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Implementing a Newborn Early Warning System

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Presentation on theme: "Implementing a Newborn Early Warning System"— Presentation transcript:

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

2 Observation chart; with critical effector limb, i
Observation chart; with critical effector limb, i.e ESCALATAION pathway, traffic light vs score Objective transparent evidence that there is deterioration Standardises observations Track and trigger, Identify and respond to patients who develop acute illness. Using currently measured observations recorded on an observation chart

3 Specific procedure Early detection Of any departure from normal frequencies By monitoring a sample of population at risk

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

6 Scoring Systems 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 Why is it relevant?

7 Antecedent events of acute deterioration/transfer to ICU:
‘Often early clinical signs missed’ Early Warning Systems Recommended CEMACH report 2006 NPSA 2007, 2009 Why is it relevant?

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

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12 Sensitivity of Pediatric EWS to Identify Patient Deterioration
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 % of cases Sensitivity of Pediatric EWS to Identify Patient Deterioration Akre et al Pediatrics, 2010; 125 : e California, Minnesota

13 Sensitivity 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 patients Test: Retrospective PEWS Outcome: Sensitivity 62% Specificity 89%  Skaletzky et al Clin Pediatr  2012 May;51(5): Epub 2011 Dec 8. Miami Children’s Hospital, Miami, FL 33155, USA.

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 Neonatal Early Warning System
Which baby will it potentially benefit? Hospitalised Not critically ill, but under observation Babies who are stable, but can deteriorate At Risk Neonatal Infant

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

17 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 Intuitive NDAU data 2011 on term admissions to nnu, and transitional care admissions

18 Neonatal Early Warning System
What impact does time to review/intervene have in ARNI with progressive deterioration? Intuitive NDAU data 2011 on term admissions to nnu, and transitional care admissions

19 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) Intuitive NDAU data 2011 on term admissions to nnu, and transitional care admissions J-C Becher Arch Dis Child FN 2012 F30-4

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

22 Limitations with Newborn Early Warning Systems

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

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25 Implementation of a Neonatal Early Warning System
Retrospective review : 122 term infants 48% ARNI had observations recorded 52% would have had earlier review with NEWS Roland D, Madar J, Conolly G Infant 2010; Vol 6, Issue

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27 Implementation of a Neonatal Early Warning System
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 Roland D, Madar J, Conolly G Infant 2010; Vol 6, Issue

28 Implementation of a Neonatal Early Warning System
England Variable implementation eg Plymouth, Liverpool, Cambridge, Northern Neonatal Network; not standardised Scotland Widespread standardised implementation in NHS, Orkney, Shetland

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

31 Objective transparent evidence that there is deterioration
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 Observation chart; with critical effector limb, triage, traffic light vs score Objective transparent evidence that there is deterioration Standardises observations

32 SSBC NN Team Theresa Pilsbury (midwifery) NXH
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

33 Feedback 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 Feedback Negative: Parent perception of scoring Documentation
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 Nurses role in EWS Critical thinking Ease of observation
Easy visualization of problematic baby Standardized escalation system Nurses role in EWS

36 Future 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

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

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39 Conclusion Fashionable
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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