Nurse Awards

Coma assessment tool revolutionises care of children with brain injury

A consultant nurse who has developed a coma assessment tool for infants, children and young people has been shortlisted in the child health category of the Nursing Standard Nurse Awards.

Nursing Standard Nurse Awards nominee, Gillian Robinson Gillian Robinson has been nominated for a Nursing Standard Nurse Award for her coma assessment tool. Picture credit: John Houlihan

Gillian Robinson has spent 15 years researching and developing the set of neurological observation charts after failures to accurately assess infants, children and young people were found to have contributed to secondary acquired brain injury.

Her work has eradicated such cases at Central Manchester University Hospitals NHS Foundation Trust.

She says is delighted and proud to be shortlisted, adding: ‘It’s a privilege to be considered’.

Assessing a child’s level of consciousness is a highly skilled component of nursing and medical practice. However, increasing evidence of inaccuracy in the recording of neurological observations was causing great concern at the trust. ‘Nationally, there were growing numbers of coroners’ inquiries where negligence in recording of neurological observations was cited to be a contributory cause of death,’ says Gillian. ‘I wanted to prevent the preventable.’

Since the 1980s numerous paediatric observation charts had evolved, all based on the Glasgow Coma Scale, but all differ on quantity and specifics of descriptors of verbal and motor responses. There were no guidelines in how to use them to assess children of various age ranges.

In 2009, with an imminent move to a new hospital, the trust started to question whether its observation tools were fit for purpose. In response, Gillian created CATNIP – the Coma Assessment Tool for Neonates, Infants, Children and Young People. The unique, evidence-based tool incorporates both an early warning coma alert and early warning scores.

‘A wide range of conditions - head injury, hydrocephalus, aneurysms, tumour, stroke, severe systemic infections, poisoning, pulmonary disease, diabetes, renal and kidney failure - may be complicated by impaired consciousness and coma,’ says Gillian. ‘Failure to note deterioration in a child's level of consciousness, or a lack of appreciation of its significance, leads to inappropriate management and could potentially cause irreversible brain damage or even death’.

Unique approach

Crucially, the chart has detailed developmental guidelines and physiological parameters tailored to five age groups – 0-4 months; four months to two years; two to five years; five to 12 years; and over 12 years.

‘This age specific approach is unique and helps nurses and doctors recognise early indications of clinical decline,’ says Gillian. ‘Most neurological charts address under four to fives and over fives. But a baby aged six months is completely different developmentally to child aged five years.’

The chart tells the clinician when to seek an urgent review from a senior medical colleague.

It was ratified by the trust's Children’s Professional Nurse Forum and Governance Committee, before a pilot study was launched in spring 2011. A total of 100 charts were analysed to see whether early warning scores and coma alerts were acted on; and clinicians’ views on its usefulness were collected.

The chart was subsequently amended to include guidelines on when and how to apply painful stimulus. Also added were colour-coded early warning coma alert and age-specific early warning vital signs graphs.

Gillian explains: ‘It made the chart more practical and reliable, but colour printing had cost implications. The original chart cost 15p each, but the new one 57p each. Nevertheless, this is negligible when you consider the cost of potential disability or even death for a child and their family – and the trust’s reputation and finances through litigation.’

This meticulous and methodical process took time but it was worth the wait. The subsequent roll-out into every ward and department in the autumn of 2011 was accompanied by a wide-ranging training programme designed to improve nurses’ and doctors’ understanding and skills in neurological assessment of neonates, infants, children and young people.

Training is on-going, with daily education sessions and it is part of the induction programme for new staff. ‘There has been an unprecedented 100% reduction in high level incidents,’ says Gillian. ‘Indeed there have been no incidents whatsoever. These charts could be used in every children’s ward and hospital throughout the UK, and have a similar impact.’

The judges agreed and were excited about the impact the ‘really proactive safety initiative’ could have in other hospitals. They were ‘blown away by everything being so age- and developmentally-focused’. North Hampshire Clinical Commissioning Group chief nurse Jan Baptiste says: ‘I’m really excited about this – knowing how children go off so quickly.’ Specialist judge Lin Graham-Ray, nurse consultant for looked-after children and care leavers at Central London Community Health Care Trust said the charts were very innovative ‘but their potential to be an agent for change is phenomenal’.

Central Manchester University Hospitals NHS Foundation Trust chief nurse and deputy chief executive Mrs Gill Heaton is pleased that Gillian’s dedication has been recognised at the Nurse Awards.

‘Gillian is a highly skilled and extremely committed consultant nurse who has worked tirelessly to develop and implement CATNIP, driven by the knowledge that coma tools used for adult patients are not appropriate for children as they do not recognise the child's unique developmental and physiological factors.

‘First and foremost the tool has had a demonstrable impact on patient safety by supporting practitioners to recognise and respond to the early signs of neurological deterioration in children, which is especially significant for our organisation as the children's major trauma centre for the region.’