Care of the Critically Ill Child Clinical Guideline Register No: 16025 Status: Public Developed in response to: Best practice Contributes to CQC Fundamental Standard 9, 12 Consulted With Post/Committee/Group Date Alison Cuthbertson / Miss Rao Clinical Director for Women, Children & June 2016 Sexual Health Directorate Victoria Machell Clinical Governance Facilitator June 2016 Consultant Paediatricians June 2016 Mel Hodge Senior Sister Phoenix Children s Unit June 2016 Melanie Chambers Matron Children and Young People June 2016 Children s Urgent & Emergency Trust wide group June 2016 Care Group Resuscitation Department RTO s & TaRT June 2016 Miss Laura Harding Consultant ENT surgeon June 2016 Teresa Tredoux Matron Burns ICU June 2016 Dr Rebecca Martin Consultant Anaesthetist Burns ICU June 2016 Dr Tim Lightfoot Consultant Anaesthetist Adult ICU June 2016 Dr Katherine Rowe Consultant Anaesthetist Adult ICU June 2016 Professionally Approved By Dr Datta July 2016 Version Number 1.0 Issuing Directorate Children and Young People Ratified by: DRAG Chairmans Action Ratified on: 18 th July 2016 Trust Executive Sign Off Date August 2016 Implementation Date 26 August 2016 Next Review Date July 2019 Author/Contact for Information Andrea Stanley Policy to be followed by (target staff) Nurses, Junior Doctors and Consultant Paediatricians Distribution Method Hard copies to all ward areas and managers, Electronic copy to all appropriate staff on email, Intranet & Website, Notified on Staff Focus Related Trust Policies (to be read in conjunction with) 11046 CYP Observation Policy 09005 Transferring children policy 04064 Safeguarding children and Young People 04071 Infection prevention policies 04071 04072 Hand Hygiene Record keeping Policy 05111 Resuscitation Policy 08071 Child death review & rapid response policy 04301 DNAR children policy 09127 Interpreting and translation policy Document Review History Version No Authored/Reviewed by Active Date 1.0 Andrea Stanley July 2016 1
INDEX 1. Purpose 2. Background 3. Equality and Diversity 4. Scope 5. Roles and Responsibilities 6. Staff competency and training 7. Infection control 8. Location 9. Equipment 10. Levels of Care 11. Recognition of a critically ill child 12. Escalation and communication 13. Procedure for calling teams 14. Paediatric resuscitation team attending an arrest call 15. Staff in attendance 16. Intensive care advice 17. Imaging Sharing Protocol 18. Intubation and Ventilation 19. Support for family 20. Moving a child to theatres 21. Post resuscitation care 22. Airway support and ventilation 23. Stabilisation 24. Emergency surgery 25. Transfer 26. HDU admission 27. Adult ICU admission 28. Death of a child 29. Organ donation 30. Audit and monitoring 31. Communication 32. References Appendices a) Equality Impact Assessment b) Interventions/categories/disorders defining level of Paediatric Critical Care c) Escalation pathway of a deteriorating paediatric patient d) Flow chart for transfer of a child to a paediatric tertiary centre 2
1.0 Purpose 1.1 This guideline aims to provide health care professionals caring for a critically ill child with an overview to the response and co-operation required between departments and healthcare teams involved in the resuscitation, stabilisation and post resuscitation care. 1.2 To ensure that all critically ill children who are admitted to Mid Essex Hospitals NHS Trust will be stabilised and transferred to tertiary care in a safe, effective and efficient manner. 2.0 Background 2.1 Any hospital that admits children and young people with an acute illness or injury should be able to provide immediate care and be able to stabilise a critically ill child before transfer to an inpatient ward or paediatric intensive care unit (PICU). 2.2 This protocol does not give specific disease or condition advice regarding treatment. The following are examples of what might be considered a critically ill child. The list is exhaustive but not complete. Respiratory failure Cardio vascular instability i.e. fluid resuscitation with more than 40ml/kg and no response Active significant bleeding Unconscious child (GCS <9) Head injury with GCS of less or equal to 8 Airway burns and stridor Others 2.3 Resuscitation should be carried out in accordance with the Trust Resuscitation Policy 2.4 Treatment will be given in accordance with local or national guidelines and/or in consultation with the Children s Acute Transport Service (CATS) or tertiary centre as applicable. 3.0 Equality and Diversity 3.1 The Trust is committed to the provision of a service that is fair, accessible and meets the needs of all individuals. 3.2 An Equality Impact Assessment is attached to the policy at Appendix 1. 4.0 Scope 4.1 This guideline is for all clinical staff caring for critically ill children and young people up to their 16 th birthday in any location within the trust. 3
5.0 Roles and Responsibilities 5.1 Chief Executive The Chief Executive has overall accountability and responsibility for ensuring safe and effective systems are in place to care for critically ill children. 5.2 The Director of Patient Safety The Director of Patient Safety is responsible for ensuring that resources and mechanisms are in place for the implementation, monitoring and review of this guideline. 5.3 Lead Consultant for Paediatric Critical Care The Lead Consultant for Paediatric Critical Care is responsible for ensuring that policies and procedures relating to the assessment and management of the critically ill child are available. They should ensure the availability of relevant training of medical staff within their area. 5.4 Lead Anaesthetist for Paediatric Critical Care The Lead Anaesthetist for Paediatric Critical Care is responsible for ensuring that policies and procedures relating to emergency and elective anaesthesia of children are available. They should ensure the availability of relevant training of medical staff within their area. 5.5 The Clinical Facilitator Children s Acute Care The clinical facilitator is responsible for providing education, training and clinical support in the recognition, assessment and management of critically ill children. The clinical facilitator will offer specialist advice and provides a link between the specialist clinical networks. The clinical facilitator will monitor standards and current practice through audit, serious incident / case reviews and reflective practice. 5.6 The Paediatric Team The critically ill child who presents to Mid Essex Hospitals NHS Trust (MEHT) will be admitted under the care of the paediatric team with a named consultant. The on-call consultant paediatrician will be responsible for the care of the child and will take the lead. They should be actively and proactively involved in the clinical management of the critically ill child until care is handed over to the retrieval team on their arrival to the trust. Children admitted to the Burns ICU are admitted under a Burns consultant. Two paediatric intensive care consultants from GOSH PICU support the burns team in the management of critically ill burns children. 4
5.7 The Anaesthetic Team The anaesthetic team are primarily responsible for the management of airway and breathing in all critically ill children (with the exception of neonates) irrespective of the location in the trust. Any neonate (aged < 28 days old from term or weighing < 3.5kg) would be primarily cared for by the paediatric team including the airway and breathing irrespective of the location in the trust. Induction, pharmacological input and support will be provided by the anaesthetic team. 5.8 The Emergency Department Team A middle grade doctor with experience in caring for a critically ill child should be immediately available and will be responsible for the care of the child until the arrival of the paediatric team. A consultant should be available to attend if required. 5.9 The Burns Unit Team The burns team consists of anaesthetists, paediatric intensivists, and nurses who have extensive experience in managing critically unwell burn injured children and the unit also stocks all necessary equipment for the care of these children. The team are available to be contacted for advice and support. 5.10 The Senior Children s Nurse in Charge The Senior Children s Nurse in Charge is accountable for the safe care and management of critically ill children in their area. They are responsible for ensuring the appropriate level of staffing including competence and experience should be available to support the care of the child at the bedside. 5.11 All clinical staff It is the responsibility of the healthcare professional designated to care for the patient to ensure that they are trained and competent to care for a critically ill child and to be accountable for their own practice. 5.12 The Children s Urgent & Emergency Care Group The Children s Urgent & Emergency Group is responsible for monitoring the implementation and effectiveness of this guideline and should ensure that nationally developed standards are met. 6.0 Staff competency and training 6.1 Clinical staff of all grades who may be expected to be involved with the care of critically ill or acutely ill children in the District General Hospital (DGH) should be familiar with the following five generic skills: to recognise the critically ill child to initiate appropriate immediate treatment. 5
to act within a team to maintain and enhance skills to be aware of issues of safeguarding children 6.2 The personnel who are expected to have these skills are: A & E clinical staff including doctors, nurses and emergency care practitioners Paediatric staff, including doctors at all levels of training and nurses Anaesthetic staff, including anaesthetists at all levels of training, ODPs Burns unit clinical staff including doctors and nurses 6.3 Training will be provided with periodic retraining made available. 6.4 Doctors at all levels have a professional responsibility to maintain their knowledge and skills. 6.5 Registered nurses must comply with NMC standards for maintaining their knowledge and skills (NMC 2015). 6.6 During induction process clinical staff will receive instruction on current policy and guidelines. 6.7 Simulation training at regular intervals should be used to keep skills of the team up to date. 6.8 All medical and nursing staff involved in the care of children must attend paediatric basic life support training regularly in accordance with their role. 6.9 At least one member of the nursing team on duty must hold an EPALS certificate and all paediatric middle grade doctors and above involved in the care of critically ill children should have EPALS/APLS training. 6.10 Where a patient s notes have demonstrated that the appropriate action has not been taken a risk event form is to be completed. This will address any further training needs for staff that requires updating. 7.0 Infection Prevention 7.1 All staff should follow Trust guidelines on infection control by ensuring that they effectively decontaminate their hands between each patient. 7.2 All equipment will be decontaminated between each patient and disposable single use items used where supplied. 6
8.0 Location 8.1 Children and young people requiring resuscitation and stabilisation are most likely to be in the Emergency Department or the Paediatric Department including Phoenix children s ward and paediatric assessment unit (PAU). Other specific locations include theatres and burns ICU. 8.2 Children may be present in other areas of the trust where it is unlikely but not impossible that paediatric resuscitation may occur. Other areas include Wizard day stay unit, children s burns ward, imaging department and children s outpatient departments. If a child becomes acutely ill in any of these areas it would be advisable to stabilise and transfer to any one of the locations identified in 8.1. 8.3 Children are rarely admitted to the adult ICU and this will mostly occur in exceptional circumstances. The decision to admit will be made jointly by the adult intensive care consultant and the consultant paediatrician on-call. The CATS team can be contacted for advice on management of the child. The matron for children or their deputy should be contacted to ensure that a children s nurse can be provided for nursing support and advice. 8.4 In the event of a Paediatric Arrest or critically ill child requiring a team response summon the Paediatric Arrest Team via the universal emergency bleep system 2222. Refer to the Trust Resuscitation Policy 05111 for further information. 9.0 Equipment 9.1 The responsibility for maintaining all the essential equipment and monitoring devices lies with the respective departments. 9.2 Resuscitation equipment is provided on standardised paediatric resuscitation trolleys using a standardised checklist produced by the Resuscitation Department. Trolleys are located in the following areas: Emergency department Phoenix children s ward Theatre recovery Wizard day stay unit Children s burns ward Burns ICU Children s outpatient department Plastic surgery outpatient department In-patient x-ray (MRI anaesthetic room) EEG (grab bag) Remote children s outpatient dept at St Peter s & Braintree (grab bag) 9.3 Additional advanced equipment that maybe required for the stabilisation of a child in preparation for retrieval is provided on standardised trolleys in the emergency department and phoenix children s ward. 9.4 Difficult airway equipment is kept in the emergency department, phoenix children s ward, theatres and burns ICU. 7
9.5 Emergency tracheostomy equipment is available in theatres in the ENT store and on phoenix children s ward. 9.6 Equipment necessary for internal and external transfers is kept in transfer grab bags in the following areas: Emergency department Theatres Phoenix children s ward Burns ICU 9.7 All areas with paediatric resuscitation trolleys have access to a manual defibrillator with both adult and paediatric pads. AED s with paediatric attenuated pads are available in outpatient areas. 10.0 Levels of Care 10.1 There are three categories of patient dependency within paediatric critical care. Level 1 and level 2 are used to describe activities which are high dependency care and level 3 is used to describe activities that should only be undertaken in a paediatric intensive care. Level 1 basic critical care 10.2 Level 1 basic critical care describes activities which should be delivered in any hospital which admits acutely ill children who requires closer monitoring and observation than is usually available on a general children s ward. The majority of children requiring this level of care start and finish their care on general children s wards. This can account for between 5 to 15% of all DGH admissions. 10.3 A Registered Children s Nurse can provide Level 1 care for a maximum of 2 children at any one time on the open ward and for 1 child if nursed in a cubicle. Level 2 intermediate critical care 10.4 Level 2 intermediate critical care describes more complex activities and interventions which are undertaken less frequently, to children with a higher level of critical illness and requires the supervision by competent medical and nursing staff. Level 3 advanced critical care 10.5 Level 3 advanced critical care describes activities that should only be undertaken within a paediatric intensive care unit (PICU). 10.6 The interventions /categories/disorders defining the level of paediatric critical care are described in appendix 2. 11.0 Recognition of a critically ill child 11.1 Cardiac arrest in children is usually the result of respiratory and or circulatory failure that develops over time and is rarely a sudden event. The recognition of a critically ill child who may deteriorate is key to improving outcomes. 11.2 Clinical judgement and experience in recognising the critically ill or deteriorating child is of paramount importance. The use of a Children s Early Warning Tool (CEWT) has been 8
introduced on the Children s Wards and the Emergency Department as an adjunct to the monitoring of unwell children to aid in the early recognition of serious illness. Refer to CYP Observation Policy 11046. 11.3 The staff should respond promptly to children whose score is 5-6 (red) or increasing as well as where there are other concerns about the child s clinical status. This scoring system has been introduced to support junior staff in the assessment of sick children and to be more objective in informing senior staff of the condition of the patient. The staff with clinical concerns about a child should not allow themselves to be falsely reassured by a low score. 12.0 Escalation and Communication 12.1 It is very important to communicate clearly about any discussion which takes place between different specialities regarding assessment and management of sick children. These discussions should be then documented in child s healthcare records. If a child is to be escalated by nursing or medical staff to a senior clinician or other speciality then the SBAR communication tool should be used. 12.2 In the following scenarios, you should escalate to the Consultant on-call. This is usually undertaken by the Registrar or Senior Nurse/ ST1-3 if Registrar is busy. Please see appendix 3 for escalation pathway of a deteriorating paediatric patient. If child s CEWT score is 5-6 (RED). Escalation should be undertaken after the Registrar s assessment If CEWT score is 5-6 (RED) and Registrar is busy with another sick child There are concerns raised by nurse or doctor looking after sick child 12.3 Early Anaesthetic review should be arranged in a child that is clinically deteriorating. The initial discussion should be undertaken by the Registrar, but further discussion should be at consultant to consultant level. 12.4 For paediatric emergencies requiring urgent (not immediate) anaesthetic assistance the following flow applies; 1. Request urgent attendance of 2 nd on-call Anaesthetist covering theatres (Bleep #6555 1310) and ODP covering resuscitation (Bleep #6555 2206/3020) 2. 2 nd on-call Anaesthetist to assess level of assistance required; a) Immediate assistance Enlist help of either; Anaesthetist covering burns unit (Bleep #6555 2413) Anaesthetist covering obstetric unit (Bleep #6555 3021) b) Consultant assistance Consultant Anaesthetist covering Obstetrics (via switchboard). Be aware it may take some time to attend if not in hospital. 12.5 There are rare instances where the Consultant Anaesthetist may be contacted directly to expedite attendance; however this should ideally be done by the referring Consultant or senior SpR/ST. Attendance of on-site anaesthetic assistance should also be requested. 12.6 If additional help is required the Intensive Care Team can be contacted. 9
13.0 Procedure for calling teams 13.1 Cardiac Arrest In the event of a cardiac and/or respiratory arrest phone 2222 and state Paediatric Cardiac Arrest give the exact location including Ward/Department name, zone letter and number e.g. phoenix children s ward Echo/E 122. Wait for the operator to repeat this back before hanging up. The Paediatric Resuscitation Team will respond to all emergency 2222 calls within the Hospital site relating to children (excluding neonates) including children in cardiac arrest, peri-arrest collapse of any cause including anaphylaxis or any child who has become acutely unwell and requires immediate medical assistance. 13.2 Urgent Response The Fast Bleep system can be used to summon a rapid response to an ill child who has not suffered a cardiac or respiratory arrest or severe collapse. This protocol supports nurses or doctors who feel that a child s clinical condition warrants a rapid, response of appropriate staff in using the Fast Bleep System. Phone 2222 and ask for the required personnel to be fast bleeped. 13.3 Alert Calls in ED (Emergency Department) for Unwell Children After receiving alert call/priority call from the Ambulance Service regarding an unwell child, ED will phone 2222 to activate the Paediatric team and Paediatric ED staff to the resuscitation area. 13.4 Paediatric Trauma call In the event of a paediatric trauma Phone 2222 and state Paediatric Trauma and give the exact location. Wait for the operator to repeat this back before hanging up. 14.0 Paediatric resuscitation team attending an arrest call 14.1 A team leader will be identified at all resuscitation attempts and is generally the most senior member of medical staff in possession of a Paediatric Advanced Life Support Course. 14.2 For a Paediatric Resuscitation the Paediatric Registrar will usually take on the role of Team Leader from their arrival at the scene of the resuscitation/paediatric cardiac arrest. They will obtain advice and support from other individuals including Consultants in other specialities as appropriate to the situation. This guidance does not aim to prevent senior clinicians in other specialities taking action they feel is appropriate in the situation but aims to provide clarity regarding the pivotal role the Team Leader plays in coordinating the response of the team and to support them in that role. 14.2 The Consultant Paediatrician on-call is ultimately responsible for the management of the situation and should be kept informed of any paediatric resuscitation/cardiac arrest. The consultant paediatrician should be contacted at the earliest possible opportunity. 10
15.0 Staff in attendance 15.1 The medical staff expected to attend include the paediatric registrar, the paediatric SHO (FY2), the anaesthetic registrar and SHO. The paediatric registrar will be the team leader and should possess a current EPALS/APLS qualification. 15.2 Other staff to attend include a resuscitation training officer, operating department practitioner, porter and a senior registered children s nurse. 15.3 The paediatric team will attend all trauma calls of children and will assist the Trauma Team as necessary 16.0 Intensive Care Advice 16.1 Advice regarding management of Children s Critical Care and Trauma patients can also be obtained from Paediatric Intensivists via the Children s Acute Transport Service (CATS) telephone 0800 085 0003. 16.2 Prior to, or whilst, contacting CATS senior medical staff should be present including the Anaesthetic Registrar and/or Consultant and Paediatric Registrar and/or Consultant as well as the most senior paediatric nurse on site. 16.3 The Consultant Paediatrician should be consulted before contacting CATS for advice or to request retrieval. 17.0 Imaging Sharing Protocol 17.1 A web based image sharing system is used by CATS to enable rapid, secure transfer of x-rays and scans. The use of this system has been agreed by the Caldicott Guardian, IT and Radiology and can be accessed via www.cats.nhs.uk. 18.0 Intubation and Ventilation 18.1 The majority of children who deteriorate slowly are on phoenix children s ward. The decision to intubate and ventilate in most cases should be made in discussion with Paediatric Consultant on-call. There may be some cases where decision needs to be jointly taken by Consultant Paediatrician and Consultant Anaesthetist. This discussion should be written clearly in child s health care records. 18.2 The Consultant Paediatrician and/or Paediatric Registrar may be more competent in intubating the smaller infants who are < 4-5Kg. 19.0 Support for family 19.1 At all stages of the resuscitation and/or stabilisation the needs of the parents will be considered. It may be appropriate for them to stay during this process but they should ideally have a member of staff with them to provide support and information. If senior members of the team feel that the presence of the parents is hindering the resuscitation and this cannot be rectified within a reasonable period of time they may be asked to leave. 19.2 During any time that the family are unable to be with their critically ill child, they must be fully informed and supported. 11
19.4 It is important that information is readily available which can be given to parents. 20.0 Moving a child to theatres 20.1 Indications Obstructed airway e.g. severe croup, suspected tracheitis, epiglottitis, inhalational injury or foreign body, where there may be a need for gaseous or inhalational induction Difficult airway, with ENT surgeon on standby Where a surgical tracheostomy is likely 20.2 Precautions The decision to transfer the child to theatre for intubation should be made by the senior Anaesthetist present in consultation with the Paediatric Team. The Consultant Anaesthetist should be present or at least should be aware of the transfer. The Anaesthetic Team in collaboration with Paediatricians should ensure that the patient is stable enough to tolerate the transfer to theatre. The Anaesthetic Team will ensure that appropriate equipment is available for transport. 20.3 Action and Personnel The child should be accompanied by the Consultant Anaesthetist or an appropriate Anaesthetist after discussion with the Consultant, the Paediatric Registrar and/or Consultant Paediatrician, ODP and Senior Paediatric Nurse. The transfer to theatre must be discussed in advance with the theatre staff and should not take place until the theatre staff is ready to receive the patient. The Senior Anaesthetist is responsible for ensuring that the necessary staff, equipment and drugs are available immediately on arrival in theatre. 21.0 Post resuscitation care 21.1 Following the successful resuscitation and/or stabilisation of the child a decision will be made by the Paediatric Team in conjunction with anaesthetic team and CATS regarding the most appropriate location for on-going care. 21.2 This location may be: Resuscitation bay, Emergency Department whilst awaiting transfer Stabilisation/Treatment Room Phoenix Ward whilst awaiting transfer. Theatres, whilst awaiting transfer High Dependency Unit, Phoenix Ward 21.2 Adult ICU may be considered in exceptional circumstances such as when CATS is temporarily unable to retrieve or there is an extreme shortage of PICU beds and the patient is expected to need short term intensive care only. Full consideration will be needed balancing the risks and benefits of this compared to the other options. 12
Continuing liaison between ICU and Paediatric Medical and Nursing staff as well as CATS would be required. The child should be transferred to a PICU in a tertiary centre if on-going intensive care is required. 21.3 The consideration would need to be given to: Availability of adult ICU bed Age and size of the child Skills of the available nursing staff on adult ICU at that particular time Availability of a paediatric nurse to assist the ICU staff Paediatric team sharing care with the anaesthetic team Current infectious risks from/to other ICU patients 21.4 Neonatal unit may also be considered in exceptional circumstances for infants with similar considerations as for adult ICU. The risk of transfer of infection to other neonatal unit patients must be given serious consideration. 21.5 Each area will require appropriate equipment that must be checked regularly and copies of drug calculation guides. Adult ICU do not have paediatric specific equipment. Additional equipment is available on Phoenix ward and should be sent to Adult ICU for the duration of the child s admission. 22.0 Airway support and Ventilation 22.1 The Anaesthetic Team (Registrar and/or Consultant) have primary responsibility for Airway Management and Ventilation after a successful resuscitation or stabilisation. They may leave the patient in the care of the Paediatric Team after full discussion if the Paediatric Team are happy to accept responsibility for this aspect of management. 22.2 When the patient is ventilated the Anaesthetic Team will stay with the patient until arrival of the retrieval team or transfer of the patient to a Paediatric Intensive Care Unit. The only exception to this would be where an infant is attached to a neonatal ventilator, with a Neonatal Nurse in attendance, and after full discussion if the Paediatric Team are happy to accept responsibility for this aspect of management. 22.3 Consideration should be given to nursing infants on a resuscitaire with access to a neopuff which can be used instead of a self-inflating bag for short term ventilation before stabilising on a ventilator. 22.4 A mechanical ventilator will be used in preference to hand bagging. The options include: Anaesthetic machine in Theatres or Phoenix Portable Ventilator (can be used on transfer if required) Baby Pac < 15kg - This should be the first choice for patients below 10kg. It is kept on phoenix ward. Oxylog 3000 > 10-15 kg in ED 22.5 End Tidal CO2 monitoring must be used for all intubated / ventilated children. 13
23.0 Stabilisation 23.1 The Paediatric Team (Registrar and/or Consultant) has overall responsibility for post resuscitation management and stabilisation. Guidance on this is contained in the APLS/EPLS Manual. Advice will normally also be obtained from the Children s Acute Transport Service (CATS) telephone 0800 085 0003. 23.2 Following resuscitation or stabilisation a patient should be monitored by continuous cardiorespiratory monitoring and observations recorded every 15 minutes unless otherwise specified. Please note: the Paediatric Consultant on-call MUST be contacted if not already done so. Priorities include: Airway and ventilation Circulation Brain Temperature control e.g. resuscitaire / warm air blankets e.g. warm touch machine Kidney and Fluids including catheterisation Liver Gastrointestinal Haematology and Biochemistry Infection Skin, Joints Vascular Access Monitoring Parents, communication 24.0 Emergency Surgery 24.1 All children under 5 years of age with suspected surgical conditions are to be seen by the paediatric team. 24.2 All children over the age of 5 years of age with suspected surgical conditions are to be seen by the surgical team even if they would need to be transferred to other centres for an operation. Joint management with the Paediatric Team may be required for those children with cardio-respiratory instability. 24.3 In an acute situation where surgery is time critical consideration should be given to transferring the child to the tertiary centre by the District General Hospital (DGH) team. See appendix 4. 24.4 Children under 3 months should be transferred to a paediatric surgical centre if surgery is required. Children over 3 months may be operated upon here depending on the condition and experience of the Surgeon and Anaesthetist. Children with suspected acute testicular torsion should be operated upon here. 14
25.0 Transfer 25.1 Effective preparation and planning are essential for all successful transfers whether the transfer is to the Imaging Department, to or between wards or to another hospital. Please refer to Transferring children policy 09005. 25.2 Transfers, including internal, must be planned considering: Whether the child is in an acceptable condition for the transfer The urgency The most appropriate personnel to perform the transfer 25.3 Inter-hospital transfers of level 3 paediatric intensive care children are usually carried out by CATS. They should be contacted at the earliest opportunity to allow a rapid response. 25.4 It is important they are kept updated of the child s progress, as deterioration in the child s condition may prompt CATS to assign a higher urgency category to the child and elicit earlier mobilisation of the retrieval team. 25.5 The following should be considered before transfer. Further details are available in the APLS/EPLS Manual and via the CATS website. A transfer checklist is available and should be used for all locally undertaken transfers. Refer to Transferring children policy 090051. 26.0 HDU admission 26.1 All children admitted to Paediatric HDU on Phoenix children s ward should be seen at least twice daily by the consultant of the week. They should be seen on morning ward round by the Consultant and then before 17.00 hours handover. The management plan should be documented clearly in healthcare records. 26.2 There should be Registrar review during the day, before evening handover at 21:00 hours and by night Registrar during night shift. They should document all reviews in healthcare records of patient and also document any discussions with Consultant and CATS team. 27.0 Adult ICU admission 27.1 All children admitted to adult ICU should be seen and reviewed as set out in 26.0. 27.2 All children admitted to adult ICU due to lack of PICU beds should be transferred to PICU after discussion with CATS team as soon as bed becomes available. A repeat attempt should be made to find the PICU bed the following day. 27.3 Any child admitted to adult ICU will be cared for by the ICU team with the support of the consultant paediatrician. 28.0 Death of a Child 28.1 In rare circumstance a child in whom death is expected e.g. with terminal malignancy may present critically ill to the hospital. In this circumstance the child should have an emergency care plan and the Consultant Paediatrician should be called immediately for advice. The default position in the absence of any information to the contrary would be to 15
offer resuscitation until a Senior Clinical Paediatrician (or Emergency Department Consultant) can speak to the family and clarify the reason for presentation. 28.2 The unexpected death of a child while in hospital will undergo formal review by the Child Death Rapid Response Team (CDRRT) process in addition to internal review by the Children s Governance process. This review should be multi-professional and all reasonable steps should be taken to involve specialties who contributed to the child s care. Some unexpected deaths may be classified as a serious incident and the Serious Incident (including Never Events) Procedure must be followed. 29.0 Organ donation Organ donation should be considered in all circumstances where a child is at high risk of death. Prior discussion with the organ donation teams will ensure that families are only approached where donation may be feasible and ensure optimal circumstances for donation. The Consultant Paediatrician will be responsible for considering this aspect of care and making the relevant enquires before approaching the family. 31.0 Audit and Monitoring 31.1 Where a child s notes have demonstrated that the appropriate action has not been taken a risk event form is to be completed. This will address any further training needs for staff that require updating. 31.2 A paediatric morbidity/mortality meeting will be led by a consultant paediatrician every 2 months. 31.3 A joint audit meeting (paediatric/anaesthetic) will be held annually to review cases and to learn from experiences. This will be open to nursing and medical staff in all areas of the Trust that may be involved in the care of a critically ill child. 31.4 Teleconference case review with CATS are held periodically on a case by case basis 32.0 Communication 32.1 Approved guidelines are published monthly in the Trust s Focus Magazine that is sent via email to all staff. 32.2 Approved guidelines will be disseminated to appropriate staff via email after ratification of guideline. 33.0 References Advanced Paediatric Life Support: The Practical Approach 6 th Edition (2016) Advanced Life Support Group. BMJ publishing Children s Acute Transport Service. www.cats.nhs.uk DOH (2006) The acutely or critically sick or injured child in the District General Hospital: A team response. DOH (2001) High Dependency care for children: Report of an expert advisory group 16
Nursing and midwifery council (NMC) (2015) The Code Professional standards of practice and behaviour for nurses and midwives (online) http://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/revised-new-nmccode.pdf accessed 01/06/2016 RCPCH (2015) Facing the Future: Together for Child Health RCPCH (2014) High Dependency Care for Children: Time to move on RCPCH (2012) Standards for children & young people in emergency care settings RCPCH (2007) Services for children in emergency departments: Report of the Intercollegiate Committee for Services for children in Emergency Departments The Royal college of Surgeons of England (2015) Standards for non-specialist Surgical Care for Children PICS Society (2015) Standards for the Care of Critically Ill Children 5 th edition 17
Appendix 1 Equality Impact Assessment (EIA) Title of document: Care of the Critically Ill Child Equality or human rights concern. (see guidance notes below) Gender Race and ethnicity Disability Religion, faith and belief Sexual orientation Age Transgender people Social class Carers. Does this item have any differential impact on the equality groups listed? Brief description of impact. None Patients and/or parents may require translation services. Access to children s wards, emergency department and Outpatient clinics. Patients and/or parents with cognitive or sensory impairment may have difficulty with understanding information. None None None None Access to services and information may be affected by financial constraints. Issues relating to race, ethnicity and disability may apply. How is this impact being addressed? Trust uses The Big Word for translation services. All facilities meet building standards. Hospital Liaison Specialist LD Nurse will support these patients and their families with LD Information on transport and reimbursement of costs is available. As above Date of assessment: 10 th May 2016 Names of Assessor (s): Andrea Stanley 18
Appendix 2 Interventions/categories/disorders defining level of Paediatric Critical Care Level 1 HDU Interventions: Continuous ECG monitoring +Oxygen therapy + continuous pulse oximetry Arrhythmia requiring IV anti-arrhythmic Upper airway obstruction requiring nebulised adrenaline Severe asthma requiring IV bronchodilator therapy DKA requiring continuous insulin infusion Apnoea - recurrent Reduced conscious level (GCS 12 or below) AND hourly or more frequent GCS monitoring Level 2 HDU Interventions: Any of the above where there is a failure to respond to treatment as expected or the requirement for intervention persists>24 hours Status epilepticus requiring continous anti-convulsant infusion Nasopharyngeal airway CVP monitoring Epidural Acute non-invasive ventilation / CPAP / BIPAP High Flow Nasal Cannula Oxygen (Optiflow / Airvo2 / Vapotherm) Arterial monitoring Acute renal replacement therapy (CVVH or HD or PD) Plasmafiltration Exchange transfusion Acute temporary pacing Inotropic/vasopressor treatment (e.g adrenaline / noradrenaline / dopamine infusion) Intravenous thrombolysis (tpa, streptokinase) ICP (intracranial pressure) monitoring or EVD (external ventricular drain) CPR (cardio-pulmonary resuscitation) in last 24 hrs Extracorporeal Liver Support (MARS) >80 mls/kg volume boluses in 24 hours Care of tracheostomy (first 7 days of admission) Care of long term ventilation patient Other interventions to Level 3: Intubation and invasive ventilation Burns >20% Body Surface Area Other situations or conditions requiring higher 1:2 nursing care or higher (please detail): 19
Appendix 3 Escalation pathway of a deteriorating paediatric patient 20
Appendix 4 Flow chart for transfer of a child to a paediatric tertiary centre 21