Developing a prototype digital risk mitigation pathway for children and young people admitted to acute paediatric NHS care in mental health crisis: Protocol of the Safety Assessment in Paediatric healthcare Environments (SAPhE) pathway study.

Background: Globally, there are increasing numbers of Children and young people (CYPs) experiencing a mental health crisis requiring admission to acute paediatric inpatient care. These CYPs can often experience fluctuating emotional states accompanied by urges to self-harm or attempt to end their life, leading to reduced safety and poorer experiences. Currently, in the UK National Health Service (NHS) there are no standardised, evidence-based interventions in acute paediatric care to mitigate or minimise immediate risk of self-harm and suicide in CYP admitted with mental health crisis. Objective: To outline the protocol for the SAPhE Pathway study which aims to: 1) identify and prioritise risk mitigation strategies to include in the digital prototype, 2) understand the feasibility of implementing a novel digital risk mitigation pathway in differing NHS contexts, and 3) co-create a prototype digital risk mitigation pathway. Methods: This is a multi-centre study uses a mixed-methods design. A systematic review and exploratory methods (interviews, surveys, and focus groups) will be used to identify the content and feasibility of implementing a digital risk mitigation pathway. Participants will include healthcare professionals, digital experts and CYP with experience of mental health conditions. Data will be collected between January 2022 and March 2023 and analysed using content and thematic analysis, case study, cross-case analysis for qualitative data and descriptive statistics for quantitative data. Findings will inform the experience-based co-design workshops. Ethics and Dissemination: The study received full ethical approval from NHS REC [Ref: 22/SC/0237 and 22/WM/0167]. Findings will be made available to all stakeholders using multiple approaches.

Paediatric family activation rapid response (FARR) in tertiary healthcare organisations: Protocol for an online, multi-lingual, application (app) intervention development study.

INTRODUCTION: At least 85% of unplanned admissions to critical care wards for children and young people (CYP) are associated with clinical deterioration. CYP and their families play an integral role in the recognition of deterioration. The Paediatric Critical Care Outreach Team (PCCOT) supports the reduction of avoidable harm through earlier recognition and treatment of the deteriorating child, acting as a welcome conduit between the multiprofessional teams, helping ensure that CYP gets the right care, at the right time and in the right place. This positions PCCOT well to respond to families who call for help as part of family activation. AIM: This protocol details the methods and process of developing a family activation rapid response online application. METHODS: This is a single-centre, sequential, multiple methods study design. Firstly, a systematic review of the international literature on rapid response interventions in paediatric family activation was conducted. Findings from the review aimed to inform the content for next stages; interviews/ focus groups and experience-based co-design (EBCD) workshops. PARTICIPANTS: parents / caregivers whose children have been discharged or admitted to an acute care hospital and healthcare professionals who care for paediatric patients (CYP). During interviews and workshops participants' opinion, views and input will be sort on designing a family activation rapid response online-app, detailing content, aesthetics, broad functionality and multi-lingual aspects. Further areas of discussions include; who will use the app, access, appropriate language and terminology for use. A suitable app development company will be identified and will be part of the stakeholders present at workshops. Data obtained will be used to develop a multi-lingual paediatric family activation rapid response web based application prototype. ETHICS AND DISSEMINATION: Full ethical approval was received from the Wales Research Ethics Committee 2. Cardiff; REC reference: 22/WA/0174. The findings will be made available to all stakeholders.

Pediatric nurse-sensitive outcomes: A systematic review of international literature.

BACKGROUND: Nurse-sensitive outcomes are measures for improvement and evaluation of the quality of nursing care delivered. The specific outcomes that need to be measured will be determined by the patient population, as well as the field and scope of practice, in which nursing care is being delivered. Currently, there is no internationally agreed upon set of nurse-sensitive outcomes for pediatric nursing, which provides specialist care to infants, children, and young people. AIM: To identify and evaluate nurse-sensitive outcomes for pediatric nursing. METHODS: A systematic review was conducted. Five electronic databases (British Nursing Index, CINAHL, EMBASE, MEDLINE, and EMCARE) were searched in the period up to February 2022. Studies were selected for inclusion using title and abstract screening using predetermined criteria. The Critical Appraisal Skills Programme tool was used for quality assessment. A narrative synthesis of the results was performed. RESULTS: A total of 633 studies were identified from online searches, with 14 studies meeting the inclusion criteria. All studies had moderate to high methodological strength. A total of 57 nurse-sensitive outcomes were identified from all included studies. Using the nurse-sensitive outcome conceptual analysis framework, 25 (45%) of the items were classified as outcome attributes, 20 (35%) as process attributes, and 13 (23%) as structure attributes. The most frequently reported nurse-sensitive outcomes included pressure ulcers, nosocomial infections, hospital-acquired infections, peripheral intravenous infiltration, failure to rescue, and staffing levels. CONCLUSIONS: This review provides an up-to-date and comprehensive list of nurse-sensitive outcomes for use in pediatric nursing and describes their frequency of use. However, further work is required to achieve consensus for an international core nurse-sensitive outcome set for pediatric nursing with policy recommendations to ensure agreed-upon minimum standards. IMPLICATIONS FOR NURSING AND HEALTH POLICY: Policy initiatives and guideline recommendations on nurse-sensitive outcome frameworks as part of patient safety should be a part of key priorities for policy makers. The commonly reported nurse-sensitive outcomes should be incorporated into daily bedside pediatric clinical nursing practice as a mechanism to evaluate and improve the quality of care, enhancement of patient safety, and better outcomes.

Paediatric family activated rapid response interventions; qualitative systematic review.

BACKGROUND: Failure to recognise deterioration early which results in patient death, is considered failure to rescue and it is identified as one of the leading causes of harm to patients. It is recognised that patients and their families can often recognise changes within the child's condition before healthcare professionals. To mitigate the risk of failure to rescue and promote early intervention, family-activated rapid response systems are becoming widely acknowledged and accepted as part of family integrated care. OBJECTIVE: To identify current family-activated rapid response interventions in hospitalised paediatric patients and understand mechanisms by which family activation works. METHODS: A narrative systematic review of published studies was conducted. Seven online databases; AMED, CINHAL, EMBASE, EMCARE, HMIC, JBI, and Medline were searched for potentially relevant papers. The critical appraisal skills programme tool was used to assess methodological rigor and validity of included studies. RESULTS: Six studies met the predefined inclusion criteria. Five telephone family activation interventions were identified; Call for Help, medical emergency-teams, Condition HELP, rapid response teams, and family initiated rapid response. Principles underpinning all interventions were founded on a principal of granting families access to a process to escalate concerns to hospital emergency teams. Identified interventions outcomes and mechanisms include; patient safety, empowerment of families, partnership working/ family centred care, effective communication and better patient outcomes. Interventions lacked multi-lingual options. CONCLUSION: Family activation rapid response system are fundamental to family integrated care and enhancing patient safety. Underlying principles and concepts in delivering interventions are transferable across global healthcare system.

Reducing failure to rescue rates in a paediatric in-patient setting: A 9-year quality improvement study.

BACKGROUND: Annually in England, over 1.5 million children and young people (CYP) are admitted to hospital. However, a proportion of these CYP will experience failure to rescue (FtR), a failure to recognize, respond and escalate clinical deterioration, which can result in significant harm or death. AIM: To identify and quantify FtR episodes from emergency events at a 110-bedded tertiary children's hospital located within a University Teaching Hospital and evaluate the impact of targeted interventions on reducing FtR. METHODS: A quality improvement approach was adopted. From 170 446 patients admitted between 2011 and 2019, all emergency event calls were systematically reviewed to identify FtR episodes. Root-cause analysis was performed to identify practice deficiencies. The Plan-Do-Study-Act fundamentals were used. RESULTS: A total of 520 emergency events were reviewed over the 9-year period. One hundred and thirty-two (n = 132; 25%) were cardiac arrest events, with the majority occurring within the PCCU setting. Three hundred and twelve (60%) of the events were in children who had been inpatient for more than 48 hours. FtR trend declined over the study period from 23.6% in 2011 when the project commenced to 2.5% or less over the following 8 years. CONCLUSIONS: Identifying rates of FtR events from routinely collected emergency events data can be used as a patient safety measure to identify emergency concerns. This enables dynamic problem solving through delivery of strategic and targeted interventions. The proposed interventions outlined in this quality improvement study have application to critical care nursing as mechanisms for reducing unplanned admissions to paediatric critical care unit (PCCU), patient mortality, and PCCU and non-PCCU cardiac arrests. RELEVANCE TO CLINICAL PRACTICE: This study emphasises the importance in understanding the antecedence of emergency events for paediatric inpatient populations. This intelligence can be used to direct targeted interventions to significantly reduce failure to rescue rates.

Nursing interventions to reduce medication errors in paediatrics and neonates: Systematic review and meta-analysis.

BACKGROUND: Medication errors are a great concern to health care organisations as they are costly and pose a significant risk to patients. Children are three times more likely to be affected by medication errors than adults with medication administration error rates reported to be over 70%. OBJECTIVE: To identify nursing interventions to reduce medication administration errors and perform a meta-analysis. METHODS: Online databases; British Nursing Index (BNI), Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE and MEDLINE were searched for relevant studies published between January 2000 to 2020. Studies with clear primary or secondary aims focusing on interventions to reduce medication administration errors in paediatrics, children and or neonates were included in the review. RESULTS: 442 studies were screened and18 studies met the inclusion criteria. Seven interventions were identified from included studies; education programmes, medication information services, clinical pharmacist involvement, double checking, barriers to reduce interruptions during drug calculation and preparation, implementation of smart pumps and improvement strategies. Educational interventional aspects were the most common identified in 13 out of 18 included studies. Meta-analysis demonstrated an associated 64% reduction in medicine administration errors post intervention (pooled OR 0.36 (95% Confidence Interval (CI) 0.21-0.63) P = 0.0003). CONCLUSION: Medication safety education is an important element of interventions to reduce administration errors. Medication errors are multifaceted that require a bundle interventional approach to address the complexities and dynamics relevant to the local context. It is imperative that causes of errors need to be identified prior to implementation of appropriate interventions.

Factors influencing retention among hospital nurses: systematic review.

BACKGROUND: Recruitment and retention of nursing staff is the biggest workforce challenge faced by healthcare institutions. Across the UK, there are currently around 50 000 nursing vacancies, and the number of people leaving the Nursing and Midwifery Council register is increasing. OBJECTIVE: This review comprehensively compiled an update on factors affecting retention among hospital nursing staff. METHODS: Five online databases; EMBASE, MEDLINE, SCOPUS, CINAHL and NICE Evidence were searched for relevant primary studies published until 31 December 2018 on retention among nurses in hospitals. RESULTS: Forty-seven studies met the inclusion criteria. Nine domains influencing staff turnover were found: nursing leadership and management, education and career advancement, organisational (work) environment, staffing levels, professional issues, support at work, personal influences, demographic influences, and financial remuneration. CONCLUSION: Identified turnover factors are long-standing. To mitigate the impact of these factors, evaluation of current workforce strategies should be high priority.

Pressure injury and risk in the inpatient paediatric and neonatal populations: A single centre point-prevalence study.

INTRODUCTION: Prevention and management of pressure injury is a key nurse-sensitive quality indicator. From clinical insights, pressure injury effects hospitalised neonates and children, however it is unclear how prevalent this is. The aim of this study was to quantify prevalence of pressure injury, assess skin integrity risk level, and quantify preventive interventions in both neonatal and child inpatient populations at a large children's hospital in the UK. METHODS: A cross-sectional study was undertaken, assessing the skin integrity of all children allocated to a paediatric or neonatal bed in June/July 2020. A data collection tool was adapted from two established pressure ulcer point prevalence surveys (EUPAP and Medstrom pre-prevalence survey). Risk assessment was performed using the Braden QD scale. RESULTS: Eighty-eight participants were included, with median age of 0.85 years [range 0-17.5 years), with 32 (36%) of participants being preterm. Median length of hospital stay was 11 days [range 0-174 days]. Pressure ulcer prevalence was 3.4%. The majority of participants had at least two medical devices, with 16 (18.2%) having more than four. Having a medical device was associated with increased risk score of developing pressure injury (odds ratio [OR] 0.03, 95% Confidence Interval [CI] 0.01-0.05, p = 0.02). Most children (39 (44%)) were reported not having proposed preventive measures in place aligned to their risk assessment. However, for those that did, 2 to 4 hourly repositioning was associated with a risk reduction on pressure damage (OR 0.13, 95% CI 0.03-0.23, p = 0.01). CONCLUSION: Overall, we found a low prevalence of pressure injury across preterm infants, children and young people at a tertiary children's hospital. Accurate risk assessment as well as availability and implementation of preventive interventions are a priority for healthcare institutes to avoid pressure injury.

A regional evaluation of the health care utilization and outcomes of children and young people with long-term ventilation needs.

BACKGROUND: Globally, the number of children and young people (CYP) with long-term ventilation (LTV) needs is increasing, with high associated health care costs, due to frequent hospital admissions and contact with community health care services. However, demographic, health care utilization and outcome details of the CYP cared for locally is unknown. This study aimed to examine health care utilization and outcomes for this patient population. METHODS: Routinely collected data from 2014 to 2018 were extracted from local LTV team records and from hospital electronic patient records. Descriptive and inferential statistical analysis was performed using SPSS 17. RESULTS: A total of 112 CYP aged 0-17 years old were included in the evaluation. Sixty per cent (n = 67) commenced ventilation in hospital, and 62% (n = 69) had at-least one hospitalization event whilst they were on LTV, with a median length of stay of 3 days. Most hospitalizations were unplanned and respiratory in nature. Ninety-five per cent (n = 106) of CYP accessed at least one clinic appointment whilst on LTV, with a median of 20 outpatient clinic appointments during the study period. The majority of CYP received time-intensive support from LTV nurses and physiotherapists during the period that they received LTV. Minimal seasonal variation existed in relation to hospital admissions. Year on year increasing trend of hospital admissions was noted. The observed mortality rate was 3.6% (n = 4), 72.3% (n = 81) remained active on LTV, 14% (n = 16) were liberated from their ventilation and 9% (n = 10) transitioned to adult care by the end of the study. CONCLUSION: The study highlights the most common modes of health care utilization for CYP with LTV needs. To enable formalization of future resource planning and accurate assessment of health care utilization in evaluations, there is an urgent need to create a systematic approach for relevant LTV data collection.

Short-term morbidity factors associated with length of hospital stay (LOS): Development and validation of a Hip Fracture specific postoperative morbidity survey (HF-POMS).

BACKGROUND: We aimed to describe and quantify postoperative complications in the older hip fracture population, develop and validate a hip fracture postoperative morbidity survey tool (HF-POMS). METHODS: A prospective clinical observation study of patients (≥ 70 years) admitted for emergency hip fracture surgery, was conducted across three English National Health Service hospitals. Outcome data items were developed from the Postoperative Morbidity Survey (POMS), Cardiac-POMS, hip fracture postoperative literature and orthogeriatric clinical team input. Postoperative outcome data were collected on days 1, 3, 5, 8 and 15; 341 patients participated. RESULTS: A 12-domain HF-POMS tool was developed with acceptable construct validity on all HF-POMS days. Patients with high perioperative risk scores as measured by the NHFS and ASA grade were more prone to develop HF-POMS defined morbidities. High morbidity rates occurred in the following domains; renal, ambulation assistance, pain and infectious. Presence of any morbidity on postoperative days 8 and 15 was associated with subsequent length of stay of 3.08 days (95% CI 0.90-5.26, p = 0.005) and 15.81 days (95% CI 13.35-18.27, p = 0.001) respectively. Observed average length of stay was 16.9 days. HF-POMS is a reliable and valid tool for measuring early postoperative complications in hip fracture patients. Additional domains are necessary to account for all morbidity aspects in this patient population compared to the original POMS. CONCLUSION: Many patients remained in hospital for non-medical reasons. HF-POMS may be a useful tool to assist in discharge planning and randomised control trial outcome definitions.

Conflict resolution in anaesthesia: systematic review.

Background: Conflict is a significant and recurrent problem in most modern healthcare systems. Given its ubiquity, effective techniques to manage or resolve conflict safely are required. Objective: This review focuses on conflict resolution interventions for improvement of patient safety through understanding and applying/teaching conflict resolution skills that critically depend on communication and improvement of staff members' ability to voice their concerns. Methods: We used the Population-Intervention-Comparator-Outcome model to outline our methodology. Relevant English language sources for both published and unpublished papers up to February 2018 were sourced across five electronic databases: the Cochrane Library, EMBASE, MEDLINE, SCOPUS and Web of Science. Results: After removal of duplicates, 1485 studies were screened. Six articles met the inclusion criteria with a total sample size of 286 healthcare worker participants. Three training programmes were identified among the included studies: (A) crisis resource management training; (B) the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) training; and (C) the two-challenge rule (a component of TeamSTEPPS), and two studies manipulating wider team behaviours. Outcomes reported included participant reaction and observer rating of conflict resolution, speaking up or advocacy-inquiry behaviours. Study results were inconsistent in showing benefits of interventions. Conclusion: The evidence for training to improve conflict resolution in the clinical environment is sparse. Novel methods that seek to influence wider team behaviours may complement traditional interventions directed at individuals.

Anaesthesia workload measurement devices: qualitative systematic review.

Background: Management of mental workload is a key aspect of safety in anaesthesia but there is no gold-standard tool to assess mental workload, risking confusion in clinical and research use of such tools. Objective: This review assessed currently used mental workload assessment tools. Methods: A systematic literature search was performed on the following electronic databases; Cochrane, EMBASE, MEDLINE, SCOPUS and Web of Science. Screening and data extraction were performed individually by two authors. We included primary published papers focusing on mental workload assessment tools in anaesthesia. Results: A total of 2331 studies were screened by title, 32 by full text and 24 studies met the inclusion criteria. Six mental workload measurement tools were observed across included studies. Reliability for the Borg rating scales and Vibrotactile device was reported in two individual studies. The rest of the studies did not record reliability of the tool measurements used. Borg rating scales, NASA-TLX and task-oriented mental work load measurements are subjective, easily available, readily accessible and takes a few minutes to complete. However, the vibrotactile and eye-tracking methods are objective, require more technical involvement, considerable time for the investigator and moderately expensive, impacting their potential use. Conclusion: We found that the measurement of mental workload in anaesthesia is an emerging field supporting patient and anaesthetist safety. The self-reported measures have the best evidence base.

Risk scoring models for predicting peri-operative morbidity and mortality in people with fragility hip fractures: Qualitative systematic review.

RATIONALE: Accurate peri-operative risk prediction is an essential element of clinical practice. Various risk stratification tools for assessing patients' risk of mortality or morbidity have been developed and applied in clinical practice over the years. This review aims to outline essential characteristics (predictive accuracy, objectivity, clinical utility) of currently available risk scoring tools for hip fracture patients. METHODS: We searched eight databases; AMED, CINHAL, Clinical Trials.gov, Cochrane, DARE, EMBASE, MEDLINE and Web of Science for all relevant studies published until April 2015. We included published English language observational studies that considered the predictive accuracy of risk stratification tools for patients with fragility hip fracture. RESULTS: After removal of duplicates, 15,620 studies were screened. Twenty-nine papers met the inclusion criteria, evaluating 25 risk stratification tools. Risk stratification tools considered in more than two studies were; ASA, CCI, E-PASS, NHFS and O-POSSUM. All tools were moderately accurate and validated in multiple studies; however there are some limitations to consider. The E-PASS and O-POSSUM are comprehensive but complex, and require intraoperative data making them a challenge for use on patient bedside. The ASA, CCI and NHFS are simple, easy and inexpensive using routinely available preoperative data. Contrary to the ASA and CCI which has subjective variables in addition to other limitations, the NHFS variables are all objective. CONCLUSION: In the search for a simple and inexpensive, easy to calculate, objective and accurate tool, the NHFS may be the most appropriate of the currently available scores for hip fracture patients. However more studies need to be undertaken before it becomes a national hip fracture risk stratification or audit tool of choice.

Maternal smoking and the risk of still birth: systematic review and meta-analysis.

BACKGROUND: Smoking in pregnancy is known to be associated with a range of adverse pregnancy outcomes, yet there is a high prevalence of smoking among pregnant women in many countries, and it remains a major public health concern. We have conducted a systematic review and meta-analysis to provide contemporary estimates of the association between maternal smoking in pregnancy and the risk of stillbirth. METHODS: We searched four databases namely MEDLINE, EMBASE, Psych Info and Web of Science for all relevant original studies published until 31(st) December 2012. We included observational studies that measured the association between maternal smoking during pregnancy and the risk of stillbirth. RESULTS: 1766 studies were screened for title analysis, of which 34 papers (21 cohorts, 8 case controls and 5 cross sectional studies) met the inclusion criteria. In meta-analysis smoking during pregnancy was significantly associated with a 47% increase in the odds of stillbirth (OR 1.47, 95% CI 1.37, 1.57, p < 0.0001). In subgroup analysis, smoking 1-9 cig/day and ≥10 cig/day was associated with an 9% and 52% increase in the odds of stillbirth respectively. Subsequently, studies defining stillbirth at ≥ 20 weeks demonstrated a 43% increase in odds for smoking mothers compared to mothers who do not smoke, (OR 1.43, 95% CI 1.32, 1.54, p < 0.0001), whereas studies with stillbirth defined at ≥ 24 weeks and ≥ 28 weeks showed 58% and 33% increase in the odds of stillbirth respectively. CONCLUSION: Our review confirms a dose-response effect of maternal smoking in pregnancy on risk of stillbirth. To minimise the risk of stillbirth, reducing current smoking prevalence in pregnancy should continue to be a key public health high priority.