Presentation on theme: "Implementing a Newborn Early Warning System"— Presentation transcript:
1Implementing a Newborn Early Warning System in the SSBC NNT PillaySSBCNNOct 2012
2Observation chart; with critical effector limb, i Observation chart; with critical effector limb, i.e ESCALATAION pathway, traffic light vs scoreObjective transparent evidence that there is deteriorationStandardises observationsTrack and trigger, Identify and respond to patients who develop acute illness. Using currently measured observations recorded on an observation chart
3Specific procedureEarly detectionOf any departure from normal frequenciesBy monitoring a sample of population at risk
5FIGURE 1 The ambulance corps of Baron Dominique-Jean Larrey, circa 1809.
6Scoring Systems Triage: rapid sorting, unwell patients Illness identification: defining features of illnessEarly Warning System: hospital wardsidentify patients at risk of deteriorationRoland 2012, Arch Dis Paed Ed PractWhy is it relevant?
7Antecedent events of acute deterioration/transfer to ICU: ‘Often early clinical signs missed’Early Warning Systems RecommendedCEMACH report 2006NPSA 2007, 2009Why is it relevant?
8The Confidential Enquiry into Maternal and Childhood Death Report, Why Children Die– A Pilot Study 2006For 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
9Improve care for acutely ill StandardisationImprove care for acutely illAddresses variability in detecting clinical Illness early2012
12Sensitivity of Pediatric EWS to Identify Patient Deterioration Cohort: 170 non-ICU RRT and 16 code eventsTest: Retrospective PEWS in last 24 hrsOutcome: Earliest indicator of deterioration detected a median of 11 hr 36 min in % of casesSensitivity of Pediatric EWS toIdentify Patient DeteriorationAkre et alPediatrics, 2010; 125 : eCalifornia, Minnesota
13Sensitivity and Specificity to Identify Patient Deterioration Validation of a modified pediatric early warning system score:a retrospective case-control study.Cohort: 100 cases 250 controls; ward patientsTest: Retrospective PEWSOutcome: Sensitivity 62%Specificity 89% Skaletzky et alClin Pediatr 2012 May;51(5): Epub 2011 Dec 8.Miami Children’s Hospital, Miami, FL 33155, USA.
14Can it make a difference to outcome? Paediatric EWS Brighton:Early identification of children at riskFewer codesMore timely transfer to ICU
15Neonatal Early Warning System Which baby will it potentially benefit?HospitalisedNot critically ill, but under observationBabies who are stable, but can deteriorateAt Risk Neonatal Infant
16Neonatal Early Warning System No defined directive for babiesBenefit?At Risk Neonatal Infants : ARNIPost natal wardTransitional care, SCBU
17Neonatal Early Warning System limited information onprogressive morbidity in early postnatal period in ARNIthe triage process, from post natal ward observations to review, investigations, intervention, admission to NNUIntuitiveNDAU data 2011 on term admissions to nnu, and transitional care admissions
18Neonatal Early Warning System What impact does time to review/intervene have in ARNI with progressive deterioration?IntuitiveNDAU data 2011 on term admissions to nnu, and transitional care admissions
19Neonatal 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)IntuitiveNDAU data 2011 on term admissions to nnu, and transitional care admissionsJ-C BecherArch Dis Child FN 2012 F30-4
25Implementation of a Neonatal Early Warning System Retrospective review : 122 term infants48% ARNI had observations recorded52% would have had earlier review with NEWSRoland D, Madar J, Conolly GInfant 2010; Vol 6, Issue
27Implementation of a Neonatal Early Warning System Prospective Study : 117 term infants71.2 % observations recordedPrompted management decision in 43% of infants requiring interventionFacilitates observation of babies assumed to be at riskPrompts earlier review in those showing clinical deteriorationConsidered beneficial by majority of midwives using itRoland D, Madar J, Conolly GInfant 2010; Vol 6, Issue
28Implementation of a Neonatal Early Warning System EnglandVariable implementation egPlymouth, Liverpool, Cambridge, Northern Neonatal Network; not standardisedScotlandWidespread standardised implementation in NHS, Orkney, Shetland
30Scottish NHS: widespread use; SCBU and post natal wards, some HDU patients
31Objective transparent evidence that there is deterioration Criteria for Newborn EWS ObservationMeconium at deliveryPROMMaternal pyrexia/infection/chorioamnionititsSGAAll babies in Transitional carePoor feedingGruntingHypoglycaemiaHypothermiaOther, as determined by Midwife/ANNP/Medical teamObservation chart; with critical effector limb, triage, traffic light vs scoreObjective transparent evidence that there is deteriorationStandardises observations
32SSBC NN Team Theresa Pilsbury (midwifery) NXH Theresa Pilsbury (midwifery) NXHClaire Cockburn, Nicola Taylor, Pam Smith (NNU) RHHAnne Clark/Jane Henley WalsallGina Hartwell (NNU) MSGEmma Hubball (midwifery) UHNSMatthew Nash Grid TraineeSSBC NN Team
33Feedback Positive: Stopped false calls Highlighted the 'zig zag' baby Prompted staff action when they might otherwise not have actedEmpowered midwifery support for post natal babiesFeedback
34Feedback Negative: Parent perception of scoring Documentation Negative:Parent perception of scoringDocumentationLack of common sense approach to duration /frequency of observations‘Why do we need a score if we can recognise a baby becoming ill?’CostFeedback
35Nurses role in EWS Critical thinking Ease of observation Easy visualization of problematic babyStandardized escalation systemNurses role in EWS
36Future Questions Does it add value to post natal care provided? 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
37Future Questions Audit/review of effectiveness: Audit/review of effectiveness:False positives (hypersensitivity)False negatives (babies not picked up)Future Questions
39Conclusion Fashionable FashionablePromoted through National bodies for Adults/PaediatricsNo standardised approach in NeonatesNo clear idea as to whetherit is indicatedit will make a differencein At Risk Neonates, not managed in HDU/ICUBeing trialed in SSBC NNConclusion