High Dependency Care Audit for Children

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High Dependency Care Audit for Children Young
People in Scotland Interim Report
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Background to the High Dependency Care (HDC) Audit

• The Kerr Report recommended
• that the age for admitting children young
  people to acute care in paediatric facilities is
  up to their 16th birthday.
• Delivering for Health
• continued provision of paediatric intensive care
  and high dependency care (HDC) is an immediate
  issue for NHSScotland in the light of trends in
  activity and case mix that may not be sustainable
  within current provision.
• SEHD commissioned NSD to conduct audit, to assess
  demand across Scotland and the current capacity
  to provide HDC
• quantity high dependency care audit
• quality assessing paediatric services against
  national standards (West Midland Guidelines).

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HDC Audit - Methodology

• Aim to identify where children with HDC needs are
  currently managed, how many, levels of HDC care
  and the number transferred.
• Development of a set of national high dependency
  care criteria and classification standards.
• 12-14 month prospective audit in all hospitals
  across Scotland.
• Include all children up to their 16th birthday.
• Pilot conducted in wards within DGH, Tertiary
  Hospitals and Adult Hospitals.

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HDC Audit roll out began in October 2006, all
hospitals were participating by end of Nov.
Health Board Childrens Wards Adult Wards
Ayrshire Arran 2 4
Borders 1 7
Dumfries Galloway 1 5
Fife 3 13
Forth Valley 2 16
Greater Glasgow Clyde 12 142
Grampian 7 9
Highland 1 19
Lanarkshire 2 13
Lothian 12 36
Orkney 0 3
Shetland 0 3
Tayside 6 10
Western Isles 0 4
Total 49 284
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12 hr episodes day / night changes in care
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Airway / Circulatory Classifications
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Co-ordination of HDC Audit

• Each hospital has a designated co-ordinator and
  deputy.
• Key to ensuring the quality of the data returned
  to NSD
• interpretation of HDC criteria peer review
• link with NSD regarding queries on the audit
  forms
• meet regularly to discuss issues.
• Completed forms returned on a weekly basis from
  paediatric wards and monthly basis from adult
  wards

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Audit forms should contain the patients
complete journey

• Each form should contain the following
• hospital ward
• patient details CHI, DoB, Postcode,
• type of admission emergency / elective
• date time per patient when HDC commenced
  ended, not shifts.
• admission from where was the patient prior to
  coming to the hospital
• primary journey how did the child get to the
  hospital
• secondary journey if child was transferred from
  another hospital how was the child transferred
• end destination when HDC ended where did the
  child go
• HDC criteria for complete 12 hr period.

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BRANNIGAN
BRANNIGAN
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HDC Audit progress

• Database Issues
• delays developing database
• backlog of data entry
• quality of initial audit forms received still
  working on clearing the outstanding queries
• delay in feedback to wards/hospitals.
• Data presented is not complete due to
  backlog/queries.
• Staffing issues within NSD.
• To end of December information on 1369 children
  has been received. (Still adding to database for
  Jan/Feb - to date 1687)

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Number of Children included in the HDC Audit
Hospital October November December Total
Aberdeen Royal Infirmary 1 2 0 3
Balfour Hospital 0 0 1 1
Belford Hospital 7 5 3 15
Borders General Hospital 8 8 2 18
Caithness General Hospital 3 6 2 11
Crosshouse Hospital 21 25 0 46
Dr Gray's Hospital 14 6 3 23
Dumfries Galloway Royal Infirmary 1 19 8 28
Gilbert Bain Hospital 2 1 2 5
Ninewells Hospital 24 42 49 115
Perth Royal Infirmary 0 3 2 5
Queen Margaret Hospital 0 3 2 5
Raigmore Hospital 15 18 11 44
Royal Aberdeen Children's Hospital 46 88 39 173
Royal Alexandra Hospital 0 9 3 12
Royal Hospital for Sick Children (Edinburgh) 58 68 49 175
Southern General Hospital 0 4 2 6
Stirling Royal Infirmary 38 29 14 81
St John's Hospital at Howden 4 4 4 12
Victoria Hospital 14 30 4 48
Wishaw General Hospital 53 36 13 102
Yorkhill NHS Trust 0 237 204 441
Total Number of Children Included in Audit 309 643 417 1369
Significant amount of outstanding data entry
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HDC Audit planning tool / issues impacting on
childrens services

• Capacity
• no of HDC episodes no. of children episodes per
  child
• Location
• where do children receive HDC type of hospital,
  regional location.
• Demand
• proportion emergency / elective admissions.
• Staffing
• proportion day / night HDC
• Patient Pathway
• how many children are transferred to another
  hospital
• how do children arrive at hospital
• where do they go after HDC.

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Treatment Code No. of Patients Categories
Post-operative airway obstruction 12  
Airway obstruction 12  
Airway intervention 13 Airway
Ventilated/Assisted respiration 13 Airway
Stable long-term ventilation 3  
O2 more than 40 63  
Recently extubated - prolonged ventilation/Intensive care step down 1  
Vasoactive, inotropic, anti-arrhythmic drugs 1  
Fluid balance 42  
Shock/hypovalaemia 4 Circulatory
Multiple IV drugs or continuous infusion 33 Circulatory
Invasive monitoring 9  
Severe haematological problem 5  
Acute hypotension/hypertension 1  
Cardioversion 1 Cardiac
CPR 1  
BMT/severe neutropenia 6 Infection
Septicaemia 10  
Acute renal replacement therapy/Hourly cycle PD/Acute renal failure 1  
Diabetic ketoacidosis (DKA) 7 Renal
Severe metabolic/fluid/electrolyte derangement 10  
Breakdown of HDC for children in audit to date.
HDC care provided in Short Stay, Paediatric Ward,
HDU.
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Treatment Code No. of Patients Categories
GCS 8-12 14  
Prolonged/recurrent seizures 9  
Complex anti-convulsants 6 Neurology
Post - craniotomy 1  
Hourly neuro observations 50  
Apnoeas/cyanotic episodes 8  
Deterioration to ventilation 7  
Severe asthma/bronchodilators 34 Respiratory
ECG and Sa02 monitoring 30  
2 chest drains hourly replacement 1  
Arrhythmias 2  
Sedation or GA for ward procedure 49  
Complex pain control 28  
Frequent sampling/dressings 10  
End of life care 3 Other
Major trauma 3  
Previous rapid deterioration resulting in PICU admission 3  
Central lines 1  
Minor surgery, same day 1 Neonates
Morphine 2  
Breakdown of HDC for children in audit to date.
HDC care provided in Short Stay, Paediatric Ward,
HDU.
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Where children who require HDC were admitted from Where children who require HDC were admitted from Where children who require HDC were admitted from Where children who require HDC were admitted from Where children who require HDC were admitted from Where children who require HDC were admitted from
  Oct Nov Dec Jan Feb
 
A E 29 25 30 22 54
Same Ward 0 1 5 0 0
HDU (transferred from HDU to Wd still requiring HDC) 6 1 6 0 0
Home 29 48 43 31 8
ICU 0 0 0 0 0
Other Ward 19 19 19 46 38
Other Hospital 12 5 3 0 0
PICU 0 0 0 0 0
Short Stay 5 1 5 1 0
Patient Journey
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HDC Audit implications for childrens nurses

• Aim is to produce report Spring 2008 supporting
  the planning of local, regional and national
  planning of critical care services.
• Assessment of paediatric facilities, will be
  included in final report.
• Provide evidence to support local needs analysis
• training differing between hospital
  environments
• staffing levels
• facilities
• equipment
• epidemiological data of patient base
  (Data Warehouse linkage).

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HDC Audit implications for childrens services

• Ethos of Delivering for Health is to provide
  services as locally as possible.
• Current paediatric service provision
  centralisation of paediatric intensive care (2)
  and high dependency units (4).
• This audit will identify the number of children
  with high dependency care needs across all
  hospitals and wards linking to the development
  of a managed critical care network.

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Acknowledgements to -Julie AdamsProject Manager
National Services
Division