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Care of Children and Young People

Presenting to Hospital with

Decreased Conscious Level

Executive Summary for Nurses

Jason Gray

Paediatric Emergency Nurse Consultant

Royal Alexandra Children’s Hospital, Brighton

Funded by the National Reyes Syndrome Foundation, UK

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Background and Methodology

• Based on the 2005 Paediatric Emergency Research Group guideline The Management of a Child with a Decreased Conscious Level

• Aim-To assess whether children with a decreased conscious level are receiving appropriate care according to the guideline’s recommendations.

• Data collection from 1 Nov 2010 to 30 Sept 2011

• Prospective case identification: (Most trusts used combined prospective/retrospective or retrospective only case identification)

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Participation

• 54 NHS trusts (comprising 66 hospitals) from England, Wales and Northern Ireland

• 51/54 (94%) trusts submitted clinical audit data (samples ranged from 1 to 73 cases) – Data submitted on 1135 eligible cases

• Place of presentation

– Mixed emergency department = 61.8% (701)

– Paediatric emergency department = 35.9% (407)

– Paediatric assessment unit = 2.2% (25)

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Clinician Survey

• 72% (182/204) respondents were consultant

paediatricians

• 46% (94/204)knew about the guideline prior to the audit

• Respondents find out about new guidelines most

commonly

– from their colleagues, journal articles, the RCPCH

website or a

– posted copy of the guideline.

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Familiarity with Guidelines

Clinicians indicated that the most important means of

promoting guideline use were the provision of:

– a one page algorithm

– quick reference summary of the guideline

– education and training sessions

– a poster of the guideline

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Lack of Nursing Involvement?

• Include nurses in distribution and dissemination of guideline.

• Include nurses in audit.

• Include the Royal College of Nursing

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Inclusion/Exclusion criteria

• 0-17 years

• AVPU assessment of voice, pain or unresponsive OR GCS 14 or less on presentation to hospital

• Repeated episodes of decreased conscious level providing there is no known or established diagnosis

Inclusion

• Previously diagnosed condition known to be the cause of the decreased conscious level

• Possession of a ventriculo-peritoneal shunt

• GCS less than 15 on a day to day basis

• Preterm or full term infants with decreased conscious level from the moment of birth onwards

• Transfers from another hospital

Exclusion

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Audit sample characteristics

• 45.2% (513/1135) female and 55.8% (622/1135) male

• Mean age of 8.3 years

• 94.9% had differential working diagnosis-

– most common were alcohol intoxication (29.0%), infective

causes (20.2%) and traumatic causes (16.4%).

• 16 deaths (1.4%), 9.9% (112/1135) transferred to paediatric intensive care units and 4.1% (46/1135) transferred to other NHS hospitals

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Audit measured 8 main areas of

management • Features of clinical history

• Observations

• Use of physiological scoring systems (GCS/AVPU)

• Recommended frequency of GCS measurements

• Recommended core investigations and tests

• Working diagnosis within 4 hours of presentation

• Management plan within 4 hours of presentation

• Parent or guardian involvement during initial

resuscitation and management

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Highlights: Clinical Audit

Findings • Good documentation of the following:

– Observations: heart rate, respiratory rate and oxygen saturation

– Working diagnosis and management plan within 4 hours of presentation

– Use of AVPU or GCS at presentation to hospital

• Areas requiring improvement in documentation

– Clinical history features of vomiting, fever, convulsions, alternating periods of consciousness, length of symptoms, ingestion of medication/recreational drugs

– Observations: blood pressure and temperature

– Communication with parents regarding their child’s diagnosis and prognosis.

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Heart Rate

02 sats

RR

Temp

BP

Observations (n = 1135)

98%

90% 74.5%

22%

61%

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Interesting Finding

• Children presenting with a decreased conscious level secondary to non-traumatic causes or unknown cause were more likely to have documentation of their respiratory rate compared with those children presenting with alcohol intoxication or traumatic causes.

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Interesting Finding

• Children who presented to mixed emergency departments or paediatric assessment units were more likely to have documentation of their respiratory rate than those children presenting to paediatric emergency departments.

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Interesting Finding for under

5’s • Children under five years were less likely to

have documentation of blood pressure on presentation as compared with those five years and over.

• Children under five years were more likely to have documentation of their temperature on presentation as compared with those five years and over.

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The assessment of consciousness and

frequency of GCS measurements

Audit standards Total audit

sample

Cases

meeting

the

standard

% Cases

meeting

the

standard

GCS or AVPU

assessment performed

and documented

1135 1099 96.8%

Recommended frequency

of GCS measurements

performed and

documented(children with

GCS performed)

903 440 48.7%

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Interesting Finding for Parental

involvement

• The levels of documentation were generally low across all types of units.

• Mixed emergency departments or paediatric assessment units were more likely to have documentation indicating that parent or guardian was allowed to stay with them during the initial resuscitation and management as compared to those children presenting to paediatric emergency departments.

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Alcohol as the cause of the

decreased conscious level

315 children or young people (28%)

presented with a decreased

conscious level secondary to

alcohol intoxication

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Alcohol Intoxication

Place of presentation to hospital

(n=315) • Mixed Emergency Department = 196 (62%)

• Paediatric Emergency Department = 116 (37%)

• Paediatric Assessment Unit = 3 (1%)

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Day of presentation (n =315)

• The majority of these cases presented on a weekend day

(63%) as compared to a week-day (37%).

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Age and Gender (n=315)

• Alcohol presentations more common with females

(55%) than male children (45%)

• Mean age = 14.7 years

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Alcohol Intoxication

Outcome (n = 315)

Outcome Numbers

Discharged 223 (70.8%)

Self discharged 3 (1.0%)

Unknown 1 (0.3%)

Transferred to the ward (paed or

adult)

83 (26.3%)

Transferred to Paed ICU or Adult

ITU

3 (1.0%)

Transferred to Other NHS Hospital 2 (0.6%)

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Findings

•Diagnosis of alcohol intoxication should be considered for older children and adolescents presenting to Emergency departments with reduced conscious level.

•These children should be reviewed by more senior staff

•There needs to be better documentation of the clinical history in these children

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Clinical Audit Findings:

Highlights • Good documentation of observations, management plan within 4 hours of presentation

• Areas for improvement in the documentation of the absence or presence of the following clinical history features

– vomiting before or at presentation = 63.2% (199/315) – headache before or at presentation = 11.4% (36/315) – convulsions before or at presentation = 9.5% (30/315) – alternating periods of consciousness = 50.5% (159/315) – trauma = 49.2% (155/315) – length of symptoms = 64.4% (203/315)

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Key Recommendations for Nurses

• All health professionals should take a comprehensive clinical history irrespective of the differential diagnosis.

• Clinical history documentation should include:

– Information on both the presence of a feature and its absence

– Reasons if unable to obtain an adequate history

• On arrival to hospital, all children with a decreased conscious level should have a complete set of observations taken including heart rate, respiratory rate, oxygen saturation, blood pressure and temperature.

• If a child requires regular evaluation of their conscious level, GCS measurements should be commenced in addition to or instead of AVPU (15 mins – 60 mins)

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Key Recommendations for Nurses

• Capillary blood glucose should be undertaken in all

children

• All children with decreased LOC due to metabolic,

infective or unknown should receive appropriate and early

investigations

• Nurses should document any discussions undertaken

with parents, CYP

• All health care professionals should inform

parents/guardians of possible diagnosis and document

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Key Recommendations for Trusts

• Nurses should receive regular training to reinforce good

record keeping skills and this should be part of all trusts’

compulsory training programme.

• Observations charts should be incorporated into the

emergency department notes whether written or

electronic.

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Thank you