Transcript Presentation heading - Patient Safety First

Paediatric Sepsis
Board Development
Devon, Cornwall & Isles of Scilly
Area Team Susan Bracefield
Introduction
In December 2010, 3 year old Sam, who was otherwise fit
and well, died after a short illness. In the days before his
death, Sam was treated by two GPs at his local surgery,
NHS direct, a local out-of-hours service and the local
hospital. Sam died within 42 hours of his initial
presentation to the first GP.
The Ombudsman found that every organisation that
provided Sam’s care failed in some way. They found that
had Sam received appropriate care and treatment, he
would have survived.
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Chronology in Brief
• There is a flu epidemic and icy conditions.
• Sam’s family, except his mum, are all unwell with flu.
• They present to their GP for review 11:20 on 21st Dec.
• Sam has been unwell for about 1 week with high fever and a
cough. Father and Sam are assessed as having a flu like illness
by the first GP. Sam is given a delayed antibiotic script just in case
things get worse over Christmas.
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.
Second GP review
• Sam’s parents call the surgery the next day at 10:45am due to their
ongoing concern about Sam.
(Sam was sleepy/ had decreased appetite/ no interest in anything/
pale/ looking sicker/ needed a nappy as so weak)
• Reception staff take Sam’s details and add him to the triage list.
• Sam’s case is triaged by a Nurse Practitioner at 1:50pm. The duty
GP calls again at 2pm and books him an appointment for review.
• Sam is assessed by the duty GP at 4:30pm and is managed
conservatively with advice.
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Out Of Hours Telephone Review
• Sam’s mum calls NHS Direct at 6pm after noticing brown lumps in
Sam’s vomit. The call taker records some information in error and
passes the call as routine to the out-of-hours service.
• OOH GP calls family back at 7pm but doesn’t make contact when
Sam’s mum is caring for Sam’s brother and misses the call.
• Sam has black vomit. Family calls OOH GP at 9pm and are
advised by non clinical reception staff to present to the local
Treatment Centre for GP review as it would be faster than going to
A&E.
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Out of Hours Treatment Centre Review
• Sam and his family arrive at Treatment Centre at 9:30pm.
They are asked to wait to be reviewed, there are 3 people in
front of them to be seen.
• At 9:55pm the family attract the attention of a nurse who is
walking past. She identifies Sam as very unwell and
arranges immediate review in a resuscitation area. 999 are
called and the ambulance arrives almost immediately.
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Secondary Care
• Sam arrives to hospital at 10:30pm. Doctors there
identify sepsis and prescribe antibiotics within an hour.
• Sam is transferred to the Paediatric HDU and is
administered the antibiotic at 1:30am.
• Sam dies of septic shock shortly after 5am.
• Cause of death: Influenza B with a super-infection of
Invasive Group A Streptococcus leading to
Streptococcal Toxic Shock Syndrome.
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Sepsis work in DCIoS
• A small working group was formed with the remit of
designing and implementing a sepsis campaign across
DCIoS
• Working from Sam’s experience the decision was made to
design a whole system’s pathway for children with
suspected severe sepsis/septic shock
• A fundamental issue for the group was to ensure everything
developed must have a common language throughout the
pathway
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The Pathway
• Pathway development day using Sam’s timeline and all of the
services he came into contact with
• NICE guidance: Feverish Illness in Children for use in primary
care and to form parental information
• UK Sepsis Trust Sepsis Six (adapted for Children) for use in
secondary care and to inform tertiary care input
• SBAR tool for communications between clinical staff and trial
to use for families
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• Education programme to implement pathway
Sepsis Pathway
Ver.4
Presentation
GP/111/A&E/MIU/
WIC
Presentation
At Pharmacy
History and
Examination
(In line with NICE
Guidance)
Assessment
Return home
Green
Advice and/or Anti
Pyretic and Nice
leaflet
Return home with
safety netting
Amber
Deterioration
Red
Immediate referral
to Emergency
Medicine (A&E)
admission
Examination/
Assessment
Signs of systemic
Sepsis
Instigate secondary
care Sepsis
Pathway/instigate
treatment
Susan Bracefield
NHS England, DCIOS Area Team, Sepsis Working Group
Consider differential
diagnosis
What to look out for if your child is not well
These may be signs of serious infection (sepsis) or other conditions that require medical assessment
Colour
(skin, lips
and tongue)
Amber (intermediate risk ) Some (but not all children) with
Red (High Risk) Most (but not all) children with these
these features are seriously unwell so it is important for a trained
health professional to assess them promptly.
features are seriously unwell, they need to be assessed
straight away in hospital
Not responding normally to family or carers
Not smiling
Difficult to wake up or unusually sleepy
Not wanting to do very much
Very pale or blue skin and sunken eyes
Cold and clammy skin
Rash that does not fade when you have lightly pressed it
Not responding to carers
Very difficult to wake up
Weak, high-pitched or continuous cry in younger children
Older children are confused or irritable
Breathing
Nostrils are flaring
Fast breathing
Unusually noisy or crackly breathing
Cough that sounds like a seal barking
Finding it much harder to breathe than normal
Grunting breathing
Very fast breathing: more than 60 breaths a minute
Stopped breathing
Circulation
Cool hands and feet
Very cool limbs
Activity
Unusually pale
Rash that fades when you have lightly pressed it
Shivering or shaking
Temperature Raised temperature for 5 days or more
and body
Swelling of a limb or joint
The child is not using or putting weight on an arm or leg, hand or foot
Vomiting,
Diarrhoea
and
hydration
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Under 1 year of age - Vomiting and/or diarrhoea
More than 5 watery poos in the last 24 hours
Has vomited more than twice in last 24 hours
Not feeding or eating much
Dry mouth
Only one wet nappy or wee in 12 hours
Contact your GP, NHS 111, your local walk-in centre or minor
injuries unit
Under 3 months with raised temperature over 38C
The soft spot on an infant’s head is bulging
Stiff neck
The child has a seizure
Very thirsty and not able to keep fluids down
Bloody or black vomit
Not had a wee for 12 hours
Call for emergency medical care
Dial 999 for an ambulance
•
•
•
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The Sepsis in Children App
provides a short explanation
of sepsis followed by the
signs and symptoms as
described in SAM including
the amber and red risks
factors.
Currently this App is
available as an information
resource. However, further
developments for an
interactive App are in
progress.
The newly design App
should make it possible for
parents to click on the
observed vital signs of their
child. The observations will
then be saved to allow
parents to bring their
assessment to the GP or
other healthcare
professionals.
Next Steps………
• Project manager 2 days per week to work with primary care on NICE
traffic light desktop application
• Work with Jayne Wheway, National Safety Lead for Children and
Young People, to develop bespoke education package
• Avatar Project, trainee GP education on sepsis
• Pilot to start Autumn in South Devon and Torbay
• Evaluation by Plymouth University using service methodology to
make changes before full roll out
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• Roll out across DCIoS and across South Region if successful.