Table 7 Positive and negative changes to paediatric early warning system - post implementation
| Â | Site 1 | Site 2 | Site 3 (Two medical wards only) | Site 4 |
|---|---|---|---|---|
Detect | + Electronic PTTT normalised + Additional computers, more timely data entry + SEPSIS-6 pathway normalised + All senior nursing staff APLS trained + All staff PEWS/SEPSIS-6 trained + New escalation policy in use. Provided explicit guidance on: shift coordinator’s seniority and position within escalation pathway; care requirements and typical vital signs of cardiac patients; when/how to escalate based on PTTT score and key vital signs + Newly-qualified staff valued PTTT score - Some loss of senior nursing staff | - New electronic PTTT: junior staff struggled to recall schedule of observations; able to view recent vital signs data only; lack of computers prevented timely data input. - Loss of experienced nursing staff, increased need for support of junior staff. | + small number of SHINE posters distributed in general medical wards only + improvements to monitoring equipment - SHINE posters not utilised by families/staff | + inventory of equipment conducted; access to monitoring equipment improved, mobile observation trolleys appropriately stocked. + laminated observation/escalation guidelines included within every patient file + posters/cards provided easily-accessible information on vital signs parameters, cards frequently and routinely used + colour-coded observations chart highlighted abnormal vital signs thresholds + storage and management of patient files improved - Low staff awareness of formal observation/escalation policy |
Plan | + Safety huddle introduced; nursing team situational awareness improved + More regular shift coordinator attendance at evening board round - Challenges with ward round remained: some conducted away from patient bedside, shift coordinators ‘pulled away’ due to competing demands/patient caseload | + New medical handover sheet included all patients, increased awareness + Safety huddle allowed rapid identification of children at risk of deterioration, aided communication of key messages, bed management issues and safeguarding concerns. Enhanced awareness of ward/patient status, facilitated appropriate medical review, introduced and normalised language of ‘watcher’ across all staff groups + New nursing handover utilised SBAR; quicker, more succinct + Electronic scoring system increased doctors’ ability to review patients away from the ward, led to closer working between ward and PAU. +Ward manager/deputy attended post ward-round meetings - Ward manager less frequent attendance at medical handover, loss of communication | + nurses introduced whiteboard to help ensure that content of safety briefing remained clear/concise in general medical wards only + shorter handover improved nurses’ concentration + new ‘4Ss whiteboard’ utilised during doctors’ handover improved shared situational awareness; information on bed status and sickest patients delivered by senior nurse immediately prior to handover, improved planning. | + Increased situational awareness amongst team; handover content improved (5Ss utilised). + At-risk children consistently given ‘watcher’ status + Whiteboard updated and utilised regularly by nursing and medical staff |
Act | + Inter-team communication improved via consistent day/night shift coordinator cover and clarification of escalation pathway. + Senior nursing staff updated training on response to deterioration (via APLS) | - New PTTT: information on escalation pathway less accessible - Increased use of agency staff, unfamiliar with escalation procedure - Newer/less experienced staff reluctant to escalate directly to medical team - Doctors review patient status away from ward, less able/likely to respond to nurse concern | + Staff had high level of awareness of escalation process in medical wards only + Appointment of new PICU consultants led to changed thresholds, increased likelihood of admission/acceptance. | + quicker escalation/transfer of at-risk children to HDU beds |