IMPROVING OUTCOMES FOR SICK CHILDREN NHS Tayside

1. IMPROVING OUTCOMES FOR SICK CHILDRENNHS Tayside

2. 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?

3. 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

4. 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

5. 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.

6. Improvement Aim – ambitious or naïve Outcome Primary Drivers Secondary Drivers (change concepts) 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) Appropriate, timely and reliable recognition and management of sick children Zero preventable readmissions, crash calls, HDU/ PICU admissions. In-ward deaths by June 2013 SBAR – handover, escalation Safety Briefing Multidisciplinary rounding Daily goals Effective discharge planning Effective readmission planning /CYADM, anticipatory care plans Multiagency Effective communication Infrastructure and culture to promote safety Empower all staff to voice concerns Safety walkrounds Learning from adverse events (case note reviews, IR1, PTT) Sharing all data with whole team +/- patients and carers Capability and capacity

7. Can we predict who will deteriorate? Can we prevent it? 80% of acute admissions to HDU have a PEWS <3 Why admit to HDU?

8. What causes concern & doesn’t score in PEWS?

9. 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)

10. 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

11. How to move towards Safety Culture of recognising deteriorating children? Communication – MDR – Safety Briefings Equipment, Medicines Emergency Simulation Case note reviews PEWS

12. Safety Brief – shared mental model MULTIDISCIPLINARY SAFETY BRIEFING WARD 29 DATE:TIME:

13. Results: process measures Reaching >98% compliance with process measures summer 2011

14. Balancing measure: HDU admission rate Ward 29, Ninewells Hospital HDU Admission Rate

15. Outcome measure – PICU admission rate Ward 29, Ninewells Hospital PICU Admission Rate

16. Outcome measure: Crash Calls Ward 29, Ninewells Hospital Crash Call Rate

17. Outcome measure: In-Ward Mortality Ward 29, Ninewells Hospital In-Ward Mortality Rate

18. Outcome measure: combined outcome Potential for national Serious Harm Index? Simulation started New PEWS charts and reliability for multiple process measures across whole unit

19. Who is the sickest patient on the ward?

20. 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+

21. 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?