Embed Size (px)
Citation preview
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
