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T Pillay SSBCNN Oct 2012 Implementing a Newborn Early Warning System in the SSBC NN.

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Presentation on theme: "T Pillay SSBCNN Oct 2012 Implementing a Newborn Early Warning System in the SSBC NN."— Presentation transcript:

1 T Pillay SSBCNN Oct 2012 Implementing a Newborn Early Warning System in the SSBC NN

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5 FIGURE 1 The ambulance corps of Baron Dominique-Jean Larrey, circa 1809.

6 Triage:rapid sorting, unwell patients Illness identification:defining features of illness Early Warning System:hospital wards identify patients at risk of deterioration Roland 2012, Arch Dis Paed Ed Pract Scoring Systems

7 Antecedent events of acute deterioration/transfer to ICU: Often early clinical signs missed Early Warning Systems Recommended CEMACH report 2006 NPSA 2007, 2009

8 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

9 Standardisation Improve care for acutely ill Addresses variability in detecting clinical Illness early 2012

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12 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 al Pediatrics, 2010; 125 : e763-769 California, Minnesota

13 Sensitivity and Specificity to Identify Patient Deterioration Skaletzky et al Clin Pediatr Clin Pediatr 2012 May;51(5):431-5. Epub 2011 Dec 8. Miami Childrens 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%

14 Can it make a difference to outcome? Paediatric EWS Brighton : Early identification of children at risk Fewer codes More timely transfer to ICU

15 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

16 No defined directive for babies Benefit? At Risk Neonatal Infants : ARNI Post natal ward Transitional care, SCBU Neonatal Early Warning System

17 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

18 What impact does time to review/intervene have in ARNI with progressive deterioration? Neonatal Early Warning System

19 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 Becher Arch Dis Child FN 2012 F30-4

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21 Can it influence provision of care? Can it influence outcomes? Neonatal Early Warning System

22 Limitations with Newborn Early Warning Systems

23 Neonatal Early Warning System Roland, Madar, Connolly. Infant 117-120, Vol6, Issue 4, 2012

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25 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 G Infant 2010; Vol 6, Issue 4 116-121

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27 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 G Infant 2010; Vol 6, Issue 4 116-121

28 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

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30 Scottish NHS: widespread use; SCBU and post natal wards, some HDU patients

31 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

32 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 NashGrid Trainee SSBC NN Team

33 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

34 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

35 Critical thinking Ease of observation Easy visualization of problematic baby Standardized escalation system Nurses role in EWS

36 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

37 Audit/review of effectiveness: False positives (hypersensitivity) False negatives (babies not picked up) Future Questions

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39 Fashionable Promoted through National bodies for Adults/Paediatrics No standardised approach in Neonates No clear idea as to whether it is indicated it will make a difference in At Risk Neonates, not managed in HDU/ICU Being trialed in SSBC NN Conclusion


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