WELSH PAEDIATRIC
CRITICAL CARE SERVICE
ANNUAL REPORT
2011
SUMMARY
· 266 children were admitted to the unit during the year 2011, 87%of whom were ventilated.
· In the year 2011, the retrieval team agreed to 101 requests for retrieval.
· Two retrievals were refused due to the lack of an available staffed bed during the winter period of peak demand.
· Four patients had their surgery postponed due to lack of a PICU bed.
· The development of the Paediatric Critical Care Network has continued with multidisciplinary audit and feedback sessions held in all Trusts.
· The UK Paediatric Intensive Care Audit Network Database (PICANet) has published its 8th report (www.picanet.org.uk).
CONTENTS
PAGE
Chapter 1 The Lead Centre 4
Paediatric Intensive Care Team
Chapter 2 The Service 5-10
Chapter 3 The Regional Paediatric 11-17
Critical Care Service
Chapter 4 Utilisation of the Lead Centre 18-22
Paediatric Intensive Care Unit
Chapter 5 The Retrieval Service 23-24
Chapter 6 Paediatric HDU at the Lead Centre 25
Chapter 7 Clinical Governance/Audit/Research 26
Acknowledgements 28
CHAPTER 1
THE LEAD CENTRE PAEDIATRIC INTENSIVE CARE TEAM
Dr Malcolm Gajraj Lead Clinician Paediatric Critical Care Service
Mrs Mary Glover Lead Nurse Paediatric Critical Care Service
Dr Rim Al-Samsam Consultant in Paediatric Intensive Care
Dr Helen Fardy Consultant in Paediatric Intensive Care
Dr Damian Pryor Consultant in Paediatric Intensive Care
Dr Allan Wardhaugh Consultant in Paediatric Intensive Care
Dr Michelle Jardine Consultant in Paediatric Intensive Care
Ms Alison Oliver Regional Training & Development Co-Ordinator for Paediatric Critical Care Services in Wales
Mr Philip Barry Directorate Manager Child Health
Miss Kath Ronchetti Senior Physiotherapist
Miss Heather Gater Senior Physiotherapist
Mrs Julie Armstrong Practice Educator
Mrs Kath Singleton Dietician
Mrs Rachel Burton Pharmacist
Mrs Pat Davies Personal Assistant to Lead Clinician
Sue Tullett Audit Clerk
CONTACT NUMBERS:
Dedicated Retrieval Line Tel: 029 20745413
Consultant via long range bleep Tel: 029 20747747 (via switchboard)
Pat Davies PA to PICU Tel: 029 20746423
Email:
CHAPTER 2
THE SERVICE
Our service has been developed based on multidisciplinary teamwork both within the Lead Centre and with our Paediatric, Anaesthetic and Emergency Medicine colleagues in the District General Hospitals throughout Wales.
Consultant Staff
The Paediatric Intensive Care Unit and Retrieval Service is covered by a team of 7 consultants. In combination, with designated general paediatricians, the team also contributes to the cover of the Paediatric High Dependency Unit.
Specialist Registrars
Due to the planned reduction in junior doctor’s hours the aim was to have 6 middle grades on the rota by September 2010. This was to be made up of 4 Paediatric registrars, one Anaesthetic registrar and a Clinical fellow.
Our advanced nurse practitioner (ANP) started doing long days during the week in December 2010 and moved onto weekends and nights by September 2011. Our Clinical fellow was appointed Sept 2010. She initially worked full-time; however moved to part-time in March 2011. This; along with the fact that nurses work reduced hours compared to doctors; meant that the two posts worked well along side each other as a job share.
Unfortunately we lost our anaesthetic trainees in August 2011. The PICU post was removed from the anaesthetic rotation. This post has now been incorporated into the paediatric rotation. Our middle grades are now made up of 5 Paediatric registrars and one Clinical fellow.
We have been unable to recruit into our new part-time clinical; part-time research posts and will have to see whether this is going to be a viable option for the future.
MEDICAL EDUCATION IN PICU
DR MALCOLM GAJRAJ
The education of our trainees is of paramount importance. PICU patients demonstrate physiological variability and the ability to monitor at close hand how management influences vital signs in a holistic way; it becomes clear that no organ functions in isolation and that consideration for other systems needs to made when managing critically ill patients. This is true at other times but in PICU the trainees are able to witness the effects more readily and can then apply this knowledge elsewhere. We can also develop critical thinking, decision making of our trainees who need to prioritise and update and enhance the communication skills they have through speaking to stressed and anxious parents. Our role as supervisors is important and we have reduced the number of consultants who oversee trainees, recognizing the importance of close scrutiny and accurate reviews for portfolios. We also recognize our ability to evaluate our trainees closely, given the intimate working relationship we have, as well as our high levels of patient management. Our system of in house review, akin to a 360 appraisal, but with information gathered from all consultants, all senior nurses and also from the trainees themselves regarding their colleagues, before both midpoint and end of placement reviews, allows input form the whole team and has offered valuable insights that can be addressed contemporaneously. This has been especially helpful when rotas and shift work limit the interactions and direct observations of supervisors with their trainees. We are also beginning to link learning outcomes with the curriculum, to try to ensure appropriate competencies are gained on placement with us. This is easier now that all our trainees are paediatricians.
INHOUSE TEACHING AND TRAINING INITIATIVES
Mock Resuscitation scenarios
We continue to run surprise mock cardiac arrests with the SIM baby twice a month throughout Paediatrics and in the Emergency Unit. We have also increased our input into the Thursday lunchtime teaching sessions for junior doctors running 4 sessions every 6 months. We continue providing a refresher session for nurses once a year (similar to PALS but with peri-arrest, ward appropriate scenarios). We have provided more sessions this year than ever before and feedback has been excellent.
Nursing Staff
Senior Nurse Paediatric Critical Care and Neonatology – Mary Glover
We have continued to work towards an integrated nursing team which will provide care for both Paediatric Intensive Care and Paediatric High Dependency patients, eventually based on a combined 15 bedded Paediatric Critical Care Unit which will be built in Phase 2 of the Children’s Hospital for Wales. Nursing representatives from both units have been involved in the planning for the new unit, and it has been an exciting time for us, realising that the service will be relocated and based in a hospital focused on children in a few years time.
The appointment of Fiona Thomas as the ward manager over both units has also helped with the integration of the nursing teams.
Education continues to be a priority in terms of developing the nursing workforce and Julie Armstrong the practice educator is working across PICU and PHDU to help achieve this. The Practice Educator works with both PICU and PHDU nurses, ensuring that we offer support and supervision in providing excellent quality nursing care and also to facilitate a joint critical care training strategy.
The Paediatric Intensive Care Course continues to be successfully provided in partnership with Birmingham City University. This has enabled our nurses to achieve a specialist award and for us to continue providing a service compliant with the Standards for Critically Ill Children in Wales. It has also helped us to develop close professional links with the PICU team in Birmingham.
The nursing team has been busy working on safer patient initiatives and updating nursing guidelines and protocols that are web based.
All of these developments will contribute to enhancing the quality of our care and assist us in the delivery of a seamless transition through critical care.
Care Bundle use on PIC
Care Bundles have been used in the region for a number of years and some have been developed and are in use on the PIC. During 2011 there were further care bundles developed and these are used for all applicable patients. There purpose being a simple check list to ensure that guidelines are implemented in practice and staff on the unit are familiar with them and compliance is good.
The bundles in use on PIC are
· Insertion of central lines (2008)
· Discharge of patients (2008)
· Ventilated patient bundle (2009)
· Insertion of urinary catheter (2011)
· Daily maintenance and review of need for urinary catheter (2011)
· Blood/blood product bundle (2011)
The PIC Bundles in use in the region are
· Head injured patients(2008)
· Respiratory failure patients(2010)
· Sepsis patients(2008)
Further bundles are in the developmental stages and will be introduced next year. All bundle compliance is audited and is ongoing in PIC.
In 2011 the veno thrombo-embolus assessment tool was also introduced to PIC to encourage nursing staff to assess our teenage age group that have multiple risk factors on admission. This has been done in partnership with our haematology colleagues using the DOH paediatric assessment tool.
Once assessed a teenager that has multiple triggers is highlighted to the medical team for a decision to be made regarding the application of anti-embolic stockings and/or the use of low molecular weight heparin. This has highlighted to both nursing and medical staff the risks and the incidence of HAT (Hospital acquired Thrombosis). Our compliance with use of the assessment will be audited next year.
The Blood Bundle has helped staff to adhere to the All Wales Guidance in the safe transfusion of blood. We particularly needed to improve upon providing information for parents and this simple checklist seems to have helped our compliance with this.
Pharmacy Report Post holder – Rachel Burton
Clinical pharmacy role on PICU
A specialist clinical pharmacist visits PICU every day Monday to Friday. Their role is to promote the correct and appropriate use of medicinal products.
These activities focus on
· maximising the clinical effect of medicines; the most effective treatment for each type of patient
· minimising the risk of treatment induced adverse events; monitoring the therapy course and the patients adherence to treatment
· minimising the expenditure for pharmacological treatments where appropriate.
All medications for every child are reviewed daily to check that they are appropriate for the age, weight and clinical condition of the child. The pre admission drug history will be checked with the parent/carer, GP or referring hospital.
Throughout the child’s stay on PICU the pharmacist advises on:
· Therapeutic drug monitoring,
· Drug dose adjustments in renal and hepatic failure
· Drug interactions
· Suspected adverse reactions to drugs
· Formulations of medicines
· IV compatibility issues
· Parenteral nutrition formulations
The pharmacist also provides advice in the preparation of guidelines and protocols, helps with drug related audits, reviews any medication incidents, promotes safe prescribing and helps with education and training.
To ensure as seamless care as possible, the pharmacist contacts the paediatric pharmacist from the ward or referring hospital that the child returns to once they leave PICU to hand over any pharmaceutical issues and answer any questions.
The pharmacist’s role is to work as part of the multidisciplinary PICU team to ensure the best care possible for our patients.
The Physiotherapy Service -
Acute Respiratory Physiotherapy Team
PICU Post Holder and Team Lead –
Kath Ronchetti - Highly Specialist PICU / Acute Respiratory Physiotherapist
(to Dec 2011)
Heather Gater - Highly Specialist PICU / Acute Respiratory Physiotherapist (from Dec 2011)
Specialist Paediatric Physiotherapists on PICU rotation during this time:
Matthew Jones
Gemma Passmore
Alice Dawson
The specialist physiotherapy service to PICU has been delivered by the acute respiratory team at the Children’s Hospital which was led by Kath Ronchetti and Heather Gater. Other specialist physiotherapists also contributed to the service when a patient under their remit was admitted. This service is provided from Monday to Friday 8am -4.30pm.
During this period the paediatric only out of hours service has continued. This has been audited by the respiratory team and been adjusted accordingly to meet the needs of the service and also to ensure that a safe and effective service is being delivered. The audit showed that 58% of our evening / overnight call outs are to PICU, and 50% of the attendances on the weekend day shifts are PICU & HDU patients.
In order to keep up to date with the latest evidence and provide the best practice we have continued to attend the ACPRC Acute Paediatric Respiratory Physiotherapy Special interest group and other study days relevant to our practice. This has provided additional support from other specialist physiotherapists and up to date knowledge to support the specialist clinical role within PICU.
There has also been the development of a new physiotherapy post which was filled by Kath Ronchetti in the Paediatric Respiratory Unit. This post is hoped to improve communication links between PICU and PRU when patients with chronic respiratory conditions or those who are on long term ventilation are admitted to PICU.
CHAPTER 3
THE REGIONAL PAEDIATRIC CRITICAL CARE SERVICE
Regional Education and Training Report 2011
Regional Training and Development Nurse for PIC Services in Wales- Alison Oliver
The topic for this year’s summer training sessions was the transportation of critically ill children by local teams. Some scenarios were actual cases that had been transferred in and there had been significant delays in the transfers for a variety of reasons so this appeared to be a learning requirement in the region.
The Welsh PIC Standards (2003) advise that certain case groups be transferred directly into PICU as the time critical nature of their illness would make retrieval too long a process. There are Welsh Government standards for the transport of critically ill adults (2009), but not for children so a scenario based theme was used to try to get local teams to think about the essential factors which would need to be considered in the transfer of a critically ill child such as equipment, personnel, method of transport and communication. It is also recommended by both the Society of British Neurological Surgeons (SBNS) and the Royal College of Anaesthetists (RCoA)(2010) that all DGH’s have a locally agreed transport policy when it is necessary to move critically ill children. These sessions were well attended and promoted a lot of discussion.
Reconfiguration plans for all Health boards continues to affect the regional service for paediatrics as it creates uncertainty and has had an ongoing affect on morale. These plans are also affecting emergency units and other areas of hospitals so the entire pathway of the critically ill child is affected. Plans have been submitted by Health boards for how future services might look alongside medical training reviews due to the ongoing problems in producing the workforce for the delivery of current and future services. It is hoped that there will be developments in these reviews in 2012 so that staff will have more certainty about how future services will look in both paediatrics and other specialties.