Safer Care Victoria (SCV) has been notified of several sentinel events involving the deterioration of children who have presented to Emergency Departments (EDs) across Victoria with sepsis. Review of these events has identified similar themes.
We share these learnings to support health care professionals in recognising and responding to clinical deterioration in children and enhance safety for children across the state.
- Parents/carers know their child best and are often aware of deterioration before abnormal clinical features are apparent. If they are worried, be worried.
- Make sure parents/carers know how they can initiate escalation of care for their child if they are worried they are getting worse in any clinical setting.
- Sepsis can be difficult to diagnose in children, be aware of diagnostic bias. Early recognition and treatment improves outcomes. Have a low threshold for prolonged observation or senior medical review if you are unsure.
- The anatomy and physiology of children is different to adults and they can deteriorate quickly. Use the Victorian Children’s Tool for Observation and Response (ViCTOR) to recognise and respond to the deteriorating child.
- When considering whether children are ready to be discharged, confirm that their vital signs have normalised or be extra cautions with children that may need to be discharged in criteria outside of the ‘normal’ range. Give all patients/parents/carers clear written and verbal discharge instructions that include when to seek further review.
What themes have been identified?
- Parent/carers experiencing difficulties in ‘being heard’ when they expressed how worried they were about their child and lack of clear systems for parents/carers to escalate care.
- Limited staff knowledge of the signs and symptoms of paediatric sepsis, contributing to insufficient monitoring and investigation, resulting in missed or delayed diagnosis.
- Lack of availability or clinician awareness of standardised paediatric pathways, policies or procedures within health services to support:
- appropriate monitoring for children, based upon their clinical features and vulnerability
- timely recognition of clinical deterioration in children and appropriate response e.g. for those displaying ViCTOR escalation criteria or with suspected or confirmed sepsis.
- Delay in escalation to senior clinicians or external services to inform clinical decision making for acutely unwell children.
- Children becoming critically ill after being discharged from ED still displaying abnormal ViCTOR criteria following a brief observation period.
What are the key learnings to share?
Parental identification that their child is getting worse
- Parents/carers are a critical part of the treating team. Listen carefully to parents/carers when they let you know that their child is getting worse and address their concerns.
- Ensure that your health service has systems to empower parents/carers to escalate care when they are worried that their child is getting worse.
- SCV has recently partnered with several pilot health services to undertake improvement work to improve parental recognition of and escalation of care for children when they are worried they are getting worse in an ED. Find out more.
Resources to support clinical decision making and care
- Check your health service uses standardised paediatric pathways, policies or procedures to support appropriate monitoring, timely recognition and response to clinical deterioration in children. For example:
- the Victorian ViCTOR ‘track and trigger’ charts/criteria in Electronic Medical Records (EMR) i.e. from triage in ED, +/- ward admission to discharge.
- guidance to inform monitoring requirements for children, including for the recording of blood pressure and neurological status.
- Paediatric Improvement Collaborative (PIC) guidelines to support the timely identification and appropriate escalation of care for the acutely unwell child.
- guidance/pathways that are applicable for use in your health service for escalation of care for children assigned triage categories 1 and 2, displaying ViCTOR escalation criteria, suspected sepsis or when parents/carers are worried their child is getting worse.
Staff orientation and training
- Orientate new medical and nursing staff to your health services’ policies, procedures, guidelines for children and to the ViCTOR and PIC resources and ensure that common paediatric and potentially serious conditions are included in your hospital’s education program.
- Consider innovative ways to remind staff to use these e.g. have visual prompts on ED Triage documentation to activate escalation pathways for sepsis.
Communication and documentation
- Use a standardise methodology for clinical handover. Have robust processes for documenting the transferring of information between health services for paediatric transfers to avoid key information being overlooked and the significance of this not being recognised.
- Remember children can deteriorate quickly: seek senior medical review/external paediatric consultation early if you are unsure.
- Clearly document your clinical findings, investigation results, decision making process, management and discharge plan.
- Give patient/parent/carers appropriate discharge information and ensure that they know how to identify if their child deteriorates at home and when to seek further medical review.
'As a Paediatric Emergency physician, I agree that listening to parents is really important.
'One aspect of Emergency Department care that deserves more commentary is staffing of the waiting room. It is extraordinary that nursing ratios, once you have a bed, is 1 to 4 or 1 to 6, but in the waiting to be seen area, it is 1 to 40 or 50.
'During very busy periods, the patient may not be seen by a doctor or nurse again for many hours. Some parents may take the initiative to find the healthcare staff in the ED to let them know their child is getting sicker, but if staff are present and actively looking at those in the waiting area on a regular basis, this lowers the barrier for parents to ask. It is a partnership. Yes the parents can raise their concerns but we can also actively look for them.
'I would also be asking the hospitals, "Where are your clinical staff in the hospital? What are they doing, can any of them be deployed to the ED when the demand is very high? Do you have clinicians who are dedicated solely to the waiting room, who are walking around checking on patients, being present and available for patients and carers to ask a question?"
The waiting room should not be a passive process but an active one with ongoing care. Maybe we need to change the name and think of something better than waiting room.'
Dr Karen Dunn
Paediatric Emergency Physician