T4: Time Taken To Treat

T4: Time Taken To Treat

Posted on By Benjamin CarterIn Clinical Decision MakingLeave a comment

Key contacts

Dr Benjamin Carter, ST3 Paediatrics, Brighton General Hospital

Dr Dannika Buckley-Denton, ST3 Paediatrics, Worthing General Hospital

Dr Rob Bomont, Consultant Neonatalogist, Trevor Mann Baby Unit

Introduction

NICE guidance for the treatment of presumed or proven early neonatal sepsis stipulates that antibiotic therapy should be commenced within 1 hour of decision to treat. Around the time of delivery it is generally well recognised that there are difficulties in initiating antibiotics when necessary and in a timely manner due to the other demands on the professionals involved. It was felt likely that at the Trevor Mann Baby Unit in Brighton (a tertiary care centre), that missing the NICE mandated target was commonplace. This project was aimed at identifying the timeframes of treatment, where the rate limiting steps lie and then formulating solutions to optimise the care and ensure the standards are better met.

SMART objectives

 S: To identify

  • Average time taken to administer empirical antibiotic therapy for early neonatal sepsis
  • Individual times taken for key steps in patient journey to antibiotic administration
  • Differences between care categories for babies, specifically when the decision to treat is in the immediate post natal period on the postnatal wards, after this period, or when babies are admitted to the neonatal unit.
  • What improvements can be made to the execution of rate limiting steps

M: All times will be logged through auditing and will give clear indication of total timeframes

A: The project has been planned out for each unit and staff made aware of the audit process. No significant barriers to data collection are anticipated

R: NICE guidelines are set with realistic goals in mind, there is no reason that improvements should not be able to be made to optimise care and bring it to the expected standard

T: The data will be collected over at least a 1 month period or at least until a set of at least 30 patients have been identified

Progress made: What have you learned from doing this?

 The initial data shows:

Less than 50% of all patient care groups had antibiotics administered within 1 hour of decision to treat

The average time to administration was 121 mins for decisions within 1hr of birth, 76 mins for decisions after 1hr from birth and 77 mins for babies admitted to the neonatal unit

When the decision to treat was within 1 hour of birth the longest delays were noted in the times taken to generate hospital numbers for the babies – without which antibiotics can not be given (according to hospital policy)

For the post 1hr and NNU groups, the time taken from cannulation to administration appeared to be the rate limiting step – indicating that different approaches are required to improved compliance with NICE guidance in different patient groups.

However this also indicates that there is scope to improve the timing for all steps of the administration pathway – as there is significant ‘knock on effect’ – performing tasks in parallel (similar to methods suggested as part of ARNI course training) may help this.

Effective communication between care teams (doctors, nurses, midwifery) is likely to improve delays by way of making sure the team are aware of tasks that need doing in a prompt fashion. This can be achieved both through new policy and guidelines, but also through maintaining positive teamworking skills.

Work is ongoing to implement new practices to aim to improve timings and then reaudit the data to monitor for progress

NICE-otonic fluids – making the switch to IV fluids containing normal saline

NICE-otonic fluids – making the switch to IV fluids containing normal saline

Posted on By Andy MarshallIn Medicines SafetyLeave a comment

Key contacts

 Dr Andy Marshall (Paediatric Registrar); Apphia Bunting (Medical Student); Dr Rhiannon Furr (Paediatric Consultant)

Introduction

NICE advises isotonic maintenance fluids as standard for all children, including most term neonates, due to evidence for hypotonic fluid-induced hyponatraemia. The limited local adoption of this guidance had been attributed, in part, to isolated cases of hypernatraemia in very small infants receiving isotonic fluids, whilst much of the relevant published evidence specifically excludes infants under 3 months.

SMART objectives

Local guidelines were updated and disseminated. A suitable range of isotonic fluids was made available on all wards in collaboration with pharmacy.

Fluid prescriptions were audited for infants under 3 months on paediatric wards, to quantify the extent of guideline uptake, and examine any associated electrolyte imbalances. Electronic record data (for medical and surgical patients, excluding neonatal units) were collected retrospectively for a 16-month period, including maintenance fluid prescriptions and biochemistry results.

Results were presented in paediatric, surgical and anaesthetic team meetings, and wider adoption of guidelines was facilitated through modifications to the electronic prescribing system.

The audit will be repeated to examine the current level of guideline uptake, and whether this has had impacts on electrolyte imbalance. Specifically, after 6 months, we will audit: the proportion of maintenance fluids which are hypotonic;  the number of patients with hypo- or hyper-natraemia, and whether these were associated with IV fluid administration.

 Progress made: What have you learned from doing this?

Audit over 16 months: Of 672 fluid prescriptions for infants under 3 months, 60% were hypotonic. Two cases of significant hyponatraemia  (<130 mmol/L) were associated with hypotonic fluid prescriptions. There were no cases of iatrogenic significant hypernatraemia (>150 mmol/L). 

Audit results were well received by all teams. An application was successfully made through IT and pharmacy to modify the electronic prescription system to promote isotonic solutions as standard for all patients. 

What’s your take home message?

 An audit of NICE IV fluid guideline uptake was successful in quantifying the degree of guideline adherence, and may have helped shift local practice.

If guideline adherence has now improved, a re-audit could further reassure clinicians of the safety of 0.9% saline in small infants.

Resources?

Balasubramanian, Karthik, et al. “Isotonic versus hypotonic fluid supplementation in term neonates with severe hyperbilirubinemia–a double‐blind, randomized, controlled trial.” Acta Paediatrica 101.3 (2012): 236-241.

Moritz, Michael L., and Juan C. Ayus. “Intravenous fluid management for the acutely ill child.” Current opinion in pediatrics 23.2 (2011): 186-193.

National Patient Safety Agency (2007) Patient Safety Alert – Reducing the risk of hyponatraemia when administering intravenous infusions to children

McNab, Sarah, et al. “140 mmol/L of sodium versus 77 mmol/L of sodium in maintenance intravenous fluid therapy for children in hospital (PIMS): a randomised controlled double-blind trial.” The Lancet 385.9974 (2015): 1190-1197.

Choong, Karen, et al. “Hypotonic versus isotonic maintenance fluids after surgery for children: a randomized controlled trial.” Pediatrics 128.5 (2011): 857-866.

Wang, Jingjing, Erdi Xu, and Yanfeng Xiao. “Isotonic versus hypotonic maintenance IV fluids in hospitalized children: a meta-analysis.” Pediatrics(2013): peds-2013.