Paediatric Critical Care Issues Database (PaediCRID) Dr Andrea - - PowerPoint PPT Presentation

Paediatric Critical Care Issues Database (PaediCRID)

Dr Andrea Cooper Clinical Governance Lead WMPCCN Aimee Hodgson Governance Support Administrator WMPCCN/KIDSNTS

Neurosurgical Emergencies Multi Site Investigation planned External Investigation of potential difficult airway Anaesthetic issues decreasing

Feedback from the Multi site Investigation Update of the External review of the potential difficult airway Learning for the Governance team Feedback from a local RCA regarding Neurosurgical Emergency case Recent case pending SIRI but already identified some regional learning and probable recommendations that will be made A case awaiting investigation locally which raises a number of issues Summary of themes reported Excellence reports

2 year old who presented with gastroenteritis and dehydration picture. Evolving sepsis concerns Cardiac compromise with tachycardia, hypotension and pallor. Metabolic acidosis on VBG with pH 6.2 and Lac 7 Referred to KIDS and started on Adrenaline infusion whilst preparing for intubation PEA arrest on induction despite appropriate cautious anaesthetic induction 2 minutes CPR and one dose adrenaline Post arrest gas pH 6.88, pCo2 7, BE -22 Lac 11 5 hour stabilisation time with KIDS No beds locally. No cardiac bed. Drive through Echocardiogram at BCH- “reduced” Ventricular function Feedback from the Multi site Investigation

Feedback from the Multi site Investigation

No beds at BCH, so transferred to another non-cardiac ICU out of region Required inotropes CTB Normal Deranged coagulation- improved by Vitamin K LP clear NPA Rhino/entero/adenovirus positive Extubated 4 days post admission and discharged back to DGH on same day Well in DGH on the day of transfer, but concerns about tachycardia the following day Bloods revealed very elevated ALT CXR showed large heart with patchy shadowing Lactate of 2, hepatomegaly 2cm Treated with frusemide and periods of improvement.

Feedback from the Multi site Investigation

Episode of tachycardia 200 – pulsed VT Dose of adenosine- no effect 5 x DC cardioversion attempts (Ketamine cover) Then amiodarone and DC Cardioversion- Sinus rhythm, but poorly perfused. Peri-arrest Required intubation and ventilation PEA on induction despite cautious induction RIP Investigation being lead by BCH Governance team. Highlights challenges of multi-site investigations and winter pressures Learning from this is important- could anything have been done differently? Family have been waiting for feedback for almost a year

Feedback from the Multi site Investigation Review the decisions made with regards to the patient pathway, taking into account bed availability regionally and nationally at the time, with the clinical information that was available at the time Coventry to BCH to Nottingham Nottingham back to Coventry identify any concerns about the choice of destination identify any concerns about time of discharge from PICU Review the clinical decisions made to see if any learning Following the Echo at BCH (17/11/18) With regards to the decision made not to repeat an Echo at Nottingham (was this possible to do?) With regards to the Echo findings at Coventry (21/11/18)

It was agreed that consideration should be given to the fact that those decisions made at the time were now being reviewed in hindsight and with information that was not available at the time. It was also considered as part of the review whether the decisions that were made, were made by the right people, at the right time and with the right information available. Feedback from the Multi site Investigation

Decision to transfer to a non-cardiac Centre:

• Following a drive through echo at BCH.
• Consultant cardiology review
• Echo was in keeping with a diagnosis of sepsis
• No concerns that further cardiology review may be required
• Would transfer to a cardiac centre or remain in BCH (had a bed been available), would

have changed the outcome?

• Consenus, if a bed had been available at BCH at the time, the patient would have

remained there with the opportunity to perform further echos, if indicated, within a shorter timeframe.

• Timeframe between the 2 echos was only 4 days, and even had the patient remained

within BCH, it is unlikely that an echo would have been repeated in this time.

• Arrest ? ECLS ? Would have changed outcome
• Presentation to a Hospital with a non-cardiac PICU, unlikely to be transferred out
• Decision making appropriate

Management in PICU:

• Extubated 2 days after arrival.
• Post extubation : interacting, moving around and eating and drinking.
• On the day of transfer she had a good appetite and there were no concerns from the team

looking after her.

• Discussion took place around the availability of echo in PIC. This is limited and at times

may not have a technician or clinician available to perform one

• Since the patient had significantly improved, and there were no on-going clinical signs of

cardiac failure, there was no indication to repeat an echo prior to discharge back to Coventry.

Decision to transfer back to Coventry:

• No Concerns from local team that PIC discharge was inappropriate
• Day 5 of illness (D1 back in DGH) the patient continued to appear well and had a pre-

planned (elective) follow up echo. This showed “left ventricular function impaired FS 21-23%, mild ventricular dilatation, mild regurgitation”.

• The 2 echos (the one performed at BCH, and the one performed after PICU discharge

in Coventry) were reviewed by an independent Cardiology Consultant at BCH.

• It was concluded that the appearances of the 2 scans were very similar.

Areas of Good Practice

• Timely identification by student nurse at Coventry that the patient was deteriorating

during the evening and appropriate escalation of concerns

• Resuscitation on the 21/11
• Support provided by KIDS team to Coventry on 21/11

Conclusion:

• Overall capacity across the region did play a part in the pathway

followed for this patient

• The decisions made at the time were made by the appropriate

staff, of the appropriate seniority, with the correct information available, and therefore that the decision made to transfer the patient to QMC was appropriate.

• It is not known whether admission to a Cardiac PICU would have

changed outcome.

Investigation of report that advice given by KIDS Consultant was potentially dangerous:

Report from local Anaesthetist 7 month old child presents with neck swelling causing stridor when asleep and lying down USS revealed large retropharyngeal abscess. Unable to exclude mediastinal extension. Recommend Urgent ENT review and CT imaging AICU had been called prior to USS to provide airway assessment Concerns that there was significant potential for airway to obstruct and intubation may become extremely difficult Local team felt that transfer to BCH should occur ASAP Local ENT team had advised that they could not intervene surgically in local hospital

Investigation of report that advice given by KIDS Consultant was potentially dangerous:

Referred to KIDS and advice was to electively intubate locally for CT scan Concerns raised by KIDS Consultant regarding transferring the child un-intubated Local ICU team refused to intubate due to concerns about difficult airway and lack of Plan B intubation plan Concerns about possible mediastinal involvement Discussed directly with BCH and accepted for CT scanning and surgery Local team felt the need to transfer and did so unintubated (with occasional stridor) Paediatric Anaesthetist took over the care- inhalational anaesthetic. Grade 1 intubation Discussed at KIDS M&M- Requested independent review of the event. Unfortunately, this did not yield a report outlining the details of the investigation or conclusions and recommendations that could be taken back to those involved and disseminated within the region

Terms of reference:

LEARNING!

PCC ODN PaediCRID Governance Process

Issue occurs Issue is raised by any

• rganisation through

the PCCN Issue Form Notification is sent to the Network Governance Group Network Governance Group writes to the Clinical Lead of the site for response Response received & accepted by Network Governance Group Issue closed and learning points shared with PCCN Board Escalate to PCC ODN Board Non-compliance to be reported to NHSE commissioners Escalate to BWCH Oversight Board / Governance

• Clinical Leads of all sites to receive issue forms, this will be sent via

email from bwc.paedicrid@nhs.net.

• Reminder will be issued at week 4 and resolution of issue should

be achieved by week 8 (unless it is determined that investigations will require more time)

• Upon receipt of response, Network Governance Group will either

agree satisfactory learning points have been captured and close the issue or escalate

Delay in transfer of a child with neuro surgical emergency to BWC theatre. 12year old, alleged assault at school. Presented to A&E Paediatric team contacted neurosurgeons at BWC. Sudden drop in GCS, unequal pupils. Paediatric Consultant contacted KIDS, KIDS advised primary transfer. Reluctance and delay by anaesthesia team in bringing the child.”

Neurosurgical Emergency

• 15:25- Alleged assault, Punch to R temple. Initially alert. Felt unwell. Collapsed.

WMAS called

• 16:50 - Handover to ED, GCS 14 on arrival. Vomited. GCS dropped to 9 (E1V3M5)

AVPU – P

• 17:14 - CT requested
• 17:52 - CT scan vetted
• 18:00 - Obs documented, GCS 3, Obs only done between 1800 and 1913 (PEWS)
• 18:20- S/B ST3 EM Plan urgent CT head, Extradural identified
• Notes say “Neuroradiology accepting child” assume means neurosurgeons.
• ED ST3 D/W Neurosurgeons directly
• 18:55 - Exit CT scanner, Returned to resus
• 19:00 - Retrospective Paed ST4 note D/W KIDS
• 19:02- Phenytoin 840mg prescribed and given
• 19:08- CT Scans linked to BCH
• 19:13- Obs documented GCS 3
• 19:14- Mannitol 10% 130ml prescribed and given

• 19:18 - ITU Reg Retrospective notes
• ITU Reg already in ED with another pt, called to review Pt
• On arrival Pt was unresponsive with unequal pupils.

Documented actions :- 1.Transferred to resus

• 2. ITU cons phoned (arrived at the time of intubation)
• 3. CCP/CCOT fast bleeped
• 4. Intubated for CT (pulmonary oedema noted)
• 5. Plan for immediate transfer to BCH after CT

• 19:15- Onset of hypoxia
• Pt. desaturated to 85%, taken off the ventilator, hand

ventilated (documented in the nursing handover)

• 19:25- 2.7% NaCl 130ml prescribed and given
• 19:51- Blood gas (recorded as venous) pO2 6.93, O2 sats 79%
• ventilation difficult, two different ventilators tried but

adequate oxygenation not achieved

• 20:35- CXR Severe pulmonary oedema
• 20:40- Depart for BCH
• Hand ventilated during transfer

Reflections and learning:

– Very good outcome for the patient despite severity of his condition. – Paediatric time critical transfer done by base team is not a frequent event, child is likely to be unstable, clinicians will be out of their comfort zone and that will increase the stressfulness of the situation. – SOP and regular simulation will improve confidence and efficiency of the team.

Delays that with retrospect could have been avoided:

– Time spent discussing which team is going to transfer the child – KIDS team vs base team. In this instance (extradural haemorrhage) base team (ITU) should transfer the child. Being aware of that from the start could have improved the time of transfer. – Time spent attempting to stabilise the child on a ventilator for the transfer – early discussion between ITU consultant and KIDS team consultant about feasibility of hand ventilation during transfer could have saved some time. – Communication between teams (ITU and Paediatrics) in Resus during stabilisation of the child was not ideal. Understanding of issues of what the

• ther speciality considers vital was not sufficient. Speed of transfer in order

to provide lifesaving surgery versus sufficient oxygenation and risk of severe hypoxic injury during the transfer was the dilemma the team was facing. We recognise that this was very difficult clinical situation.

• Develop SOP for time critical transfer in progress
• Human factors/communication training – regular simulation.
• Ensure clear and direct communication between KIDS team and

intensive care team if ventilation/organ support is not straightforward (part of SOP).

• Feed back to KIDS team

Actions

• 6 and a half year old, previously F&W boy
• One week Hx of cough and cold
• Mum had planned to take him to GP Friday morning
• Thursday night 0200 had an acute deterioration
• Under Ix by GP since August with enlarged cervical LN
• “noisy breathing”in ED
• Trialled B2B nebs- no effect
• Chest appeared Barrelled
• Saturating 90% in air RR 38, SC recessions
• CXR large mediastinal mass
• Bloods NAD other than LDH 957
• Admitted to HDU – advised to sit up

Oncology case

Very large anterior mediastinal mass, measuring approx 10.8 x 8.8 x 12.9 cm

Mass is significantly compressing the left and right main bronchus at the level of the carina and displacing the mediastinal structures posteriorly Moderate sized right pleural effusion, with atelectasis of the underlying lung Images are so sub-optimal that alternative/repeat imaging may be required No comment about pericardial effusion, but that’s also seen Oncology case

Oncology case

• Discussed with Oncology team and images PACSed over
• Transferred to BCH with nurse and paramedic
• “Audible wheeze” in ambulance with moderate WOB
• Auscultated by Paramedic
• Arrives in BCH at 6pm
• Clerked by Oncology SpR
• Red Bleep informed that child is on the ward
• RB in PAU, but will ask night Reg to review asap
• 15 minutes later (8pm) ZH rolls over in bed and suffers cardiac arrest
• Ward team unable to BMV

• Intubated by Consultant Paediatric Anaesthetist
• 5 minute downtime- ROSC with intubation
• Further loss of ETCO2 and output
• Reintubated with larger, cuffed ETT. Endobronchial intubation and pulled back to

carina

• ROSC
• Admitted to PIC
• HFOV- high settings
• Inotropic requirement ++
• Normothermia, post arrest care
• Pericardial effusion re-scanned- very high risk procedure

Oncology case

Oncology case- Questions immediately raised?

• Why need to CTB locally? Especially as reported as “sub-optimal”
• Were Anaesthetics involved?
• What was Oncology advice?
• Decision to send with nurse and paramedic?
• Did that team know how high risk the transfer was?
• Should KIDS be consulted for all mediastinal masses?
• Consensus from KIDS M&M is that the child should have been considered for PIC

admission

• Need to engage with BCH Oncologists to involve KIDS
• Pathway? BCH CT scan? Regional Education?

High Risk Intubation Anaesthetics

4yr old child well known to KIDS team, background Trisomy 21, ASD, Pulmonary hypertension

• n sildenafil, nocturnal Bipap

Admitted for management of LRI at DGH. Desaturation noticed by KIDS team while awaiting lifts >10mins in DGH on the way to KIDS ambulance. KIDS team leader decision to transfer child to resus to stabilise, refused access by duty bed manager. Child had to be taken to KIDS ambulance, attempts made to stabilise. Child did not settle, KIDS team leader's decision to intubate and ventilate. Plan agreed with KIDS consultant.

Teamwork Issues:

Ambulance technician requested resus access and local anaesthesia back up. Local anaesthesia registrar attended in resus, took charge and as per KIDS team refused to work collaboratively with the team. There will be an SI in DGH. Parental Complaint regarding lack of access to Resus and attitude and behaviour of Anaesthetic Middle Grade. KIDS team debrief done Teamwork Issues:

Areas to explore:

• 1. Refusal of access to resus bay for a deteriorating critically ill child.
• 2. Attitude and undermining behaviour of Anaesthesia middle grade.
• 3. Lack of PIC capacity. Should the patient have been transferred sooner?

Teamwork Issues:

Human Factors Communication – what went wrong? Awareness of progression of Advanced Practice? Availability of beds Patient specific contributors

Drug calculations and preparation Adult MTC refused a 16 year old as fears specialities wouldn’t accept Delay in getting CT Brain for a child with red flags on presentation. Delay in transfer Teenager with Verapamil overdose, Complete Heart Block on ECG (dealyed recognistion). No preparation to give Calcium chloride (or gluconate) was made and the team was not prepared to deliver transthoracic pacing. These measures should have been done in a case of significant cardioselective CCB poisoning CTB result falsely communicated resulting in time critical transfer by KIDS Test circuit used to ventilate a patient Communication – Antibiotics, bedding issues at BCH Empyema pathway/care Request that DGH investigates a case where a F&W 9 month old was treated for Status Epilepticus (local CTB reported as NAD), but developed F&D pupils and unfortunately died following withdrawal of Life sustaining care after MRI confirmed coning.

Other themes:

Excellence “As the KIDS on call consultant I took a referral from Dr Gorst (my apologies if spelling incorrect) who was the Paediatric Registrar overnight 28/1 to 29/1. This struck me during the call that this was one of the best KIDS referrals I’ve received over the winter period and deserved some positive feedback”

Excellence

Whole team calm and professional despite being faced with a very difficult clinical situation. Had attempted to transfer on NIV due to the risks of intubation and recognized this not safe and therefore returned to A+E. Although dealing with a high risk patient made sure a member of the team had time to keep Mum up to date. Once patient 'stable' although was the end of their shift elected to go with patient knowing how complex the case was. This although the round trip was going to take hours

Excellence

There was timely management of a 14 year old girl who had been involved in an RTC and suffered a skull fracture with EDH. The referral was excellent and management had occurred as

• expected. The team rapidly stabilised and facilitated a time

critical local transfer. TBI and Neurosurgical emergencies can often cause issues with delays in stabilisation and reluctance to perform local

• transfer. In this case this not only happened, but in very timely

manner and the child had a very good outcome

Excellence

“Very sick cyanotic cardiac baby with unknown diagnosis, presumed tga or truncus. This was a high risk baby or induction of anaesthesia – I was able to have to have conversations with both the Paediatric and Anaesthetic Consultants and we were able to make a collaborative plan for a safe induction. The local team (from students to radiologists to nurses to medics) were safe and efficient and a pleasure to work with despite the baby being so sick

Excellence

On arrival at Royal Stoke University Hospital, while waiting for a lift to go to PICU the ventilated baby in our care had a sudden and unexpected bradycardia followed by desaturation. This resulted in us having to put out a paediatric arrest call. A passing member of staff then offered to take us to resus (we were not aware of how close-by it was) We rapidly moved the baby to ED resus, arriving unannounced. The whole ED team accommodated us into a resus bay without any fuss. The ED medical team leader (Ben Hall) waited patiently until we had plugged into wall power and O2 and defib pads attached at my request and we were able to take a breath and were ready to give a brief SBAR. The whole ED team were calm and supportive of our needs despite having no idea of who we were and where we had appeared from!

Excellence

Case from the weekend! Not yet reported, but needs sharing! NEWTS Local Surgeons AICU/Anaesthetics

Please continue to report and respond!