Emergency nurse wins RCNi Nurse Award for work with children with sepsis
Drew McDonald, senior staff nurse at the Royal Aberdeen Children’s Hospital emergency department, has won an RCNi Nurse Award for his development of a tool for identifying sepsis in children.
Sepsis symptoms can be hard to spot and one in five patients admitted to paediatric intensive care units (PICUs) with severe sepsis die.
Drew McDonald, senior staff nurse in the emergency department (ED) at Royal Aberdeen Children’s Hospital (RACH), was concerned that this could happen in his workplace. He says: ‘My goal as a nurse is to ensure that every child that attends our department is given the best care possible. We should treat the families as if they were our own, and I knew we were not good enough at dealing with sepsis.’
He therefore developed a clear and easy-to-use sepsis recognition tool for nursing staff to refer to during triage. It integrates the diagnosis and treatment pathway sepsis 6 into ED practice, takes 20 seconds to complete and has been successfully implemented at RACH. His leadership and commitment saw Drew announced winner of the Child Health category of the RCNi Nurse Awards, the profession’s top accolade.
Drew says of his reasons for developing the tool: ‘By the time a child gets to the PICU 200 miles away, the damage is done. What we do beforehand is vital, but our care was not good enough and I knew it.
‘Good pre-PICU care – early recognition and early treatment with antibiotics, cardiovascular support including fluids and inotropes – can greatly improve outcomes. But there were inconsistencies at triage, with different nurses having different knowledge.
‘I wanted to make sure every child got the same thorough assessment, regardless of their nurse’s experience. Nurses were concerned when they were approaching doctors about a sick child.’
Drew realised the answer was an effective recognition tool. ‘At this stage it was just me, and I had no experience of improvement and my sepsis knowledge was poor. Staff were averse to change and I didn’t know where to begin.
is the average cost of a single case of sepsis in a developed country
Source: Sepsis Trust
‘So I started small and put together a team – the sepsis working group. I met with an NHS Grampian improvement adviser, which improved my sepsis knowledge. Then I started engaging staff.’
Drew designed the sepsis recognition tool and established an agreed pathway for requesting a senior doctor review. This was supported by face-to-face training for all staff.
Since then the tool has been adjusted and is now on version 5.
The tool is used for all children with illness admissions and can be completed by nurses at any level. If a child meets the tool’s criteria, he or she receives a senior doctor review. It takes into account symptoms not considered in a paediatric early warning score, which covers alert, verbal response, pain response and unresponsive scores along with temperature, heart rate, respiratory rate, blood pressure and oxygen saturation.
Drew’s sepsis recognition tool checks for poor perfusion, including central refill time, mottling and poor peripheral perfusion, as well as altered mental state, including, irritability, sleepiness, ‘floppiness’ and lethargy.
A further document ensures that once identified, the sepsis is managed appropriately with an easy-to-follow six-step treatment plan.
is the improvement in the sepsis survival rate if the basics of care are delivered
Source: Sepsis Trust
Drew says: ‘Previously, there was no sepsis algorithm tool in our hospital. Different doctors gave different treatments and different antibiotics. Fluid bolus dosage was never consistent and nurses were scared to use inotropes.
‘Confusion means delayed treatment, but the new tool ensures that treatment plans for every patient are consistent. It includes simple antibiotic and fluid dosages, and an easy-to-follow inotropic support procedure. Staff are less anxious to use these drugs now.’
One challenge was getting the medical team on side. ‘The ED doctors were not a problem – they knew we needed to improve on sepsis – but when we approached the medical side, their first response was that they were already good with sepsis. But I brought a team together that included a paediatric consultant and antibiotic consultant, which helped change their minds.’
Drew spent time engaging nursing staff and clinicians to ensure the tool was embedded into practice. He presented it at nursing team, consultant and medical staff meetings.
More than 5,000 patients have been screened for sepsis in Drew’s ED and staff using the tool have not missed any patients with the condition. The department treats 2.3% of its total illness presentations with sepsis 6 protocol and 73% of these patients are treated within the first 60 minutes. ‘There is no over treatment,’ says Drew.
Other benefits include a significant improvement in awareness and knowledge of sepsis in the ED. ‘I am proud of the level of knowledge in our nurses,’ Drew says. ‘You can ask any nurse about sepsis and they will tell you about it.’
One in five
patients with severe sepsis admitted to paediatric intensive care units die
Source: PICANet 2004-05
There has also been an impact on RACH staff. ‘They have now embraced change and many nurses and doctors are now involved in their own improvement projects.’
The tool is being used in RACH’s paediatric assessment unit, Elgin district general ED and children’s ward, and Glasgow paediatric ED. There has been interest in it from hospitals and primary care services all over Scotland, as well as in Sheffield, and Australia, South Africa and Switzerland.
Senior nurse for NHS Grampian Caroline Clark, who has overall responsibility for the children's hospital and the neonatal unit, nominated Drew for the award. She says his commitment and leadership has ensured its success and inspired the trust’s nursing community.
‘As with any change management programme this was not without its challenges, but Drew adapted the tool, trialled it and persevered to ensure staff were fully on board with it before it was fully implemented.
‘Drew’s commitment and belief in the tool inspired the team to implement the necessary changes. He attended meetings and answered challenging questions, came back with answers and audit results, and continued with the programme with determination.’
‘One of Drew's aims when he came back from presenting in South Africa was to motivate and inspire the nursing staff, and he has continued to support and encourage others since. He has become an advocate for the nursing team and has visibly grown in confidence since taking on this work.’
RACH ED consultant Catharina Hartman says Drew’s project has made ‘far-reaching’ improvements in patient care.
‘Drew communicated his vision – to provide cutting-edge treatment to children with sepsis – in an engaging manner,’ she says. ‘His teaching sessions to colleagues were inspiring and this has transformed the triage process into a structured assessment.’
She points out that all patients have benefited from Drew’s work as sicker patients, regardless of aetiology, are highlighted more precisely.
‘The prominent display of performance charts helps to inspire staff because it confirms that they are providing excellent care,’ she adds.
‘But success has been possible only through hard work, and a tireless process of incremental changes and enhancements. Drew's low-key attitude and unflappable leadership were vital to our success and I would highly recommend this approach in any children's emergency department.’
The RCNi Nurse Awards judges were impressed. North East London Foundation Trust nurse consultant for children and young people Joan Myers was one of this year’s RCNi Nurse Awards judges. She says: ‘Drew was courageous yet humble in his approach. He persevered despite the challenges and he remained focused knowing that it would improve clinical effectiveness, patient outcome and experience.
‘His tool has gone from local to international in a short time, even before sepsis management became high on the agenda. Drew has all the characteristics that should epitomise the child health nurse of the year.’
of patients with sepsis receive the basics of care
Source: Surviving Sepsis Campaign
Now that use of the tool is embedded at RACH, Drew continues to monitor its use through data collection. He is working on implementing it in the PAU as well as promoting the tool nationally.
‘My hope and goal is to have our sepsis tools distributed nationally and used in every emergency department and PAU in Scotland and beyond,’ he says.
‘It wasn’t easy. I am a senior staff nurse in the ED so most of it was done in my own time. People don’t like change and it was sometimes difficult getting them to listen. I’ve been laughed at. And it is difficult maintaining standards.
‘Although I seem to get all the credit for this, there is a great team of people helping and supporting me. A lot of people contributed to making it a success and my team and I will never stop trying to improve our service for the children and families that use it.’
Recognising the threat of sepsis
Drew McDonald says: ‘When my son was two months old he was a bit grumpy and not himself for a day. The next morning he was hot and irritable, but still feeding so I gave him pain relief. I then went to a wedding where I was the best man and preoccupied with my role.
‘At the wedding he continued to be grumpy, but had some bright spells. That night I checked him and he was extremely hot and irritable. I knew I needed to get him into hospital. He was admitted to the paediatric assessment unit and given a full septic screen, and IV antibiotics and fluids. Nothing came back on the blood cultures, but he was treated as if he had viral meningitis. He turned out to not have a bacterial sepsis, but had all the same symptoms and it could have been more sinister.
‘I was an experienced nurse at this point but I didn't fully understand the threat of sepsis or the complexities of recognising it.
‘I have always felt guilty that I did not deal with it better, and that the pressure of being a best man and my speech clouded my judgement. It wasn't the trigger for my project, but it made me sit up and recognise that sepsis is a problem and if I can miss it on my own son, it could happen to anyone. When the chance of helping staff to recognise and treat sepsis better came up, I jumped at it.
‘I have a passion for the recognition of sick children and my own children have a lot to do with that. Losing a child is the worst thing I can think of and I don't want it to happen to anyone because of sepsis. Not all child deaths are preventable, but sepsis can be if you get it right.
‘I'm on a mission now.’