Realistic evaluation of Situation Awareness for Everyone (SAFE) on paediatric wards: study protocol

INTRODUCTION

Evidence suggests that health outcomes for hospitalised children in the UK are worse than other countries in Europe, with an estimated 1500 preventable deaths in hospital each year. It is presumed that some of these deaths are due to unanticipated deterioration, which could have been prevented by earlier intervention, for example, sepsis. The Situation Awareness For Everyone (SAFE) intervention aims to redirect the 'clinical gaze' to encompass a range of prospective indicators of risk or deterioration, including clinical indicators and staff concerns, so that professionals can review relevant information for any given situation. Implementing the routine use of huddles is central to increasing situation awareness in SAFE.

METHODS AND ANALYSIS

In this article, we describe the realistic evaluation framework within which we are evaluating the SAFE programme. Multiple methods and data sources are used to help provide a comprehensive understanding of what mechanisms for change are triggered by an intervention and how they have an impact on the existing social processes sustaining the behaviour or circumstances that are being targeted for change.

ETHICS AND DISSEMINATION

Ethics approval was obtained from London-Dulwich Research Ethics Committee (14/LO/0875). It is anticipated that the findings will enable us to understand what the important elements of SAFE and the huddle are, the processes by which they might be effective and-given the short timeframes of the project-initial effects of the intervention on outcomes. The present research will add to the extant literature by providing the first evidence of implementation of SAFE and huddles in paediatric wards in the UK.

Multi-method evaluation of a paediatric ambulatory care unit (PACU): impact on families and staff

AIM

To assess the impact of a purpose-built, short stay paediatric ambulatory care unit (PACU) on the patient journey and perceptions of parents, staff and referrers.

METHODS

Multi-method evaluation, including a parent survey (n = 104), patient journey mapping (n = 10), staff interviews (n = 10), a referrer survey (n = 16), routine activity analysis, and a comparison with the A&E service (A&E parent survey: n = 41).

RESULTS

Almost all parents attending PACU (94%) were satisfied with the service and significantly more likely to feel "very" satisfied than parents attending A&E (PACU: 51%, A&E: 31%; p = 0.03). Further, over three quarters (77%) of PACU parents preferred the new model to traditional A&E services. They reported receiving sufficient information (93%), reduced anxiety (55% anxious before service, 13% anxious after; p<0.001), "quick" waiting times (median: 35 min), and enhanced confidence (87%) and understanding (89%) in dealing with their ill child. The number of stages in the patient journey was reduced from six ("traditional" A&E pathway) to four (PACU pathway). Staff and referrers reported this was a "superior" model to A&E, but that improvements were required around appropriate referrals and the need for more multi-disciplinary protocols and liaison.

CONCLUSION

Our study suggests that the PACU model is perceived to be an effective alternative to standard A&E services for the assessment and early management of acutely ill children and their families attending a hospital. It is highly valued by users, staff and referrers and enhances the patient journey. Lessons learnt include the need to enhance multi-disciplinary processes and clarify the role of this form of acute care provision in the wider healthcare system.

Wheeze detection: recordings vs. assessment of physician and parent

BACKGROUND

Parental and professional agreement as to the presence of wheezing in infants and preschool children has been shown to be poor. Agreement on the absence or presence of physical signs on chest examination in these populations is far from perfect, even among experienced physicians.

OBJECTIVES

We sought to compare the assessment of a parent, nurse, and physician with the "gold standard" of acoustic analysis for the presence of wheezing in infants and preschool children attending a hospital clinic.

SETTING AND SUBJECTS

Urban district general hospital in North London, England. Wheezy children under 6 years old attending a "walk-in" emergency pediatric ambulatory care unit.

RESULTS

Comparisions were completed on 31 children (age range 4-62 months). The severity of wheeze was independently evaluated by a parent, nurse, and experienced pediatrician, and these were compared with breath sounds recorded and analyzed by acoustic techniques for the presence and severity of wheezing. In only 10 of 31 (32%) children did the parent and the physician agree on the wheeze severity score. In 13 infants, the parent scored higher than the doctor and in 8 the parent scored lower. In 16 (52%) of the children, there was complete agreement as to the severity of wheezing by the nurse and the physician. In 24 of the 31 children (77%), the acoustic wheeze score agreed with the physician wheeze score; in 6 children the acoustic score was lower and in 1 it was higher.

CONCLUSIONS

The physician was able reliably to judge the severity of wheeze measured objectively, whereas nurses and parents were not. This study has important implications for the interpretation of parental questionnaire studies of asthma prevalence and severity.

Intravenous salbutamol bolus compared with an aminophylline infusion in children with severe asthma: a randomised controlled trial

BACKGROUND

The relative efficacies of aminophylline and salbutamol in severe acute childhood asthma are currently unclear. A single bolus of salbutamol was compared with a continuous aminophylline infusion in children with severe asthma in a randomised double blind study.

METHODS

Children aged 1-16 years with acute severe asthma were enrolled if they showed little improvement with three nebulisers (combined salbutamol and ipratropium) administered over an hour and systemic steroids. Subjects were randomised to receive either a short intravenous bolus of salbutamol (15 micro g/kg over 20 minutes) followed by a saline infusion or an aminophylline infusion (5 mg/kg over 20 minutes) followed by 0.9 mg/kg/h.

RESULTS

Forty four subjects were enrolled, with 18 randomly allocated to receive salbutamol and 26 to receive aminophylline. The groups were well matched at baseline. An intention to treat analysis showed that there was no statistically significant difference in the asthma severity score (ASS) at 2 hours between the two groups (median (IQR) 6 (6, 8) and 6.5 (5, 8) for salbutamol and aminophylline respectively, p=0.93). A similar improvement in ASS to 2 hours was seen in the two groups (mean difference -0.08, 95% CI -0.97 to 0.80), there was a trend (p=0.07) towards a longer duration of oxygen therapy in the salbutamol group (17.8 hours (95% CI 8.5 to 37.5) v 7.0 hours (95% CI 3.4 to 14.2)), and a significantly (p=0.02) longer length of hospital stay in the salbutamol group (85.4 (95% CI 66.1 to 110.2) hours v 57.3 hours (95% CI 45.6 to 72.0)). There was no significant difference in adverse events between the two groups.

CONCLUSIONS

This study suggests that, in severe childhood asthma, there is no significant difference in the effectiveness of a bolus of salbutamol and an aminophylline infusion in the first 2 hours of treatment. Overall, the aminophylline infusion was superior as it significantly reduced the length of stay in hospital.

Issues in the identification of comorbidity of mental retardation and psychopathology in a multicultural context

Identification of the comorbidity of mental retardation and psychopathology in a multicultural setting raises manifold difficulties. The present study explored the sampling and identification issues implicated in estimating the prevalence of this dual diagnosis in a South African clinic sample. The relations between the prevalence of dual diagnosis and socioeconomic status, gender, and severity level of retardation were investigated. The detection rate of 4.36% was significantly lower than that of other studies. Prevalence was found to be greater in areas of high socioeconomic status, among males, and among less severely retarded individuals. Implications of these findings for cross-cultural studies and for allocation of service resources for patients with dual diagnosis are considered.

Association between the diagnosis of mental retardation and socioeconomic factors

Clinic data from the regional hospital in Cape Town, South Africa, over 4 years for 538 children with a diagnosis of mental retardation were examined in order to establish whether differences in mental retardation referral patterns existed between low and high socioeconomic areas. Results indicate that mild mental retardation referrals were underrepresented in low socioeconomic areas and that paramedical agencies were the primary referral source in these areas. Differences in mild mental retardation referral patterns by area over time may stem from service difficulties or variations in referral thresholds. Cross-cultural implications of the findings were discussed with relevance to the development of culturally sensitive community-based intervention programs.

The aetiology of learning disability in preschool children with special reference to preventability

The aims of the study were to determine the aetiology of moderate and severe learning disability in preschool children in Cape Town, to consider the causes by race and to assess the degree of preventability. All children under the age of 6 years who presented to the Developmental Assessment Clinics at the Red Cross Children's Hospital with a developmental quotient of less than 50 over a 1-year period were included. The Development Assessment Clinics form a regional multidisciplinary service for the evaluation of preschool children with development disabilities. Over the 12-month period, 232 children were identified, of whom 65% were Coloured, 32% African and the remaining 3% white. This roughly corresponds with teh breakdown of births by race in the region. Regarding the aetiology, in 45% the disability was prenatal in origin, in 17% perinatal, in 9% postnatal and in a quarter it was idiopathic. In the Coloured and white children, the cause in over a half arose prenatally and in 8.3% postnatally. In contrast, the cause in less than a third of the African cases arose in the prenatal period, but 36% resulted from perinatal complications. More of the African children had multiple disabilities and additional disabilities were more common in the perinatal and postnatal categories. Forty per cent of all cases were considered to be preventable, 16% with existing knowledge and current practice. There was no significant difference in preventability between the races.

Breaking bad news to parents with disabled children--a cross-cultural study

This cross-cultural retrospective study investigates the problems parents experience when told that their child is physically and/or mentally disabled. The authors try to compare, where relevant, some of the responses of the parents from different ethnic groups. The parents of 40 randomly selected coloured, 26 white and 24 black pre-school children who were first seen at the Developmental Assessment Clinic at the Red Cross War Memorial Children's Hospital in Cape Town, South Africa between January 1989 and December 1990 were asked to participate in this study. The final sample comprised 65 children. Except for the Xhosa speaking parents, the majority of parents received the diagnosis in their own language (English or Afrikaans). Most Xhosa speaking parents denied having received an explanation of the diagnosis, or having had an opportunity to ask questions. Only a few black parents reported being asked as to their understanding of the diagnosis. White parents tended to deny the diagnosis of mental handicap more often than the other groups despite reporting that explanations were given. The majority of parents would have liked a written report after the first consultation. Despite these findings, most parents felt satisfied with the way the news were given to them, reported good progress in their children and some of them expected their children to go to a normal school. Use of a language other than the parent's tongue tends to have a negative influence on the communication between doctors and parents. A diagnosis of mild mental handicap, a 'perception' of good progress and an absence of visible signs of the disability contribute to parental denial of the reality of the child's developmental delay and its scholastic consequences. The process of 'breaking the news' can be facilitated by the introduction of a few simple measures as described in the recommendations.

Missed opportunities for measles immunisation in selected western Cape hospitals

Measles is still a major cause of childhood mortality and morbidity in South Africa. The World Health Organisation (WHO) has recently recommended that greater attention be paid to opportunities for immunisation in the curative sector. This study quantified the extent of missed opportunities for measles immunisation in children attending primary, secondary and tertiary level curative hospitals in the western Cape. Exit interviews of 1,068 carers of children aged between 6 and 59 months inclusive showed that 2.4-40.7% of carers had been requested to produce a Road-to-Health card, and that 4.8-43.1% of carers had a card available. The proportion of children with documented evidence of measles immunisation available ranged from 4.8% to 40.0% between facilities. The study demonstrated that a considerable number of potential opportunities to immunise children against measles are currently being missed in children attending hospitals and day hospitals in the western Cape. The study documents the effect of a fragmented approach to health care, and indicates a need for rapid integration of preventive and curative components of health care into a metropolitan-based primary health care service.

Gastric fistulas in Crohn's disease. Report of cases

Nine cases of gastric fistula occurring in patients with Crohn's disease were treated at The Mount Sinai Hospital over the past three decades. Six cases were found in a review of 1480 patients with Crohn's disease admitted between 1960 and 1983. Three others seen at this institution outside the time frame of the author's study have also been included. Among six new cases, five with cologastric fistula occurred among 907 patients with Crohn's disease involving the colon (0.6 percent), while only one with ileogastric fistula was encountered among 1211 patients with ileal disease (0.08 percent). Fistulas between the stomach and colon always originated in an area of colitis, usually passing from distal transverse colon to greater curvature, but occasionally from midtransverse colon to antrum. The only pathognomonic clinical features were feculent vomiting, eructations, or odor. Diagnosis usually was made by barium enema or, less frequently, by upper gastrointestinal series; rarely, the gastric fistula was found unexpectedly at surgery. The conventional and recommended therapy is colectomy with wedge excision of the stomach. Medical treatment with 6-mercaptopurine has been completely successful in one patient and intermittently successful in a second patient.

Computerized intraoperative calculation of instantaneous prosthetic aortic valve area

Improved assessment of valve area is essential to understanding the performance of prosthetic valves. The authors studied six patients undergoing aortic valve replacement using mechanical (ME) or porcine (PO) prostheses. Instantaneous cardiac output (CO) (L/min) was measured in the aorta using an ultrasonic flow probe. Left ventricular and aortic pressures (mmHg) were measured using Millar catheters. Data were analyzed using an IBM PC-AT. Valve area (cm2) was determined using Gorlin's formula (AG) and a new formula for instantaneous area derived mathematically and using a theoretic constant. AG, mean (AI) and peak (Apk) instantaneous areas were compared to geometric measures of area (Aactual) in vitro. Peak instantaneous area correlates best with measured area. Intraoperative assessment using the ultrasonic flow probe and computer analysis is helpful in understanding the dynamic properties of prosthetic valves in vivo.

Perforating and non-perforating indications for repeated operations in Crohn's disease: evidence for two clinical forms

The surgical indications in 770 patients with Crohn's disease undergoing intestinal resection at The Mount Sinai Hospital from 1960-83 have been reviewed. Surgical indications were divided into two principal categories: 375 cases with perforating indications and 395 cases non-perforating. Among 292 patients who underwent second operations for recurrent Crohn's disease, the indications for second operation were closely dependent on the indication for primary resection. Second operations were undertaken for perforating indications much more often among cases where the initial indication had been perforating, than among those whose initial indications had been non-perforating (73% v 29%, p less than 0.00001). This trend to similarities in the indications which bring patients to surgery was maintained within each anatomical category of Crohn's disease and even between second and third operations (p less than 0.001). Operations for perforating indications were followed by reoperation approximately twice as fast as operations for non-perforating indications, whether going from first to second operation (perforating 4.7 v non-perforating 8.8 years, p less than 0.001), or from second to third (perforating 2.3 v non-perforating 5.2 years, p less than 0.005). Crohn's disease thus seems to occur in two different clinical patterns, independent of anatomic distribution. These are a relatively aggressive perforating type and a more indolent non-perforating type, which tend to retain their identities between repeated operations and to influence the speed with which reoperation occurs.

Spontaneous free perforation and perforated abscess in 30 patients with Crohn's disease

Spontaneous free perforation is an uncommon event in the natural history of Crohn's disease. It occurred in 21 of 1415 patients (1.5%) admitted with Crohn's disease to The Mount Sinai Hospital between 1960 and 1983. The mean duration from onset of Crohn's disease to occurrence of perforation was 3.3 years. Ten patients had small bowel perforation, ten patients had large bowel perforation, and one patient had simultaneous perforation of both ileum and cecum. The incidence of perforation in disease segments of small bowel was 1.0% (jejunum 6.0%, ileum 0.7%), and in the colon, 1.3%. Besides the 21 patients with spontaneous free perforation, an additional nine patients had spontaneous free rupture of an abscess into the peritoneal cavity. The mean duration from onset of Crohn's disease to rupture of abscess was 8.5 years. All 30 patients had surgery within 24 hours of perforation or rupture. All 21 patients with spontaneous free perforations survived, as did all but one of the nine patients with perforated abscess. The cornerstone of the treatment of ileocolonic lesions perforating into the general peritoneal cavity is proximal diversion with delayed reconstruction of intestinal continuity whenever possible. With perforation of the small bowel, primary reanastomosis is possible in selected patients.