Upload
others
View
0
Download
0
Embed Size (px)
Citation preview
Emergency - Quality, Education and
Safety Teleconference
For smaller EDs
Dr Joseph Marwood
Emergency Care Institute
Thanks for joining
House rules
Agenda
• Case review
• Underlying causes
• Clinical context
• NSW Health guidance
Participation encouraged throughout(But please turn off camera & mute mic when not talking)
Case – Initial presentation
Sunday morning 0230 Rural ED
4 month old boy
BIB mum
Unwell 3 days
Vomiting post feeds
2 wet nappies / 24 hrs
Case - presentation
Obs
RR 60
SaO2 90-94%
HR 150
T 36.9
Tracheal tug, intercostal recession
Audible wheeze & grunt
ATS Category?
Case - review
VMO review in 5 mins
‘Brief cyanosis’
Tolerated nasal prong O2
P/C to Base Hospital paediatric reg
Cannula
IVF bolus 20ml/kg 0.9% saline, + infusion
CXR
Booked ANSW transfer (non urgent)
Case – initial progress
0415 CXR reviewed – ‘right upper lobe pneumonia’
0420 IV Ampicillin 100mg
0425 VMO leaves hospital
0455 Ambulance arrives
HR 160 bpm SaO2 86% (96% on 8L) RR 44
Ambulance query need for NETS call
TF to base hospital (lights & sirens)
THOUGHTS? Could this reflect a case at your ED?
Case – progress @ RRH
0635 Arrival @ Base Hospital
No pre-arrival ATS Cat 2 “SOB”
0640 IV Cefotaxime, rpt CXR – ‘cardiomegaly’
0650 Severe respiratory distress
HR 195 T 38.4
Moved to resus
ED consultant called & attended
NETS called
Case - progress0800 FACEM intubation unsuccessful,
Bradycardic arrest ROSC
0810 Anaesthetist intubation unsuccessful
Bradycardic arrest ROSC
0840 Anaesthetist re-intubation successful
Bradycardic arrest ROSC
Fentanyl & dopamine infusion
0930 Bradycardic arrest ROSC
Case - outcome
1015 NETS arrival, TF to Tertiary hospital
Diagnosed with coarctation of aorta
Theatre for aortic stent
Sadly died from hypoxic brain injury
THOUGHTS ON THE CASE?
Issues impacting outcome?
Patient
High risk population
Rare underlying diagnosis (No ∆ to disposition)
Difficult airway / complex resuscitation
Personnel
Culture, communication & rapport
Cognitive bias / diagnostic anchoring
Practices
Lack of specialist input
Transfer urgency
How might we prevent this occurring?
Individual level
Care of the transferred patient
Question cognitive biases
(alternative diagnoses in neonate – ‘THE MISFITS’)
Systems Level
Inter-disciplinary culture (“Its OK to ask”)
Care of the deteriorating patient
Pre-arrival notification (batphone)
?
?
Inter-facility transfers of children
“Ensure that the child’s condition has been assessed and
stabilised as much as possible prior to transfer [in
consultation with a clinician at the receiving hospital].
Ensure the child’s safety at all times with regard to transfer
decisions.
Medical and nursing staff should consult with Ambulance
officers in decisions about transfer and clarify the
responsibilities of key staff during the transfer.”
Lost opportunity to discuss alternative transfer
Inter-facility transfers of children
“NETS needs to be consulted in all children with a triage
category of 1 and 2 and all children with a triage category
of 3 who are not improving.”
NETS would normally expect to be called about… High
oxygen requirement…Respiratory failure …
What is your experience to using NETS?
Are there barriers to involving the service?
Sick Neonates
Scary
Sepsis?
Sepsis plus…?
Trauma
Heart
Endocrine
Metabolic
Inborn errors
Seizures
Formula
Intestinal
Toxins
Sepsis
?
Trauma including NAI
1/3 of head trauma missed
Risk factors for NAI?
Look for - bruises, bulging fontanelle, abnormal pupils, retinal
haemorrhages
Admission, survey, mandatory reporter guide
+/- surgical opinion
Heart - Congenital disease / SVT
Look for - shock (cap refill), cyanosis
Absent femoral pulses, ?big liver?
ECG
NETS / Cardiology opinion
Endocrine
Hypoglycaemia, congenital adrenal hyperplasia
Look for ↓glucose, resistant shock, ↑K+, ↓Na+, ?ambiguous genitalia
Hypoglycaemia: 10% Dextrose 2ml/kg
Shock: 0.9% NaCl 20mls/kg
Resistant shock: Hydrocortisone 4mg/kg
Inborn Errors – Acid base ∆s
Seizures
60% hypoxia / ↓perfusion
10% CNS infection (no ‘febrile seizures’
Formula
Electrolyte disorder, especially ↑or↓ Na+
Intestinal catastrophe
Malrotation/ Intussusception/ Obstruction / Pyloric stenosis
Hx of bilious vomiting
Look for – peritonitis, ?abdo mass?
ABX, IVF& surgical opinion
Toxins
Ingestion, breast-milk, dermal
Look for – toxidromes: opioids, amphetamines, botulism
BSL, ECG, toxicology advice
Sepsis
Prematurity, GBS +ve mother, PROM, < 1month, un immunised
Look for ↓or↑ temp, localising signs, shock
Early empirical ABX < 1 hr (Local guidelines)
e.g cefotaxime 50mg/kg
+ flucloxacillin 50mg OR vancomycin 15mg/kg
+/- gentamicin 5mg/kg)
IVF 20ml/kg bolus
Correct diagnosis
Correct treatment
Correct disposition
Recognition of the sick child
Survival
Clinical Tools
Recognition of the sick baby
Recognition of the deteriorating patient
Deterioration = Escalation
Do you agree?
Culture
How can we empower staff to challenge decisions?
Nursing
Medical
Allied Health
Patient / parent
Medical
Nursing Allied Health
Patient /
Parent
Any further thoughts?
E-QuESTs so far
• Atypical Chest Pain - ACS
• Sepsis in the elderly
• Abdominal pain in the elderly - AAA & Ischaemic gut
• Scrotal emergencies
• Deadly headaches
• Paediatric deterioration
Looking to next month, please…
• Share your cases
• Share your patient safety actions
• Spread the word with your colleagues
(or send me their email: [email protected])
What would you like to see / hear about?
Further Info
“Paediatric Watch” – other great safety cases with analysis
http://www.cec.health.nsw.gov.au/patient-safety-programs/paediatric-
patient-safety/paediatric-watch
“NSW Mandatory Reporter Guide”
https://reporter.childstory.nsw.gov.au/s/
http://www.cec.health.nsw.gov.au/patient-safety-programs/paediatric-patient-safety/paediatric-watchhttps://reporter.childstory.nsw.gov.au/s/
Further Info
Clinical Excellence Commission guidelines on M&M http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0018/352215/clinical-review-m-
and-m-oct-2016.pdf Google “CEC M&M”
ED Quality Framework Death Audithttps://www.aci.health.nsw.gov.au/networks/eci/administration/ed-qf-project/ed-qf-death-
audit Google “ECI death audit”
http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0018/352215/clinical-review-m-and-m-oct-2016.pdfhttps://www.aci.health.nsw.gov.au/networks/eci/administration/ed-qf-project/ed-qf-death-audit
Many thanks
Next E-QUEST
Thursday 14th December 0800
Level 4, Sage Building 67 Albert Avenue PO Box 699 T 02 9464 4674 www.ecinsw.com.au
Chatswood NSW 2067 Chatswood NSW 2057 F 02 9464 4728 ABN 89 809 648 636
Look out for our email survey
We need your responses to guide future work