Prehospital Care of the Unwell Newborn: Tackling the Problem of Knowledge Transfer. Gary Strong September 2017

Transcription

1 Prehospital Care of the Unwell Newborn: Tackling the Problem of Knowledge Transfer Gary Strong September 2017

2 Networking..

3 The Problem Small review of newborn babies transferred into hospital by ambulance (n=15) Explored factors leading to potential compromise: thermal care, oxygenation, ventilation, management of hypoglycaemia identified significant variation in immediate care when compared with RCUK guidelines high incidence of hypothermia potentially associated with significant and avoidable morbidity

4 The team Dr John Madar, Consultant Neonatologist, Plymouth Hospitals NHS Trust Dr Tom Siese, Neonatal Specialist Jennie Clavey, Specialist Nurse, Plymouth Hospitals NHS Trust Gary Strong, National CPD Lead, College of Paramedics

5 Aims: Explore the scale and dimensions of the problem Map out paramedic learning needs Consider and address the challenges associated with knowledge retention and application (knowledge transfer) Design educational intervention(s) which will help to improve prehospital care of the unwell newborn

6 Method Iterative process used to develop a 32 element questionnaire exploring factors affecting paramedic care of the newborn mixed methods approach seeking: useable numerical data real feelings of paramedics approaching this category of patient national perspective sought

7 Areas of enquiry demographics, including route of entry to the profession confidence and experience training received custom and practice (focussed upon thermal care and recording of vital signs) equipment availability paramedic knowledge (using MCQs) record keeping desired training

8 Analysis and Presentation of Results Numerical data presented using summary statistics provided by Survey Monkey software. Free text data subjected to thematic analysis Focus upon confidence and knowledge

9 Results

10 Results

11 Results

12 Results Very rare job and therefore unpractised Having done ALS once on a newborn as a student, and through the use of simulations I have developed confidence. But I am yet to do Newborn ALS without supervision Worried about causing damage to such a small and fragile infant

13 Results

14 The Confidence Question SUB-THEMES (units grouped together) Little, lack of, not, no, never, rare, exposure, experience, practice, training, CPD, refresher, simulation, equipment Skill fade, skill decay Maternity placement CCP, teaching, advanced practitioner, midwife, NLS Trained, familiar, confident, remember, understand, working knowledge, excellent tuition, up to date, happy THEMES Particular emphasis on lack of exposure and experience along with lack of regular training. Trained but lacking in practice and experience Importance of pre and post registration placement experience Those in advanced or enhanced roles are more confident, perhaps due to more exposure to cases/training/nls course Amongst those who feel confident there are several whose confidence is based upon learning and knowledge, with little practical experience.

15 Results: Thermal Care

16 Summary of Results (n = 72) More than half of respondents expressed lack of confidence or neither confident nor unconfident Recent experience varied from 1 week to 15 years. 26% had attended more than 15 newborns during their career Only 52% routinely measured temperature 59% used tympanic probes (may be unsuitable) Only 32% correctly identified the normal temperature range for newborns

17 Summary of Results 82% knew the normal respiratory rate in a newborn 97% knew the normal heart rate in a newborn. Interventional thresholds for hypoglycaemia not well understood (16%). Significant variation in availability of suitable equipment for NLS existed. 75% indicated a wish/need for further training, half of whom indicated a preference for simulation.

18 The Literature Case studies, reflections, teaching articles, developing world studies, interhospital transport studies.. Little discussion of paramedic competence and confidence Even less research Useful study by Loughney et al (2006) Groundbreaking work by McLelland et al (2014)

19 Loughney et al (2006) Study of associations and consequences of BBA Cohort (n = 124) matched with two control groups BBA associated with multiparity & previous short second stage labour less pain, less frequent contractions & later spontaneous rupture of the membranes Maternal consequences include prolonged third stage, haemorrhage & blood transfusion Neonatal consequences limited to a failure to maintain body temperature

20 McLelland et al (2014) Global literature review of paramedics using clinical and critical skills attending unplanned birth studies included from US, UK and Europe 8 studies reported the most common maternal complication was excessive postpartum haemorrhage 9 reported the most frequent neonatal complication was hypothermia regardless of gestation Further studies by McLelland on paramedic attendance at unplanned and planned BBAs in Victoria, Australia Affirms need to enhance paramedic education and interprofessional collboration

21 Knowledge Transfer

22 The problem of knowledge transfer In 2008 London Ambulance Service (LAS) attended over 1000 imminent births calls (Lingen-Stallard, 2008) In context: LAS receives over 4000 calls per day So less than 0.1% of the workload The target factor

23 The problem of knowledge transfer So how can paramedics maintain currency and confidence? Confidence levels higher in those who receive frequent training But these are a minority Suggests need for regular updates but how?

24 What respondents wanted:

25 Tackling the problem Role of the College of Paramedics in facilitating CPD Create simulation opportunities Bite size refreshers Online CPD Social media Case studies NLS grab bag Prompt cards EPCR prompts Post-registration placement?

26 Questions?

27 References and Bibliography Cheng, A., & Hartfield, D. (2011). Minimum equipment guidelines for paediatric prehospital care. Paediatrics & Child Health, 16(3), Cottrell E, et al. (2014). Understanding Safety in Prehospital Emergency Medical Services for Children. Prehospital Emergency Care, Volume 18, Issue 3. Drayna P, Browne L, Guse C, Brousseau D, Lerner E. (2015) Prehospital Pediatric Care: Opportunities for training, treatment and research. Prehospital Emergency Care, 19, Eaton, G & Renshaw, J. (2012). Critique of the pre-hospital obstetric emergency training course: ALSG. Journal of Paramedic Practice 4:11. Hadar A, Rabinovich A, Sheiner E, Landau D, Hallak M, Mazor M. (2005) Obstetric characteristics and neonatal outcome of unplanned out-of-hospital term deliveries: a prospective, case-control study. Journal of Reproductive Medicine. Nov;50(11): Lingen-Stallard, A. (2009). Normal Labour and Birth. Journal of Paramedic Practice 1:11. Loughney, A; Collis, R; Dastgir, S (2006). Birth before arrival at delivery suite: Associations and consequences. British Journal of Midwifery 14:4. Madar, J (2011). Resuscitation of the newborn. Anaesthesia and Intensive Care Medicine 12:4. McCall EM, Alderdice F, Halliday HL, Jenkins JG, Vohra S (2010). Interventions to prevent hypothermia at birth in preterm and/or low birthweight infants (Review). Cochrane Database of Systematic Reviews 2010 Issue 3. McLelland, G E; McKenna, L G; Archer, F (2013). No fixed place of birth: Unplanned BBAs in Victoria, Australia. Midwifery 29 e19-e25.

28 References and Bibliography McLelland, G E; Morgans, A E; McKenna, L G (2014). Involvement of emergency medical services at unplanned births before arrival to hospital: a structured review. Emergency Medicine Journal 31: McLelland, G E; Morgans, A E; McKenna, L G, Smith, K (2016). Paramedics' involvement in planned home birth: A one-year case study. Midwifery Moscovitz H, Magriples U, Keissling M, Schriver J. (2000) Care and outcome of out-of-hospital deliveries. Academic Emergency Medicine. Volume 7;7. Petty, J. (ND). Neonatal Thermoregulation. University of Hertfordshire. Available at data/assets/pdf_file/0005/62951/5thermoregulation.pdf Accessed 15 August 2017 Prosad Paul, S & Heaton, P (2013). Pre-mature babies born in the pre-hospital setting: A challenging situation. Journal of Paramedic Practice 5:2 Rodie V, Thomson A, Norman J. (2002). Accidental out-of-hospital deliveries: an obstetric and neonatal case control study. Acta Obstetricia et Gynecolica Scandinavica. Jan;81(1):50-4. Scott T & Esen U. (2005) Unplanned out of hospital births--who delivers the babies? Irish Medical Journal. Mar;98(3):70-2. Smith, J; Alcock, G;Usher, K. (2013) Temperature measurement in the preterm and term neonate: A review of the literature. Neonatal Network, 32 (1): Yarrington, A. (2017). A spring baby turning up the heat on a fast delivery! Standby CPD 17.4 Zur M, Hadar A, Sheiner E, Mazor M. (2003). Out of hospital deliveries: incidence, obstetrical characteristics and perinatal outcome. Harefuah Jan;142(1):38-41, 78, 77.