Paediatric Study Day – Alder Hey Network March 2017

I was delighted to be asked to present a topic at the inaugural Alder Hey Children’s Hospital’s joint surgical and anaesthetic network meeting.  It was a great day, with lots of speakers getting the message about joint working and sharing information, about clinical topics, good governance and human factors.  I thought I’d share a few of my notes of the day in case any of it is helpful to you.

Setting up a Paeds network

There are many advantages to setting up a highly functioning network between tertiary centres and the peripheral hospitals:

  • minimising variation in care
  • uniformity of standards
  • access to expertise in tertiary centres

It’s not just about sending information out from a hub to its spokes, it is just as important to share information between peripheral hospitals too.

One of the most difficult challenges to overcome is the development of an effective communication network.

Surgical Transfer

Acute surgical networks can be particularly tricky, the expertise to cast eyes on a patient in a peripheral hospital just isn’t there, and the availability of operative expertise is even more scarce.  This could be mitigated by regular visiting surgeons from the paediatric centre, or by investing in a rapid transfer network with concurrent development of in-hospital rapid assessment/transfer protocols.  The latter risks overwhelming the tertiary centre; something which has occurred since the advice in the last decade that surgery should be centralised.

There are many steps to arranging assessment and transfer, all of which can incur delay, some of the longest can be in misunderstandings during communications.  Use of a structured communication tool can minimise this, eg SBAR

  • Situation – What the immediate problem is
  • Background – The story behind it
  • Assessment – What the current situation is surrounding the problem
  • Recommendations/Requirements – What I want to happen/you to do.

In a time-critical transfer that is in effect, use of the ATMISTER tool may be appropriate:

  • Age/sex/demographics – as far as is necessary
  • Time of injury/illness onset
  • Mechanism of injury
  • Injuries/illness suspected/proven
  • Symptoms and Signs
  • Treatment given
  • Estimated time of arrival
  • Requirements on arrival

Use of closed-loop communication is important when ending a communication episode, including a summary of what each party is going to do before contact is reestablished.

How is the UK doing?

Comparing UK with best in Europe – if we were doing as well as them, there would be 5 fewer deaths per day!

DGHs in UK are not providing emergency out-of-hours care for paediatrics. Anaesthetics and surgical theatre nursing overnight in fewer than a quarter of DGHs.

There is a new 5 year strategy for improving children’s surgery in the UK – should be local when possible, avoiding transfer delays and putting tertiary centres over capacity.  But experienced adult surgeons retiring, new surgeons don’t have paeds experience. Paeds surgical is no longer in an adult surgeon’s mandatory training.  Adult surgeons are being encouraged to operate on children in time sensitive cases eg torsion testis, appendicitis, etc.

If we were to encourage the standardisation of equipment across regions with visiting satellite surgeons, this would reduce errors due to increased familiarity, we also need to ensure staff are trained in critical incident and paeds life support (APLS).

Discussions – how much specialisation/generalisation is the right amount? How much centralisation/regionalisation is safest?  Maximising flexibility is important. Maintenance of broad scope of practice in unplanned care.

For anaesthetists, the Royal College of Anaesthetists have issued guidance – anaesthetists may have out of hours duty with a chance of paeds encounters; if these anaesthetists have no daytime lists with children, they should arrange to be supernumerary on lists with children to keep their experience up.

Anaesthetists in all centres working with children need to keep up to date with CPD, the RCoA matrix includes:

  • sick child assessment
  • Vascular access
  • Fluid management
  • Analgesia
  • Training

Basic levels of training should make all anaesthetists competent in the anaesthesia of children aged 3 or above.

Advanced training should allow for the stabilisation of sick babies pre-transfer, which will be difficult in a DGH, as there is such little exposure.

Alder Hey in the Park Children’s hospital can provide on application: accompanied lists with alder hey consultant, with hands on practice.  You just need to ask for availability. This could proved invaluable for colleagues in need of more practice.  They also put on a paediatric difficult airway study day

Challenges:

  • engaging with adult surgeons in dgh for visiting surgeons
  • provision of nursing staff for complex surgery
  • reskilling since centralisation
  • outreach

Critical incident reporting and M&M:

Critical incident reporting needs an overhaul in most Trusts in the NHS.

Technological solutions – case reporting – system needs to be fast to complete, but thorough enough for analysis.  Needs to be able to spot trends in errors/incidents with a rapid acting governance system to back it up.

Learning needs to occur across speciality boundaries; sharing of information is currently poor.  External scrutiny – outside of department, captures wider system problems.

There should be a low threshold for reporting, every occurrence, hence the need for it to be quick to report.

In specific cases, there needs to be a mechanism for feedback to families (duty of candour, etc), it must be open and transparent.

M&M meetings should include feedback re previous action points, both to relate learnt points and system changes, but also to engage staff in the process, if they see changes being made, they are more likely to report in the first place.

Review of mortality – network development will help to include outreach patients at other units.

Governance systems need to change, there must be an emphasis on system/process issues and changes rather than clinical failings.  The ‘no-blame culture’ is a long way off in the NHS, there is still learning to be done from the aviation industry.

If a response governance system is in place, extraordinary meetings should be possible if clusters of problems are spotted or especially complex cases need to be discussed.

The Golden Hour: Paediatric Major Trauma

The clinical aspects of the resuscitation of paeds patients with major trauma were discussed.  Mainly, the message was that most of the recommendations on how to treat children with major haemorrhage are extrapolated from adults, the doctrine of empiric 1:1:1 blood product resus, the use of tranexamic acid and the possible use of bedside point of care testing like TEG/ROTEM was explained.  There isn’t the research out there to provide strong recommendations for children at this time.

As an aside, there is a good overview article of paediatric massive transfusion to found at the BJA: Paediatric Massive Tranfusion, from August 2016.

My talk was about the ways a peripheral hospital can shave time off a time-critical transfer. The slides can be found here.  In summary, it is about running simultaneous workstreams; diagnosis, referral, stabilisation and transfer all at the same time.  The key messages are:

  • Delegate tasks so simultaneous workstreams are effective
  • Minimise interventions to only those that will make a difference before/during transfer
  • Communicate well and often with destination
  • Use standardised communication tools to streamline discussions and minimise confusion, misunderstandings and waffle.
  • Implement a “Call and Send” policy – automatic acceptance of patients, less debate about “if” and more about “how”.

Schwartz rounds

This was something I had not heard about before, a Schwartz round is an opportunity for staff to get together and share emotions, feelings and social aspects surrounding working in healthcare, perhaps a specific care episode that was particularly difficult on a personal level.  An example Schwartz round was demonstrated, I have great respect for the clinicians who took part, it cannot be easy to speak about these topics in a room full of peers.

There was a great deal of introspection in each of us, lots of discussion around empath, guilt, doubt,  and self-preservation and selfishness.  I found this experience to be very productive, and will add this technique into my current working practice, perhaps as a modification to my current debriefing process.

The Point of Care foundation website can provide more information on this.

Safe, sustainable pain relief:

Premedication is much better for analgesia than intraoperative (eg suppositories), mainly because it has time to act, particularly beneficial in short procedures.  It is also much simpler to administer.

Dexamethasone has been shown to reduce opiate requirements in addition to its anti-emetic effect, with few side-effects.

Intraoperatively, a multi-modal analgesic approach should be employed; use of local anaesthetics, dexamethasone, clonidine, ketamine. Opiates are for rescue analgesia.

Children are experiencing pain at home, reattendance is occurring at the ED or the patient’s GP, so worth considering getting the post-op regime correct.  Also, there is a hidden impact on families, who need to look after the child, who may incur loss of earnings etc.  We could better educate parents about analgesic regimes, what about pain assessment tools for parents, education of dosing schedules, the benefits of regular medication over PRN, what about innovation – SMS reminders to give pain-relief on a regular basis?

How can we get individual clinicians to change, and get on board with new thinking with regard to analgesia?  I once heard a Freakonomics podcast about Riding the Herd Mentality which describes the effect of peer-pressure on an individual’s behaviour; it argues the best motivators for change and guilt and shame!  It was suggested at the meeting that perhaps league tables of post-op rescue analgesic requirements might effect the change needed with remarkable efficiacy!

Integrated care pathways:

Good for standardisation of care, auditing services and compliance with standards.

Pathways reduce length of stay, costs and complications.

Challenge:

  • Forcing adherence to guidelines or completing a checklist to ensure care provided.

A description of a successful care pathway was demonstrated, paediatric appendicectomy. A simple bundle of care yield much better outcomes, including length of stay and reduction in complications.  This bundle responded to new evidence:

  • reduction in antibiotic use
  • uselessness of imaging abdomen for collection before 7 days
  • trends of CRP instead of absolute values.
  • pathway is responsive to need for antibiotics based on inflammatory parameters, tailors care despite being a pathway.

The EIDO patient information leaflets are used at Alder Hey; they are a good resource, there are many, covering lots of different surgeries, if there isn’t one for the particular operation you need, there is opportunity to write one, and they will pay you for it. Good deal!

Alder Hey happy to share the appendicetomy pathway, and then maybe conduct a regional audit of outcomes.

Technology and Innovation:

There are lots of cutting edge developments in healthcare occurring behind the scenes, from patient monitoring to neural networks and data sharing/mining. Some examples include:

  • Transdermal sensing of lactate and haemoglobin, wireless
  • Potential for remote sensing and reporting from peripheral hospitals
  • Interacting with children through app before and during admission, including learning about children’s likes, and reminds about appointments etc.  It can show the child a virtual tour of the hospital making it more familiar.  This is already being implemented.  The information gained can inform play specialists, and even alter the environment the child experiences when they arrive.
  • Using videoconferencing links to reunite children and parents separated by care facilities, including babies on NICU when mother is still at base hospital or on maternity ward.

Patient and carer feedback:

This session discussed the importance of getting the experience right for patients and carers/parents.  There are lots of different methods of sourcing information, and all of them can be used to inform change processes. Each source must be interpreted in the light of its various biases. For example:

A good example of this was explained; the patient journey through ED as surgical pathway, areas to improve identified were:

  • Analgesia
  • Flow through ED
  • Angry parents

Asked patients how to improve; developed a patient and family centred care development programme:

  • About treating patients and families with respect and dignity.
  • Allowed development of abdominal pain pathway

It was common to have a long wait for assessment/investigations/length of stay in patients with generalised abdominal pain.

A Surgical decision unit was piloted – 4 beds. Including ward attenders

  • Emphasis on flow and good analgesia.
  • Direct pharmacy access.

Resulted in lower length of stay, rapid decision making, nurse led discharge

Experience of day surgery; another example:

Problems:

  • Waiting
  • Fasting

Waiting. Changed admission times to phased every 2 hours, was am/pm. Additional pause was built into the morning list for pre-operative assessment.  This helped admission times, wait times, car parking. Ward flow. Greater parent satisfaction. Better timing of premeds.

Fasting. Changed the fasting policy:

  • <1 year – 6 hours solids, 4 hours formula milk, 3 hours breast milk
  • >1 year – 6 hours solids

Both – 1 hour clear fluids.  This is being audited, no additional risk of aspiration detected thus far, and has improved patient and parent satisfaction.

Summary

It was an excellent meeting, with many clinicians who share the goal of improving communication with their tertiary centre, helping to target the transfer of patients, instead of sending all surgical patients.  The sharing of information of treatment pathways will help to standardise care, including transfer guidance and may help to standardise equipment for when surgeons visit DGHs from the tertiary centre.

More meetings will be planned in future, and the networking will only improve from now on.  Great stuff.

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