Paediatric Critical Care Issues Database (PaediCRID) Dr Andrea - - PowerPoint PPT Presentation
Paediatric Critical Care Issues Database (PaediCRID) Dr Andrea Cooper Consultant Paediatric Intensivist KIDSNTS and BWC Aimee Haynes Governance Support Administrator WMPCCN/KIDSNTS Since 28 th November 2017: Gathering information Encouraging
Dr Andrea Cooper Consultant Paediatric Intensivist KIDSNTS and BWC Aimee Haynes Governance Support Administrator WMPCCN/KIDSNTS
Since 28th November 2017: Gathering information Encouraging reporting Identifying themes Some uniformity throughout the region Others seem to affect some trusts more than others RCAs/SIRIS Now time to share some learning!
Themes causing issues: Neurosurgical Emergencies: Recognition Management Time critical/local transfer Anaesthetic/AICU support: Intubation Extubation Support whilst awaiting Transport team
Themes for Excellence reporting: Anaesthetic Support/Involvement Neonatal Units supporting patient pathway delays due to winter pressures Palliative Care and Community support both in local hospitals and in PICU
Neurosurgical Emergencies: 6 reports around Neurosurgical Emergencies One RCA carried out with excellent learning Another very extensive investigation into delays obtaining CT Brain with good learning.
2.5 hr delay in referring a child with intracranial bleed. This child required time critical transfer, had developed unequal pupils an hour before being referred to KIDS. At referral child was bradycardic. Advised to intubate & ventilate, neuroprotective strategy. We activated CAT 1 transfer and informed Consultant Paediatrician to also organise transfer. Child further deteriorated with increase in unequal pupils which improved after administration of
Earlier in the day (around 1pm?) Paediatric Consultant had contacted neurosurgical registrar, NS registrar had asked to resend the scans and around 2.15 had contacted PICU Consultant for PIC bed. I was the KIDS Consultant and alerted about this patient at 2.30pm when I tried contacting the DGH to get information.
11 year old presented to ED @1130- right sided headache, vomiting and neck pain. Developed slurred speech en-route. ED Reg assesses- GCS 11-12, PERL. Not moving left side Paediatric Reg informed and urgent CTB requested CTB performed at 1200 and a large intracranial bleed is identified 1220 1230 ED Nurse notes that child is struggling to swallow saliva and requiring 15 minutely suctioning Paediatric Consultant informed and reviews pt in ED. Refers to BCH Neurosurgeons and requests images to be PACSed across to BCH for NS to review
1245 Call from BCH Neurosurgery to say that images have not been received 1327 CT images were transferred electronically to BCH PACS
No record from Radiology as to when they were requested to send the images over, but state that they did it immediately. Neurosurgical Registrar calls back at 1334. He advises that he will speak to BCH PIC and that the Paediatric Consultant should call KIDS.
Paediatric Consultant re-reviews the child Referral to KIDS 1405-1430 (BCH PIC Cons calls KIDS Cons to ask about child in the meantime) KIDS team despatched with view that whoever is ready first facilitates the time critical transfer. Anaesthetic team informed about the child at 1455. KIDS arrived 1510 (child already intubated!) Departed 1705
Concerns raised by Local Consultant Anaesthetist- why not contacted as soon as bleed diagnosed as could have facilitated TCT? Paedicrid raised by KIDS Consultant
RCA identified: Numerous points where Anaesthetics could/should have been contacted Lack of understanding about what Anaesthetics role is: I&V, Neuroprotection, CTB, Transfer Local policies do exist, but some give conflicting information KIDS guideline not accessed Another child in ED Resus at the time this case was also present
Recommendations from RCA:
conditions and transfer to critical care units should be reviewed urgently to ensure consistency in their guidance in relation to referral to KIDS; and subsequently communicated to all the relevant staff- DONE
paediatric neurosurgical cases. Protocol to be shared across paediatrics and presented at both Paediatric and ED Governance- DONE
In addition: Neurosurgical Emergency guideline updated, reviewed and discussed Time Critical Transfer Guideline reviewed Local Education and debrief MDT Training- “walk through” of patient pathway
KIDS CLINICAL GUIDELINE – NEUROSURGICAL EMERGENCY TRANSFER
CONSIDER RAISED ICP Reduced GCS, focal neurological deficit, unequal or dilated pupils, relative bradycardia & hypertension, seizures, abnormal posture If present, commence resuscitation as below and inform anaesthetic team ASAP. Alert radiology of a patient requiring urgent CT brain. Call KIDS on 0300 200 1100 - A conference call will be set up with the KIDS Consultant, Neurosurgeons and other relevant parties. If head injury Activate Trauma Team where local provision exists. Time critical emergencies will require a primary transfer by the referring team! INITIAL ASSESSMENT AND MANAGEMENT INITIAL ASSESSMENT AND MANAGEMENT AIRWAY & BREATHING (AVOID HYPOXIA!) – Assess and maintain airway patency – Seek senior anaesthetic support early – Assess adequacy of ventilation and support with bag & mask if necessary Criteria for intubation: – Loss of airway reflexes – GCS ≤ 8 – Signs of raised ICP – ‘Blown’ pupil, ↑BP ↓HR – Respiratory insufficiency
spontaneous hyperventilation (CO2 ≤ 3.5 ) TRAUMA PATIENTS REQUIRE CONTINUOUS C-SPINE IMMOBILISATION (Do not use cervical collars!) POST – INTUBATION: – Secure ET tube using tapes (click for description) – Sedate and paralyse with Morphine, Midazolam (>6 months) and Rocuronium – see calculator – Ensure PaCO2 4.5-5.0 kPa & PaO2 10-12kPa – Monitor End-Tidal CO2 – – Keep PEEP at 5cm H2O where possible – Maintain 30o head up tilt – PERFORM URGENT CT BRAIN and discuss result CIRCULATION (AVOID HYPOTENSION!) – Continuous ECG and SpO2 monitoring – Cycle NIBP every at least every 3 minutes – Insert IV access x 2 – Consider invasive BP monitoring – Do not delay CT to insert lines Use mean arterial pressure targets as shown below: AGE TARGET MBP <2 60-65 mmHg 2-6 70-75 mmHg >6 80-85 mmHg Fluid boluses: 10 mls/kg 0.9% Saline Inotropes may be needed to maintain MAP – seek KIDS advice. Bleeding trauma patients require blood products – see guidance DISABILITY & EXPOSURE – Perform 15 minute neurological observations – Maintain normothermia and normoglycaemia – Keep Hb > 10g/dL and correct coagulopathy – Give phenytoin 20 mg/kg – If open fracture, give IV antibiotics
V1.0.4 J Tyler / B Fule, July 2016 Review June 2019
PREPARATION FOR TRANSFER CHECKLIST
(e.g. unequal or dilated unreactive pupil, ↑BP ↓HR) – Ensure all routine measures as opposite are instituted (e.g. well sedated, 30o head up) – Give osmotherapy:
ACUTELY RAISED ICP - EMERGENCY TREATMENT
Emergency airway equipment inc. AmbuBag Secure IV access x2 with long extension connected to allow fluid / drug administration Sufficient volumes of infusion drugs and rates checked Emergency drugs including osmotherapy Sufficient portable O2 for whole journey x2 Sufficient battery life on monitor and infusion pumps Case notes, blood results, observation and prescription charts photocopied Images sent to receiving unit via PACS Satisfactory restraint (protect C-spine!) Receiving unit notified of departure
Delay in local team mobilising for time critical transfer. 3month old with sub dural bleed, midline shift. Needs time critical transfer. Child attended A&E around 12noon, CT head done "an hour before KIDS referral" I looked at the scans- shows massive midline shift. While on the phone waiting for neurosurgeon to join the conference call, I advised the Paed consultant to come off the conference call and organise time critical transfer by his anaesthetist. KIDS had another pending referral which was likely to need transfer. Called back 30minutes later(17.35) I was informed that the anaesthesia registrar had seen the child and had gone to speak to his consultant. They had not called for an ambulance yet. I mobilised KIDS team as CAT 1.
Concerns raised around reluctance to perform time critical transfer and delays in stabilising patient with a neurosurgical emergency. 4 weeks old, head injury, suspected NAI. Referral came in as a child with intracranial bleed (extraDURAL haematoma was heard during the referral, turned out to be extraCRANIAL [scalp] haematoma after reviewing the CT, with complex skull fractures and some traumatic SAH). He presented with Hb 50. Baby arrived to ED at 13:00, CT head commenced at 15:30, call to KIDS at 16:42 requesting transfer by us. The anaesthetic team was called on my advice during the referral. Blood given between 17:00 and 18:00, Intubation after 18:00, arrival to BCH PIC at 21:00. Concerns are:
decided to be PICU rather than theatres during the referral.
Patient with fluctuating GCS. On arrival patient was unresponsive. Intubated and ventilated and then taken for CT scan. This was a potential neurosurgical emergency - to be treated as time critical. There were two head CT scans planned, a non contrast and contrast. Each scan took one hour to be reported and so we were unable to move patient in between the scans. Overall there was a large delay as the information required from the CT scan would inform the team if the patient needed a neurosurgical centre or not as destination. Delay caused as no on site radiologist overnight, and service is outsourced to third party and not easily able to interact with.
Excellent investigation!
This was a 4 year old child who presented to A&E resus with fever, vomiting and confusion. Conference call with PICU & Neurosurgery Team advised an urgent unenhanced CT head and if normal proceed to contrast CT head with the aim of identifying time critical neuro-surgical lesion and determine the most appropriate final site of care, either a PICU bed or neurosurgical input. An unenhanced CT head was requested with the out of hours teleradiology service and the scan completed. The Paediatric Team were unable to request a contrast CT head until the initial scan had been reported, which took some time. The scan showed hydrocephalus but no bleed. A contrast CT was duly requested and performed followed by a 45 minute wait for the report. The child spent more than 1 hour located on the scanner as the Paediatric team did not want to move the child unnecessarily due to the acute nature of his condition.
There then appears to be a 10 minute delay between the scan being undertaken and tele-radiology being informed that the study had been uploaded ready to report. Appears the call out and scan time has taken 1 hour and the report time has taken 1 hour. As it stands with the current service profile, there is every opportunity for these timescales to be experienced again as they are inbuilt within the current service (30 minute call out + 30 minute scan and patient care time + 1 hour standard reporting time)
Learning from the investigation: No tele-radiology service can offer immediate review of images. There are protocols for polytrauma, but none for other clinical cases No option for “quick look” service to diagnose or guide further imaging Team are now better informed about what information is required on a request and the processes involved Many trusts are now using outsourced out of hours radiology services and we need to be aware of the limitations of these. Should the child have gone to a Neurosurgical Unit based on the first scan anyway?
A separate trust has raised concerns about the time it takes to get CTB out of hours. Issue report: 10 month old with status epilepticus on the background of one month history of nystagmus and developmental delay. CTB shows hydrocephalus (MRI one month ago normal). Child needs emergency EVD. Local team transfer, but pupils blown on departure. Issues raised
hour)
communication of leucodystrophy)
10 issues raised around Anaesthetic support Refusal to intubate a child in status epilepticus (CD Anaes and Paeds involved) Another episode of refusal to intubate a child in status epilepticus due to size and possibility of difficult airway (eventually intubated by Anaes Reg with KIDS team and KIDS Consultant present) Intubation of child in status epilepticus. KIDS team out, but advised to extubate as waking up. Local Anaeshetic/AICU team stated that they could not support caring for this child whilst awaiting transport team or to facilitate extubation. Refusal of local AICU to extubate a child locally following seizures, but also to support whilst awaiting KIDS. Statement that the child was putting the rest of the patients in AICU at risk. Child waking normally on arrival KIDS team, but parents distressed, therefore transferred.
13/12 status epilepticus requiring RSI. Local team took more than an hour to
cons.) The child has aspirated and was hypoxic with sats 60-80. LMA was inserted after advice from KIDS. Two issues:
prepared how to manage it. Another report: Confusion about cutting a ETT in a child with profound respiratory
No recent issues around induction agents
Investigations outstanding to be aware of: 1. Multi site SIRI- 2 year old presents collapsed to ED, arrests on induction. Transferred to a non-cardiac centre but with drive through Echo. Returns to local hospital 5 days later, but arrests after 36 hours with VF. RIP 2. Local Investigation of Adult Cardiology involvement (apprehension) in post
adult cardiology and cardiac surgical services and PICU. Local teams reluctant to perform drainage locally in view of patient's age. Advised that the patient will not be accepted for transfer until drainage has been performed locally due to very high risk of cardiac arrest in the back of an ambulance if not drained
3. Investigation of report that advice given by KIDS Consultant was potentially dangerous- Internal responses received, awaiting independent review
Excellence reports:
Three reports around the care given to a young boy with meningococcal disease and his family. One of these was with regards to the Anaesthetic team:
“1. Great confidence to carry out the intubation of a sick child with the use of incremental doses of Ketamine and an adrenaline infusion to cover the induction process.
left.
incredibly helpful, making a very sad situation into a very controlled and well run arrest.
upset people. Their input and participation really added to the value of the debrief and showed a fantastic team approach. Im sure that the team are not in either of these scenarios very often, but approached both with sensitivity, logic and confidence”
Local AICU Consultant assisted Paediatric team with a child in SVT who they were unable to get Vascular access on. Child displaying signs of cardiac failure. Concerns that sedation would be needed to get access. AICU Cons saw a window of opportunity to transfer, facilitated a discussion around
7 month old with difficult airway. Local team sought appropriate advice from KIDS, expertly managed the airway and managed to intubate a difficult intubation. The plan was for the KIDS consultant to go to the local hospital if local team was unable to secure the airway. The local team also kept the child ventilated as there was no KIDS team available for 3 hours post intubation
Excellent end of life care: KIDS team went out for an extremely difficult case with a diagnosis of severe hypoxic ischemic encephalopathy. After multiple joint discussions with MDT teams from KIDS/local/BCH and discussion with parents decision made to palliate locally. Patients local paediatrician also came in from home to join in family discussions. This enabled the child and family to stay in their local hospital and have continued support from the local team. The dedication and support of the local team, (nurses, consultant and pediatrician) to the child and family was excellent.
KIDS retrieved a child requiring intensive care. His community consultant had come in to see him. She waited all through the retrieval with the family, talking them through it all. He was a child who was quite difficult to ventilate and needed a reasonable amount of input. This allowed us to focus on this as she was supporting the family so well. Reports about local teams facilitating extubation locally, especially over winter where team availability and bed availability was limited. AICU team facilitated Organ Donation locally – Not on Paedicrid, but should be! Area of excellence identified in a local RCA- Anaesthetic trainee performing needle decompression of gastro-thorax in cardiac arrest.
Summary: Themes identified Some widespread issues Others more focussed- ? How can region support Dissemination of learning Governance engagement is going to be crucial in network development Some very good examples of engagement Remember why reports are written: Focus on the learning Are we seeing improvements in the services were are providing in the region?