to improve quality of care. Following a single centre experience the EMPATHIC 30 Poland study should be continued as a national project.

Objective To define the demographic characteristics, clinical features and outcome of patients with brain death and to emphasise the importance of organ donation in children. Setting Centre I: 14-bed, tertiary care Paediatric Intensive Care Unit (PICU). Centre II: Tertiary care Intensive Care Unit (ICU), Trauma centre. Methods Data were collected from September 2009 to October 2012 retrospectively. Twenty children who were diagnosed as brain death were included. Data including demographics, disease leading to brain death, duration of brain death evaluation, ancillary tests to confirm the brain death, complications and outcome, duration of hospitalisation, status of survival and organ donation were collected for statistical evaluation. Results The mean age were 6.2 ± 5.3 (median:3.8) years. Male/female ratio was 1.85. Disease leading to brain death was traumatic brain injury in 11(55%) patients. The mean duration of brain death evaluation was 6.7 ± 6.4 (median:4) and 1.7 ± 1(median:1) days in Centres I and II respectively. The duration of hospitalisation was 12.5 ± 10.7 (median:7.5) days. Electroensefalography (EEG) was applied in 18(90%) patients. Complications included diabetes incipitus in 9(45%) cases. Duration of survival was 9.8 ± 9.4 (median:6) days. One of the patients’ parents give consent to organ donation in Centre I while 4 parents accepted organ donation in Centre II. The study demonstrated that duration of brain death evaluation in Centre I was longer when compared to Centre II (p 0.05). Conclusion The early diagnosis of brain death and prompt evaluation of the patients by the ICU physicians once the diagnosis is considered will probably yield better organs and reduce costs. Training of the PICU physicians, nurses and organ donation coordinators and increasing the awareness of the children via public means may increase the families’ acceptance rate for organ donation in future.

Background Broviac lines are a common source of catheter-associated bloodstream infection (CABSI) in our 22-bed tertiary paediatric intensive care unit (PICU). Aims To assess data in Broviac lines CABSI cases Methods Prospective clinical and laboratory data on all PICU admissions for 24 months (3/2010–3/2012), missing data was supplemented retrospectively using electronic patient records. The UK National Patient Safety Association ‘Matching Michigan’ case definitions were utilised to identify bloodstream infections and CABSI. The study was approved by the Clinical Audit Department- a division of the Directorate of Research and Clinical Development at Alder Hey Children’s Hospital. Results PICU-acquired CABSI rate was 7.35 per 1000 central line days. Device utilisation ratio (CVC days per patient days) was 0.77. Central line associated with CABSI: Broviac line 23 (39%); Triple lumen CVC femoral 14 and jugular 13; ECMO circuit 4; Renal/Vascatheter 3; Portacath 2. Conclusions In our patient population Broviac lines are commonly associated with CABSI and especially in less than one year age group.

Objective To determine the indication and need for echocardiographic assessment according to clinical severity of patients and therapeutic interventions performed after echocardiographic evaluation in critically ill children. Design Prospective observational study. Setting 14-bed, tertiary care Paediatric Intensive Care Unit (PICU). Methods The PICU is a multidisciplinary referral centre. A total of 140 children; 75 mechanically ventilated (MV) and 65 spontaneously breathing (SB) who were admitted to our unit consecutively from March to August 2013 were included into the study. The indication for echocardiography and therapeutic interventions performed after cardiology consultation were recorded. For the estimation of severity of disease the paediatric risk of mortality score (PRISM) III was determined. The correlation between Prism III score and the need for echocardiographic evaluations were analysed. Results Ages of all patients were between 45 days to 18 years. The male-female ratio was 1.33. Echocardiography was indicated in 88% (n = 66) of MV and%46.2 (n = 30) of SB patients. In 35.4% (n = 34) of patients who underwent echocardiographic evaluation no definitive change occured in treatment strategy while in 64.6% (n = 62) of patients decisive/supplemental information was obtained. Echocardiographic evaluation was necessary in MV children (p Conclusion Echocardiographic evaluation is essential in mechanically ventilated children and the need for echocardiographic assesment increases according to clinical severity of patients. Basic training for intensivists in this technique is challenging and needs to be developed and supported in critically ill children.

Background and aims Communication is an essential component of high quality medical referrals. The aim was to evaluate the completion of intensive care referral forms and to develop a streamlined document to improve data capture as part of the referral process. Methods The intensive care referral forms were audited over a three month period to assess degree of completion. A streamlined referral document was subsequently devised using the UK PICS ‘Example of essential referral information’. A re-audit was performed to assess for improvement in completion of referral data. Data was collected retrospectively and the new streamlined forms were reviewed as per the proforma set out in the initial audit of January–March 2013. The audit standard was that all sections of the referral form should contain information - 100% of details for each referral should be recorded. Results Improvement was noted in a number of sections of the referral form. Completion of patient details improved by 57%. Capture of referral source details, circulatory status and disability status each improved by 7%. Recording of infection status improved by 8%. Recording of transport details improved by 79%. There was no improvement in recording airway status, breathing status or results of any initial investigations. Advice was recorded as being given prior to transfer in 93% of cases, an improvement of 9%. Conclusions A concise referral document using UKPICS example has shown an improvement in various areas of data collection. Simplifying the form further may further improve data collection however risks overlooking essential information.

Aim To determine whether biochemical nutritional indices predict clinical outcomes in children undergoing cardiac surgery. Methods Retrospective single centre study between July 2012 and June 2013. Biochemical nutritional indices included serum albumin and total lymphocyte count (TLC) which was used to calculate Onodera’s prognostic nutritional index (PNI) [10 x serum albumin (g/dL) + 0.005 x TLC (/mL)]. Severity of illness assessed using Paediatric Risk of Mortality (PRISM) III score. Surgery categorised using the risk adjusted classification for congenital heart surgery (RACHS-1) score. Outcomes included hospital mortality, paediatric intensive care unit (PICU) length of stay (LOS) and duration of mechanical ventilation (MV). Results Total of 31 patients identified. Median age was 2.0 (0.7–41.0) months. Median PRISM III score was 8.0 (5.0–13.0). 14 (45%) underwent RACHS-1 category 2 surgery and 6 (20%) had ventricular septal defects. Median albumin and TLC were 3.2 (2.6–4.2) g/dL and 4280 (2810–5100)/uL respectively. Median PNI score was 52.7 (41.2–69.7). There was no hospital mortality. Median PICU LOS was 5.0 (3.0–8.0) days. Hypoalbuminaemia ≤3.0 g/dL associated with longer median PICU LOS (7.0 vs. 4.0 days, p = 0.016) and duration of MV (156 vs. 33 h, p = 0.007). PNI ≤ 58 associated with longer median PICU LOS (6.0 vs. 3.0 days, p = 0.041). Adjusting for age and RACHS-1 score, for every 1 g/dL drop in albumin, PICU LOS increased by 0.5 days (p = 0.006). Conclusions Hypoalbuminaemia and PNI ≤ 58 were associated with adverse postoperative outcomes. Future studies to study effect of perioperative aggressive nutrition care on biochemical indices and clinical outcomes.

Background Approximately 4% of the children admitted to the PICU at Odense University Hospital, Denmark, dies every year. Parents are invited routinely for a multidisciplinary follow-up conversation in the PICU 4–8 weeks after the child’s death. There are no previous studies on parents’ experiences of these follow-ups in Denmark. Aim To identify parents’ experience of the follow-up conversation and to investigate whether it is adequate for the needs of parents for a follow-up after their child’s death in the PICU. Methods Semi-structured interviews with 6 pairs of parents 2–12 weeks after the follow-up conversation. The interviews were held in their own homes on the parents’ request. Data was analysed using Malteruds’ qualitative approach. Results The analysis revealed the following themes: The way back to the PICU Certainty and clarity Close and known relationships Completion of the stay in the PICU Conclusions The parents were experiencing nervousness before the follow-up conversation, but were all pleased to have participated in these follow-ups. It was meaningful to the parents that the follow-up conversation was interdisciplinary, since it was possible to get answers to questions both about treatment and care. It was important that the staff involved in the follow-up conversation was the same that had been present through the hospitalisation and at the time of death of the child. It was very important that parents were invited to the follow-up conversation. Parents experienced the follow-up conversation as being a completion of the course in the PICU, regardless the length of the hospitalisation.

Background and aims In a previous study on suffering of children during admission to a paediatric intensive care unit (PICU), we found that parents described suffering of their child mainly in relation to physical symptoms. In this study we evaluated if these children still have signs of suffering four years after the PICU admission and if the symptoms of suffering, as perceived by the parents, are different compared to the PICU period. Methods A structured audio taped interview with 15 parents of children four years after admission to a 20 bed level III PICU of a university teaching hospital to assess whether their child perceived to suffer and to identify perceived aspects of suffering. Results About 50% of the parents experienced 4 years after PICU admission suffering in their child. Parents of 8 children did not perceive suffering in their child. Parents indicated that the suffering during the PICU admission was due to physical and psychosocial factors. Psychosocial factors were related to the disease causing the admission to the PICU, the treatment and the hospital stay. Four years later the signs of suffering are related to communication, physical and mental retardation and being different from mates. Conclusions A child’s admission to a PICU and its suffering not only cause suffering in the child during admission, but often suffering is still present four years after admission. Caregivers in paediatrics need to be aware of these perceived symptoms. In long-term follow up of critically ill children this phenomena needs attention.

Background Critically ill children admitted to a Paediatric Intensive Care Unit (PICU) experience pain and distress. The COMFORT Behaviour (COMFORT B) Scale is a widely used pain and distress assessment scale, validated in children less than 3 years. Minimal studies assess whether the scale is sensitive to detect changes in pain and sedation levels after a treatment intervention is administered. Sensitivity to change, defined as the ability of a measure to detect statistically significant changes after pain treatment, is a relevant psychometric property for pain instruments. With many PICUs now making decisions about analgesia and sedation management based on COMFORT B assessments, it is crucial that these issues are rigorously explored. The aim of the study is to determine if the COMFORT B Scale is sensitive to change. Methods The study is a prospective observational study. Admissions to the PICU of children less than 3 years, who had a COMFORT B score indicating pain or under sedation were included. Re-administration of the COMFORT B scale within 2 h of an intervention was performed to assess sensitivity to change. Results An initial pilot study found excellent interrater reliability in 97 assessments performed by 2 nurses blinded to each other’s scores. Consequently, single nurse paired assessments were completed before and after an intervention and sensitivity to change was established. Conclusions The study identifies that the COMFORT B scale is sensitive to detect change following pharmacological and non pharmacological interventions. Thus proposing the COMFORT B scale effectively guides pain and sedation management.

Background and aims Health professionals in the PICU support both child and parents when the death of a child is imminent. The aim of this contribution is to emphasise that parents can suffer from the altered physical appearance of their child (e.g. severe oedema, bruises and cuts) but physical proximity in the final hours can help them cope. Methods Parents of 24 children who died 4 to 5 years ago in the ICU were invited for a semi-structured interview. Qualitative analysis was applied with Atlas-ti 7.0. Results Parents of 14 children (response rate 58.3%) participated. The children (aged 2 weeks to 13 years) were admitted in PICU from 2 h up to 7 months. The importance of the integrity of their child’s physical appearance stood out in their narratives. Parents spoke of the ‘damaged’ body as a result of necessary medical interventions, quote: “It was terrible, after the reanimation his ribs were broken. He was looking black. It was awful, really awful.” However, getting physically close to the child in the hour of death helped, quote: “We actually crept into bed with her bed, to hold her.” Caring for the body afterwards also helped parents, quote: “After she had died I brushed her teeth like I always did when the kids were smaller. That was so good to do.” Conclusions End-of-life care asks for awareness that the child’s damaged body deeply affects parents. Yet, being able to stay physically close helps them to be the parent they want to be.

Background and aims Compliance with pain assessment in Paediatric Intensive Care Units is not always perfect. We aimed to identify factors explaining compliance or noncompliance with pain assessment in PICU patients. Methods PICU nurses were asked 5 times to complete the same survey on pain management of the most critically ill child they cared for during the shift. Questions informed after the usefulness of pain assessment in this specific child, whether the nurse had assessed pain according to protocol, and any negative/positive impressions of the current shift. Relationships between compliance and these factors were evaluated with Fisher exact tests. Results Ninety-three nurses returned 1 to 5 surveys (response rate 77%), in total 407 surveys. The median working experience of the nurses (94.6% females) at the PICU was 8 years (2 to 33 years). Pain was assessed in 89.4% of 406 surveys. Most shifts were perceived as positive (82%), 10% as negative, 5% mixed and 3% as neutral. Assessment yes/no was not significantly related to a negatively or positively experienced shift (p = 0.82 and 0.81 respectively). In 30% of surveys nurses considered assessment not useful but this was not significantly related to assessment yes/no (p = 0.36). Conclusions Compliance to pain assessment was acceptable. Whether non-compliance is primarily related to patient factors or nurse factors needs to be further unravelled.