IMPROVING OUTCOMES FOR SICK CHILDRENNHS Tayside

Sick Children – Our Journey in Tayside

• 7000 acutely unwell children referred annually– ~30% admitted

• ICU admissions ~ 7 per 1000 admissions– Tayside accounts for 10% of all inpatient paediatric admissions

per annum in Scotland, only 5% of PICU admissions

• How many patients deteriorate in our care?• How many ICU admissions/deaths are preventable?• Can we improve?

Team ‘buy in’ - What is your Project 1?• What really drives the team nuts – what is the biggest

waste, safety, inefficiency issue that annoys all staff

• Start there

• Consult all staff re the process and empower all staff to test changes

• Don’t dismiss ideas until you have tried them

• Credit the team with team success

Tayside “Project 1”

• 5/12 old boy• Presented at 10 am to SSAA• Unwell for 3-4 hours with pyrexia and runny nose, still

feeding and babbling and smiling• Known to unit – complicated neonatal course• Thought to be well but not discharged due to parental

concern – first febrile illness since discharge• Sudden collapse in unit and died with meningococcal

sepsis by 6pm

Case review• Non recognition of the sick child• Then late recognition and failure to act promptly• Failure to escalate• Once escalated senior multidisciplinary team involved in

simultaneous resuscitation

• Team invested in this patient as well known to unit • huge division in team ensued with a blame culture

• How do we turn this around and restore faith in each other and our team? We do our best to ensure we provide the appropriate and timely care to all our patients.

Improvement Aim – ambitious or naïve

Outcome Primary DriversSecondary Drivers (change concepts)

Appropriate, timely and

reliable recognition and management of

sick children

Infrastructure and culture to

promote safety

Effective communication

Zero preventable readmissions,

crash calls,HDU/ PICU

admissions. In-ward deaths

by June 2013

Empower all staff to voice concernsSafety walkroundsLearning from adverse events (case note reviews, IR1, PTT)Sharing all data with whole team +/- patients and carersCapability and capacity

Early recognition (PEWS, watcher criteria)Appropriate escalation (PEWS escalation flow chart)Appropriately trained staff (life support courses, senior review, up skilling, regular updates)Testing theory in real time real place (emergency simulation)

Guidelines for common emergencies updated and immediately accessible (review dates and website updating)

Functioning appropriate equipment (bedspace checks, resus trolley)

Appropriate medicines ( in date, algorithms, remove unused)

Timely ( teaching re timelines, process change)

SBAR – handover, escalationSafety BriefingMultidisciplinary roundingDaily goalsEffective discharge planningEffective readmission planning /CYADM, anticipatory care plansMultiagency

Can we predict who will deteriorate? Can we prevent it?

% acute admissions to HDU Tayside Childrens Hospital Nov 2011 - April 2012

05

101520253035

0 1 2 3 4 5 6 7

PEWS score

%

80% of acute admissions to HDU have a PEWS <3

Why admit to HDU?

What causes concern & doesn’t score in PEWS?

Watchers

Gut Feelings.......“Researchers explain that intuition represents one of the ways our brains store, process

and retrieve information........ The researchers .... concluded that intuition - a feeling that something is right or wrong - is the brain drawing on past

experiences and current external cues to make a decision; a process so rapid that the reaction is subconscious.”

British Journal of Psychology (April 2008)

How do we know a change is an improvement?

• Outcome measures– Crash call rate, HDU & ICU admission rates, In ward mortality

rate– Prediction of Watchers

• Process Measures– PEWS, SBAR, MDR, DG, safety brief, equipment checks,

guideline checks, simulations, time to first dose of antibiotics,

adherence to specific guidelines • Balancing measures

– HDU admission rate, staff feedback (simulation), time invested in measuring v delivering service

How to move towards Safety Culture of recognising deteriorating children?

Com

mun

icat

ion

– M

DR

– S

afet

y B

riefin

gs

Equi

pmen

t, M

edic

ines

Emer

genc

y Si

mul

atio

nC

ase

note

revi

ews

PEW

S

Safety Brief – shared mental model

MULTIDISCIPLINARY SAFETY BRIEFING WARD 29 DATE: TIME:

EMPTY BEDS (bays/SR) /

ANTICIPATED DISCHARGES

PLANNED ADMISSIONS

WARD ISSUES PROBLEM DETAILS (including bed number)

YES NO

PATIENTS WITH SIMILAR NAMES

HIGH PEWS / WATCHERS

PATIENTS WITH INDIVIDUALISED PROTOCOLS (eg CYPADM)

Results: process measures

Reaching >98% compliance with process measures summer 2011

Balancing measure: HDU admission rate

Ward 29, Ninewells HospitalHDU Admission Rate

0102030405060708090

100110120130140150160170180190200

Ward 29, Ninewells HospitalHDU Admission Rate

Outcome measure – PICU admission rate

Ward 29, Ninewells HospitalICU Admission Rate

0

5

10

15

20

Ward 29, Ninewells HospitalPICU Admission Rate

Outcome measure: Crash Calls

Ward 29,HDU, SSAA Ninewells HospitalCrash Call Rate

0

10

20

Ward 29, Ninewells HospitalCrash Call Rate

Outcome measure: In-Ward Mortality

Ward 29, Ninewells HospitalIn Ward Mortality Rate

0

10

Ward 29, Ninewells HospitalIn-Ward Mortality Rate

Outcome measure: combined outcome Potential for national Serious Harm Index?

Ward 29 Ninewells Hospital total significant events rate (total mortality + crash calls + ICU admissions)

0

5

10

15

20

25

30

35

40

Jan-

10

Feb-

10

Mar

-10

Apr

-10

May

-10

Jun-

10

Jul-1

0

Aug

-10

Sep-

10

Oct

-10

Nov

-10

Dec

-10

Jan-

11

Feb-

11

Mar

-11

Apr

-11

May

-11

Jun-

11

Jul-1

1

Aug

-11

Sep-

11

Oct

-11

Nov

-11

Dec

-11

Jan-

12

Feb-

12

Mar

-12

Apr

-12

May

-12

Simulation started

New PEWS charts and reliability for multiple process measures across whole unit

Who is the sickest patient on the ward?

May 2011

• 16 different responses• Little overlap• No agreement with attending

Consultant

May 2012

• Agreement• Theory: Early recognition

and shared mental model increases number of reviews, decreases time to treatment and prevents deterioration

Tayside “Project 1” outcomes

• Tayside team believe in themselves as individuals and as a team

• We know we are providing high quality care (and have the data to show it)

• We may be improving outcomes for children but it is early days

• We know we have improved staff morale (and have data to prove it!)

• We now we have a team who “knows how to improve” • We are now on project 40+

Learning / Challenges – developing a Safety Culture

• Data is everything:– Baseline– And accurate, appropriate measurement

• Person dependence & improvement fatigue• Capability and capacity• Culture – transparency about “bad data”• Running before we could walk – especially simulation• “spread control”• What do we not know? Should we be worried about it?