Conscious of deterioration

Nurse consultant Gillian Robinson developed a coma assessment tool that has helped to radically improve the safety of care provided to neonates, infants, children and young people. Crucially, the tool is tailored to specific age groups. Ms Robinson’s achievement was recognised earlier this year when she won the child health category in this year’s Nursing Standard Nurse Awards.

Gillian Robinson started to look at producing a better assessment tool more than five years ago

Picture credit: John Houlihan

Gillian Robinson has spent years researching and developing a coma assessment tool for infants, children and young people. Her commitment paid off – the neurological observation chart has helped eradicate related high and low-level incidents at her trust.

The nurse consultant’s achievement gained national recognition this year when she won the child health category of Nursing Standard’s 2015 Nurse Awards.

Her motivation was simple: ‘I wanted to prevent the preventable.’ Assessing a child’s level of consciousness is a skilled component of nursing and medical practice. Ms Robinson knew that at her trust and nationally there was increasing evidence of inaccuracy in recording neurological observations.

‘Nationally, there were growing numbers of coroners’ inquiries where negligence in the recording of neurological observations was cited to be a contributory cause of death,’ says Ms Robinson, who works for Central Manchester University Hospitals NHS Foundation Trust.

Since the 1980s, numerous paediatric observation charts had evolved, all based on the Glasgow Coma Scale, but there were no guidelines on assessing children in various age ranges.

In 2009, Ms Robinson’s trust started to question whether its observation tools were good enough and she created a unique evidence-based tool called CATNIP – the Coma Assessment Tool for Neonates, Infants, Children and Young People.

Detailed guidelines

‘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,’ she says.

‘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 cause irreversible brain damage or even death.’

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

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

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

Ms Robinson became interested in the issue during her post-registration studies, producing a small-scale quantitative study of nurses’ knowledge and proficiency in assessing levels of consciousness.

In 2010 she conducted a worldwide literature search examining all the paediatric charts available before considering her results and designing the new chart. ‘My colleagues lived and breathed this with me,’ she says. ‘Nursing and consultant colleagues reviewed my preparatory work and blueprints.

‘I have undertaken retrospective audits of neurological charts and attended national interdisciplinary forums and benchmarking meetings, where strengths and weaknesses of various neurological charts were debated. The finalised chart was actually the tenth draft.’

The chart was ratified by the trust’s children’s professional nurse forum and governance committee, before a pilot study was set up in spring 2011. A total of 100 charts were analysed to see whether early warning scores and coma alerts were acted on. Clinicians’ views on its usefulness were sought.

The chart was amended to include guidelines on when and how to apply painful stimuli. Also added were a colour-coded early warning coma alert and an age-specific early warning, vital signs graph.

The subsequent implementation in every ward and department in the autumn of 2011 was accompanied by a training programme for nurses and doctors. Training is a continuing process and also part of the staff induction programme.

‘There has been 100% reduction in high-level incidents,’ says Ms Robinson. Indeed, there have been no incidents, whatsoever. She insists that ‘these charts could be used in every children’s ward and hospital throughout the UK, and have a similar impact’.

The Nurse Awards judges agreed. The charts are clearly innovative ‘but their potential to be an agent for change is phenomenal’ said specialist judge Lin Graham-Ray, nurse consultant for looked-after children and care leavers at Central London Community Health Care Trust, and a former Nursing Standard Nurse of the Year.

Central Manchester University Hospitals NHS Foundation Trust chief nurse and deputy chief executive Gill Heaton says Ms Robinson worked tirelessly on CATNIP. ‘She was driven by the knowledge that coma tools used for adult patients are inappropriate for children because they do not recognise the child’s unique developmental and physiological factors.

‘The tool supported practitioners to recognise and respond to the early signs of neurological deterioration in children.’

Ms Robinson says: ‘Seeing something you have worked tirelessly to develop put into practice, and making such a difference, reminds me of the importance of the art of nursing’.

Automated and bespoke alert system

CATNIP – the Coma Assessment Tool for Neonates, Infants, Children and Young People – could be automated as a result of discussions Gillian Robinson is now having with designers. ‘This would enable us to provide a bespoke chart for each patient, because we could modify functional parameters to reflect the child’s norm,’ she says.

‘For example, a child with learning disability will not have reached the developmental milestones of another child of similar age, and a child with an underlying cardiac problem will have altered heart rate. Furthermore, the wireless system automatically alerts the nursing or medical personnel via the bleep system to enable an immediate emergency response.’

Ms Robinson is looking for opportunities to disseminate her work. She has already shared it at a conference with the Royal College of Paediatrics and Child Health, British Paediatric Neurology Association and Association of Chief Children’s Nurses.

As a member of the Northwest Neurosciences Network Board and Major Trauma Network, Ms Robinson has also been able to share the work with allied health professionals such as paramedics, advanced practitioners and therapists.

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