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G554(P) Implementation of an integrated inpatient paediatric mortality reduction intervention
  1. M Huddart
  1. Paediatrics, Calderdale and Huddersfield NHS Trust, Leeds, UK

Abstract

Background Based at a University teaching hospital in Northern Ethiopia, the author was placed through Voluntary Services Oversea’s (VSO) as a Paediatric Senior. The department witnesses a high Paediatric mortality rate amongst inpatients (30%, non-neonatal). Ward level care is largely provided by junior doctors (Interns). A gap in knowledge and skills of up-to-date resuscitation practices was identified in this group.

Project design The project included an intervention to improve Intern knowledge and skills. The intervention comprised development of a resuscitation protocol package with suitable training. A baseline audit of all Paediatric admissions (excluding neonates) over a three month period provided mortality data including specifics of disease category. This highlighted the conditions with highest rates of mortality at our hospital: severe acute malnutrition, coma, meningitis, congestive heart failure (CHF), hypovolaemic shock and meningitis. The Paediatric senior faculty developed five, locally appropriate, protocols to address the acute management of these conditions plus added three complementary protocols based on those promoted by the Emergency Triage, Assessment and Treatment (ETAT), WHO. The final protocol package included: respiratory distress, hypovolaemic shock, septic shock, coma, CHF, airway emergencies, seizure and cardio-pulmonary resuscitation (CPR). The nuances of acute malnutrition were addressed in each protocol. The package provided readily available, locally appropriate guidelines to provide evidence based information for Interns.

The protocol package was implemented with a training programme of all Interns rotating through the Paediatric department during the study period (n = 21, September 6th to December 9th 2011). A full day simulation based training course was developed to introduce the concept and use of the protocol package plus development of key resuscitation skills: bag mask ventilation, CPR plus intra-osseous needle placement. Simulation based scenarios were developed to build on theoretical knowledge provided in short didactic lectures and allow practice of skills.

Results 474 patients were admitted in the baseline group and 432 following the intervention. No change was observed for overall mortality (crude OR=0.72, 95% CI 0.40–1.29, p = 0.265). No change was observed in first-24-hour mortality (crude OR 0.97, 95% CI 0.37–2.55, p = 0.959).

Total examination scores improved from median 32.6 to 73.5% (p < 0.001), with improvements observed for all tested skills. Median scores improved from 11.1 to 77.8% on bag mask ventilation, from 11.1 to 88.9% on CPR, from 40.0 to 100% on intraosseous needle placement, and from 21.7 to 87.0% in aggregate for all observed procedural skills (p < 0.001 for all parameters).

Evaluation Two aspects were evaluated to aid measurement of success. An audit of inpatient admissions was carried out pre and post Intern training. Data was collected from the ward log book and entered into an Excel spreadsheet. The primary and secondary outcomes included crude mortality plus mortality within the first 24 h and were expressed as a percentage of admissions. Odds ratios for these outcomes were calculated using univariable logistic regression.

Evaluation of Intern knowledge and skills took place pre- and post-training to assess the impact of the simulation based program. Testing took place in multiple choice format with videos of critically ill children to focus on pattern recognition and triage skills plus a theory paper to assess problem-solving in emergency situations. Procedural skills were tested by direct observation. Trainees were asked to demonstrate skills covered in the course while project coordinators applied a standardised, checklist-based marking tool to evaluate their performance. Median trainee examination scores were calculated as percentage answered correctly and pre- and post-training results were compared by Wilcoxon matched-pairs signed ranks test.

Conclusions Combining care standardisation, management protocols, and simulation-based training did not red uce mortality among non-neonatal Paediatric inpatients in this study. Simulation-based training improved short-term test performance among Ethiopian medical trainees.

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