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Statewide Paediatric Observation and Response Chart (SPORC) Project

Phase One & Phase Two Report

August, 2014

Preface This report was prepared by the Statewide Paediatric Observation and Response Chart (SPORC) project team for the Paediatric Clinical Network, Department of Health, Victoria Dr Sharon Kinney SPORC Nursing Lead Royal Children’s Hospital/The University of Melbourne Jennifer Sloane SPORC Coordinator Royal Children’s Hospital/Paediatric Clinical Network Dr Annie Moulden SPORC Medical Lead Monash Children’s

Acknowledgements The Phase One and Two of the SPORC project was supported by the Victorian Government. The SPORC team also gratefully acknowledge the contributions and support from the following: The Paediatric Clinical Network (PCN) – particularly Juliette Begg (Manager), Associate Professor Jill Sewell (former co-Clinical Lead), Associate Professor David Armstrong (co-Clinical Lead) and Dr Peter McDougall (co-Clinical Lead). The Victorian Paediatric NUM Network Group All 12 SPORC pilot sites, especially the nurse educators, pilot site champions and executive staff RCH Educational Resource Centre, specifically Bill Reid for his work with the design of the charts Peter Watson at Allenby Printing Leanne Holmes of Holmes Information Services Malcolm Green, NSW Clinical Excellence Commission, for his ongoing support and encouragement Professor Fiona Newall, Director, Nursing Research, Royal Children’s Hospital

Statewide Paediatric Observation and Response Project: Phase 1 and 2 report Page | 3

Contents Preface .................................................................................................................................................... 2

Acknowledgements ................................................................................................................................. 2

Executive Summary ................................................................................................................................. 6

Summary of Recommendations ......................................................................................................... 7

1. Introduction .................................................................................................................................... 8

2. Background ..................................................................................................................................... 8

3. Project Aim ...................................................................................................................................... 9

4. The Project Logic ............................................................................................................................. 9

5. The Approach ................................................................................................................................ 10

Scoping ............................................................................................................................................. 10

Engagement ...................................................................................................................................... 10

Establishment of pilot sites ....................................................................................................... 10

Development .................................................................................................................................... 10

Charts ........................................................................................................................................ 10

Education Package .................................................................................................................... 11

Implementation ................................................................................................................................ 11

Education .................................................................................................................................. 11

Rollout ....................................................................................................................................... 11

Printing and Distribution ........................................................................................................... 11

6. Evaluation ..................................................................................................................................... 12

Aim/objectives .................................................................................................................................. 12

Methods............................................................................................................................................ 12

Survey ........................................................................................................................................ 12

Focus groups ............................................................................................................................. 12

Chart Audit ................................................................................................................................ 13

Escalation and Response (EAR) audit ........................................................................................ 13

Data analysis ............................................................................................................................. 13

Ethical considerations ............................................................................................................... 13

7. Results ........................................................................................................................................... 13

User Survey ............................................................................................................................... 13

Focus Groups ............................................................................................................................. 15

Chart Audit ................................................................................................................................ 20

Escalation and Response (EAR) Audit ....................................................................................... 21

8. Summary of findings ..................................................................................................................... 22

9. Summary Recommendations ........................................................................................................ 23

10. Expanded Recommendations ....................................................................................................... 23

References ............................................................................................................................................ 26


Appendix A. SPORC Reference group and key contributors ................................................................. 27

Appendix B. SPORC Pilot Sites .............................................................................................................. 29

Appendix C. Revised SPORC Chart ....................................................................................................... 30


List of Tables Table 1. Medical and nursing classification of survey respondents (N=162) ....................................... 14 Table 2. Percentage of respondents who 'Agreed' or 'Strongly Agreed' with statements (N=162) ..... 15 Table 3. Focus group participants according to pilot site ..................................................................... 16 Table 4. Qualitative findings from focus groups and user survey ........................................................ 18 Table 5. Chart audits according to age groups ..................................................................................... 20 Table 6. Observations recorded with the last set of observations ....................................................... 20 Table 7. Patient observations in Orange Zone ...................................................................................... 21 Table 8. Patient observations in Purple Zone ....................................................................................... 21 Table 9. Escalation and Response Audit according to age group ......................................................... 21 Table 10. Critical events prior to patient transfer ................................................................................ 22

List of Figures Figure 1. Project logic .............................................................................................................................. 9 Figure 2. Focus group themes and sub-theme ..................................................................................... 17 Figure 3. Patient transfers according to day of week ........................................................................... 22


Executive Summary Whilst other states in Australia had developed and implemented standardised observation and response charts for hospitalised children, there was not a consistent statewide approach in Victoria. With the goal of reducing paediatric morbidity and mortality related to inadequate detection of, and response to, the deteriorating paediatric, the Statewide Paediatric Observation and Response Chart (SPORC) project was established in February, 2013. Phase 1 and Phase 2 implementation Initial funding was secured from the State Government, via the Paediatric Clinical Network for Phase 1 of the project. Key activities included the scoping of existing Victorian and Australian paediatric track and trigger charts, review of the literature, and extensive stakeholder engagement with expert clinicians from both rural and metropolitan settings. A set of standardised observation charts suitable for children over 5 age groups, was designed in accordance with National Standard 9: Recognition and Response of the Deteriorating Patient (ACSQHC, 2011). Two types of charts were developed; one for the inpatient setting and another for short stay patients requiring admission < 24 hours. The charts were supported with an accompanying education package. A subsequent increase in budget and extension to the project timeline was granted for Phase 2 of the project, which involved piloting and evaluating the charts. An expression of interest to pilot the charts generated 21 applications and 10 health services (12 hospitals) across Victoria were chosen to trial the charts over a 5 month period. A multi-method evaluation was conducted with the aim of determining the appropriateness of, and user satisfaction with the charts. User surveys were completed by 162 respondents (20 medical and 132 nursing) and 121 nursing staff and 24 medical staff participated in focus groups. Chart audits were conducted for 223 patients across the 12 trial hospitals. Escalation and response (EAR) audits were completed for 68 patients that were transferred to another hospital or transferred to a higher level of care (pilot sites, n=55 and non-pilot sites, n=13). Key findings Overall findings indicated that the majority of clinicians found the charts to be suitable for, recording clinical observations, detecting patient deterioration and communicating clinical care in paediatric patients. 93% of the survey respondents preferred the SPORC charts compared with their previous hospital charts. The favourable chart layout, with distinct age-group parameters and the ease of identifying trends were viewed positively. Key chart design concerns related to the inability to visualise normal temperatures, limited space in some sections (particularly with the short stay charts) and difficulties with documentation when in the middle of the chart. The provision of clear escalation processes was highlighted by most clinicians and the fact that the charts promoted consistent communication across departments or hospitals was highly valued. Nevertheless, the escalation processes were not always followed and the inapplicability of trigger parameters to all patients, was noted at times to be problematic. Difficulties in accessing medical staff to modify parameters was also highlighted. Not all staff were aware of the site-specific modification procedures and establishing who the most appropriate clinician was to modify parameters (i.e. with suitable paediatric expertise) was also a concern, particularly for sites where children were admitted under an adult-based surgical bedcard. Compliance with recording and documenting on the charts according to the instructions was generally good. There were three instances where the incorrect age-group chart was in use. The majority of respiratory rate and heart rate recordings were plotted with a dot and joined with a line (enhanced trending) but plotting occurred less frequently for some other parameters where a number was recorded instead (e.g. Temp).


The charts audits (n=223) also revealed that 50 observations were recorded in the orange zone for 47 patients (3 patients had both an elevated RR and HR). Sixteen (34%) of these patients had a documented medical review consistent with the escalation recommendation. Eight observations were recorded for 7 patients and 2 (29%) of these patients had an emergency call. Findings from the EAR audit provided some insight into the characteristics of paediatric patients that were transferred to a higher level of care, due to unexpected deterioration. Of the 55 transfers from the pilot sites 42 (76%) patients had a documented request for medical review within 10 minutes of the first abnormal parameter (defined as an orange zone parameter). Twenty-nine (53%) patients had an emergency call (e.g. MET) in the 12 hour period prior to transfer. Two patients had a cardiac arrest, one patient was intubated and 10 patients required bag-mask ventilation prior to transfer. Findings from this multi-method evaluation have informed changes to chart design, identified essential education areas to be addressed when introducing the charts to new organisations (e.g reinforcing plotting the dot, modification practices) and has highlighted the importance of having adequate site-specific procedures in place in preparation for a state-wide roll out.

Summary of Recommendations A statewide rollout of the revised SPORC charts to paediatric wards/sites that are supported

with a paediatrician or other appropriate medical staff (e.g. GP with paediatric interest). Piloting of charts in Special Care Nurseries and Urgent Care Centres or equivalent sites, would be desirable, before use in these settings. The pilot short stay charts are to be discontinued.

Continuation of statewide printing and maintenance of generic charts. The charts have been specifically designed, utilising human factor principles and other features to enhance useability. We believe it is critical that the chart is not modified by individual sites, to ensure that the benefits of these features are maintained. Furthermore, a statewide commitment to printing a generic set of charts, without individual hospital logos, will result in significant cost savings.

A comprehensive implementation plan is followed. An implementation guide, including an educational video, will be available for health care facilities that introduce the SPORC charts. New sites will be required to identify a site champion, ensure local paediatric escalation responses are adequate, and undertake a widespread education and promotional campaign.

A standardised approach to education about paediatric assessment is developed and implemented statewide. We believe that the education should not only encompass the performance of paediatric observations, but greater emphasis should be given to the interpretation of observations and assessment of children, in order to appropriately recognise and respond to paediatric clinical deterioration.


1. Introduction The Statewide Paediatric Observation and Response Chart (SPORC) project is a jointly led initiative by the Royal Children’s Hospital and Monash Children’s, and is funded by the State Government via the Paediatric Clinical Network. The goal of the project is to improve the early detection of, and response to, patient deterioration, through the implementation of charts that are suitable for recording observations of children. The SPORC project commenced in February 2013 with a review of the evidence, an examination of paediatric charts in use around Australia, and extensive stakeholder engagement with clinicians around the state. This extensive scoping phase resulted in the development of a set of standardised observation and response charts for five age groups. They were designed in accordance with the National Safety and Quality Health Service Standards, National Standard 9: Recognition and Response of the Deteriorating Patient (ACSQHC, 2011) and the guiding principles outlined in the National Consensus Statement: Essential elements for recognising and responding to clinical deterioration (ACSQHC, 2010). The charts were piloted in 12 hospitals across the state, and after a multi-method evaluation, revisions were made in readiness for a statewide rollout in September 2014. This report describes the development, implementation and evaluation of the SPORC project (Phases 1 – 2) that was conducted between February 2013 and July 2014.

2. Background Inconsistencies and time delays between the recognition of patient deterioration and escalation of care have been acknowledged worldwide (Kause et al., 2004). In Australia, as part of a national safety and quality health service program, minimum standards are provided to guide health care facilities with the implementation of systems to support the detection and management of patient deterioration (ACSQHC, 2011). The standards incorporate elements that specifically relate to the measurement and documentation of observations and escalation of care processes. Recommendations include, utilizing human factors principles in the design of the observation charts and identifying thresholds that indicate physiological abnormalities, with the incorporation of a ‘track and trigger’ system to escalate care when deterioration occurs. In 2012, the Australian Commission for Safety and Quality in Healthcare (ACSQHC) developed a suite of standardised observation and response charts suitable for use with adult patients across all states and territories. There were no such plans to develop a national chart for paediatric patients. NSW, ACT, SA and Queensland had already implemented paediatric standardised observation and response charts over a number of age groups, but there was not a similar uniform approach in Victoria. Although some Victorian hospitals had implemented paediatric ‘track and trigger’ charts, there was great variation in the age-related physiological parameters that had been chosen to trigger a medical review or emergency response. Establishing suitable paediatric physiological parameters to trigger escalation of care is challenging because of age-related changes and the diversity of illnesses in the paediatric population. Most vital sign reference ranges have been estimated from studies of non-hospitalised children (Fleming et al., 2011). A more recent study has established heart rate and respiratory rate percentiles based on data from a large cohort of hospitalised children in Philadelphia and Cincinnati (Bonafide et al., 2013). Few studies have evaluated the impact of observation charts that incorporate a ‘track and trigger’ system. Three Australian studies (Hammond et al., 2013; Kansal & Havill, 2012; McKay et al., 2013), including one paediatric study (McKay et al., 2013) have demonstrated improved documentation of


vital signs, better communication and time to medical review, although there is limited evidence linking the specific type of chart to patient outcomes.

3. Project Aim The principal goal of the SPORC project is to reduce paediatric morbidity and mortality related to inadequate detection of, and response to, the deteriorating paediatric patient. The project objectives were to:

1. Develop a track and trigger observation chart system utilising evidenced-based human factors principles.

2. Develop a set of charts founded on evidence-based age specific centile ranges for paediatric vital signs.

3. Develop a chart which has the capacity to clearly outline the service specific actions during the escalation of patient care.

4. Provide a standardised Statewide mechanism for recording paediatric physiological observations.

5. Develop an audit tool to measure the impact of the implementation of the new charts across pilot sites. Expand this tool across the State following Statewide implementation of the charts.

4. The Project Logic To achieve the principal goal of the SPORC project, the use of a vertical project logic enabled the project team to develop a clear project goal and work ‘backwards’ to outline definitive ‘phases’ or ‘results’, each underpinned by the project objectives (Goeschel, Weiss, & Pronovost, 2012). As summarised in Figure 1 each ‘phase/result’ had clear deliverables and requirements which built towards the principal goal. The phases were planned to deliver the most efficient and effective use of budget with the fundamental outputs, activities and inputs providing the building blocks of each objective and related phase.

OVERALL GOAL: Reduction in Victorian paediatric morbidity and mortality related to inadequate detection of the deteriorating paediatric patient in Victorian health settings

Objective 1:

A track & trigger system utilising

evidenced based human factors

principles

Objective 3:

A chart which has the capacity to

clearly outline the service specific

actions during the escalation of patient

care.

Objective 2:

A set of charts that provides evidence-based age specific centile ranges for

paediatric core vital signs

Objective 4: A standardised

state-wide mechanism for

recording paediatric

physiological observations.

Objective 5:

An audit tool to measure the impact

of the implementation of

the new charts across the state.

PHASES/RESULTS:

(Stage 1 short term – Stage 3 long term)

A set of early detection paediatric charts evaluated and implemented across

Victoria.

SPORC PROJECT INPUTS (TASKS), ACTIVITIES, OUTPUTS

(Adapted from Goeschel et al 2012, p. 331) Figure 1. Project logic


5. The Approach

Scoping The NUM group of the Paediatric Clinical Network was instrumental in the initial SPORC scoping phase. Multiple phone calls and sites visits were conducted by the project team and this personable approach to scoping and engagement proved essential in forming ongoing relationships, as well as gaining an insight into individual site requirements. During this scoping phase, the project team were introduced to various local site staff and groups whose contribution remained essential for the project’s success. The key elements of scoping included:

Widespread communication with Victorian Paediatric services, specifically those with a representative on the PCN NUM network group.

The identification of existing Victorian and other State based paediatric charts, including early warning charts, and establishing age-related vital sign parameter ranges (points of escalation).

Determination of a ‘need’ and ‘want’ of individual paediatric organisations for a Statewide approach to recognition and response of paediatric deterioration.

Engagement A Statewide reference group (see Appendix A) was founded to assist in the design of the charts, the ongoing development of the project and the development of outcome measures. The group met monthly to drive both the project objectives and maintain statewide engagement.

Establishment of pilot sites An Expression of Interest to pilot the charts was opened in September 2013 and with National Standards compliance as an incentive to get involved, interest in the SPORC pilot was high. Twenty one sites applied to participate in the pilot project, well exceeding the 6 – 8 sites initially expected. After applicant interviews and site visits by the project team, 12 pilot sites from 10 organisations, including an unexpected inclusion (at the request of pilot sites) of 6 Emergency Departments were selected to pilot the SPORC charts. Once the pilot sites were confirmed a new reference group was formed comprising medical and nursing representatives (SPORC key champion) from each pilot site. Other key engagement activities included writing to CEO’s and Directors of Paediatrics outlining the project and seeking their support.

Development

Charts A set of standardised observation charts for children were developed for the following age groups: less than 3 months, 3 to 12 months, 1 to 4 years, 5 to 11 years and 12 to 18 years. Two types of charts were created; one designed for the inpatient setting and another which was considered more suitable for short stay patients requiring admission for less than 24 hours (e.g Emergency Department, Day Surgery). The development of the SPORC’s was consistent with the requirements outlined in National Standard 9: Recognition and Response of the Deteriorating Patient (ACSQHC, 2011). Following extensive stakeholder engagement, the decision was made to adopt a format using a single parameter trigger, with a two level escalation response. That is, concerning changes in any one parameter (vital signs such as heart rate or respiratory rate) would trigger a medical review of the child. The type and urgency of the medical review would depend on the degree of abnormality. The abnormal parameters were indicated by two coloured zones on the chart. If a child’s vital signs fell into the orange coloured zone then a medical review of the child was required within 30 minutes,


and if within the purple coloured zone an immediate call of an emergency response team (eg the Medical Emergency Team (MET)) was required. The abnormal heart rate and respiratory rate parameters were derived from observations collected from approximately 14,000 hospitalised children (Bonafide et al., 2013). The orange zones on the charts represented the 5th and 95th centiles according to the upper and lower limit of the age-related relevant parameter. Observations in the purple zone represented the 1st and 99th centiles. Age-related, low blood pressure (BP) parameters (purple zone only) were estimated from the 5th percentile for systolic BP and 50th height percentile as determined by Haque & Zaritsky (Haque & Zaritsky, 2007). High BP parameters (orange zone only) were estimated from the 99th centile +5mmHg, considered equivalent to cut-off for stage 2 hypertension (Dionne, Abitbol, & Flynn, 2012a, 2012b; Lurbe et al., 2009). SpO2 values of <90% were chosen for the purple zone which was based on established paediatric MET criteria (Tibballs, Kinney, Duke, Oakley, & Hennessy, 2005). The charts were designed utilising human factors principles but notable differences to most other paediatric charts included:

A3 portrait orientation to enable viewing of the observations on the same page

Smaller scaling increments chosen to enhance the identification of trends in vital signs

Modification section for recording alterations of criteria placed next to the relevant vital sign parameter

Small comments section at the bottom of the page for recording key information to assist interpretation of clinical status

Additional comments section on the back page to document parent concerns and communication with parents

Education Package A detailed education package was developed through PowerPoint and delivered in a ‘Train the Trainer’ format. The education package was designed to train the pilot site champions so that they had a full background to the project, could act as a liaison for local staff and could be a conduit between the project team and local site. At the request of pilot sites, another two modified education packages (shortened) were designed specifically for ward staff and medical staff, respectively.

Implementation

Education A half day ‘train-the-trainer’ education session was conducted by project staff for the pilot site champions to enable training in an efficient manner at their local sites. This was supported up by the supply of SPORC education PowerPoints to educate both ward staff and medical staff.

Rollout Following a localised education program (driven by the SPORC champions), staged implementation commenced at the first sites on the 18th November 2013, with 2 – 3 sites transitioning weekly to the charts over the following 4 weeks. The staged approach allowed upcoming implementation sites to benefit from preceding pilot sites’ experiences (e.g. time of day to launch the charts, estimating initial quantities of charts). Weekly teleconferences and email correspondence were held throughout the implementation phase.

Printing and Distribution SPORC pilot charts were paid for by the project for the duration of the pilot project. The coordination of generic printing and delivery of charts across the 12 pilot sites was critical to the implementation phase. This was a time intensive process, during which pilot sites had to estimate numbers of charts by age group and chart type (Inpatient or Short stay) for the duration of the pilot


(November – March). Due to fluctuations in admissions, bed closures and one miss-calculation of chart requirements, three separate orders and deliveries were necessary. When the pilot ceased on 31st March 2014, sites had the option to continue to use the charts (by paying the printer directly) or reverting back to their previous charts. All sites chose to continue with the SPORC.

6. Evaluation

Aim/objectives The aim of the evaluation phase was to test the appropriateness of, and user satisfaction with, the charts. Specific objectives were:

To examine whether the charts were suitable for recording clinical observations of hospitalised children in Victoria;

To examine whether the charts were suitable for communicating clinical care and associated medical review in deteriorating paediatric patients;

To evaluate compliance with completion of observations and escalation of care processes, as outlined on the SPORC; and

To identify any sections of the chart that required modification.

Methods A multi-method approach was used to evaluate the charts using data from surveys, focus groups, chart audits, and an audit of patients who had deteriorated.

Survey Nursing and medical staff working, or reviewing patients on the trial wards or emergency departments were invited to complete an anonymous online survey (LimeSurvey™) taking approximately 5 minutes to complete. The survey was a modified version of a previously developed survey used for evaluation of the Australian adult observation and response charts (Elliott D., 2011) and was pre- tested on four occasions. The survey broadly addressed issues in relation to the layout of the chart, clarity of text (size, font) and ease of use. It consisted of 12 questions where responses were recorded on a 5-point Likert agreement scale, 6 short response questions (e.g. yes/no), 1 open response question and 5 demographic questions.

Focus groups Small focus groups with nursing and medical staff from participating wards or emergency departments of approximately 30-40 minutes were conducted to explore the issues for staff when using the chart. A ‘Claims, Concerns and Issues’ framework was used to facilitate group discussion, which was approached in the following way:

Claims were explored by asking the participants to identify favourable aspects of the chart (what was working well?)

Concerns – participants were asked to identify any unfavourable aspects of the charts (what could be better?)

Issues were drawn from the claims and concerns discussion and priority issues were established via group consensus and ways forward were identified.

One member of the project team facilitated the discussion and another member took notes. The focus groups were audio- recorded which was used, if necessary, to clarify information that the group provided.


Chart Audit An audit of completion of the SPORC charts for each patient at the trial sites was conducted on a single day during the study period. Data was collected about the adequacy of patient and chart identification, documentation of observations, modifications of observations and escalation of care processes. The data collection tool was piloted on six patients prior to conducting the audits. The observation charts for the preceding 24 hour period were reviewed and data was entered directly into the data collection tool via LimeSurvey™ using an electronic notebook.

Escalation and Response (EAR) audit The EAR audit examined the observation charts and medical records of patients that were un-expectantly transferred out from the trial wards to another hospital, or to a higher level of care within the current hospital (e.g. ICU). The data was collected by the SPORC pilot site champion who entered the patient details directly into an online data collection tool via LimeSurvey™. Data was collected about the nature of physiological deterioration and written communication of patient deterioration. SPORC pilot site champions assisted with the development and piloted the data collection tool on eight patients prior to its implementation.

Data analysis For the Survey and Audits, descriptive data analyses was undertaken using Microsoft Excel®, including frequency counts and percentages for all outcome variables of interest. Responses from the one open-ended question in the survey were summarised and a list of themes generated. Qualitative content and themed analysis of the focus group data was conducted.

Ethical considerations Each pilot site approved the study as a Low and Negligible risk project. Consent to participate in the survey was implicit by electing to complete the survey. Written consent to participate in the focus groups was completed by the participants prior to participation in the focus group. Confidentiality of participant’s identity was guaranteed. No patient identifiable information was collected for either of the audits. The data collected from each pilot site was aggregated and summarised so that Individual hospital data was not identifiable (although individual hospital data was later made available to each pilot site). Survey and audit data were stored on password protected files and all other hardcopy data were stored securely, consistent with NHMRC guidelines.

7. Results

User Survey

Demographics

The user survey was opened for eight days from Thursday 22nd June until close of business on Friday 30th June. The surveys were sent by email to site champions for local site distribution. There were 206 responses registered - 42 responders did not complete the survey, leaving 162 completed surveys. The majority of respondents were from the three Monash Children’s sites (36.4%), the Royal Children’s Hospital (17.3%) and North East Health Wangaratta (13%). The respondents included 132 Nurses and 30 Medical staff and the majority were female (85%). Many respondents were experienced clinicians as highlighted in Table 1.


Table 1. Medical and nursing classification of survey respondents (N=162)

Main Findings

One hundred and fifty one respondents indicated that they predominantly used the inpatient charts with only 11 nominating the short stay charts. Ninety three percent of the respondents preferred the SPORC compared with the previous charts that they had used in their hospital. Key findings from the survey are shown in Table 2. Most respondents found the chart easy to use and were generally satisfied with the layout and design. The main concerns related to font size, especially with the short stay chart, and not enough space for graphing, particularly in the temperature section.

Discipline n %

Medical (n=30)

Consultant 14 8.6%

Fellow 2 1.2%

Registrar 4 2.5%

Resident 8 4.9%

Intern 2 1.2%

Nursing (n=132)

AUM / NUM 30 18.5%

CNC / Nurse Co-ordinator 2 1.2%

Clinical Nurse Specialist 27 16.7%

CNS / Nurse Educator 7 4.3%

Graduate Nurse 5 3.1%

RN / EN 60 37.0%


Table 2. Percentage of respondents who 'Agreed' or 'Strongly Agreed' with statements (N=162)

Survey Statements %

1. The chart is easy to use 93

2. The language used throughout is easy to understand 93

3. The colours help me to identify when my patient is at risk 89

4. The modification section is appropriately placed next to the relevant vital sign 87

5. The chart aids the management of the deteriorating patient 87

6. The scales chosen to graph vital signs (vertical axis) enhances the identification of any increasing or decreasing trends in paediatric patients

83

7. The STYLE of text/font is easy to read 80

8. The chart assists in handover of my patient's clinical status 78

9. The general instructions section (on the back of the chart) is helpful 70

10. The chart assists in effective communication regarding parental/carer concerns about a child's clinical state.

64

11. The SIZE of text/font is easy to read 59

12. Enough space is provided to document in the vital sign graphing section 57

Focus Groups Demographics

Eighteen focus groups were conducted between the 4th April and the 27th May, 2014. Two separate groups were organised at six of the pilot sites in order to maximise participation. Of the 145 focus group participants, 121 were nursing staff and 24 were medical staff. 88% of participants were females. Table 3 shows participation according to the pilot sites.


Table 3. Focus group participants according to pilot site

Pilot Site Nursing Participants Medical Participants

Monash Children’s - Clayton 17 6

Royal Children’s Hospital 17 3

Horsham 10 2

Frankston 9 4

Wangaratta 8 3

Warrnambool 7 4

Ballarat 9 1

Monash Children’s - Dandenong 9 1

Cabrini 9 0

Monash Children’s - Casey 8 0

Warragul 9 0

Box Hill 9 0

TOTAL 121 24

Findings

Through categorisation of the themes that were established in each focus group, three overriding themes were identified: 1. Recognition (interpreting clinical status), 2. Response (actions and responsibilities) and 3. Education (guidance and knowledge). The subthemes are displayed in Figure 3 and are presented as either a claim or concern. Further examples of the subthemes are summarised in Table 4. Qualitative findings from the survey open response question are also incorporated into this table.

Figure 2. Focus group themes and sub-theme


Table 4. Qualitative findings from focus groups and user survey

CLAIMS

Recognition – Interpreting Clinical Status

Sub Theme Examples

Ease of identifying trends “By plotting on the graph you can easily see the trend of observations“ “Good to see trends over time with clinical notes to justify changes”

Distinct age group parameters “Having separate charts for the different age groups is very helpful as it identifies what is 'normal' ranges for that age group instead of having to guess or look it up all the time” “SPORC chart is great. Easy to use. Appropriate notification parameters”

Favourable chart layout • Observations viewed on one page

• Colours outline very clear cut-offs

• Ease of interpretation “Graphical representation of vital sign data is an important step forward” “Great advance in paediatric charting” “The colours are a helpful reminder of acceptable limits”

Response – Consistent and clear action

Sub Theme Examples

Consistency in communication Improves flow of information with patient transfers Internal: OT/ED → Ward External: between hospitals

“Statewide universal chart, great for transfers” “Like that observations flow on one chart from first presentation to ED, to ward rather than having separate charts.”

Clear escalation process Clearly outlines when an emergency call is required “Provides better identifications of at risk children”

Education – Guidance and Knowledge

Sub Theme Examples

Decision Support • Provides support when escalating care “Like using the charts. Feel more confident when calling MET's.”

Guidance • Modifications • Frequency of observations • Clinical instructions “Gives you good back up for calling a MET or escalating to medical staff”

Improved Knowledge • Helpful for new staff, bank/agency staff, those not familiar with paediatric patients and parents

“SPORC chart for identification of deteriorating patient excellent for non-paediatric trained staff”


Table 4. Qualitative findings from focus groups and user survey (cont)

CONCERNS Recognition – Interpreting Clinical Status

Sub Theme Examples

Chart design issues • Temperature section unclear

• Not enough room in comments section

• ‘lost in the middle of the page’

• No section for neurological observations “Hard to quickly identify correct line for plotting in the middle of the page”

Inapplicability of parameters to all patients

“(When) fit healthy kids, especially older, automatically appear in the orange/purple (zones)” “Adolescent patients are often off the charts, Heart rate < 45 for example”

Effectiveness of Short stay charts

Too small

No comments section “Not enough space/room, especially on the short stay chart to document observations required”

Response – Timely Actions & Responsibilities

Sub Theme Examples

Escalation process not followed

• Nurses not escalating the patient when in orange or purple zone “(they) remove clinical judgement leading to a feeling of boy crying wolf at some MET calls”

Modification practices • Difficulties accessing medical staff to modify parameters • Timely response from medical staff • Modification responsibilities (e.g. surgeon/adult physician or

paediatrician) “ Not all specialities are embracing the chart, (they) don’t all get the emphasis on review and importance of modifying” “Only issue is getting Registrar's to alter criteria”

Education – Guidance and Knowledge

Sub Theme • Examples

Knowledge deficit regarding chart use

• Writing numbers versus plotting values • Medical staff awareness of charts • Non paediatric staff (adult) use of chart • Observations required (e.g. BP) “Overall nursing staff seem to know how to use the charts but often are not supported in this by medical staff & feel uncomfortable calling for review if they are likely to be made feel stupid!” “ED just don’t get it” “Some doctors still not clear on modification ranges”


Chart Audit

Demographics

223 charts were audited across the 12 pilot sites. Of these 193 (86.5%) were inpatient charts and 30 (13.5%) were short stay charts. The breakdown of age groups is shown in Table 5. Table 5. Chart audits according to age groups

Age group n %

0 - 3 months 31 13.9%

3 - 12 months 27 12.1%

1 - 4 years 49 22.0%

5 - 11 years 57 25.6%

12 - 18 years 59 26.5%

Findings There was very good compliance (approximately 93%) with the recording of patient identifiers (e.g. name, UR). Documentation of the patient’s actual age and weight was recorded on 84% and 73% of occasions, respectively. There were three instances when the incorrect age-group chart was in use. Approximately 85% of respiratory rate and heart rate recordings were plotted with a dot and joined with a line, but plotting occurred less often for other parameters such as temperature (50%) and level of consciousness (24%). The observations that were recorded with the most recent set of observations are outlined in Table 6. Documentation of blood pressure was the observation recorded the least frequently. Table 6. Observations recorded with the last set of observations

A total of eight charts had modified orange zone parameters, with a high respiratory rate being the most frequently modified parameter. Fifteen purple zone parameters were modified and low heart rate and BP values were the most common. The number of observations (i.e. 2 or more consecutive observations) that were recorded in the orange zone and purple zones are presented in Tables 7 and 8. Fifty observations were recorded in the orange zone for 47 patients (3 patients had both an elevated RR and HR). Sixteen (34%) of these patients had a documented medical review consistent with the escalation recommendation. Eight observations were recorded in the purple zone for 7 patients (1 patient had both an elevated RR and HR) and 2 (29%) of these patients had an emergency call.

Observation n %

HR 222 99.6%

RR 215 96.4%

SpO2 211 94.6%

Respiratory distress 206 92.4%

LOC 181 81.2%

Temp 158 70.9%

Pain 127 57.0%

BP 103 46.2%


Table 7. Patient observations in Orange Zone

Table 8. Patient observations in Purple Zone

Escalation and Response (EAR) Audit Demographics

EAR data was entered by all pilot sites (n=12) and opened to 4 non-pilot sites from November 18th 2013 to 31st March 2014. Findings

Across both pilot and non-pilot sites, 68 patients were ‘transferred out’ or ‘transferred up’ with unexpected clinical deterioration. The 55 patient transfers from the pilot sites are summarised in the following section and the age groups are shown in Table 9. Table 9. Escalation and Response Audit according to age group

Of the 55 unexpected transfers, 14 were transferred to another hospital and 41 transferred internally to ICU. The most frequent primary admission diagnosis was respiratory illness (62%) followed by neurological conditions (14.5%). The average time from admission to transfer was 67 hours. There was little variation in the number of transfers according to the day of week (see Figure 3).

Vital Sign n %

↑RR 18 8.07

↓RR 3 1.35

↑HR 11 4.93

↓HR 13 5.83

↑BP 2 0.90

Temperature 3 1.35

Vital Sign n %

↑RR 2 0.90

↓RR 0 0.00

↑HR 2 0.90

↓HR 0 0.00

↓BP 4 1.79

SpO2 0 0.00

Age group n

Under 3 months 9

3-12 months 11

1-4 years 19

5-11 years 9

12-18 years 7


Figure 3. Patient transfers according to day of week

Of the transfers, 42 (76%) patients had a documented request for medical review within 10 minutes of the first abnormal parameter (defined as an orange zone parameter). Twenty-nine (53%) patients had an emergency call (e.g. MET) in the 12 hour period prior to transfer. Critical events were reported for 13 (24%) patients prior to transfer (see Table 10). The provision of bag-mask ventilation was the most frequent critical event. Table 10. Critical events prior to patient transfer

8. Summary of findings Overall, the findings from the survey, focus groups and chart audits established that the charts were generally suitable for the recording of clinical observations and communicating clinical care in paediatric patients. Based on the feedback from the stakeholders, subsequent changes have been made to the chart design (see Appendix C) and include:

Creating more space in the written text sections

Removing the small comments section on the vital sign page (front page)

The addition of an orange zone to the SpO2 section

Improved scaling of the temperature section, including a dashed line to indicate normal temperature and the addition of an upper orange zone for the < 3 month age group

Separating the level of consciousness and level of sedation sections

The provision of an example modification order

Combining the parental concerns section into the Event/Comments section on the back page

Incorporating the guide to assess respiratory distress on the chart, as well as the level of sedation scoring system

Changing the orange zone, response criteria from initiating a mandatory clinical review within 30 minutes, to a recommended clinical review, which allows for the option of consulting with the nurse in charge and deciding if a medical review is required.

02468

1012

Day of week

Critical events n

Cardiac Arrest 2

Intubation 1

Bag-mask ventilation 10

Reversal analgesia 0

Extensive fluid resuscitation 0


This evaluation has also identified the essential education areas to be addressed when introducing the charts into new organisations (e.g. reinforcing plotting the dot, modification practices) and has highlighted the importance of embedding site specific procedures so that they are well known by all staff. Findings from the EAR audit have provided a better understanding of paediatric patients that are transferred to a higher level of care, due to unexpected deterioration. This audit was considered a preliminary step to establishing appropriate outcome measures for evaluating the impact of the implementation of the charts statewide.

9. Summary Recommendations The following six recommendations are directed at an organisational, statewide and broader project level, and are explained in greater detail under expanded recommendations.

1) The paediatric charts be rolled out to Victorian health services which are supported by a

Paediatrician or GP (with paediatric interest).

2) The current charts are not recommended for Special Care Nurseries or Urgent Care Centres. Separate pilot projects are recommended to demonstrate the safety and efficiency of the charts in these areas.

3) The short stay charts be discontinued due to their limited use during piloting.

4) The charts are maintained in a generic format, branded only with the State Government logo and Australian standard barcode.

5) A comprehensive implementation plan (provided by the project team) is followed by

individual sites to ensure successful implementation.

6) Standardised paediatric assessment and education packages are developed and implemented throughout Victoria to support the care of paediatric patients in Victoria.

10. Expanded Recommendations Recommendation 1. The paediatric charts be rolled out to Victorian health services which are supported by a Paediatrician or GP (with paediatric interest). The SPORC project restricted its pilot to paediatric wards/sites supported by a Paediatrician or GP (with paediatric interest) and therefore can only recommend the introduction of the SPORC to sites with similar medical supports. Recommendation 2. The current charts are not recommended for Special Care Nurseries or Urgent Care Centres. The SPORC has not been trialled in either Special Care Nurseries or Urgent Care Centres (UCC) and therefore the project team cannot comment on the use, nor effectiveness, of the charts in these settings. It is however reasonable to presume that with careful review of the individual sites


escalation and action response, that the charts would be an effective tool for recognising and responding to paediatric and possibly neonatal deterioration. Piloting of the charts at such sites would be an appropriate and safe, next step.

Recommendation 3. The short stay charts be discontinued due to their limited use during piloting. Despite a collective recommendation from the reference group to develop a short stay chart, the use of these charts was at best, limited. The main reported concern with the short stay charts was the size of the text including the numbers and the lack of space to document written notes. There was also confusion about which charts (inpatient or short stay) to use at admission and at what stage a patient transferred to the ward should change over to an inpatient chart. We recommend the removal of these charts. Recommendation 4. The charts are maintained in a generic format, branded only with the State Government logo and Australian standard barcode. The charts have been specifically designed, utilising human factor principles and other features to enhance useability, as detailed in this report. We believe it is critical that the chart is not modified by individual sites, to ensure that the benefits of these features are maintained. Furthermore, the costs associated with A3 double sided colour printing are significant and proportionate to the quantity ordered. A statewide commitment to printing a generic set of charts, branded with the State Government logo and generic barcode (AS2828), dramatically reduces cost (e.g. $23 for 50 charts versus $7.40 per 50 charts) depending on total numbers ordered. We estimate potential savings of at least $100,000.00 annually. Recommendation 5. A comprehensive implementation plan (provided by the project team) is followed by individual sites to ensure successful implementation. An implementation guide will be produced for Victorian health care facilities wishing to introduce the SPORC charts in their organisation. An existing pilot site champion will be nominated to act as a mentor for a new site. To ensure a smooth transition to SPORC chart use, new sites will be required to:

Identify a site champion

Review paediatric escalation response processes including dedicated emergency call and training of emergency code/MET responders

Implement a widespread SPORC promotional campaign across the organisation

Undertake a widespread implementation education campaign, specifically targeting nurses and doctors who work with paediatric patients

Advise types of folders suitable for locating the charts. Recommendation 6. Standardised paediatric assessment and education packages are developed and implemented throughout Victoria to support the care of paediatric patients in Victoria. Throughout the lifespan of this project clear paediatric education deficits and inconsistencies across the pilot sites became apparent, specifically relating to the recognition and response of paediatric deterioration. It was clear that the majority of sites do not provide a dedicated paediatric education package (apart from basic life support) for staff. The SPORC team believes that education should not only encompass the performance of paediatric observations, but greater emphasis should be given to the interpretation of observations and assessment of children, in order to appropriately recognise and respond to paediatric clinical deterioration. The Victorian organisations who care for paediatric patients should meet the following key educational components: Providing: Knowledge/Skills to Clinicians Foundational Paediatric Assessment skills

identifying normal observations


physiological differences between adult and paediatric patients

early and late warning signs ‘when to worry’

Awareness and use of SPORC

Site specific escalation (Call for nursing review/calling for medical review/initiating an emergency call)

Paediatric Basic Life Support

Paediatric Advanced Life Support – for emergency responders Standardising: Communication/documentation systems

Handover and communication using the ISBAR acronym

SPORC uptake Reviewing: Paediatric emergency systems (site specific)

Having a dedicated paediatric emergency call / escalation response

Appropriately trained clinicians to respond to paediatric emergencies. It is envisaged that a consistent paediatric education approach (as described) delivered via local hubs would be an advantageous approach to continue progress in the care of paediatric patients across the State.


References ACSQHC. (2010). National Consensus Statement: Essential Elements for Recognising and Responding

to Clinical Deterioration Sydney: Australian Commission on Safety and Quality in Health Care ACSQHC. (2011). National Safety and Quality Health Service Standards Sydney: Australian

Commission on Safety and Quality in Health Care. Bonafide, C. P., Brady, P. W., Keren, R., Conway, P. H., Marsolo, K., & Daymont, C. (2013).

Development of Heart and Respiratory Rate Percentile Curves for Hospitalized Children. Pediatrics, 131(4), e1150-e1157.

Dionne, J., Abitbol, C., & Flynn, J. (2012a). Erratum to: Hypertension in infancy: diagnosis, management and outcome. Pediatric Nephrology, 27(1), 159-160.

Dionne, J., Abitbol, C., & Flynn, J. (2012b). Hypertension in infancy: diagnosis, management and outcome. Pediatric Nephrology, 27(1), 17-32.

Elliott D., M. S., Perry L., Duffield C., Iedema R., Gallagher R., Fry M., Roche, M., Allen E. (2011). Observation and Response Chart Usability Testing Report: University of Technology, Sydney.

Fleming, S., Thompson, M., Stevens, R., Heneghan, C., Plüddemann, A., Maconochie, I., . . . Mant, D. (2011). Normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: a systematic review of observational studies. The Lancet, 377(9770), 1011-1018.

Goeschel, C., Weiss, W., & Pronovost, P. (2012). Using a logic model to design and evaluate quality and patient safety improvement programs. International Journal for Quality in Health Care, 24(4), 330 – 337.

Hammond, N. E., Spooner, A. J., Barnett, A. G., Corley, A., Brown, P., & Fraser, J. F. (2013). The effect of implementing a modified early warning scoring (MEWS) system on the adequacy of vital sign documentation. Australian Critical Care, 26(1), 18-22.

Haque, I. & Zaritsky, A. (2007). Analysis of the evidence for the lower limit of systolic and mean arterial pressure in children. Pediatric Critical Care Medicine, 8(2), 138-144.

Kansal, A., & Havill, K. (2012). The effects of introduction of new observation charts and calling criteria on call characteristics and outcome of hopsitalised patients Critical Care and Resuscitation, 14(1), 38-43.

Kause, J., Smith, G., Prytherch, D., Parr, M., Flabouris, A., & Hillman, K. (2004). A comparison of Antecedents to Cardiac Arrests, Deaths and EMergency Intensive care Admissions in Australia and New Zealand, and the United Kingdom--the ACADEMIA study. Resuscitation, 62(3), 275-282.

Lurbe, E., Cifkova, R., Cruickshank, J. K., Dillon, M. J., Ferreira, I., Invitti, C., . . . Zanchetti, A. (2009). Management of high blood pressure in children and adolescents: recommendations of the European Society of Hypertension. Journal of Hypertension, 27(9), 1719-1742.

McKay, H., Mitchell, I. A., Sinn, K., Mugridge, H., Lafferty, T., Van Leuvan, C., . . . Abdel-Latif, M. E. (2013). Effect of a multifaceted intervention on documentation of vital signs and staff communication regarding deteriorating paediatric patients. Journal of Paediatrics and Child Health, 49(1), 48-56.

Tibballs, J., Kinney, S., Duke, T., Oakley, E., & Hennessy, M. (2005). Reduction of paediatric in-patient cardiac arrest and death with a medical emergency team: Preliminary results. Archives of Disease in Childhood, 90(11), 1148-1152.


Appendix A. SPORC Reference group and key contributors

Name Role Organisation

Annie Moulden SPORC Medical Lead Monash Children’s Hospital

Sharon Kinney SPORC Nursing Lead Royal Children’s Hospital/The University of Melbourne

Jennifer Sloane SPORC Project Co-ordinator Royal Children’s Hospital

Peter McDougall Director of Medicine Royal Children’s Hospital

Jim Tibballs Deputy Director ICU Royal Children’s Hospital

Meredith Allen Director of Medical Education Royal Children’s Hospital

Danielle Smith NUM Paediatrics Royal Children’s Hospital

Ash Doherty NUM Paediatrics Royal Children’s Hospital

Alison Ellis Former NUM Paediatrics Royal Children’s Hospital

Helen Codman & Annabelle Santos

Educators Paediatrics Royal Children’s Hospital

Nick Freezer Medical Director, Monash Children's and Women's Program

Monash Children’s Hospital

Cathy McAdam Department Head, General Paediatrics Monash Children’s – Clayton

Chrissie Kellaway NUM Paediatrics Monash Children’s – Clayton

Liz Brown NUM Paediatrics Monash Children’s – Casey

Janine Maloney NUM Paediatrics Monash Children’s – Dandenong

Deana Lynn, Leanne Czerniecki & Megan Barnett

Educators, Paediatrics Monash Children’s

Dimi Simatos Director of Paediatrics Eastern Health

Libby White NUM Paediatrics Eastern Health (Box Hill)

Shirley Burke Practice Development Manager Eastern Health

Kathy McMahon Director of Paediatrics Peninsula Health (Frankston)

Helen Hutchins NUM Paediatrics Peninsula Health (Frankston)

Lynsey Parkes Registered Nurse Peninsula Health (Frankston)

Dave Tickell Director of Paediatrics Ballarat Health

Jo Gilbert Director of Women’s & Children’s Ballarat Health

Kathryn Pegg AUM Paediatrics Ballarat Health

Clinton Griffiths NUM Paediatrics Ballarat Health

Debbie Forbes NUM Paediatrics Bendigo Hospital


Andy Lovett Director of Paediatrics Bendigo Hospital

Helen Dunlop NUM Paediatrics West Gippsland Healthcare Group

Melissa Pinch Educator West Gippsland Healthcare Group

Sue Schena Registered Nurse West Gippsland Healthcare Group

Nick Thies Director of Paediatrics SouthWest Health (Warrnambool)

Sue Marsh NUM Paediatrics SouthWest Health (Warrnambool)

David Fuller Director of Paediatrics Barwon Health

Julia Obrien Educator Paediatrics Barwon Health

Sandra Von Roon NUM Paediatrics Barwon Health

Clara Officer NUM Paediatrics Cabrini

Jo Miller Paediatric Educator Cabrini

Kelly Sherman Clinical Nurse Specialist Cabrini

Clare McGinness Former Director of Women’s & Children’s

Cabrini

Karrianne Long CNC, Standard 9 North East Health (Wangaratta)

Peter Lee CNC, Paediatrics North East Health (Wangaratta)

Hilton Jones NUM Yandilla ward Wimmera Health Care Group (Horsham)

Chris Dobson Educator Wimmera Health Care Group (Horsham)

Ann Russell ICU Nurse, Standard (Coordinator) Wimmera Health Care Group (Horsham)

Greg Plummer CNC Critical Care Mildura Base Hospital

Linda Riddell NUM Paediatrics Shepparton Base Hospital


Appendix B. SPORC Pilot Sites

Stage 2: SPORC Pilot sitesORGANISATION REGION WARD / UNIT

Monash Children's (x 3 sites) Tertiary All Paediatric wards & Day medical

unit

Royal Children's Hospital Tertiary Cardiac & Medical wards

Eastern Health Metro Paediatric ward

Frankston Hospital Metro Paediatric ward & ED

Cabrini Private Paediatric ward & ED

West Gippsland Health Service (Warragul) Regional Paediatric ward & ED

Ballarat Health Services Regional Paediatric ward

Wimmera Health Care Group (Horsham) Regional Paediatric ward & ED

North East Health (Wangaratta) Regional Paediatric ward & ED

South West Healthcare (Warrnambool) Regional Paediatric ward & ED


Appendix C. Revised SPORC Chart

statewide paediatric observation and response chart (sporc ...€¦ · statewide paediatric...

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