High Dependency Care Audit for Children & Young People in Scotland – Interim Report

Background to the High Dependency Care (HDC) Audit The Kerr Report recommended: “that the age for admitting children & young people to acute care in paediatric facilities is up to their 16 th birthday”. Delivering for Health: –“continued provision of paediatric intensive care and high dependency care (HDC) is an immediate issue for NHSScotland in the light of trends in activity and case mix that may not be sustainable within current provision.” SEHD commissioned NSD to conduct audit, to assess demand across Scotland and the current capacity to provide HDC: –quantity – high dependency care audit; –quality – assessing paediatric services against national standards (West Midland Guidelines).

HDC Audit - Methodology Aim to identify where children with HDC needs are currently managed, how many, levels of HDC care and the number transferred. Development of a set of national high dependency care criteria and classification standards month prospective audit – in all hospitals across Scotland. Include all children up to their 16 th birthday. Pilot conducted in wards within DGH, Tertiary Hospitals and Adult Hospitals.

HDC Audit – roll out began in October 2006, all hospitals were participating by end of Nov. Health BoardChildren’s WardsAdult Wards Ayrshire & Arran 24 Borders 17 Dumfries & Galloway 15 Fife 313 Forth Valley 216 Greater Glasgow & Clyde Grampian 79 Highland 119 Lanarkshire 213 Lothian 1236 Orkney 03 Shetland 03 Tayside 610 Western Isles 04 Total49284

12 hr episodes: day / night; changes in care

Airway / Circulatory Classifications

Co-ordination of HDC Audit Each hospital has a designated co-ordinator and deputy. Key to ensuring the quality of the data returned to NSD: –interpretation of HDC criteria – peer review; –link with NSD regarding queries on the audit forms; –meet regularly to discuss issues. Completed forms returned on a weekly basis from paediatric wards and monthly basis from adult wards

Audit forms should contain – the patient’s complete journey Each form should contain the following: hospital & ward; patient details – CHI, DoB, Postcode, type of admission – emergency / elective; date & time per patient – when HDC commenced & ended, not shifts. admission from – where was the patient prior to coming to the hospital; primary journey – how did the child get to the hospital; secondary journey – if child was transferred from another hospital – how was the child transferred; end destination – when HDC ended where did the child go; HDC criteria – for complete 12 hr period.

BRANNI GAN

HDC Audit progress Database Issues: –delays developing database; –backlog of data entry; –quality of initial audit forms received – still working on clearing the outstanding queries; –delay in feedback to wards/hospitals. Data presented is not complete due to backlog/queries. Staffing issues within NSD. To end of December information on 1369 children has been received. (Still adding to database for Jan/Feb - to date 1687)

Number of Children included in the HDC Audit HospitalOctoberNovemberDecemberTotal Aberdeen Royal Infirmary1203 Balfour Hospital0011 Belford Hospital75315 Borders General Hospital88218 Caithness General Hospital36211 Crosshouse Hospital Dr Gray's Hospital Dumfries & Galloway Royal Infirmary Gilbert Bain Hospital2125 Ninewells Hospital Perth Royal Infirmary0325 Queen Margaret Hospital0325 Raigmore Hospital Royal Aberdeen Children's Hospital Royal Alexandra Hospital09312 Royal Hospital for Sick Children (Edinburgh) * Southern General Hospital0426 Stirling Royal Infirmary St John's Hospital at Howden44412 Victoria Hospital Wishaw General Hospital Yorkhill NHS Trust * Total Number of Children Included in Audit * Significant amount of outstanding data entry

HDC Audit – planning tool / issues impacting on children’s services Capacity: –no of HDC episodes; no. of children; episodes per child; Location: –where do children receive HDC; type of hospital, regional location. Demand: –proportion emergency / elective admissions. Staffing: –proportion day / night HDC Patient Pathway: –how many children are transferred to another hospital; –how do children arrive at hospital; –where do they go after HDC.

Breakdown of HDC for children in audit to date. HDC care provided in Short Stay, Paediatric Ward, HDU. Treatment Code No. of Patients Categories Post-operative airway obstruction12 Airway obstruction12 Airway intervention13 Airway Ventilated/Assisted respiration13 Stable long-term ventilation3 O2 more than 40%63 Recently extubated - prolonged ventilation/Intensive care step down 1 Vasoactive, inotropic, anti-arrhythmic drugs1 Fluid balance42 Shock/hypovalaemia4 Circulatory Multiple IV drugs or continuous infusion33 Invasive monitoring9 Severe haematological problem5 Acute hypotension/hypertension1 Cardioversion1 Cardiac CPR1 BMT/severe neutropenia6 Infection Septicaemia10 Acute renal replacement therapy/Hourly cycle PD/Acute renal failure 1 Diabetic ketoacidosis (DKA)7 Renal Severe metabolic/fluid/electrolyte derangement10

Treatment Code No. of PatientsCategories GCS Prolonged/recurrent seizures9 Complex anti-convulsants6 Neurology Post - craniotomy1 Hourly neuro observations50 Apnoeas/cyanotic episodes8 Deterioration to ventilation7 Severe asthma/bronchodilators34 Respiratory ECG and Sa02 monitoring30 2+ chest drains & hourly replacement1 Arrhythmias2 Sedation or GA for ward procedure49 Complex pain control28 Frequent sampling/dressings10 End of life care3 Other Major trauma3 Previous rapid deterioration resulting in PICU admission3 Central lines1 Minor surgery, same day1 Neonates Morphine2 Breakdown of HDC for children in audit to date. HDC care provided in Short Stay, Paediatric Ward, HDU.

Where children who require HDC were admitted from: OctNovDecJanFeb %%% A & E Same Ward01500 HDU (transferred from HDU to Wd still requiring HDC) Home ICU Other Ward Other Hospital PICU00000 Short Stay51510 Patient Journey

HDC Audit – implications for children’s nurses Aim is to produce report Spring 2008; supporting the planning of local, regional and national planning of critical care services. Assessment of paediatric facilities, will be included in final report. Provide evidence to support local needs analysis: –training – differing between hospital environments; –staffing levels; –facilities; –equipment –epidemiological data of patient base (Data Warehouse linkage).

HDC Audit – implications for children’s services Ethos of Delivering for Health is to provide services as locally as possible. Current paediatric service provision – centralisation of paediatric intensive care (2) and high dependency units (4). This audit will identify the number of children with high dependency care needs across all hospitals and wards – linking to the development of a managed critical care network.

Acknowledgements to - Julie Adams Project Manager National Services Division