The Children’s Early Warning Tool (PDF 1470 KB) · The Children’s Early Warning Tool ... CEWT...

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The Children’s Early Warning Tool Kevin McCaffery Staff Specialist in Paediatric Intensive Care, Brisbane Senior Medical Advisor, Patient Safety Centre, Brisbane

Transcript of The Children’s Early Warning Tool (PDF 1470 KB) · The Children’s Early Warning Tool ... CEWT...

The Children’s Early Warning Tool

Kevin McCaffery

Staff Specialist in Paediatric Intensive Care, BrisbaneSenior Medical Advisor, Patient Safety Centre, Brisbane

Objective• To design a suite of tools to meet the needs of

bedside clinicians

• Observation chart

• Reference ranges for age

• Early warning score

• Clinical escalation

• Tool to assess interventions

• Triage tool

• Customisable

Design

• Blank canvas

• What observations predict deterioration?• Normal ranges for age?

• Single point vs. cumulative score? (both…?)

• Weighting of observations

• What observations – pragmatic

• Human factors approach to design

Validation• Retrospective

• All patients admitted PICU from ward in 2007• CEWT detected patients before PICU admission

• Prospective• Twelve pilot sites (tertiary / regional / rural)• Two month trial• Phased roll-out

• Retrieval population

• Root Cause Analysis

• Semi-qualitative implementation study

Retrospective validationICU admissions

0

1

2

3

4

5

6

7

8

9

10

11

-48 -45 -42 -39 -36 -33 -30 -27 -24 -21 -18 -15 -12 -9 -6 -3 0

time (hours)

CEW

T sc

ore

bronchiolitis n=20pneumonia n=5reactive airways n=4sepsis n=14

CEWT – BronchiolitisICU admissions: bronchiolitis

0

1

2

3

4

5

6

7

8

-48 -45 -42 -39 -36 -33 -30 -27 -24 -21 -18 -15 -12 -9 -6 -3 0

time (hours)

CEW

T sc

ore

CEWT – Bronchiolitis controlsBronchiolitis - Controls

0

1

2

3

4

5

6

7

8

9

10

3 12 21 30 39 48 57 66 75 84 93 102

111

120

129

138

147

156

165

174

183

time (hours)

Bronchiolitis - Controls

Prospective trial

• Approximately 1900 patients

• Currently analysing data• Optimise physiological weighting

• Optimise action box (for different institutional capabilities)

• Impression is that scoring seems appropriate

• Two critical incidents• Patients had respiratory arrests

• In both cases, CEWT had been overruled by registrar

Maximum CEWT score

0

100

200

300

400

500

600

0 1 2 3 4 5 6 7 8 9 10 11 12 13CEWT score

Patie

nts

83%

n =1886

CEWT scores by centre

0

20

40

60

80

100

120

140

160

0 1 2 3 4 5 6 7 8 9 10 11 12 13

CEWT score

Patie

nts

TertiaryRegional 1Regional 2Regional 3Regional 4Regional 5Rural

Bronchiolitis: Index vs. Controls

0

1

2

3

4

5

6

7

8

9

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60

time (hours)

CEW

T sc

ore

ProspectiveRetrospective controlsRetrospective index

*

Respiratory Rate: Index vs. Controls

0

10

20

30

40

50

60

70

80

1 6 11 16 21 26 31 36 41 46 51 56 61

Hours

CEW

T sc

ore

Retrospective ControlsRetrospective Index

*

Retrieval CEWT

• 4 month convenience sample of retrieval referrals

• Evaluate state-wide implemetation

• Identify early and late referrers

• Improve objectivity in co-ordination

Retrieval patients - CEWT score

0

5

10

15

20

25

30

35

40

45

50

0 1 2 3 4 5 6 7 8 9 10 11 12 13

n = 204

23%

51%

CEWT score by diagnostic group

0

5

10

15

20

25

0 1 to 3 4,5 6,7 ³ 8

Trauma Gen SurgeryResp infection AsthmaSepsis DKASeizure

Retrieval team composition vs. CEWT

0

5

10

15

20

25

30

0 1 2 3 4 5 6 7 8 9 10 11 12 13

CEWT score

Nurse / ICP

Doctor / nurse

Root Cause Analysis

• Currently reviewing state-wide data in last 3 years

• 20 cases filed (RCAs not total deaths)

• 1 late identification spinal injury

• 2 – haemorrhage during / post surgery

• 1 out-of-hospital arrest (discharged that day)

• 1 SUDEP

Semi-quantitative implementation study

• Questionnaire at end of prospective trial period

• Evaluation of trial-site experience• Staff demographics• Impact on perceived ability to care for hospitalised children• Ease of use• Educational material / support

• Inform design of state-wide implementation strategy

Children's Early Warning Tool - Respondents

0

5

10

15

20

25

30

35

40

45

50

Paed Nurse<3 yr

Paed Nurse>3yr

Adult / PaedNurse

Paedresident

Paedregistrar

Paedconsultant

GP

n = 115

What impact has CEWT had on your ability to care for children in hospital?

1

1.5

2

2.5

3

3.5

4

4.5

5

TertiaryHDU

TertiaryOncology

TertiaryMedical /Surgical

Regional1

Regional2

Regional3

Regional4

Regional5

Rural 1 Rural 2 Rural 3 Rural 4 Rural 5

No change

Improved

Worsened

How difficult was the CEWT chart to use?

1

1.5

2

2.5

3

3.5

4

4.5

5

Tertiar

y HDU

Tertiar

y Onc

ology

Tertiar

y Med

ical /

Surgica

lReg

ional

1Reg

ional

2Reg

ional

3Reg

ional

4Reg

ional

5

Rural 1

Rural 2

Rural 3

Rural 4

Rural 5

Very easy

Very hard

How did you rate the educational material and support?

1

1.5

2

2.5

3

3.5

4

4.5

5

TertiaryHDU

TertiaryOncology

TertiaryMedical /Surgical

Regional1

Regional2

Regional3

Regional4

Regional5

Rural 1 Rural 2 Rural 3 Rural 4 Rural 5Poor

Acceptable

Excellent

What next…• Complete prospective analysis• Optimise CEWT• Design state-wide implementation• Work collaboratively across borders• Further projects

• Other charts• Telemedicine• Computers

?

Acknowledgements

• The staff of the Patient Safety Centre, Brisbane• John Wakefield, Jillann Farmer, Rowena Richardson,

Hayden Scotter, Lynette Adams

• The other members of the CEWT team• Jo-Anne Stephens• Ruth McCaffery

• The staff who participated in the prospective trial