t pillay ssbcnn oct 2012 implementing a newborn early warning system in the ssbc nn

T Pillay SSBCNNOct 2012

Implementing a Newborn Early Warning System

in the SSBC NN

FIGURE 1 The ambulance corps of Baron Dominique-Jean Larrey, circa 1809.

Triage: rapid sorting, unwell patients

Illness identification: defining features of illness

Early Warning System: hospital wardsidentify patients at risk of

deterioration

Roland 2012, Arch Dis Paed Ed Pract

Scoring Systems

Antecedent events of acute deterioration/transfer to ICU:

‘Often early clinical signs missed’

Early Warning Systems Recommended

CEMACH report 2006 NPSA 2007, 2009

The Confidential Enquiry into Maternal and Childhood

Death Report, Why Children Die–

A Pilot Study 2006

For paediatric care in hospital - recommend a

standardised and rational monitoring system with

imbedded early identification systems for children

developing critical illness - an early warning score

Standardisation

Improve care for acutely ill

Addresses variability in

detecting clinical Illness early

2012

Cohort: 170 non-ICU RRT and 16 code events

Test: Retrospective PEWS in last 24 hrs

Outcome: Earliest indicator of deterioration

detected a median of 11 hr 36 min in

85.5% of cases

Sensitivity of Pediatric EWS to Identify Patient Deterioration

Akre et alPediatrics, 2010; 125 : e763-769California, Minnesota

Sensitivity and Specificity to Identify Patient Deterioration

Skaletzky et alClin Pediatr 2012 May;51(5):431-5. Epub 2011 Dec 8.Miami Children’s Hospital, Miami, FL 33155, USA.

Validation of a modified pediatric early warning system score: a retrospective case-control study.

Cohort: 100 cases 250 controls; ward patients

Test: Retrospective PEWS

Outcome: Sensitivity 62%

Specificity 89%

Can it make a difference to outcome?

Paediatric EWS Brighton:

• Early identification of children at risk

• Fewer codes

• More timely transfer to ICU

Which baby will it potentially benefit?

Hospitalised

Not critically ill, but under observation

Babies who are stable, but can deteriorate

At Risk Neonatal Infant

Neonatal Early Warning System

No defined directive for babies

Benefit?

At Risk Neonatal Infants : ARNI

Post natal ward

Transitional care, SCBU

Neonatal Early Warning System

• limited information on

• progressive morbidity in early postnatal period in

ARNI

• the triage process, from post natal ward

observations to review, investigations, intervention,

admission to NNU

Neonatal Early Warning System

• What impact does time to review/intervene have in

ARNI with progressive deterioration?

Neonatal Early Warning System

• What impact does time to review/intervene have in

ARNI with progressive deterioration?

• Sudden Unexpected Postnatal Collapse/Death

(incidence 0.05/1000 live births)

Neonatal Early Warning System

J-C BecherArch Dis Child FN 2012 F30-4

• Can it influence provision of care?

• Can it influence outcomes?

Neonatal Early Warning System

Limitations with Newborn Early Warning Systems

Neonatal Early Warning System

Roland, Madar, Connolly. Infant 117-120, Vol6, Issue 4, 2012

Retrospective review : 122 term infants

48% ARNI had observations recorded

52% would have had earlier review with NEWS

Implementation of a Neonatal Early Warning System

Roland D, Madar J, Conolly GInfant 2010; Vol 6, Issue 4 116-121

Prospective Study : 117 term infants

71.2 % observations recorded

Prompted management decision in 43% of

infants requiring intervention

Facilitates observation of babies assumed to be at risk

Prompts earlier review in those showing clinical deterioration

Considered beneficial by majority of midwives using it

Implementation of a Neonatal Early Warning System

Roland D, Madar J, Conolly GInfant 2010; Vol 6, Issue 4 116-121

England

Variable implementation eg

Plymouth, Liverpool, Cambridge, Northern Neonatal

Network; not standardised

Scotland

Widespread standardised implementation in NHS,

Orkney, Shetland

Implementation of a Neonatal Early Warning System

Scottish NHS: widespread use; SCBU and post natal wards, some HDU patients

Criteria for Newborn EWS Observation

Meconium at delivery

PROM

Maternal pyrexia/infection/chorioamnionitits

SGA

All babies in Transitional care

Poor feeding

Grunting

Hypoglycaemia

Hypothermia

Other, as determined by Midwife/ANNP/Medical team

Theresa Pilsbury (midwifery) NXH

Claire Cockburn, Nicola Taylor, Pam Smith (NNU) RHH

Anne Clark/Jane Henley Walsall

Gina Hartwell (NNU) MSG

Emma Hubball (midwifery) UHNS

Matthew Nash Grid Trainee

SSBC NN Team

Positive:

Stopped false calls

Highlighted the 'zig zag' baby

Prompted staff action when they might otherwise not have acted

Empowered midwifery support for post natal babies

Feedback

Negative:

Parent perception of scoring

Documentation

Lack of common sense approach to duration

/frequency of observations

‘Why do we need a score if we can recognise a

baby becoming ill?’

Cost

Feedback

Critical thinking

Ease of observation

Easy visualization of problematic baby

Standardized escalation system

Nurses role in EWS

Does it add value to post natal care provided?

Does it streamline nursing service provision?

Is it cost effective and time – effective?

Does it empower nursing team to think critically?

Does it make a difference to outcome?

Future Questions

Audit/review of effectiveness:

False positives (hypersensitivity)

False negatives (babies not picked up)

Future Questions

Fashionable Promoted through National bodies for

Adults/Paediatrics No standardised approach in Neonates

No clear idea as to whether it is indicatedit will make a difference

in At Risk Neonates, not managed in HDU/ICU

Being trialed in SSBC NN

Conclusion