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Working together to improve patient safety

How the Royal Belfast Hospital for Sick Children emergency department has enhanced care within financial restraints.
Belfast_ED

How the Royal Belfast Hospital for Sick Children emergency department has enhanced care within financial restraints.

One of our core aims at the Royal Belfast Hospital for Sick Children (RBHSC) emergency department (ED) is to ensure patient safety within financial and resource constraints.

The RBHSC is the only hospital devoted to paediatric care in Northern Ireland. It ranks in the top 30 most technologically advanced childrens hospitals in the world and has developed robust safety practices to ensure all children receive the best possible treatment.

It has also introduced innovative programmes, such as the child or neonate needing emergency critical care transport, or CONNECT, in which integrated paediatric and

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How the Royal Belfast Hospital for Sick Children emergency department has enhanced care within financial restraints.

Belfast_ED
Picture: Getty Images

One of our core aims at the Royal Belfast Hospital for Sick Children (RBHSC) emergency department (ED) is to ensure patient safety within financial and resource constraints.

The RBHSC is the only hospital devoted to paediatric care in Northern Ireland. It ranks in the top 30 most technologically advanced children’s hospitals in the world and has developed robust safety practices to ensure all children receive the best possible treatment.

It has also introduced innovative programmes, such as the child or neonate needing emergency critical care transport, or CONNECT, in which integrated paediatric and neonatal teams provide a dedicated ambulance service to the ED.

The RBHSC’s type one ED provides specialty treatment to about 38,000 children aged up to 14 from all over the country. It has a 24-hour consultant-led service and its triage nurses are registered children’s nurses with at least one year’s paediatric ED experience.  

Experienced staff

Immediately after children arrive at the ED, an experienced team member assesses the severity of their conditions and determines whether they can wait for triage. The team takes down observations of the children and brief histories from parents, and each child is allocated a triage category according to the Manchester Triage System.

While each child is waiting to be seen by medical staff, experienced paediatric triage nurses advise the parents on oral fluid management based on the child’s weight.

We encourage parents to measure the amount their child drinks with an oral syringe and record the result on a chart. This allows children’s urine samples to be obtained and tested in the hospital laboratory early, and in some cases test results are returned before the child has been seen by a doctor.

If blood sugar testing is required, we carry it out at triage so any necessary hydration therapy can begin. We also dispense common medications, such as analgesia or local anaesthetic, at triage according to patient group directives.

Morale boost

We received a morale boost earlier this year when the emergency care team came second in the openness and honesty category of the Belfast Trust Chairman’s Awards, which celebrate innovation in health and social care.

The £3,000 prize money we received was reinvested in our service. We bought a sepsis trolley with specialised neonatal sepsis packs, intravenous (IV) fluids and sets, and equipment for urine catheterisation and lumbar puncture to treat septic children. This equipment has improved our practice by ensuring children get treatment promptly.

Our triage nurse is trained to identify sepsis symptoms at the start of each patient’s journey. Babies under three months old who have pyrexia commence a sepsis care pathway within 10 minutes of their arrival. Investigations, such as blood sampling, urine testing and, if necessary, lumbar puncture, are carried out before antibiotic therapy within one hour of arrival, in line with the Sepsis Trust sepsis six bundle.

We try to make our patients’ journeys as positive as possible, and we have a dedicated play specialist to help with difficult and painful procedures. Children are given trauma teddies to take home with them.

Training staff

Weekly simulated multidisciplinary resuscitation scenarios involving medical and nursing staff are held at junior doctors’ teaching sessions.

New staff are taught to manage cardiac scenarios, seizures and trauma. All staff attend a paediatric immediate life support course each year and senior staff attend an advanced paediatric life support course every four years. A hospital-based major incident medical management course is also available to senior staff.

Nursing students on placement in the department receive a written induction booklet when they arrive which includes department orientation, a weekly guide on learning expectations and written emergency scenarios for the student to work through. This encourages reflective practice, in line with revalidation requirements for registered nurses. As a result, many students return to the ED as staff nurses.

The ED is the highest performing in the country. In 2014/2015, there were no cases where a child was not seen or treated within 12 hours and we have robust systems to investigate when four-hour breaches occur.

Safeguarding issues

In December 2014, one of our consultants introduced a daily morning multidisciplinary safety brief in the ED. The nurse in charge, a senior doctor and other healthcare staff complete a patient data collection sheet, and discuss incident reports received in the previous 24 hours so that all staff can learn from them.

During the brief each member of staff can raise safety concerns, and we also discuss medical and nursing staffing, equipment problems, deaths, issues raised and events planned that may affect the ED. On average, five issues that must be addressed are identified each week. 

A multidisciplinary safety goal is also set each week, and these have led to increased reporting of equipment problems and clinical errors, and improved practice and communication among team members.

A doctor and nurse are allocated to patient tracking on each shift to prevent 12-hour and four-hour breaches. They document each patient’s time of arrival, time to triage and time to see a doctor so that staff can understand the causes of each four-hour breach, including specimen chute or blood result delays.

Breaches are displayed on a white safety board along with breaches in other Northern Ireland EDs, our safety goal of the week and any new guidelines or changes to practice. The ED also displays new research guidelines, for example sepsis posters showing paediatric clinical guidelines as well as symptoms, so that all staff can keep up to date.

Consultants are on site in the ED until 11pm every night. They review case notes every morning, 365 days a year, to ensure clinical errors or safeguarding issues are acted on as soon as possible.

Sharing information

Communication and honesty are key to our high-quality service. Safeguarding questions are asked at triage, and we communicate with the GP and health visitor of each child who attends the ED so that all medical information can be shared with community services. A consultant checks blood, microbiology and X-ray results to ensure follow-up is provided.

A staff-activated television screen in the ED waiting area displays waiting times, as well as first aid advice and home safety guidelines for parents from the Royal Society for the Prevention of Accidents.

We are proud of the safe service delivered by our highly motivated, well-trained staff despite limited staffing levels and rising patient numbers.

Safe treatment in the RBHSC ED: as easy as ABC

Introduction

The Royal Belfast Hospital for Sick Children emergency department provides safe, high quality care to about 38000 children each year.

Trauma teddies

Objectives

To provide the highest quality of care from start to finish of each patient’s journey.

Materials and methods

  • Patients are ‘eyeballed’ and prioritised by an experienced triage nurse.
  • Some children require immediate resuscitation.
  • Parents are given advice about, for example fluids, from triage.
  • We strive constantly to learn new techniques.
  • We use simulated resuscitation situations to ensure we are ready for any emergency.

SimulatedResus

Results

  • There is a multidisciplinary safety brief.
  • We set a safety goal each week.
  • There are daily opportunities for all staff to raise concerns.
  • There were no 12-hour breaches in 2014-15.
  • Systems are in place to assess all four-hour breaches.

Conclusions

  • We won second place at the Belfast Trust Chairman’s Awards, which was a great boost to team morale.

Award

  • We are a proud team and teamwork is excellent.
  • Emergency department placements are popular with student nurses and we receive excellent feedback
  • Nurses have come back as staff nurses.
  • It feels good to know that our work is noticed.

About the author

JenniferMorissey

Jennifer Morrissey is deputy emergency department sister at Royal Belfast Hospital for Sick Children

 

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