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Care of children and young people with a decreased conscious level (multi-site audit 2010-2011)
  1. SA Smith1,
  2. CN Long2,
  3. G Denney3,
  4. J Gray4,
  5. M Lakhanpaul5,
  6. I Maconochie6,
  7. L Oates7,
  8. A Rashid8,
  9. R Slater9
  1. 1Paediatrics, Nottingham Children's Hospital, Nottingham, UK
  2. 2Research and Policy, RCPCH, London, UK
  3. 3National Reyes Syndrome Foundation, Woking, UK
  4. 4RCN, London, UK
  5. 5Community Paediatrics, University of Leicester, Leicester, UK
  6. 6Children's Emergency Department, St Mary's, London, UK
  7. 7Lay Representative, RCPCH, London, UK
  8. 8PICU, Nottingham Children's Hospital, Nottingham, UK
  9. 9Children's Emergency Department, St Mary's, London, UK

Abstract

Aim To present the findings of the Decreased Conscious Level Multi-site Audit which examined selected recommendations from the RCPCH-endorsed guideline: The Management of a Child with a Decreased Conscious Level.

Methods 51 NHS trusts collected data on consecutive cases of children less than 18 years who presented acutely with a decreased conscious level between the period: 1 November 2010 to 30 September 2011. These trusts used either a wholly retrospective or a combined prospective/retrospective approach to identify the cases. Data was collected on 1147 cases, of which 1132 met the audit's inclusion/exclusion criteria.

Results Trusts performed well for the documentation of heart rate (50/51, 98.0%) and to a lesser degree for respiratory rate (37/51, 72.5%), oxygen saturation (46/51, 90.2%) and the use of either Glasgow Coma Scale or AVPU scale to assess the level of consciousness (46/51, 90.2%). However, the documentation of blood pressure (11/51, 21.6%) and temperature (31/51, 60.8%) was of a poorer standard.

In the majority of trusts, there was a failure to meet the audit standards for the recommended clinical history features which should be elicited from these children and young people. Very few trusts met the performance targets for the documentation of the presence or absence of the following clinical history features: vomiting (4/51, 7.8%), fever (4/51, 7.8%), convulsions (4/51, 7.8%), alternating periods of consciousness (11/51, 21.6%), trauma (2/51, 3.9%), ingestion of medication or recreational drugs (2/51, 3.9%) and length of symptoms (23/51, 45.1%). Measurement of capillary glucose only met the standard in 18/48 (37.5%) trusts.

Although, no performance targets were set for these areas, the majority of the trusts failed to achieve even a minimum level of 75% or more. There were low levels of documentation on whether parents were allowed to stay with their child (9/51, 17.6%), informed regarding their child's possible diagnosis (13/51, 25.5%) and possible prognosis (8/51, 15.7%).

Conclusions There were significant gaps in the documentation of observations, clinical history, investigations and communication with parents in the care of children and young people presenting acutely with a recognised decreased conscious level. A revised guideline will aim to address these issues.

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