Senior 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

‘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.’

One in five patients with severe sepsis admitted to paediatric intensive care units (PICUs) die and Royal Aberdeen Children’s Hospital (RACH) emergency department (ED) senior staff nurse Drew McDonald was concerned that this could happen in his workplace. 

He therefore developed a clear and easy-to-use sepsis recognition tool for nursing staff to refer to during triage. The tool, which takes 20 seconds to complete, integrates Sepsis 6 into ED practice. It was implemented successfully at RACH.

His leadership and commitment saw him announced winner of the child health category of the RCNi Nurse Awards, the profession’s top accolade.

Improving outcomes

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. 

‘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 start.

‘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, and then I started engaging staff.’

First, 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.

Treatment plan

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.

The tool includes symptoms not considered in a paediatric early warning score (PEWS), such as poor perfusion, mottling and poor peripheral perfusion, as well as altered mental states, such as irritability and ‘floppiness’.

If sepsis is identified, it is managed appropriately with an easy-to-follow six-step treatment plan. 

Drew says: ‘Previously, different doctors gave different treatments and different antibiotics. Fluid bolus dosage was never consistent and nurses were scared to used 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.’

Engaging staff

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. 

‘All of our PICU patients have returned to Aberdeen well, although unfortunately two children with sepsis have died in our ED since 2014.’

Drew adds: ‘I am proud of the level of knowledge in our nurses. The wider staff have now embraced change, and many nurses and doctors are involved in their own improvement projects.’

The tool is being used in RACH’s paediatric assessment unit and at hospitals in Elgin and Glasgow. 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.

Change management

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 it 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. He has become an advocate for the nursing team.’

Joan Myers, nurse consultant for children and young people at North East London Foundation Trust, 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.’

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.’