Post on 22-Aug-2020
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Care of Children and Young People
Presenting to Hospital with
Decreased Conscious Level
Executive Summary for Nurses
Jason Gray
Paediatric Emergency Nurse Consultant
Royal Alexandra Children’s Hospital, Brighton
Funded by the National Reyes Syndrome Foundation, UK
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Background and Methodology
• Based on the 2005 Paediatric Emergency Research Group guideline The Management of a Child with a Decreased Conscious Level
• Aim-To assess whether children with a decreased conscious level are receiving appropriate care according to the guideline’s recommendations.
• Data collection from 1 Nov 2010 to 30 Sept 2011
• Prospective case identification: (Most trusts used combined prospective/retrospective or retrospective only case identification)
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Participation
• 54 NHS trusts (comprising 66 hospitals) from England, Wales and Northern Ireland
• 51/54 (94%) trusts submitted clinical audit data (samples ranged from 1 to 73 cases) – Data submitted on 1135 eligible cases
• Place of presentation
– Mixed emergency department = 61.8% (701)
– Paediatric emergency department = 35.9% (407)
– Paediatric assessment unit = 2.2% (25)
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Clinician Survey
• 72% (182/204) respondents were consultant
paediatricians
• 46% (94/204)knew about the guideline prior to the audit
• Respondents find out about new guidelines most
commonly
– from their colleagues, journal articles, the RCPCH
website or a
– posted copy of the guideline.
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Familiarity with Guidelines
Clinicians indicated that the most important means of
promoting guideline use were the provision of:
– a one page algorithm
– quick reference summary of the guideline
– education and training sessions
– a poster of the guideline
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Lack of Nursing Involvement?
• Include nurses in distribution and dissemination of guideline.
• Include nurses in audit.
• Include the Royal College of Nursing
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Inclusion/Exclusion criteria
• 0-17 years
• AVPU assessment of voice, pain or unresponsive OR GCS 14 or less on presentation to hospital
• Repeated episodes of decreased conscious level providing there is no known or established diagnosis
Inclusion
• Previously diagnosed condition known to be the cause of the decreased conscious level
• Possession of a ventriculo-peritoneal shunt
• GCS less than 15 on a day to day basis
• Preterm or full term infants with decreased conscious level from the moment of birth onwards
• Transfers from another hospital
Exclusion
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Audit sample characteristics
• 45.2% (513/1135) female and 55.8% (622/1135) male
• Mean age of 8.3 years
• 94.9% had differential working diagnosis-
– most common were alcohol intoxication (29.0%), infective
causes (20.2%) and traumatic causes (16.4%).
• 16 deaths (1.4%), 9.9% (112/1135) transferred to paediatric intensive care units and 4.1% (46/1135) transferred to other NHS hospitals
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Audit measured 8 main areas of
management • Features of clinical history
• Observations
• Use of physiological scoring systems (GCS/AVPU)
• Recommended frequency of GCS measurements
• Recommended core investigations and tests
• Working diagnosis within 4 hours of presentation
• Management plan within 4 hours of presentation
• Parent or guardian involvement during initial
resuscitation and management
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Highlights: Clinical Audit
Findings • Good documentation of the following:
– Observations: heart rate, respiratory rate and oxygen saturation
– Working diagnosis and management plan within 4 hours of presentation
– Use of AVPU or GCS at presentation to hospital
• Areas requiring improvement in documentation
– Clinical history features of vomiting, fever, convulsions, alternating periods of consciousness, length of symptoms, ingestion of medication/recreational drugs
– Observations: blood pressure and temperature
– Communication with parents regarding their child’s diagnosis and prognosis.
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Heart Rate
02 sats
RR
Temp
BP
Observations (n = 1135)
98%
90% 74.5%
22%
61%
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Interesting Finding
• Children presenting with a decreased conscious level secondary to non-traumatic causes or unknown cause were more likely to have documentation of their respiratory rate compared with those children presenting with alcohol intoxication or traumatic causes.
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Interesting Finding
• Children who presented to mixed emergency departments or paediatric assessment units were more likely to have documentation of their respiratory rate than those children presenting to paediatric emergency departments.
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Interesting Finding for under
5’s • Children under five years were less likely to
have documentation of blood pressure on presentation as compared with those five years and over.
• Children under five years were more likely to have documentation of their temperature on presentation as compared with those five years and over.
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The assessment of consciousness and
frequency of GCS measurements
Audit standards Total audit
sample
Cases
meeting
the
standard
% Cases
meeting
the
standard
GCS or AVPU
assessment performed
and documented
1135 1099 96.8%
Recommended frequency
of GCS measurements
performed and
documented(children with
GCS performed)
903 440 48.7%
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Interesting Finding for Parental
involvement
• The levels of documentation were generally low across all types of units.
• Mixed emergency departments or paediatric assessment units were more likely to have documentation indicating that parent or guardian was allowed to stay with them during the initial resuscitation and management as compared to those children presenting to paediatric emergency departments.
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Alcohol as the cause of the
decreased conscious level
315 children or young people (28%)
presented with a decreased
conscious level secondary to
alcohol intoxication
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Alcohol Intoxication
Place of presentation to hospital
(n=315) • Mixed Emergency Department = 196 (62%)
• Paediatric Emergency Department = 116 (37%)
• Paediatric Assessment Unit = 3 (1%)
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Day of presentation (n =315)
• The majority of these cases presented on a weekend day
(63%) as compared to a week-day (37%).
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Age and Gender (n=315)
• Alcohol presentations more common with females
(55%) than male children (45%)
• Mean age = 14.7 years
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Alcohol Intoxication
Outcome (n = 315)
Outcome Numbers
Discharged 223 (70.8%)
Self discharged 3 (1.0%)
Unknown 1 (0.3%)
Transferred to the ward (paed or
adult)
83 (26.3%)
Transferred to Paed ICU or Adult
ITU
3 (1.0%)
Transferred to Other NHS Hospital 2 (0.6%)
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Findings
•Diagnosis of alcohol intoxication should be considered for older children and adolescents presenting to Emergency departments with reduced conscious level.
•These children should be reviewed by more senior staff
•There needs to be better documentation of the clinical history in these children
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Clinical Audit Findings:
Highlights • Good documentation of observations, management plan within 4 hours of presentation
• Areas for improvement in the documentation of the absence or presence of the following clinical history features
– vomiting before or at presentation = 63.2% (199/315) – headache before or at presentation = 11.4% (36/315) – convulsions before or at presentation = 9.5% (30/315) – alternating periods of consciousness = 50.5% (159/315) – trauma = 49.2% (155/315) – length of symptoms = 64.4% (203/315)
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Key Recommendations for Nurses
• All health professionals should take a comprehensive clinical history irrespective of the differential diagnosis.
• Clinical history documentation should include:
– Information on both the presence of a feature and its absence
– Reasons if unable to obtain an adequate history
• On arrival to hospital, all children with a decreased conscious level should have a complete set of observations taken including heart rate, respiratory rate, oxygen saturation, blood pressure and temperature.
• If a child requires regular evaluation of their conscious level, GCS measurements should be commenced in addition to or instead of AVPU (15 mins – 60 mins)
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Key Recommendations for Nurses
• Capillary blood glucose should be undertaken in all
children
• All children with decreased LOC due to metabolic,
infective or unknown should receive appropriate and early
investigations
• Nurses should document any discussions undertaken
with parents, CYP
• All health care professionals should inform
parents/guardians of possible diagnosis and document
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Key Recommendations for Trusts
• Nurses should receive regular training to reinforce good
record keeping skills and this should be part of all trusts’
compulsory training programme.
• Observations charts should be incorporated into the
emergency department notes whether written or
electronic.
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Thank you