RSS 1.0Paediatrics
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Online life for a child in careFor children and young people their online life is as real to them as their real life. This article considers the positives and negatives of online life, why children in care are more vulnerable, and the specific impact for child protection and health. It provides advice and guidance for healthcare professionals working with children. There are useful resources about managing disclosures and safeguarding concerns. We will consider how to incorporate online life in a paediatric medical history and the impacts of online use on physical and emotional health.
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Retrospective review of treatment outcomes and costs in children with sleep disordered breathing assessed with multi-channel studies.Current UK guidance on OSA management recommends only selective use of sleep studies - when there is diagnostic uncertainty, in children with comorbidities or to evaluate perioperative risk in those with suspected severe OSA. Routine use of sleep studies to confirm a diagnosis of obstructive sleep apnoea (OSA) in children before adenotonsillectomy is not currently recommended. We report the findings of a novel paediatric sleep service based on routine use of multi-channel sleep studies (MCSS) before adenotonsillectomy and present the results of a service evaluation assessing the impact of our practise on treatment outcomes and cost. We conducted a retrospective study of 264 children with sleep disordered breathing seen in our centre between July 2018–June 2019, using medical records and a sleep study database to determine treatment outcomes and costs. Using responses from a questionnaire completed by otolaryngologists for a separate prospective study, we compare our costs with estimates of those associated with a standard UK model of care i.e. with selective use of sleep studies. We estimate that our routine use of MCSS reduced the number of adenotonsillectomies by 44 % but at higher monetary costs than those estimated for the standard model of care. We note however, that reconfiguring our service to arrange a sleep study before the initial appointment, rather than after, would result in the service being cost neutral compared with the standard model. We also estimate that use of home multi-channel studies in our service would bring a significant cost saving (∼£50,000 - £80,000 per annum) compared to standard care.
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Prospective evaluation of the impact of multi-channel studies on treatment outcomes in children with sleep disordered breathingThere are significant variations in practice regarding the use of sleep studies in children with symptoms of sleep disordered breathing (SDB) prior to adenotonsillectomy. Current UK guidance recommends the selective use of sleep studies to confirm a diagnosis of obstructive sleep apnoea (OSA) when there is diagnostic uncertainty, in children with comorbidities, or to assess perioperative risk when severe OSA is suspected. We have developed a novel paediatric sleep service over the past decade based on the routine use of multi-channel sleep studies (MCSS) before adenotonsillectomy. We present the results of a prospective evaluation assessing the impact of our service on treatment outcomes. We conducted a prospective service evaluation of 49 children with SDB seen between July 2021 and August 2022. We used medical records and a sleep study database to determine treatment outcomes. Otolaryngologists completed a questionnaire before each multi-channel sleep study to help evaluate the impact of sleep study findings on surgical decision making. Questionnaire responses before MCSS showed that clinicians thought 66 % of children were ‘likely’, ‘very likely’ or ‘definitely’ would require surgery but only 54 % of children underwent surgery following their sleep study. We estimate that the use of MCSS was associated with a 21 % reduction in children undergoing surgery in this small sample. We conclude that our use of MCSS facilitates conservative management, allowing a significant reduction in the number of children with SDB undergoing surgery, but further validation of MCSS against polysomnography is required.
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Reducing epilepsy diagnostic and treatment gaps: Standardized paediatric epilepsy training courses for health care professionals.Aim: To evaluate improvement in knowledge and clinical behaviour among healthcare professionals after attendance at paediatric epilepsy training (PET) courses. Method: Since 2005, 1-day PET courses have taught evidence-based paediatric epilepsy management to doctors and nurses in low-, middle-, and high-income countries. A cohort study was performed of 7528 participants attending 252 1-day PET courses between 2005 and 2020 in 17 low-, middle-, and high-income countries, and which gathered data from participants immediately after the course and then 6 months later. Training outcomes were measured prospectively in three domains (reaction, learning, and behaviour) using a mixed-methods approach involving a feedback questionnaire, a knowledge quiz before and after the course, and a 6-month survey. Results: Ninety-eight per cent (7217 of 7395) of participants rated the course as excellent or good. Participants demonstrated knowledge gain, answering a significantly higher proportion of questions correctly after the course compared to before the course (88% [47 883 of 54 196], correct answers/all quiz answers, vs 75% [40 424 of 54 196]; p < 0.001). Most survey responders reported that the course had improved their epilepsy diagnosis and management (73% [311 of 425]), clinical service (68% [290 of 427]), and local epilepsy training (68% [290 of 427]). Interpretation: This was the largest evaluation of a global epilepsy training course. Participants reported high course satisfaction, showed knowledge gain, and described improvements in clinical behaviour 6 months later. PET supports the global reduction in the epilepsy 'treatment gap' as promoted by the World Health Organization.
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The utility of volumetric MRI in assessment of volume changes in ventral diencephalon in autistic children.Abstract Background Autism spectrum disorder (ASD) is a neurobehavioural disorder, characterized by abnormal affiliative and socio-emotional responses which are generally regulated by certain neuropeptides in the hypothalamus (an anatomic component of the ventral diencephalon (VD)). The use of volumetric MRI for studying VD volume change could provide a novel approach for identification of structural brain changes in ASD; this could assist in understanding the pathophysiology of ASD and would reflect on treatment strategies. The aim of the current work was to investigate the role of MRI volumetric analysis of the ventral diencephalon in young children diagnosed with autism spectrum disorder. Methods Fifty children diagnosed with ASD underwent volumetric brain analysis, on a fully automated MRI brain volumetry system (volBrain), with voxel-based morphometry of various segmental structures of the brain including the VD, using vol2Brain 1.0 pipeline software analysis suite. Results There were 48 out of 50 children who demonstrated abnormal VD volume which was found below the normal limits compared with reference standard normalized volume. All cases were normocephalic demonstrating normal intra-cranial cavity volumes. Forty out of fifty cases showed increased total volume of grey matter, and eighteen out of fifty cases showed increased total volume of white matter. Regarding the amygdala and hippocampus, there were only two cases (4.0%) which showed slightly increased relative volume of the total amygdala, and two other cases (4.0%) demonstrated increased relative volume of the total hippocampus. Comparison between the autistic patients and normal references revealed a significant difference regarding the VD volume and total volume of grey matter, whereas no significant differences were found regarding the white matter amygdala and hippocampus. Conclusions Based on the consistent significant volume decrease in the ventral diencephalon in patients with childhood autism, this study concluded that volumetric MRI analysis could be useful for diagnosis of childhood spectrum disorder and could be utilized as a reliable screening method in the clinically vague cases. Further study with a larger sample size including more age groups is recommended for more validation of the results.
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DELIVERY OF HEALTH APPOINTMENTS TO SPECIAL SCHOOLS.Objective There are a range of health needs for children and young people who attend special schools. Some have regular paediatric and specialist outpatient appointments whereas some are discharged from formal paediatric follow up. These health appointments were traditionally delivered within the SEND school itself. The Covid-19 pandemic gave the opportunity to explore alternative methods of paediatric health appointments. Face to face appointments in school have advantages and disadvantages. Professionals, teachers and parents have different opinions and preferences about how we should move forward delivering health reviews for this complex group of children and young people. But this needs to take into account the facilities, time and support available to professionals to deliver meaningful health reviews. We sought to gather opinions regarding health appointments, including preference of patient’s families to help formulate recommendations for service delivery moving forward. Methods An online survey was conducted to obtain feedback from parents/carers, special school teachers and health professionals regarding different types of appointment, availability of staff, and information sharing. Results 71 parents/carers; 11 teachers; 4 health professionals responded: 60% of parents/carers expressed preference for all face to face appointments (school based with or without TA or hospital appointment) over video consultations. 42% of parents/carers expressed preference for appointment at special school. 68% of clinicians prefer face to face appointments (school based with or without TA or hospital appointment) but expressed preference for an opportunity to speak to teachers pre/post appointment. 50% of clinicians expressed preference for appointment based at the special schools. 84% of parents/carers feel having teachers attend the appointment would be valuable. 100% of clinicians reported having a teacher who knows the child, at the assessment is valuable (or at least a pre/post appointment). Conclusion 42% parents/carers and 50% health professionals preferred face to face appointments within the special school setting, despite lack of secure private clinic room, examination couch and handwashing facilities. Therefore there is an argument that to provide appropriate, safe and meaningful health appointments, facilities in hospital would be better than school setting. It would be difficult to deliver a service where only some SEND schools were offered onsite clinics. Video clinic can be useful for children who have mostly behavioural problems and less physical concerns, allowing the option of video consultations. Liaison with schools is needed to discuss their important contribution and how that can be managed.
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BLOOD BORNE INFECTION SCREENING AT INITIAL HEALTH ASSESSMENTS FOR LOOKED AFTER CHILDREN IN A DISTRICT HOSPITALObjectives To improve time scales for blood borne infection (BBI) screening for looked after children after initial health assessment (IHA). Methods Retrospective data collection from IHAs completed over 6 months. Data analysis reviewed time intervals within process from IHA to action of blood tests. This was re-audited after 6 months of implemented changes. Results Initial data collection identified 49 patients with completed IHAs between June-November 2021; 34 with BBI screening recommended, of whom 11 had BBI blood tests completed. Reasons for not having blood tests included: prior antenatal testing, non-attendance, patient/parent refusal, moved out of area, referral to sexual health. Initial data demonstrated significant time between IHA to BBI bloods taken, on average 129.8 days (range 46–230). Analysis identified time from posting consent form to receipt of completed consent via social care as the longest stage: 79 days (10–257). Significant time intervals were also identified between: IHA to consent form posted 22.3 days (6–61). Receipt of consent to bloods taken 47.5 days (8–82). Bloods taken to issue of results letter 23.6 days (3–106). Several interventions were made BBI consent obtained at IHA where possible, local guideline issued outlining indications for BBI screening as per national guidance1 Blood test availability increased, next available allocated instead of partial booking. Doctor informed when blood test completed, prompting timely review of results and issue of standardised results letter. Several interventions were madeReaudit after 6 months identified 53 completed IHAs; 28 with BBI screening recommended, of whom 8 consented in clinic. Of those consented in clinic, 5 had bloods tests, with mean time from IHA to blood test of 28.2 days (range 14–40). For the 20 not consented at IHA, 14 had blood tests; mean time from IHA to bloods taken was 53.1 days (7–79 days). Reasons for not having blood tests remained comparable: return to care of birth parent, non-responders, non-attendance, declining blood test. In summary data from reaudit demonstrates that completing consent at IHA reduced interval between IHA and bloods by 24.9 days. Compared with initial data prior to all interventions a reduction of 101.6 days (78%) from IHA to bloods taken. Conclusion We highlighted lengthy timescales in process of BBI screening recommended from IHA and where these delays occurred. After implementing quality improvement strategies, the most pertinent of which was obtaining consent at IHA, we have demonstrated significant improvement in timescales for BBI screening for looked after children.
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SURVEY ON THE VARIABILITY IN PROVISION OF PAEDIATRIC RESPIRATORY MEDICINE (PRM) SERVICES IN DISTRICT GENERAL HOSPITALS ACROSS THE UK.Objectives In the UK there is national guidance for provision of Paediatric Respiratory Medicine (PRM) services in tertiary hospitals.1 However, no such guidance exists for district general hospitals (DGHs). We wanted to explore if there are any disparities in the provision of PRM services across DGHs in the UK. To evaluate the variabilities in provision of PRM services in DGHs in the UK. Methods An online survey was conducted amongst PRM in DGHs between April and December 2020. Information obtained: demographics, workforce, respiratory investigations, clinic and referral pathways. Results Level of completed training and composition of the multi-disciplinary team (MDT): 34 responses were received, of whom 16 (47%) completed the PRM special interest module, 8 (24%) completed PRM subspecialty training, and 10 (29%) had no specific PRM training. Over 25 (74%) respondents have respiratory nurse specialists and physiotherapists in their multi-disciplinary team (MDT). Less than 19 (56%) respondents have psychologists and allied health professionals in their MDT. There is a variation between DGHs for the types of respiratory conditions that are managed locally or shared care with a tertiary centre from less than a third to nearly 100% (table 1). Referral pathways for tertiary care exist for certain conditions. There is a similar variability in availability of various respiratory investigations in DGHs (table 2). Conclusions There is a variability in the level of completed training, composition of MDT, conditions managed, investigations available and established referral pathways to tertiary centres. The challenges in providing adequate respiratory care vary from the MDT to difficulty in accessing respiratory investigations. Further evaluation is required to establish the reasons for differences in DGH Paediatric respiratory service and identify the expected standard of care.
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British Thoracic Society guideline for diagnosing and monitoring paediatric sleep-disordered breathing.Please note that sleep-disordered breathing (SDB) in children without comorbidities is related to snoring and upper airway obstruction and commonly referred to as obstructive sleep apnoea (OSA). Diagnosing sleep-disordered breathing in children with suspected sleep-disordered breathing Sleep questionnaires, combined sleep questionnaires and ‘protocol-driven’ clinical assessments, sleep video recordings and sleep audio recordings Children without comorbidities
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How to be a named or designated doctor for looked-after children.There are approximately 100,000 looked after children within the care system in the UK. Children and young people enter the care system with unmet health needs and missed routine health screening and poor management of existing health conditions. They may have delayed development due to neglect and many have unmet and significant emotional health needs. Named and Designated Doctors for looked after children are passionate experts willing to stand up and advocate for children and young people. They exert influence on a larger scale within the healthcare system, offering senior level problem solving and contributions to interagency liaison and service planning. The Named and Designated roles are statutory in the UK. However, each of the four nations in the UK has slightly different versions of looked after children and safeguarding children legislation. The RCPCH, RCN and RCGPs, which support all four UK nations, have also produced guidance - Looked After Children: Roles and Competencies of Healthcare Staff. The document sets out the required knowledge, skills, and competencies at each level of health professional working with children and young people. This short review summarises some of the key aspects of the role fulfilled by Named and Designated doctors and offers practical advice to those considering the role and some real world examples of how it can be successfully implemented.
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671 Are clinicians assessing the impact of social media and/or time spent online on the physical and mental health of adolescents in paediatric admissions?Aims There is significant evidence that prolonged periods of screen time are associated with a variety of negative impacts on adolescent mental and physical wellbeing; namely adiposity, unhealthy diet, depressive symptoms and quality of life (1). However, the evidence-base to support a direct link between 'toxic' screen time causing obesity, mental health problems and educational failure has always been contested (2 3). Current RCPCH guidance on the health impacts of screen time highlights the link between higher screen time and less healthy diets, higher energy intake and obesity. There is a complex relationship between mental health and digital use with positive impacts e.g. maintain social friendships/ groups, support for health conditions, online education and negative impacts e.g. cyber-bullying, body dysmorphia, exploitation/grooming. The aim of this audit was to ascertain whether social media/time spent online is discussed and documented in the admission clerking or the first detailed history. If possible, we wanted to establish any associations between indicators of poor mental and physical health with social media/time spent online The majority of evidence in the current RCPCH guidance is based on television time, but recommendations now need to focus on newer uses of digital media, such as social media. A recommendation to include social media as an important factor in assessing adolescent health and wellbeing was advocated in 2018 (4). Methods We undertook a retrospective review of 40 paediatric admissions in a medium district general hospital. Patients were eligible if they were admitted, for any reason, from 1st January 2021 - 31st May 2021, aged 11 years old and above. Results Of the 38 admissions included, three had documentation regarding social media/time spent online (figure 1); one of these had a HEADSSSS assessment (figure 2). A further two had HEADSSSS assessments without clarifying social media/time spent online. Of these five patients: * Two admission documentations specified time spent online platform (XBOX), of which, one patient had a BMI of 30 * Three HEADSSSS assessments were carried out in patients with a presentation and/or history of mental health problems * Of these, one HEADSSSS assessment specified which social media platform the patient was using, and if they experienced cyber bullying Conclusion Our audit highlights a gap in use of social media screening in paediatric medical histories amongst health care professionals. Good practice was demonstrated for young people presenting with emotional health problems. This was a broad cohort, therefore questions relating to impact of social media may not be appropriate for every patient. The updated HEADSSSS assessment includes a fourth 'S' for social media use (4). Updating the clerking proforma to include this and raising awareness through training will support professionals to appropriately assess for new and evolving factors such as social media use, which are impacting on adolescent physical and mental health.
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Genomic medicine for the paediatrician.Genomic medicine is the use of sequence data from an individual's entire genetic code to aid diagnosis and personalise therapeutic options. An important goal of the 100,000 genomes project in the UK is to embed the infrastructure for the widespread use of whole genome sequencing into the National Health Service. Paediatricians will be at the forefront in using this new technology in the diagnosis of children with multiple congenital anomalies, developmental delay and other suspected genetic conditions. This article provides a description of the basic concepts of genomic medicine. The types of genomic testing that are available are discussed and examples of how genomics is already being used in paediatrics are given. Finally, the challenges for genomic medicine are summarised.
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Does decentralisation of surgical management improve outcomes for paediatric testicular torsion?.Summary Introduction In testicular torsion (TT), delayed emergency scrotal exploration (ESE) increases the risk of orchidectomy. Transfer of a patient with suspected TT from a district general hospital (DGH) to a paediatric surgical centre (PSC) delays ESE and potentially puts them at increased risk of testicular loss.Prior to 1st January 2017, all boys under aged <16 years presenting to a DGH within the East Midlands Clinical Network (EMCN) would be referred to the PSC. From this date, it was agreed within the EMCN that boys aged ≥5 years with suspected TT presenting to a network DGH would be managed locally, barring exceptional circumstances. Boys aged Methods All patients who underwent ESE under the care of paediatric surgery in the PSC, and all patients <16 years old who underwent ESE in 4 EMCN DGHs between January 2017 and December 2019 were identified. Neonatal cases and inpatient referrals were excluded. Comparison was made with published data on ESE performed in the PSC over the 9 years 2008–2016 prior to decentralisation. Results In the 9 years prior to decentralisation, there were 110 cases of TT in the PSC. In the subsequent 3 years, there were 40 in the PSC and 37 in the DGHs. The orchidectomy rate of boys with TT presenting to DGHs and undergoing exploration locally (16%, 6/37) contrasts with the rate in those transferred from DGHs to the PSC for exploration (58%, 15/26). The difference is highly significant (p = 0.00059, RR 0.28 [95% CI 0.13–0.63]) and indicates that in the EMCN, avoiding hospital transfer and performing ESE at the presenting DGH reduces the risk of orchidectomy by 72%. Conclusion Decentralisation of the provision of ESE in boys with TT has resulted in a significantly lower orchidectomy rate in boys undergoing ESE in the presenting hospital than when transferred to the PSC. This study reinforces existing literature that demonstrates the effect of delayed ESE on orchidectomy rate, and supports the recommendations of national guidelines in the UK that transfer of boys to a PSC for ESE should only occur in exceptional circumstances.
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Chameleon project: a children’s end-of-life care quality improvement projectIn response to there being no specialist paediatric palliative care (PPC) team in a region of England, we undertook a 12-month quality improvement project (funded by National Health Service England’s Marginal Rate Emergency Threshold and Readmission fund) to improve children’s end-of-life care. Improvements were implemented during two plan–do–study–act (PDSA) cycles and included specialist experts, clinical champions, focused education and training, and tools and materials to support identification, care planning and communication. A lead paediatrician with expertise in PPC (10 hours/week) led the project, supported by a PPC nurse (3 days/week) and a network administrator (2 days/week). Children who died an expected death were identified from the child death review teams. Numbers of non-elective hospital admissions, bed days, and costs were identified. Twenty-nine children died an expected death during the 12 months of the project and coincidentally 29 children died an expected death during the previous 12 months. The median number of non-elective admissions in the last 12 months of life was reduced from two per child to one. There was a reduction in specialist hospital (14%) and district general hospital (38%) bed days. The percentage of children who died an expected death who had anticipatory care plans rose from 50% to 72%. The results indicate that a network of clinicians with expertise in PPC working together across a region can improve personalised care planning and reduce admissions and bed days for children in their last year-of-life with reduced bed utilisation costs.
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Treatment of Multisystem Inflammatory Syndrome in ChildrenBackground: Evidence is urgently needed to support treatment decisions for children with multisystem inflammatory syndrome (MIS-C) associated with severe acute respiratory syndrome coronavirus 2. Methods: We performed an international observational cohort study of clinical and outcome data regarding suspected MIS-C that had been uploaded by physicians onto a Web-based database. We used inverse-probability weighting and generalized linear models to evaluate intravenous immune globulin (IVIG) as a reference, as compared with IVIG plus glucocorticoids and glucocorticoids alone. There were two primary outcomes: the first was a composite of inotropic support or mechanical ventilation by day 2 or later or death; the second was a reduction in disease severity on an ordinal scale by day 2. Secondary outcomes included treatment escalation and the time until a reduction in organ failure and inflammation. Results: Data were available regarding the course of treatment for 614 children from 32 countries from June 2020 through February 2021; 490 met the World Health Organization criteria for MIS-C. Of the 614 children with suspected MIS-C, 246 received primary treatment with IVIG alone, 208 with IVIG plus glucocorticoids, and 99 with glucocorticoids alone; 22 children received other treatment combinations, including biologic agents, and 39 received no immunomodulatory therapy. Receipt of inotropic or ventilatory support or death occurred in 56 patients who received IVIG plus glucocorticoids (adjusted odds ratio for the comparison with IVIG alone, 0.77; 95% confidence interval [CI], 0.33 to 1.82) and in 17 patients who received glucocorticoids alone (adjusted odds ratio, 0.54; 95% CI, 0.22 to 1.33). The adjusted odds ratios for a reduction in disease severity were similar in the two groups, as compared with IVIG alone (0.90 for IVIG plus glucocorticoids and 0.93 for glucocorticoids alone). The time until a reduction in disease severity was similar in the three groups. Conclusions: We found no evidence that recovery from MIS-C differed after primary treatment with IVIG alone, IVIG plus glucocorticoids, or glucocorticoids alone, although significant differences may emerge as more data accrue. (Funded by the European Union's Horizon 2020 Program and others; BATS ISRCTN number, ISRCTN69546370.).
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Presenting features of patients with ataxia-telangiectasia (A-T): A scoping review.Background Ataxia-telangiectasia (A-T) is a rare autosomal recessive, progressive, multi-system disease caused by mutations in the ataxia-telangiectasia mutated (ATM) gene on chromosome 11q.26. There are 2 types of A-T; the more severe phenotype of classical A-T with a complete absence of ATM protein kinase, and the milder phenotype of variant A-T in which there is some residual protein kinase activity. A-T has a wide spectrum of manifestations including cerebellar ataxia, movement disorders, ocular telangiectasia, recurrent infections, and an increased risk of malignancy. Although textbook narratives exist describing the clinical features of A-T, no attempt has been made to collate the available information to give a complete picture of the presenting features of this rare disease. Objectives To describe the presenting features of A-T and determine any difference in presenting features between classical and variant A-T. Methods 17 searches were carried out in each of 5 databases (Ovid SP (Medline), EMBASE, Web of Science, PubMed, Scopus). The Cochrane Library was also searched. The search protocol is available. The inclusion criteria were all dates, all languages, all ages, human subjects, and clinical relevance. The exclusion criteria were: no reference to A-T within the article, not an original article, animal studies, article not clinically relevant. Results Search returned 194,890 articles; 14,622 titles and abstracts were reviewed after removing 180,268 duplicates. Full text review of 1,163 articles was performed and 1,039 studies were included (13,459 exclusions, 124 excluded after full text review). The presenting symptoms (first symptom) were reported in 1209 cases with a total of 1702 signs or symptoms included. The most common presenting complaint reported was an abnormal gait (n=931), followed by recurrent infections (n=223), speech difficulties (n=113) and movement disorder and other co-ordination difficulties (n=69). Cerebellar ataxia was the most common pattern of abnormal gait. Although cerebellar ataxia was the most common first presenting feature, chronologically we found other symptoms that presented at an earlier age included recurrent infections and other neurological signs and symptoms. The age of onset of presenting symptoms will be presented in more detail. The median age of diagnosis for classical A-T was 6 years (IQR 3 – 9 years) and for variant it was much later in life with a median age of 30 years 6 months (IQR 19.25–40.25 years). Conclusions A-T has a wide variety of presenting features which is further complicated by a wide difference in the age of diagnosis of between classical and variant A-T. The most common presenting feature was an abnormal gait of which cerebellar ataxia was the most common pattern. However other symptoms appear to present earlier including telangiectasia and recurrent infections and dystonia in variant A-T. It is hoped that by developing a better understanding of the spectrum of presenting features of A-T may reduce the age of diagnosis of both forms of A-T.
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1449 Drug drills: improving paediatric team performance and confidence when prescribing and preparing unfamiliar emergency medicationsBackground Emergency medications are infrequently required in district general paediatric departments, however when they are it is important for them to be given in a timely manner. Feedback from local simulation scenarios revealed that prescribing and preparing unfamiliar emergency medications was something that both medical and nursing teams felt anxious about. Regular simulation practice is therefore essential for improving patient care and safety in emergency scenarios. Objectives The aim of this project was to improve paediatric team ability and confidence when prescribing and preparing unfamiliar emergency medications in order to improve patient care and safety. Methods A series of ‘drug drills’ involving emergency medication were created: asthma (salbutamol and magnesium sulphate); sedation (morphine and midazolam); duct dependent cardiac disease (prostaglandin) and septic shock (adrenaline and noradrenaline). Doctors timed how long it took to prescribe the medication after reading a scenario. Nursing staff subsequently timed how long it took them to prepare and administer the medication. Participants completed an online survey after the ‘drug drill’ and were asked to record how long it took for them to complete the drill, and whether they felt more or less confident prescribing/preparing these medications. They were also encouraged to provide feedback and learning points to be shared amongst the team to facilitate shared learning. In future,‘drug drills’ will be repeated to assess whether our performance and confidence has improved as a result of extra practice and group feedback. Results To date, ‘drug drills’ have been completed by 19 doctors and 12 nurses. Preliminary results and feedback have been positive with 100% of staff saying they felt more confident prescribing/preparing medication after completion. As a result of the feedback received, changes have already been implemented to help staff in future. For example, we have increased the stock number of 50ml syringes in the resuscitation room as this consistently delayed drug preparation. Also, prescription and administration guidelines are now available on a tablet in the resuscitation room for ease of access. Conclusions Staff had improved confidence after completing the ‘drug drills’, which is expected to translate into better performance and patient care. We aim to repeat these drills in the future to see if our prescribing and preparation times have improved, and whether we have leant from learning points that were identified from feedback.
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Targeted learning through paediatric simulationBackground Simulation is regularly run with the paediatric multi-disciplinary team at a district general hospital. This facilitates learning on an individual and team level, while improving processes of patient care in a safe environment. In this quality improvement project themes were noted in simulation involving paediatric resuscitation, therefore targeted interventions were put in place to make improvements. Objectives Intervention One: Covid-19 has altered healthcare professionals approach to patient contact through the use of personal protective equipment (PPE) to ensure infection control. The Advanced Life Support Group endorsed guidance that in emergencies the patient should be assumed to have Covid-19 and full PPE should be used by responders. In paediatrics breathing support is essential; therefore unplanned simulation was run with staff to practice this skill while maintaining the safe use of PPE. Intervention Two: In simulated cardiac arrest the time taken to administer the first Adrenaline dose was over 13 minutes. Delays in administering Adrenaline in paediatric, in-hospital cardiac arrest with a non-shockable rhythm is associated with decreased survival, ROSC and survival with a favourable neurological outcome. ‘The Arrest to Adrenaline Race’ was launched with the aim to decrease the time taken to administer Adrenaline; so that in a real life scenario the patient would have the best chance of survival. Methods Intervention One: In simulation it took 156 seconds until the patient was first bagged after responders correctly donned PPE, which would have a detrimental impact to successful resuscitation. ‘The Amber Bagging Race’ was launched where teams of healthcare professionals practiced the procedure in a race scenario; from recognition of a deteriorated patient, to the correct use of PPE and then successful bagging. Intervention Two: Healthcare professionals engaged in race scenarios with a manikin, where they timed the process taken from recognition of an arrested patient, initiating resuscitation, obtaining interosseous access and administering Adrenaline at the correct prescribed dose for weight. Results Intervention One: Over two weeks thirteen teams participated and the average time to bag was reduced to 56 seconds in week one and 41 seconds in week two. In a second unplanned paediatric resuscitation following ‘The Amber Bagging Race’ the time taken to bag the patient was 46 seconds; a significant improvement in clinical practice. Intervention Two: Over two weeks fourteen teams participated and the average time taken to administer Adrenaline reduced to 324 seconds in week one and 138 seconds in week two. In further simulation scenarios following ‘The Arrest to Adrenaline Race’ the time taken to administer Adrenaline averaged 5 minutes and 23 seconds. Conclusions Conclusion: Simulation identified key areas for improvement in paediatric resuscitation and targeted interventions enabled specific practice of skills, with the aim to improve patient care in a real life scenario. Learning was disseminated to the wider team and processes were altered to further improvements in patient safety. The races brought an atmosphere of fun to the ward, improving engagement and morale. People are often fearful of simulation; an environment of fun rather than fear is conducive to more effective learning.
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Worldwide differences in childhood type 1 diabetes: The SWEET experienceObjective To study worldwide differences in childhood diabetes, comparing relevant indicators among five regions within the SWEET initiative. Subjects We investigated 26 726 individuals with type 1 diabetes (T1D) from 54 centers in the European region; 7768 individuals from 30 centers in the Asia/Middle East/Africa region; 2642 people from five centers in Australia/New Zealand; 10 839 individuals from seven centers in North America, and 1114 patients from five centers in South America. Methods The SWEET database was analyzed based on the following inclusion criteria: T1D, time period 2015-2019, and age < 21 years, with analysis of the most recent documented year of therapy. For the statistical analysis, we used multivariable linear and logistic regression models to adjust for age (<6 years, 6- < 12 years, 12- < 18 years, 18- < 21 years), gender, and duration of diabetes (<2 years, 2- < 5 years, 5- < 10 years, ≥10 years). Results Adjusted HbA1c means ranged from 7.8% (95%-confidence interval: 7.6-8.1) in Europe to 9.5% (9.2-9.8) in Asia/Middle East/Africa. Mean daily insulin dose ranged from 0.8 units/kg in Europe (0.7-0.8) and Australia/New Zealand (0.6-0.9) to 1.0 unit/kg 0.9-1.1) in Asia/Middle East/Africa. Percentage of pump use was highest in North America (80.7% [79.8-81.6]) and lowest in South America (4.2% [3.2-5.6]). Significant differences between the five regions were also observed with regards to body mass index SD scores, frequency of blood glucose monitoring and presence of severe hypoglycaemia. Conclusions We found significant heterogeneity in diabetes care and outcomes across the five regions. The aim of optimal care for each child remains a challenge.
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Observational Study of Pulse Transit Time in Children With Sleep Disordered Breathing.Background: Pulse transit time (PTT) is a non-invasive measure of arousals and respiratory effort for which we aim to identify threshold values that detect sleep disordered breathing (SDB) in children. We also compare the sensitivity and specificity of oximetry with the findings of a multi-channel study. Methods: We performed a cross-sectional observational study of 521 children with SDB admitted for multi-channel sleep studies (pulse oximetry, ECG, video, sound, movement, PTT) in a secondary care centre. PTT data was available in 368 children. Studies were categorised as normal; primary snoring; upper airway resistance syndrome (UARS); obstructive sleep apnoea (OSA), and "abnormal other." Receiver operator characteristic curves were constructed for different PTT (Respiratory swing; Arousal index) thresholds using a random sample of 50% of children studied (training set); calculated thresholds of interest were validated against the other 50% (test set). Study findings were compared with oximetry categories (normal, inconclusive, abnormal) using data (mean and minimum oxygen saturations; oxygen desaturations > 4%) obtained during the study. Results: Respiratory swing of 17.92 ms identified SDB (OSA/UARS) with sensitivity: 0.80 (C.I. 0.62-0.90) and specificity 0.79 (C.I. 0.49-0.87). PTT arousal index of 16.06/ hour identified SDB (OSA/UARS) with sensitivity: 0.85 (95% C.I. 0.67-0.92) and specificity 0.37 (95% C.I. 0.17-0.48). Oximetry identified SDB (OSA) with sensitivity: 0.38 (C.I. 0.31-0.46) and specificity 0.98 (C.I. 0.97-1.00). Conclusions: PTT is more sensitive but less specific than oximetry at detecting SDB in children. The additional use of video and sound enabled detection of SDB in twice as many children as oximetry alone.
