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.
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.
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, 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.
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.
is the improvement in the sepsis survival rate if the basics of care are delivered
Source: Sepsis Trust
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.’
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.’
One in five
patients with severe sepsis admitted to paediatric intensive care units die
Source: PICANet 2004-05
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.
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.’
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.’
RCNi Nurse Awards 2017 finalists
Lucy Andrews and Karen Higgins, Sunflowers Care, Cambridgeshire
Nurse managers Lucy and Karen created a home from home for children and young people with complex health care needs to support early hospital discharge, and to offer rehabilitation and respite care. They found a property and developed a business case in their own time. A highly skilled, multidisciplinary team supports children and their families while a fun, stimulating environment meets developmental needs and offers education and social activities. Parent feedback is unanimously positive.
Catherine Brindle, Liverpool Community Health
Catherine secured funding for training enabling school nurses to recognise and assess the increasing number of young people presenting with self-harm and suicide ideation. The specialist school nurse for emotional health and wellbeing and a team of school nurses deliver the package to peers.
Nurses report feeling more confident and better equipped to support a young person in crisis. Young people report that they feel listened to and their concerns are taken seriously.
Carrie James, Walsall Healthcare NHS Trust
Carrie’s holistic transition service helps prepare young people with complex conditions/disabilities for adulthood.
Young people are comprehensively assessed and receive advice and signposting, keeping them and their families central to decision making. They are supported by a key worker and role models with disabilities employed by the service. There are social evenings, confidence building holidays, and practical skills groups such as driving and self-care. The service has improved engagement, saved money and increased face-to-face support.
Helen Thornton, St Helens & Knowsley NHS Teaching Trust
Helen ensured the Goals of Diabetes Education – a national structured programme providing measureable, age-expected, competencies – was made available to help UK children and young people manage type 1 diabetes effectively. The programme also supports parents.
Helen, a clinical nurse specialist for children and young people with diabetes, completely rewrote the resource in 2015, updating it to reflect National Institute for Health and Care Excellence guidance. Copies have been distributed to every UK children’s diabetes clinic.