Development, implementation and evaluation of an evidence-based paediatric early warning system improvement programme: the PUMA mixed methods study

Background Paediatric mortality rates in the United Kingdom are amongst the highest in Europe. Clinically missed deterioration is a contributory factor. Evidence to support any single intervention to address this problem is limited, but a cumulative body of research highlights the need for a systems approach. Methods An evidence-based, theoretically informed, paediatric early warning system improvement programme (PUMA Programme) was developed and implemented in two general hospitals (no onsite Paediatric Intensive Care Unit) and two tertiary hospitals (with onsite Paediatric Intensive Care Unit) in the United Kingdom. Designed to harness local expertise to implement contextually appropriate improvement initiatives, the PUMA Programme includes a propositional model of a paediatric early warning system, system assessment tools, guidance to support improvement initiatives and structured facilitation and support. Each hospital was evaluated using interrupted time series and qualitative case studies. The primary quantitative outcome was a composite metric (adverse events), representing the number of children monthly that experienced one of the following: mortality, cardiac arrest, respiratory arrest, unplanned admission to Paediatric Intensive Care Unit, or unplanned admission to Higher Dependency Unit. System changes were assessed qualitatively through observations of clinical practice and interviews with staff and parents. A qualitative evaluation of implementation processes was undertaken. Results All sites assessed their paediatric early warning systems and identified areas for improvement. All made contextually appropriate system changes, despite implementation challenges. There was a decline in the adverse event rate trend in three sites; in one site where system wide changes were organisationally supported, the decline was significant (ß = -0.09 (95% CI: − 0.15, − 0.05); p = < 0.001). Changes in trends coincided with implementation of site-specific changes. Conclusions System level change to improve paediatric early warning systems can bring about positive impacts on clinical outcomes, but in paediatric practice, where the patient population is smaller and clinical outcomes event rates are low, alternative outcome measures are required to support research and quality improvement beyond large specialist centres, and methodological work on rare events is indicated. With investment in the development of alternative outcome measures and methodologies, programmes like PUMA could improve mortality and morbidity in paediatrics and other patient populations.

An innovative mobile application to improve the efficiency of common procedures in the paediatric intensive care unit: a pilot study

Background/Aims Procedures performed in the paediatric intensive care unit require optimal efficiency. This study evaluated the feasibility of a mobile app for paediatric critical care trainees to help improve the efficiency of three common procedures: central line placement, arterial line insertion and chest tube insertion. Methods Data regarding frequency of forgotten items were collected during the pre-intervention stage. A mobile app was developed with a checklist to help users to gather all the correct equipment. Data regarding the number of forgotten items were collected from the app in the period following initial implementation (March–August 2019) and after a software update (August–October 2019). Results Once the mobile application was introduced, all 13 (100%) fellows and 2 (20%) of the 10 advanced practice registered nurses accessed the application's checklist to record their procedures. From March–August 2019, 19 users submitted post-completion assessments, of which four included records of forgotten items (21%). After a software update, from August–October 2019, there were eight post-procedure assessments submitted with zero forgotten items. After using the mobile application, over half (13/24) of users surveyed agreed that the mobile application was useful for helping select items. Conclusions A considerable decrease in the proportion of procedures with forgotten items was recorded after the implementation of the app and after the software update. However, there was also a decrease in use of the app during the study period, so more research is required into the use of mobile apps for this purpose.

Evaluation of an Automated Dispensing Cabinet in Paediatric Intensive Care – Focus on Controlled Medications

Evidence is limited of automated dispensing cabinets (ADCs) impact on effectiveness and efficiency of controlled drugs’ (CDs) governance processes. We carried out a mixed-methods study of an ADC in an intensive care unit. We found ADC improved effectiveness and efficiency of governance of CDs through secure storage, alerts and automated recording of transactions. Limitations were associated with ADC design and ‘fit’ between ADC and some types of CDs.

Challenges of Digital Commons: A Qualitative Study of an Automated Dispensing Cabinet in a Paediatric Intensive Care Unit

Missed medication doses can affect patient safety in hospitals. The use of automated dispensing cabinets (ADC) in clinical areas may reduce the occurrence of medications being unavailable at the time of need by alerting pharmacy to replenish stock. However, workarounds in ADC use can affect this capability. We studied nurses’ use of an ADC in a paediatric intensive care unit with 54 hours of observation, semi-structure interviews (19 nurses; 4 pharmacy/management staff) and review of reported incidents. We found running out of medication a recurrent problem despite the ADC. Contributing factors affecting data entry in the ADC, and therefore replenishment alerts to pharmacy, included: the organisation of medication activities in the ward, nurses’ information needs, patients’ medication needs, and ADC design. Running out of medications was a ‘tragedy of the commons’. Effective solutions may require going beyond user training and directives for accurate data entry, to work process redesign.