Scoring Systems in Paediatric Emergency Care Damian Roland

Disclaimer I have developed an Children’s Emergency and Urgent care acuity scoring tool: The Paediatric Observation Priority Score (POPS) with Dr. Ffion Davies I am co-director of a Medical Apps firm quackapps.com

Roland D, Shahzad MW, Davies F Roland D, Shahzad MW, Davies F. The importance of currency in data trends. Arch Dis Child 2013;98:568-569

Definitions Roland D. Paediatric early warning scores: Holy Grail and Achilles' heel  Arch Dis Child Educ Pract Ed. 2012 Dec;97(6):208-15.

Definitions Triage Roland D. Paediatric early warning scores: Holy Grail and Achilles' heel  Arch Dis Child Educ Pract Ed. 2012 Dec;97(6):208-15.

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2009, 17:38

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2009, 17:38

Serious infection life-threatening Intermediate infection: longer than 10 days or have a non life-threatening complication Minor infection: recover without sequelae Not infection group: NOT an acute infection Arch Dis Child 2009;94:888–893

Illness Identification Definitions Illness Identification Triage Roland D. Paediatric early warning scores: Holy Grail and Achilles' heel  Arch Dis Child Educ Pract Ed. 2012 Dec;97(6):208-15.

Minor infection: recover without sequelae Arch Dis Child 2009;94:888–893

Illness Identification Definitions Illness Identification Triage EWS Roland D. Paediatric early warning scores: Holy Grail and Achilles' heel  Arch Dis Child Educ Pract Ed. 2012 Dec;97(6):208-15.

Score doesn’t ‘activate’ Score ‘activates’ FLAGS UP DETERIORATING KIDS POTENTIALLY DRAINS RESOURCES Not Deteriorating Deteriorating FAILS TO RECOGNISE DETERIORATION MONITORS EFFECTIVELY Score doesn’t ‘activate’ @damian_roland Original concept by Akmal Hussein, Royal Berkshire Hospital

Concern PEWS may generate work… O’Leary F and Chayan G. Predicting the impact on workload with the application of inpatient clinical review criteria into a paediatric emergency department. Emergency Medicine Australasia (2011) 23, 748–753

..the review activations might have generated an extra 7060 min of additional workload… O’Leary F and Chayan G. Predicting the impact on workload with the application of inpatient clinical review criteria into a paediatric emergency department. Emergency Medicine Australasia (2011) 23, 748–753

Physiological Parameters Junction A Septic Thought to have sepsis Presentation Physiological Parameters General Appearance Not Septic Not thought to have sepsis Septic Not Septic Concept Tree by @damian_roland

Optimal Treatment or Outcome Septic Junction A Junction B Optimal Treatment or Outcome Septic Thought to have sepsis Suboptimal Treatment or Outcome Presentation Physiological Parameters General Appearance Not Septic Suboptimal Treatment or Outcome Not thought to have sepsis Septic Optimal Treatment or Outcome Not Septic Concept Tree by @damian_roland

Optimal Treatment or Outcome Ill Junction A Junction B Optimal Treatment or Outcome Ill Thought to be ill Suboptimal Treatment or Outcome Presentation Physiological Parameters General Appearance Not Ill Suboptimal Treatment or Outcome Not thought to be ill Ill Optimal Treatment or Outcome Not Ill Concept Tree by @damian_roland

Roland D, McCaffery , Davies F Roland D, McCaffery , Davies F. Scoring Systems in Paediatric Emergency: Panacea or Paper Exercise J Paediatr Child Health 2016 Feb 52 (2) 181-6

High Patient Load Roland D, McCaffery , Davies F. Scoring Systems in Paediatric Emergency: Panacea or Paper Exercise J Paediatr Child Health 2016 Feb 52 (2) 181-6

High Patient Load Time Pressures Roland D, McCaffery , Davies F. Scoring Systems in Paediatric Emergency: Panacea or Paper Exercise J Paediatr Child Health 2016 Feb 52 (2) 181-6

High Patient Load Multiple Handovers Time Pressures Roland D, McCaffery , Davies F. Scoring Systems in Paediatric Emergency: Panacea or Paper Exercise J Paediatr Child Health 2016 Feb 52 (2) 181-6

High Patient Load Inexperienced Staff Multiple Handovers Time Pressures Roland D, McCaffery , Davies F. Scoring Systems in Paediatric Emergency: Panacea or Paper Exercise J Paediatr Child Health 2016 Feb 52 (2) 181-6

Diagnostic Uncertainty High Patient Load Inexperienced Staff Multiple Handovers Diagnostic Uncertainty Time Pressures Roland D, McCaffery , Davies F. Scoring Systems in Paediatric Emergency: Panacea or Paper Exercise J Paediatr Child Health 2016 Feb 52 (2) 181-6

Systems should ameliorate.. Failure of… Diagnostics Recognition of Severity Communication

An Optimal ED tool should.. Decrease Cognitive Load Reduce Knowledge Deficit Escalate Senior Review Identify both tails of the Distribution curve Improve Communication

The paediatric literature included 7 full papers and 11 abstracts; 7 were prospective studies and 8 examined a score designed for ED use (4 of these assessed the Paediatric Observation Priority Score tool). Challen K and Roland D. Early Warning Scores: a health warning EMJ doi:10.1136/emermed-2014-204250

Valid, safe, and user-friendly in pilot testing1,23 Roland D, Lewis G, Davies F. Determining the effect of objective and subjective criteria on a risk assessment tool in a paediatric emergency department. Emerg Med J 2011;28:A12 Roland D, Lewis G and Davies F. Maintaining Safety while reducing admission in a high risk patient group. Poster Presentation at International Forum on Quality and Safety in Healthcare. London April 2013 Roland D, Gareth L and Davies F.  Addition of a subjective nursing assessment improves specificity of a tool to predict admission of children to hospital from an emergency department. e-Poster at European Paediatric Research Society Newcastle October 2011

Roland D, Davies F and Coats T Roland D, Davies F and Coats T. The Paediatric Observation Priority Score (POPS): Outcomes Of 24000 Patients Arch Dis Child 2014;99:A24

Aggregate Results

Relative Results (%)

Externality

Figure 2 – Triage Assessment Documentation

What do we need to know?

What do we need to know? Is the best outcome illness detection or safe discharge? Is specificity more important that commonality? Is the ‘score’ more relevant than the system behind it?

What do we need to know? Is the best outcome illness detection or safe discharge? Is specificity more important that commonality? Is the ‘score’ more relevant than the system behind it?

What do we need to know? Is the best outcome illness detection or safe discharge? Is specificity more important that commonality? Is the ‘score’ more relevant than the system behind it?

Thanks Dr. Ffion Davies Prof. Tim Coats Prof. Andrew Rowlands and colleagues in Manchester The staff at the Leicester Royal Infirmary

Dr. Damian Roland dr98@le.ac.uk @damian_roland Leicester Emergency Medicine Academic Group (EMAG) www.le.ac.uk/emag Paediatric Emergency Medicine Leicester Academic (PEMLA) www.le.ac.uk/pemla East Midlands Emergency Medicine Educational Media (EM3) https://twitter.com/EM3FOAMed

Systems should amelioriate Diagnostic failure: Failure to establish the correct diagnosis sufficiently early to permit effective treatment Failure to recognise illness severity: The correct diagnosis is established but illness severity is underestimated, leading to delayed escalation of support Failure of communication: Communication between staff may be absent or ineffective. This includes inaccurate medical information as well as human factors  

Optimal ED tool should..   Reducing Knowledge Deficit: Most tools define an acceptable reference range for each physiological variable commonly measured. This assists junior staff, particularly if inexperienced with children Decreasing cognitive load: Graphical or numerical display of physiological observations ,whether at the triage stage or repeatedly over time, allows clear identification of sick children. Escalating seniority of review: Specific scores activate senior clinician involvement Identifying both tails of the distribution curve: Ability to identify potentially critically unwell children as well as those fit for discharge without hospital admission, is the fundamental purpose of an ED Improving Communication: Many tools are now integral to the process of patient handover and triage. Handover is well known to be a high-risk transition for patients, and objectivity and alerts are possible using scoring systems.