Emergency - Quality, Education and

Safety Teleconference

For smaller EDs

Dr Joseph Marwood

Emergency Care Institute

Thanks for joining

House rules

Agenda

• Case review

• Underlying causes

• Clinical context

• NSW Health guidance

Participation encouraged throughout(But please turn off camera & mute mic when not talking)

Case – Initial presentation

Sunday morning 0230 Rural ED

4 month old boy

BIB mum

Unwell 3 days

Vomiting post feeds

2 wet nappies / 24 hrs

Case - presentation

Obs

RR 60

SaO2 90-94%

HR 150

T 36.9

Tracheal tug, intercostal recession

Audible wheeze & grunt

ATS Category?

Case - review

VMO review in 5 mins

‘Brief cyanosis’

Tolerated nasal prong O2

P/C to Base Hospital paediatric reg

Cannula

IVF bolus 20ml/kg 0.9% saline, + infusion

CXR

Booked ANSW transfer (non urgent)

Case – initial progress

0415 CXR reviewed – ‘right upper lobe pneumonia’

0420 IV Ampicillin 100mg

0425 VMO leaves hospital

0455 Ambulance arrives

HR 160 bpm SaO2 86% (96% on 8L) RR 44

Ambulance query need for NETS call

TF to base hospital (lights & sirens)

THOUGHTS? Could this reflect a case at your ED?

Case – progress @ RRH

0635 Arrival @ Base Hospital

No pre-arrival ATS Cat 2 “SOB”

0640 IV Cefotaxime, rpt CXR – ‘cardiomegaly’

0650 Severe respiratory distress

HR 195 T 38.4

Moved to resus

ED consultant called & attended

NETS called

Case - progress0800 FACEM intubation unsuccessful,

Bradycardic arrest ROSC

0810 Anaesthetist intubation unsuccessful

Bradycardic arrest ROSC

0840 Anaesthetist re-intubation successful

Bradycardic arrest ROSC

Fentanyl & dopamine infusion

0930 Bradycardic arrest ROSC

Case - outcome

1015 NETS arrival, TF to Tertiary hospital

Diagnosed with coarctation of aorta

Theatre for aortic stent

Sadly died from hypoxic brain injury

THOUGHTS ON THE CASE?

Issues impacting outcome?

Patient

High risk population

Rare underlying diagnosis (No ∆ to disposition)

Difficult airway / complex resuscitation

Personnel

Culture, communication & rapport

Cognitive bias / diagnostic anchoring

Practices

Lack of specialist input

Transfer urgency

How might we prevent this occurring?

Individual level

Care of the transferred patient

Question cognitive biases

(alternative diagnoses in neonate – ‘THE MISFITS’)

Systems Level

Inter-disciplinary culture (“Its OK to ask”)

Care of the deteriorating patient

Pre-arrival notification (batphone)

?

?

Inter-facility transfers of children

“Ensure that the child’s condition has been assessed and

stabilised as much as possible prior to transfer [in

consultation with a clinician at the receiving hospital].

Ensure the child’s safety at all times with regard to transfer

decisions.

Medical and nursing staff should consult with Ambulance

officers in decisions about transfer and clarify the

responsibilities of key staff during the transfer.”

Lost opportunity to discuss alternative transfer

Inter-facility transfers of children

“NETS needs to be consulted in all children with a triage

category of 1 and 2 and all children with a triage category

of 3 who are not improving.”

NETS would normally expect to be called about… High

oxygen requirement…Respiratory failure …

What is your experience to using NETS?

Are there barriers to involving the service?

Sick Neonates

Scary

Sepsis?

Sepsis plus…?

Trauma

Heart

Endocrine

Metabolic

Inborn errors

Seizures

Formula

Intestinal

Toxins

Sepsis

?

Trauma including NAI

1/3 of head trauma missed

Risk factors for NAI?

Look for - bruises, bulging fontanelle, abnormal pupils, retinal

haemorrhages

Admission, survey, mandatory reporter guide

+/- surgical opinion

Heart - Congenital disease / SVT

Look for - shock (cap refill), cyanosis

Absent femoral pulses, ?big liver?

ECG

NETS / Cardiology opinion

Endocrine

Hypoglycaemia, congenital adrenal hyperplasia

Look for ↓glucose, resistant shock, ↑K+, ↓Na+, ?ambiguous genitalia

Hypoglycaemia: 10% Dextrose 2ml/kg

Shock: 0.9% NaCl 20mls/kg

Resistant shock: Hydrocortisone 4mg/kg

Inborn Errors – Acid base ∆s

Seizures

60% hypoxia / ↓perfusion

10% CNS infection (no ‘febrile seizures’

Formula

Electrolyte disorder, especially ↑or↓ Na+

Intestinal catastrophe

Malrotation/ Intussusception/ Obstruction / Pyloric stenosis

Hx of bilious vomiting

Look for – peritonitis, ?abdo mass?

ABX, IVF& surgical opinion

Toxins

Ingestion, breast-milk, dermal

Look for – toxidromes: opioids, amphetamines, botulism

BSL, ECG, toxicology advice

Sepsis

Prematurity, GBS +ve mother, PROM, < 1month, un immunised

Look for ↓or↑ temp, localising signs, shock

Early empirical ABX < 1 hr (Local guidelines)

e.g cefotaxime 50mg/kg

+ flucloxacillin 50mg OR vancomycin 15mg/kg

+/- gentamicin 5mg/kg)

IVF 20ml/kg bolus

Correct diagnosis

Correct treatment

Correct disposition

Recognition of the sick child

Survival

Clinical Tools

Recognition of the sick baby

Recognition of the deteriorating patient

Deterioration = Escalation

Do you agree?

Culture

How can we empower staff to challenge decisions?

Nursing

Medical

Allied Health

Patient / parent

Medical

Nursing Allied Health

Patient /

Parent

Any further thoughts?

E-QuESTs so far

• Atypical Chest Pain - ACS

• Sepsis in the elderly

• Abdominal pain in the elderly - AAA & Ischaemic gut

• Scrotal emergencies

• Deadly headaches

• Paediatric deterioration

Looking to next month, please…

• Share your cases

• Share your patient safety actions

• Spread the word with your colleagues

(or send me their email: joseph.marwood@health.nsw.gov.au)

What would you like to see / hear about?

Further Info

“Paediatric Watch” – other great safety cases with analysis

http://www.cec.health.nsw.gov.au/patient-safety-programs/paediatric-

patient-safety/paediatric-watch

“NSW Mandatory Reporter Guide”

https://reporter.childstory.nsw.gov.au/s/

http://www.cec.health.nsw.gov.au/patient-safety-programs/paediatric-patient-safety/paediatric-watchhttps://reporter.childstory.nsw.gov.au/s/

Further Info

Clinical Excellence Commission guidelines on M&M http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0018/352215/clinical-review-m-

and-m-oct-2016.pdf Google “CEC M&M”

ED Quality Framework Death Audithttps://www.aci.health.nsw.gov.au/networks/eci/administration/ed-qf-project/ed-qf-death-

audit Google “ECI death audit”

http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0018/352215/clinical-review-m-and-m-oct-2016.pdfhttps://www.aci.health.nsw.gov.au/networks/eci/administration/ed-qf-project/ed-qf-death-audit

Many thanks

Next E-QUEST

Thursday 14th December 0800

Level 4, Sage Building 67 Albert Avenue PO Box 699 T 02 9464 4674 www.ecinsw.com.au

Chatswood NSW 2067 Chatswood NSW 2057 F 02 9464 4728 ABN 89 809 648 636

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