Paediatric Critical Care Issues Database (PaediCRID) Dr Andrea Cooper Clinical Governance Lead WMPCCN Aimee Hodgson Governance Support Administrator WMPCCN/KIDSNTS
Neurosurgical Emergencies Multi Site Investigation planned External Investigation of potential difficult airway Anaesthetic issues decreasing
Feedback from the Multi site Investigation Update of the External review of the potential difficult airway Learning for the Governance team Feedback from a local RCA regarding Neurosurgical Emergency case Recent case pending SIRI but already identified some regional learning and probable recommendations that will be made A case awaiting investigation locally which raises a number of issues Summary of themes reported Excellence reports
Feedback from the Multi site Investigation 2 year old who presented with gastroenteritis and dehydration picture. Evolving sepsis concerns Cardiac compromise with tachycardia, hypotension and pallor. Metabolic acidosis on VBG with pH 6.2 and Lac 7 Referred to KIDS and started on Adrenaline infusion whilst preparing for intubation PEA arrest on induction despite appropriate cautious anaesthetic induction 2 minutes CPR and one dose adrenaline Post arrest gas pH 6.88, pCo2 7, BE -22 Lac 11 5 hour stabilisation time with KIDS No beds locally. No cardiac bed. Drive through Echocardiogram at BCH- “reduced” Ventricular function
Feedback from the Multi site Investigation No beds at BCH, so transferred to another non-cardiac ICU out of region Required inotropes CTB Normal Deranged coagulation- improved by Vitamin K LP clear NPA Rhino/entero/adenovirus positive Extubated 4 days post admission and discharged back to DGH on same day Well in DGH on the day of transfer, but concerns about tachycardia the following day Bloods revealed very elevated ALT CXR showed large heart with patchy shadowing Lactate of 2, hepatomegaly 2cm Treated with frusemide and periods of improvement.
Feedback from the Multi site Investigation Episode of tachycardia 200 – pulsed VT Dose of adenosine- no effect 5 x DC cardioversion attempts (Ketamine cover) Then amiodarone and DC Cardioversion- Sinus rhythm, but poorly perfused. Peri-arrest Required intubation and ventilation PEA on induction despite cautious induction RIP Investigation being lead by BCH Governance team. Highlights challenges of multi-site investigations and winter pressures Learning from this is important- could anything have been done differently? Family have been waiting for feedback for almost a year
Feedback from the Multi site Investigation Review the decisions made with regards to the patient pathway, taking into account bed availability regionally and nationally at the time, with the clinical information that was available at the time Coventry to BCH to Nottingham Nottingham back to Coventry identify any concerns about the choice of destination identify any concerns about time of discharge from PICU Review the clinical decisions made to see if any learning Following the Echo at BCH (17/11/18) With regards to the decision made not to repeat an Echo at Nottingham (was this possible to do?) With regards to the Echo findings at Coventry (21/11/18)
Feedback from the Multi site Investigation It was agreed that consideration should be given to the fact that those decisions made at the time were now being reviewed in hindsight and with information that was not available at the time. It was also considered as part of the review whether the decisions that were made, were made by the right people, at the right time and with the right information available.
Decision to transfer to a non-cardiac Centre: • Following a drive through echo at BCH. • Consultant cardiology review • Echo was in keeping with a diagnosis of sepsis • No concerns that further cardiology review may be required • Would transfer to a cardiac centre or remain in BCH (had a bed been available), would have changed the outcome? • Consenus, if a bed had been available at BCH at the time, the patient would have remained there with the opportunity to perform further echos, if indicated, within a shorter timeframe. • Timeframe between the 2 echos was only 4 days, and even had the patient remained within BCH, it is unlikely that an echo would have been repeated in this time. • Arrest ? ECLS ? Would have changed outcome • Presentation to a Hospital with a non-cardiac PICU, unlikely to be transferred out • Decision making appropriate
Management in PICU: • Extubated 2 days after arrival. • Post extubation : interacting, moving around and eating and drinking. • On the day of transfer she had a good appetite and there were no concerns from the team looking after her. • Discussion took place around the availability of echo in PIC. This is limited and at times may not have a technician or clinician available to perform one • Since the patient had significantly improved, and there were no on-going clinical signs of cardiac failure, there was no indication to repeat an echo prior to discharge back to Coventry.
Decision to transfer back to Coventry: • No Concerns from local team that PIC discharge was inappropriate • Day 5 of illness (D1 back in DGH) the patient continued to appear well and had a pre- planned (elective) follow up echo. This showed “left ventricular function impaired FS 21- 23%, mild ventricular dilatation, mild regurgitation”. • The 2 echos (the one performed at BCH, and the one performed after PICU discharge in Coventry) were reviewed by an independent Cardiology Consultant at BCH. It was concluded that the appearances of the 2 scans were very similar. • Areas of Good Practice • Timely identification by student nurse at Coventry that the patient was deteriorating during the evening and appropriate escalation of concerns • Resuscitation on the 21/11 • Support provided by KIDS team to Coventry on 21/11
Conclusion: • Overall capacity across the region did play a part in the pathway followed for this patient • The decisions made at the time were made by the appropriate staff, of the appropriate seniority, with the correct information available, and therefore that the decision made to transfer the patient to QMC was appropriate. • It is not known whether admission to a Cardiac PICU would have changed outcome.
Investigation of report that advice given by KIDS Consultant was potentially dangerous: Report from local Anaesthetist 7 month old child presents with neck swelling causing stridor when asleep and lying down USS revealed large retropharyngeal abscess. Unable to exclude mediastinal extension. Recommend Urgent ENT review and CT imaging AICU had been called prior to USS to provide airway assessment Concerns that there was significant potential for airway to obstruct and intubation may become extremely difficult Local team felt that transfer to BCH should occur ASAP Local ENT team had advised that they could not intervene surgically in local hospital
Investigation of report that advice given by KIDS Consultant was potentially dangerous: Referred to KIDS and advice was to electively intubate locally for CT scan Concerns raised by KIDS Consultant regarding transferring the child un-intubated Local ICU team refused to intubate due to concerns about difficult airway and lack of Plan B intubation plan Concerns about possible mediastinal involvement Discussed directly with BCH and accepted for CT scanning and surgery Local team felt the need to transfer and did so unintubated (with occasional stridor) Paediatric Anaesthetist took over the care- inhalational anaesthetic. Grade 1 intubation Discussed at KIDS M&M- Requested independent review of the event. Unfortunately, this did not yield a report outlining the details of the investigation or conclusions and recommendations that could be taken back to those involved and disseminated within the region
Terms of reference:
LEARNING!
Issue occurs PCC ODN PaediCRID Governance Process Issue is raised by any organisation through the PCCN Issue Form • Clinical Leads of all sites to receive issue forms, this will be sent via email from bwc.paedicrid@nhs.net. Notification is sent to • Reminder will be issued at week 4 and resolution of issue should be achieved by week 8 (unless it is determined that investigations the Network will require more time) Governance Group • Upon receipt of response, Network Governance Group will either agree satisfactory learning points have been captured and close Network Governance the issue or escalate Group writes to the Clinical Lead of the site for response Response received & Escalate to PCC ODN Escalate to BWCH accepted by Network Board Oversight Board / Governance Group Governance Issue closed and learning points Non-compliance to be reported to shared with PCCN Board NHSE commissioners
Neurosurgical Emergency Delay in transfer of a child with neuro surgical emergency to BWC theatre. 12year old, alleged assault at school. Presented to A&E Paediatric team contacted neurosurgeons at BWC. Sudden drop in GCS, unequal pupils. Paediatric Consultant contacted KIDS, KIDS advised primary transfer. Reluctance and delay by anaesthesia team in bringing the child.”
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