Background

Low morale amongst its workforce is one of the main challenges facing the NHS. Figures show 38% of staff needed time off in the last year due to “work related stress”¹. Excellence reporting (ER) is where examples of excellence in the workplace are recorded and then fed back to the staff involved.

Objectives

To discover if there was a positive effect on staff moral and well-being after the introduction of excellence reporting.

Methods

We assessed colleague’s morale/well-being by asking that they complete a questionnaire based on the “Short Warwick-Edinburgh Mental Well-being Scale”. We then implemented the electronic excellence reporting system on the unit. After 6 weeks the questionnaire was repeated to see if there were any significant changes.

Results

During the 6-week period following implementation of ER, 142 reports were completed. 37 colleagues responded to each questionnaire, and results following implementation show a higher number of positive responses. There was a median improvement of 50% across the scales measured (Graph).

Conclusion

Implementation of ER can deliver improvements in staff moral and well-being. At a time when workforce pressures are increasing, and sickness levels are high, interventions to improve staff moral would have a positive effect on patient care and how departments function.

1) Staff Survey Coordination Centre (2017) National NHS Staff Survey[online]. Oxford, Picker Institute Europe. Available: http://www.nhsstaffsurveys.com/Page/1064/Latest-Results/2017-Results/

Background

Intensive care services are expensive for both hospitals and patients.Burden of out of pocket expenditure for patients in low and middle-income countries (LMIC) is high.Cost analysis of pediatric intensive care is important for effective allocation and utilization of limited resources.

Objectives

To calculate the total and variable PICU cost incurred per patient

Methods

This prospective study was conducted in 299 PICU admissions over four, 1 monthly intervals between July 2017 to December 2018.Total cost incurred was a sum of fixed and variable costs. Former included cost of infrastructure, equipment and PICU staff salaries. Latter included drugs, disposables, laboratory tests, food, bed, travel and accommodation charges and salary loss to family.Total cost of PICU care and average out of pocket expenditure per patient were calculated. Association between cost and PRISM, ventilation and PICU stay was studied.

Results

Mean ± SD PRISM score of cohort was 22.23 ± 7.3.The median (IQR) length of PICU stay was 5(3–8) days. Average total cost incurred per patient was USD1861; of which USD1442 and 418 were fixed and variable cost respectively. Average out of pocket expenditure per patient was USD 418. Eighty % of total cost was borne by hospital and 20% by patient. The median(IQR) variable cost of a ventilated was twice that of non- ventilated child[USD 456(287–627) vs.264(150–438);p=0.0001].

Conclusion

PICU fixed costs are 3.5 times more than variable costs.Severe illness, longer ICU stay and ventilation were associated with increased costs. Intensive care in India is less expensive than developed countries.

Background

Routine treatment of the PDA has not been shown to improve long term outcomes. There is a trend toward more conservative management of the PDA.

Objectives

To evaluate differences in rates of PDA treatment and ligation, before and after the initiation of a standardized PDA guideline in extremely preterm infants.

Methods

This is a single center before and after study. A PDA management guideline incorporating a clinical and echocardiographic scoring system to guide PDA treatment was introduced. The aims of the guideline are to introduce a more conservative standardized approach to PDA management and decrease PDA treatment rates. Rates of PDA treatment and PDA ligation were compared for infants born between 23-27 weeks gestation in the pre and post intervention periods.

Results

A total of 43 infants were included. PDA treatment occurred in 15/28 (54%) in the pre-intervention period and 12/15 (80%) in the post-intervention period (OR 1.48 (0.97-2.29), p=0.17). PDA ligations occurred in 9/28 (32%) in the pre-intervention period and 2/15 (13%) in the post-intervention period (OR 0.41 (0.10-1.67), p = 0.32). On multivariate logistic regression analysis when correcting for gestational age, birth weight, and gender, there was no difference in the odds of PDA treatment (OR 2.32 (0.45-14.3, p=0.32); However, the odds of PDA ligation were significantly lower in the post-intervention period (OR 0.09 (0.006-0.72), p=0.04). The rate of BPD/death didn't differ between two periods.

Conclusion

Following the implementation of a standardized PDA guideline, the PDA ligation rate decreased in extremely preterm infants without a significant change in the rate of BPD/death.

Background

Standard concentration infusions (SCIs) and smart-pumps are recognised as best practice for delivery of high-risk medications. Implementation rates in European hospitals remain low. In 2012, a smart-pump library of SCIs was implemented into the paediatric intensive care unit (PICU) of Our Lady’s Children’s Hospital, Crumlin, Dublin. All other sites caring for children continued to use weight-based infusions and traditional infusion pumps.

Objectives

To progress the use of smart-pump technology and standardise infusion practices across all sites providing acute care for infants and children in Ireland.

Methods

A multidisciplinary collaborative process was employed. Working groups, with representation from PICU, Neonatal ICU and Emergency Department (ED) clinicians, pharmacists, nursing and clinical engineering were formed. Legally binding agreements were drawn up to prevent future drug library deviations.

Results

The original smart-pump drug library has expanded from a single ‘care-unit’ with 42 drug lines, to a master file with 7 speciality-specific ‘care-units’ and a total of 216 drug lines. This national system is currently operational across all PICU sites, paediatric transport services and 4 of 19 neonatal sites. Implementation into 2 of 3 tertiary EDs, 2 further neonatal sites and neonatal transport services is imminent (Q1 2019). Phased implementation into regional EDs, adult ICUs and the remaining neonatal units is planned. Funding for dedicated pharmacy and nursing resources has been secured. Supporting documentation and training material continues to evolve.

Conclusion

Strategic planning and cross-site collaboration can lead to the delivery of standardisation of infusions at a national level. Significant patient safety and economic gains are anticipated.

Background

20% of admissions to UK Neonatal Intensive Care Units (NICU) involve babies 34+0 to 36+6 weeks gestation. Enabling babies to stay with mums improves perinatal experiences, bonding and breastfeeding rates.

Objectives

We aimed to assess common reasons for late preterm admissions to our unit, average length of stay, and barriers to earlier discharge. We wanted to assess whether enhancing Inreach support and home nasogastric tube-feeding packages could help prevent or shorten late preterm NICU admissions.

Methods

Using Badgernet we collated information on all admissions of 34+0 to 36+6 babies admitted to NICU over a 3 month period.

We deemed admissions potentially preventable if:
• routine admission <35/40 or <1.8kg
• no respiratory support required; needed feeding support or thermoregulation alone
• hypoglycaemia where blood sugar was always >1.0mmol/L

Results

61 babies born at 34+0 and 36+6 weeks were admitted from October to December 2017; 47% were 34/40.

The commonest reasons for admission were:

• Respiratory distress (31)
• Routine admission <35/40 (8)
• Surgical (5)
• Birth weight <1.8kg (4)
• Hypoglycaemia (3)

We subsequently deemed 14 admissions potentially preventable. A further 8 could have been shortened, whereby babies required respiratory support initially but then spent on average 10.5 days in SCBU for feeding support.

Conclusion

With enhanced Inreach care, home tube-feeding packages, optimal thermoregulation and hypoglycaemia management, we estimate 199 “special” or “normal care days” could be saved every 3 months. We’ll explore the possibility of expanding Inreach support, and re-audit one year from launching our home tube-feeding package for well NICU babies.

Background

A collaborative approach to Quality Improvement (QI) is key to enhance ownership and engagement.

Objectives

To identify and prioritise QI areas for our mixed cardiac and general UK PICU.

Methods

A modified three-round e-Delphi study was undertaken in December – January 2019 involving all clinical professionals working in PICU.

Results

Sixty topics were submitted by 36 respondents in round 1.These were categorised into 10 broad domains of 60 topics: 1) Staff wellbeing, 2) Professional development and education, 3) Communication with families, 4) Communication within health care team, 5) Service delivery, 6) Clinical care, 7) Cost effectiveness, 8) Information Technology and Computer Integrated System, 9) Quality and safety, and 10) Medication and drug safety. Sixty three participants completed the ranking in round 2. Topics with a mean score <4 were removed leaving 37 topics for final ranking in round 3. This generated a final list of 5 top ranked topics for prioritisation under the 8 domains. The 5 highest scoring topics were: 1) Strategies to improve staff health, safety, support and wellbeing, 2) Strategies to improve parental communication, 3) Interventions to reduce noise in PICU and improve patient sleep and comfort, 4) Reducing the parallel duplication process in computer systems, and 5) Developing and implementing a structured ward round to improve patient care, communication and education.

Conclusion

The delphi method is a useful tool to identify QI priorities for PIC staff. The results of this survey will allow us to prioritise QI projects in the highest ranked topics.

Background

Nutritional status has profound effects on metabolic response to injury and can impact significantly on patient outcome in the paediatric intensive care unit. Optimal provision of nutritional support should form an integral part of paediatric critical care. Enteral nutrition is cost-effective, maintains gut integrity and reduces infectious complications when compared to parenteral nutrition.

Objectives

An audit performed in January 2017 showed poor compliance to a local enteral nutrition feeding guidelines. Our aim therefore was to improve staff understanding on the importance of adequate nutrition and as a result improve guideline compliance.

Methods

We updated our enteral feeding guideline and instigated an educational drive within the Critical Care Department. We held weekly teaching sessions and made the guideline more easily accessible to staff. Flow diagrams were produced and laminated copies placed in each patient bedspace. Posters with prompts on the early introduction of enteral feeding were displayed on the unit and assessment of feeding practices for each patient made a standard part of medical handover.

Following a 2-month education period we performed a re-audit to check if compliance to the guideline had improved.

Results

Our re-audit showed improvements in unit compliance to the enteral feeding guideline. In particular there was a vast improvement in the number of children being assessed for enteral nutrition within 24hrs of admission (82% to 100%) and commencement of age appropriate feeds (47% to 72%).

Conclusion

Continued efforts to educate staff on the importance of optimal nutrition should be an aim with quarterly audits performed to track improvements and drive change.

Background

Alongside introducing a new, dedicated, Consultant-led HDU service within our hospital, a critical care outreach service was also created to support the management of deteriorating children outwith critical care and aid in the transition of care following critical care admission.

Objectives

To assess the impact of a Critical Care Outreach Team (CCOT) on patient care and hospital response to deteriorating patients.

Methods

A dedicated CCOT (comprising paediatric HDU Consultant, trainee and PICU nurse) was introduced in our hospital. The team responded to calls from ED and wards and reviewed “patients at risk” identified by our “watcher” system. CCOT also reviewed children within 24hrs of discharge from critical care. Proformas to record patient contact episodes were developed to obtain patient data for analysis on CCOT assessment and outcome.

Results

In a 2 month period (Oct-Nov 2018) the CCOT was involved in the care of 79 children (105 episodes). 28 (35%) were inpatient referrals, 4 of these were admitted to HDU, the majority were stabilised on the ward, often with ongoing CCOT input. 38 children were reviewed post discharge from Critical Care, CCOT provided continuity of care for families and staff. 17/18 reviewed in ED were transferred to critical care. Hospital-wide qualitative feedback has been extremely positive. Impact of team on time to admission to critical care needs to be further analysed.

Conclusion

Critical care outreach service has been successfully piloted at our hospital and has shown benefits in patient flow and in supporting ward areas in the management of deteriorating patients.

Background

Point of care ultrasound (POCUS) use is becoming widespread tool in the management of critically ill patients. Despite its increasing use there are not clear recommendations for the use of POCUS by pediatric intensive care providers.

Objectives

Describe current use of POCUS in Pediatric Intensive Care Units (PICUs) in an European country. Define factors related to clinical impact of explorations.

Methods

A prospective cross-sectional multicenter study was carried out in 26 PICUs. During 7 consecutive days data from all POCUS explorations performed by the medical and nursing staff of the participating units were registered.

Results

269 POCUS explorations were registered involving 136 patients. POCUS operators were attending physicians (73.6%), residents (20.8%) and nurses (5.6%). 57.6% of explorations included thorax and 29.4% echocardiography. A new diagnosis was obtained in 53.9%, resulting in therapeutic modifications (TM) in 36.4%. Explorations were more likely to result in TM when performed by attending physicians (82.7% vs 17.3%, p=0.031), in cardiac patients (52.1% vs 34.6%, p=0.011), including thorax (45.6% vs 29.4%, p=0.010) or urological examination (77.8% vs 37.6%, p=0.015). TM were also more likely when the objective of the exploration was diagnostic (46.2% vs 18.5%, p<0.001), and less likely when objective was teaching (18.4% vs 42.7%, p=0.005). Operator previous experience on POCUS teaching was related with TM (59.2% vs 40.8%, p=0.003).

Conclusion

POCUS is becoming a highly used tool in PICUS frequently resulting in new diagnostic findings and therapeutic modifications. Clinical experience and previous training in POCUS seem to be related to clinical impact of POCUS explorations.