Paediatric Sepsis Series — Retrieval of the child with sepsis

Transcript

Right everyone, I think we'll, we'll, uh, kick off. Um,

uh, cuz we've got a pretty packed, uh, lunch hour for you.

And I wanted first of all to thank you all for, for taking time out to, to um,

uh, come and listen to this webinar.

Obviously pediatric sepsis is very close to my heart,

but I know it's something that you all face regularly in your,

in your departments and, um, hopefully this will be of some use to you.

Um, before we kick off,

oh, I just wanted to, um,

acknowledge the traditional custodians of the land and which we're meeting,

which for me is the, um, Gaby, Gaby people in the sunny coast. Um,

but obviously would be different for, um,

the different lands in which you are all, um,

meeting today across Queensland and I wanted to pay my respects to elders past,

present and emerging.

Now I'm very grateful to be joined by um,

two of my pediatric intensivist colleagues. Uh, the first is Dr. Paul Holmes,

who works, um, and is the director of the Children's Health, um,

Queensland retrieval service or Checkers. So he runs the, um,

the retrieval service, um, for Queensland. And, uh, Dr. Greg Wiseman,

who's the director of the northern part of that retrieval service called

Alluring. So thanks for joining me guys. I'm really appreciative, um,

of you sharing your experience and your wisdom after having done retrievals of

septic children over many years. So just to run through what we're gonna cover.

But the most important thing is that we're gonna discuss our new revised sepsis

pathway. And the key points I want you to remember is that this,

if you use this pathway,

you are compliant with the new Australian sepsis standard and you will be

delivering high quality sepsis care to your children.

There's only one pathway for all the facilities in Queensland,

whether you're an inpatient pediatric unit in ed, a rural and remote facility.

There's only one pathway and it covers the whole of the admission.

It's not what we're gonna talk about today cause we're talking about retrievals,

but it does cover the whole of the admission.

Paul is gonna run through a case with his um, one, I think one of his trainees,

Caroline and Grace is gonna give us some perspective from the far north

Queensland. I hope we have some time for questions and answers. Um,

please pop any questions you've got in the chat.

If we don't manage to get to them today, then we will, um,

contact you and ask them. Um, and if we start to run over time,

we will continue. And if you are able to stay with us then that's great,

but if not, it'll be available in recording later. Right.

So we all know that sepsis has a fancy definition,

but the most important thing to remember is it's an infection with associated

organ dysfunction.

And most importantly it is a clinical diagnosis for which there is no gold

standard test and there is no single sign or symptom that is a

defin makes a definitive diagnosis. So for us poor clinicians at the bedside,

that's quite difficult cause we all know that organ dysfunction isn't absent

one minute and present the next. We know it kind of evolves over time.

Now we know in sepsis that evolution that time is pretty short. It can be rapid,

it can be a couple of hours only,

but it makes it difficult for us because we're not always that certain of the

diagnosis.

And that uncertainty or certainty is actually in this pathway

and does help you. So do use it.

The other tricky thing about kids is that we know pediatric stasis is pretty

rare, but when it's late it's pretty easy to diagnose.

No one would miss those children on the right hand side.

They would peric rash and and and requiring mechanical ventilation, et cetera.

But how do you pick them out of the thousands of kids who present with common

childhood infections?

And that early diagnosis we know is important because that means we can stop

treatment early and we have better outcomes. So how do you do that?

And the important thing here is to remember that we've proven with research that

if you use a screening tool and a recognition tool,

it improves our pickup of these children.

And it's important to remember that what we are doing is not screening for

sepsis in our tool.

We are screening for children with features of severe illness.

And the reason for that is because I've already said there is no single sign of

sepsis or symptom of sepsis that is diagnostic. Rather,

it is a constellation of pulling all of a number of bits of information

together, which means that in order to learn to diagnose sepsis,

you probably need to have seen it before.

So experience is very important in your ability to diagnose sepsis.

So what we have done with the screening tool is we have um,

you isolate a cohort of children who have features of severe illness

and then you get a senior clinician who will have seen it before,

will have experience of sepsis to review those children and they will pick

out the children in that cohort who have severe sepsis.

So we are rather looking at how sick as a child rather than how septic the child

is. And we know our clinicians are pretty good at this. Um,

in the collaborative where we screened three and a half thousand, um,

kids who had features of severe illness, when a senior clinician saw them,

they thought about maybe half of them didn't have sepsis,

they only got that wrong in three and a half percent.

And where they thought there was sepsis,

they were absolutely correct later on blood cultures and everything else, um,

44% of the time.

So our clinicians are pretty good at spotting it if you give them a cohort of

children with severe, uh, illness features.

The other thing to remember is that the more often you see sepsis,

the better you are diagnosing it. And this is just a,

a plea to show that pediatric intensivists, this is one in 10 of our patients,

has sepsis. This is common to us. It's bread and butter.

And the person that's on the end of the RSQ line,

the the pmc the pediatric medical coordinator is an intensive.

So there's gonna be someone very experienced in diagnosing and treating sepsis

ed Physicians are pretty experienced too, so it's 0.1% of their caseload.

So they see sepsis quite a bit throughout their careers.

But some gps or primary healthcare physicians may never see it in their careers

cuz it is a rare thing.

And do we have a problem with it where we treat and and recognize sepsis in

Queensland? And the answer to that is absolutely.

So this is five years worth of data looking at 28 cases of severe adverse

events. And unfortunately 23 of these children died.

And when we looked at the contributing factors to their poor outcomes,

we saw there was a lot of route delay in recognition and treatment.

And when you look at that, it's diagnostic error, it's inadequate assessments,

it's not monitoring adequately, it's not investigating adequately,

it's not escalating clear adequately.

There were systems failures as well with guideline policies not using the,

the acute scores accurately. And there are a few human factors.

All of these things are addressed with the revised sepsis pathway and some of

those human cognitive factors are gonna be addressed by you just dialing in,

in this link to this webinar.

So the new sepsis pathway comes in at a whopping 11 pages.

There will be some bits of it that are very familiar to you and that's the

screening and recognition tool, the treatment bundle,

the antibiotic guidelines and the checklist that you give to parents.

But the new bits are a monitoring and reassessment guide,

comprehensive management plan and the new information sheet for parents where

the kids are gonna be admitted and we'll run through those, um,

a bit more carefully. So this is the screening and recognition very familiar.

It hasn't changed very much. And importantly, you are asking a question,

could this be sepsis? You performing a set of, um, observations,

looking for features of severe illness? If you see features of severe illness,

tachy or tachycardia, you're going to get senior medical eyes on that patient.

Now, if you are in a remote or rural area,

that may need to be RS phoning rsq and doing telehealth with the

um, P M C. And that actually you can see is in that purple box,

um, in the first purple box that you see there. Now, um,

once it's reviewed by the senior medical person, they may say, yes,

absolutely there's a sepsis. You go onto your treatment bundle.

If you haven't already involved R S Q, then there is a,

a reminder there to involve R S Q and to get that senior, uh,

PMC in on the call.

But you may find that the child has no features of severe illness or has been

reviewed and people don't think that this is sepsis right now.

Or it might be sepsis, but we're just not sure.

So this is where the light pink box comes in and that certainty of the

diagnosis. So you give yourself a,

a time ticking clock of three hours to decide whether with a bit more

investigation, a bit more monitoring, whether this might become sepsis,

in which case you start your treatment bundle. And if it isn't,

then you don't need to. Or you may decide this isn't sepsis at all,

it's something else, it's just bronchiolitis, whatever.

And if you do send that child home,

please give the parents the checklist because this is a checklist of signs of

deterioration when to come back to hospital and say,

my child isn't getting better, there's something else wrong.

So the this is a checklist that they should be discharged with that will be

familiar too. It's not you.

So moving onto the treatment bundle that looks very similar to how it looked

before. Importantly, you've got to monitor your saturations, keep them over 94%,

you're going to get intravenous or osseous access.

And when you do, if it is possible, please take a blood culture.

If it's still possible, please take a, a lactate and a blood sugar. And if it's,

if you're Brit, you might even be able to take other bloods as well.

It's not necessary.

You're then going to choose the appropriate an empiric antibiotic

for where you think the source of sepsis is,

and you'll go to antibiotic guideline to do that and we'll talk through that in

a minute. Um, and then you're gonna start some fluid resuscitation.

10 mil per 10 mil per kilo, either balanced solution or normal saline.

And then you're gonna monitor for signs of fluid overload.

You may think about repeating that later on if you need to.

You're gonna think about your blood sugar and giving, um, 10%, um, uh,

dextrose if you need to. And you may think about a second, uh,

line if you've got time later on.

It's one of those things that's in the to-do list.

And then you are also gonna be considering inotropic support, um, after,

after giving some fluid. And at the, and in number six down there,

there is a recipe for drawing up, um, adrenaline infusions in kids.

So that's a useful thing to have there. And remember,

if you are thinking about drawing up, um, an inotrope,

you really need to be talking to R S Q. And again, the number is, is there.

So there are several points of escalation up to R S Q and reminders and,

and the numbers for you to call to do that.

So just going back to the antibiotics,

remember our antibiotic guidelines have three parts.

The first is the empiric prescribing guidelines.

What is the appropriate antibiotic for where you think the source of infection

is? And this takes into account whether you think there's an allergy or not,

whether you think there's, um, MRSA or not. Um,

and importantly write up at the,

at the top here is if you have septic shock requiring inotropic supports,

you always add in gentamycin plus vancomycin

in addition to the, um, the source antibiotic.

So it is just a reminder to to do that where you think there's shock.

And in far north Queensland there are slightly different options which Greg is

going to going to talk about.

And there are also antimicrobial dose recommendations. So your poor, um,

clinician who's writing up the antibiotics has got a guide as to how to which

dose is appropriate for, for which weight. Um,

and importantly here, we had a little question submitted before, um,

before the presentation. So I'm just gonna answer that here.

And particularly in neonates, we don't like to give iv, uh,

IM ceftriaxone if you cannot get intravenous access. So what you do in neonate,

the answer is please do try IO first because IO is brilliant.

But if you don't manage to get io,

then you can give IMAX And the Q C H

um, uh, site has an intramuscular injection guide, remembering that,

uh, the volume per injection site is quite small in neo innate.

So for a neo eight of five kilos,

the total dose of axium would be 0.75 mil.

So you'd have to give it in two lots into each thigh.

So just a reminder of where you can find that information. And then lastly,

there's an antimicrobial administration guidelines. So this is, uh,

a helpful guide for nurses who to dilute and draw up the particular dose that

has been described and how to give it. And just a reminder here on the,

on the side of the Queensland pediatric emergency case site, um,

the icon that you can get on your desktops and this will lead you to the credit

book, which is electronic,

which helps with all of the first hour ed type drugs and infusions,

but also leads you to the retrievals checklist,

which is very important because you are gonna be speaking with retrievals.

So once you've delivered your treatment bundle, what next?

Now on our new pathway,

the first thing it takes you to is a bereavement section cuz we all know that

there are some children that come in quite late and despite your best in best

resuscitation efforts, they, they die. And for those kids we need to,

to know what to do for them. So there's a little bit, uh, of, of, of, um,

advice there. And importantly,

the c HQ bereavement service is statewide.

So even if you're in far north Queensland, give that number to the parents,

they will be in contact and they will support those parents. Um,

even that far away. Luckily the vast majority of our patients do are do survive.

And this is the point,

once you've given the treatment model at which you need to reassess,

how are they doing, how are they responding to treatment?

And you do that by taking a, a set of vital signs.

And if they're improving, you know that the signs of sepsis are resolving.

You may be looking at stepping down to ward type care, but if you are,

if the patient does signs of persisting or deteriorating,

then actually those children need more input and they are in that sort of purple

box there. And this is very useful for,

for those services who are having to hold onto children waiting for retrieval

services to come. You've done that first quick hour of treatment.

Now what do you do?

So the first thing it talks about is what you monitor and how frequently.

So the continuous types of monitoring,

the 15 minutely monitoring and then your reassessment.

So how do you collate that information that you're getting from your monitoring,

um, and how you collate that into what needs to be done next.

So you should be reassessing.

So assessing all of those vital signs after every intervention.

So if you give a fluid bonus, you should reassess,

you should do it after every sort of vital sign changed.

So if your blood pressure was okay and then suddenly dropped,

you should do a full set again. And as a minimum, if everything is okay,

you should be doing them, um, 60 minutely. Um,

and if anything is not improving or,

or this is the point again at which you need to be talking to the pmc cuz you

may be needing to think about different treatments. So either more fluid boats,

it's adding in another inotrope thinking about mechanical ventilation,

all of those things that are a little bit more complicated.

And you really need to be talking to your, your medical expert who's your,

your the retrievals P M C. And the number again is listed there.

So it is a little bit of a useful guide as to what you need to be doing waiting

for retrieval services. There's also a section that, uh,

consumers contributed a lot to,

which is what information do they want at that stage?

And there's a little bit of a list there remembering to involve your social

workers if it's in ours.

And thinking about indigenous health liaison offices if you have access to them.

But there is also this new information sheet,

which is designed for parents who are going to have their children admitted into

hospital. So this is what, what's going to be happening over the next, um,

hours and days. And then lastly,

the last bit of our management plan is thinking about if you've got time,

once you've done all of this and your fluid policy is going in and everything

is, is settling down, you're waiting for retrieval services,

can you be finishing off some of your investigations?

So is there a we that you could maybe, um, collect? Is there a stool,

a dirty nappy that you could maybe collect? Um,

and it is also at this point you make sure your documentation is complete and

that your communication plans with r rsq are complete and with the parents are

complete and that that's well documented.

So I'm gonna stop there and I'm gonna hand over to Paul who I hope

is online. Um, yes, there he is.

And Paul, I'm gonna be managing the slides.

So just tell me to move on when you want me to.

Okay, first of all, Paul, can you hear me?

Yes we can.

Fantastic. Just had some technical difficulties.

So I'm running this on my phone, um, but it seems to be working okay. Um,

I'm just gonna shout out thanks to Caroline Venner who's working at part-time as

a fellow with us who helped write some of the slides. Um,

she's also an SMO in Gladstone Ed and is gonna be working with RSQ a little bit

in the future. Okay, next slide.

So this is, I'll just go through a really quick case just um,

illustrating a lot of the stuff Paul's already talked about so I won't linger

too long on it. Um, this is four year old Susie, um, that's not her,

that's an actor. Um, she's normally fit and well.

She doesn't take any regular meds, no allergies up to date, their immunizations.

Um, no covid risk factors such lives for mum and dad. Next slide.

Um, and she was well during the day mum and dad are both um,

started with a bit of a cold or something with sore throats and she went to bed

with a bit warm so they gave her some roofing cause she was complaining a bit of

sore throat,

but she woke up a couple of hours later and they gave her some Panadol cause she

seemed to be hot again. And then she had a large vomit.

They weren't happy with the way she looked. She seemed to be irritable,

which not normally, um, the way she looks.

And so they took her to the emergency department, um,

and she has a further vomit at triage and those are initial obs.

So she's a bit technique.

SATs in room air possibly aren't as high as you'd expect them.

She's tachycardic. She does have a temperature though. So I mean this is the,

the tricky thing isn't it? You know,

a lot of kids have temperatures and that makes you technique and

tachycardic and how do you pick which ones you're worried about? Next slide.

Um, so I guess what are the red flags? Could this be sepsis?

Well we're talking about it at a sepsis talk, so that's a bit of a red flag. Um,

next slide. But for her, um,

she's got signs of infection with the temperature, um,

and she's looking a bit sick around the edges. So we're gonna go with, um,

ticking the screening there, um, as Paul's already said into, yeah,

that's fine intensivists. Um,

I don't have a problem recognizing people are septic cuz normally someone comes

and tells me that they're septic.

It's not something that I have to do where I'm looking at a hundred people and

trying to find the one.

Normally I think everybody's got sepsis and it's who doesn't,

so it's a slightly different, um, way of looking at things. Anyway,

this kitty was miserable. She had a red throat,

she had increased work of breathing and the TA apnea ongoing,

she got warmer up to 38 2, the SATs still, um, okay,

but not great. Um, there's nothing to hear in the chest.

She's more tachycardic now,

170 and she's a bit cool around the edges and has a central cap refill,

which is three seconds.

Her abdomens softer while she's complaining for some tummy pain.

Doesn't that many rashes. Um, and they must do a finger prick and get a sugar,

which is okay. And ketones are low, nothing in the urine and they get, um,

they stick a, a swab off and get the fourplex back, which is negative.

So what now, click again.

So she's got this work of breathing and TA up near.

Um,

so that gives her features of severe illness plus I think this clinician concern

as well. And so putting that all together,

we have to say that she's likely to have sepsis,

so they go on to attempt to get IV access on the next

slide, but she's actually quite difficult because she is looking a bit cooler

peripherally now. Um,

and they managed to get some blood off and that's the gas,

but they don't manage to get the drip in. As you can see, she's acidotic there.

That's a bit worrying. The CO2 is low. So she's tagging me,

but she's still acidotic with that and the lactates up at four. So as we know,

the cutoff for concern if you think someone's got sepsis is around two.

So four is quite concerning if you are thinking the diagnosis is sepsis.

So we have to take that seriously. Now I know, um,

if you're getting capillary samples,

there's a risk for squeeze samples and that can artificially raise the lactate,

but that's not something to ignore in a patient where you are genuinely

concerned that or you are on the sepsis pathway.

I think you have to take it seriously and plan to repeat it. Um,

so because they're not happy with the way she's looking,

they actually go for an io. Um, and there's a few places there. They go for the,

um, tibia one and give some fluids. So they give a a saline baus,

um, and start some fluid running through that. Um,

and give the keta straightaway. So that's 50 per kilo

through the im And so, uh, sorry, through the io.

So you can give anything through an IO pretty much. Um,

iOS are a bit like central lines or that's how I think about them.

You can give just about anything through them, uh, can't rate them enough.

So they give another bolus. She's still got this prolonged cap refill.

And at this point, after the second bolus of vein comes up, so they get another,

uh, they get a drip in. So she's got two points of access. Now, unfortunately,

they'll repeat gas isn't any better, it's a bit worse.

So the lactate's going the wrong way. Um, she's still got an okay sugar.

Um, so they go on to give a third fluid bolus and you can see she's still

tachycardic 160. Um, I think the temperature's settled by now.

So she's got a tachycardia despite having a normal temperature.

And so that's concerning.

The blood pressure's getting a bit saggy and the cap refill's getting worse and

there's evidence of end organ, um,

involvement now because she's becoming less responsive, um,

she's less alert. So what do we do now?

Well probably if you haven't already, um,

you would have had a senior review and, uh,

probably a call to R S Q at this point.

And that's where we'll go to the next slide.

Oh, sorry.

So that's the icon that should be on every desktop, um, in Queensland house.

So if you click on that click, you'll get this up.

And then resuscitation, uh,

is handling one of the top things and you click on that, you get to this,

and then there's a bunch of things.

And the quickest way to get to the sepsis thing is to click the flow charts one,

and then you, you'll get, and then sepsis is there.

You don't need to click on it. I've already, yep, perfect.

So we've already looked at that. Paul's already been through it. Um,

so here's the rsq bit. So what happens when you call rsq? Um,

so the first thing is they ask if it's for an adult or a pediatric neonate

or obstetric patient. Um,

you'll be collected to connected to the clinical nurse,

the nurse coordinator at R rsq who will then do the triage tool with you.

The triage tool is also available on that website. Um,

you can look at it for your own information.

It wasn't designed to be used by referring clinicians to to to give,

to make you do it. Um, it is done by catch, it's done by R S Q,

um, and it works out who goes down the critical arm and then that automatically

comes to a PMC throughout the state.

And the pmcs are all pediatric intensivists

like myself. And, um,

So there's triage and then if you want to talk to a PMC and you haven't

been triaged to talk to a pmc, you can just say, I'd like to talk to the pmc.

And then you get through as well. So that's one of the criteria.

So it's a very safe triage tool. There's physiological things, there's um,

uh, condition things and then there's just clinician concern or nurse concern or

sometimes the, the, the R RSQ nurse will go, um, at the p c for this. Okay,

next

Click.

Um, so here we go.

So the first thing a PMC is likely to do is check that you've got your local

escalation policy. So even if you're not, even if you don't have any, um,

pediatrics on site or you're not, whatever,

you don't have the C S C F or whatever you do need to have,

every hospital needs to have a policy to deal with sick children coming in.

It's just the way it is. Children don't know,

they're not allowed to come into your facility and so they might do.

And so you need to have some kind of medical escalation thing and sometimes R S

Q can help with that.

Sometimes we might know if there's a clinician nearby who could drive, get,

jump in a car and drive to you or something like that. Um,

particularly if you don't have, um, you know, medical officer are on site.

Sometimes we get phone calls from nurses where's just a couple of nurses in a

clinic and in, you know, very sick cases, um,

severe sepsis out of possible cardiac arrest.

What we'll try and do is talk to the R S Q medical coordinator to what we call

front load the logistics.

And that means get boots on the ground medical support. Um, and if you,

if that, if you know you need that, then it's okay to ask that up front. Um,

obviously if you're the largest enter and you've got five consultants there

already, then you don't need, um, just the first team coming. You need the,

the specialist team. And so we could, you know, we'll set that up as well. Okay,

so for this case,

we've clicked on the credit as we can see with the handy little thing there. Um,

we've got,

we've confirmed there's a second access and we might try for a second drip just

in case the IO goes, but it's not, um, a hundred percent iOS are usually fine.

And once they're placed and working, they usually do really well. Um,

so we recommend a further 10 kilo fluid base that's now what are we up to 40?

Um, and then we're talking about preparing peripheral inotrope.

And this is adrenaline. I say peripheral,

but you could give it through the IO perfectly fine.

And a reasonable starting rate would be 0.05 there.

Considering other antibiotics. If, if we,

so do we have any other clues or concerns for mrsa?

If we're giving the inotrope, we automatically, as Paul said, we have to give,

um, I say was it gent and f? Um,

and then we need to have a think about is it any other conditions? So in, um,

you know, your your 10 day old baby, is it the duct closing?

Have they actually got, um,

a mis coarctation or something like that if they got a metabolic condition? Um,

unlikely in this kitty, I would say. Although we,

we did have one co-opt presented, an 11 year old Anyway,

um, then the other thing is we've given a fair amount of fluid.

Not every child who needs 40 per kilo needs intubating,

but if you're gonna keep having to give fluid bolus, it might go that way.

And so we would probably start flagging, you know, do you have, you know,

calling the appropriate staff?

Do you need to flag it with your ED people to do the ss i p process?

You have an anesthetics GP anesthetist, um,

you've got local ICU u and if that's the case,

is your patient in the right place? Do they need to go to EDUs theaters?

You know, where's the right place?

So you have a cubicle that this all sorts of happens in and click again. So, um,

Caroline put this in and then I just corrected it. Just click one more time.

Yeah, there we go. That's sorted. That's perfect Now.

So we're gonna start with adrenaline and then the next thing you're gonna give,

um, is Nora adrenaline next. Okay,

so what happens next? Um,

so retrievals take a while and I'm gonna talk a bit about, um,

some of the numbers, um, in a minute. Uh,

but we're not gonna be there straight away. And so what are you gonna do? Well,

if things get better, you're gonna still need to monitor your patient.

Cause we know with SSIS it can go a bit up and down and patients can get worse.

And so you also need to reassess. So don't put your patient in a dark room,

let everybody have a nap. Um,

we want these patients in a monitored with continuous monitoring as you can see

there. So the light pink is the if things are getting better, um, and we,

you know,

expect blood pressures every hour and temperatures and keeping an eye on the

fluid balance and making sure they're still learnt, checking the temperature.

And if things are getting worse, you've got the purple halfway to go down.

What are we gonna do? Fluids and inotropes. So we,

we've already said you're probably gonna start with adrenaline. Um,

if that's not enough, you're gonna add in NORAD plus minus vasopressin,

you're gonna need to keep giving fluid. Um,

now obviously how much fluid do you give is the million dollar question and the

answer is enough. How do you know what's enough? Well,

you have to give enough to have something to have a circulation.

It doesn't matter how much inotrope press you put on,

if you don't have a circulation, uh, it blood isn't gonna go round and round.

Now we do know that, you know,

these people are gonna have capillary leak endothelial injury and they might

start to leak into the lungs.

And that's one of the reasons why you need to intubate in addition to taking

control of, you know, that, that aspect of things. Um,

but you just have to keep giving fluid if you have to keep giving fluid. Um,

there isn't really two ways about it. Um,

if you do have to intubate them, if it's going that way,

then obviously intubation in these patients can be a high risk,

uh, venture. Um,

and so you would want to have your inotropes on and your fluid bolus in just at

the point that you're thinking of inducing. Uh, you would want to have bolus,

uh, inotrope suppressors. So either, um,

OSI adrenaline or meta tramadol, whatever you are more familiar with.

And in terms of induction, normally when we're talking to people about, um,

intubating children who aren't used to doing it, um,

usually that's not the time to learn a completely new technique. Um,

so we normally say just do what you are familiar with but modify it. Um,

cause that's usually easier than doing something completely different. However,

I would say thi is a definite no-no in sepsis. Um,

you're gonna, you know, the chances of arresting with that are,

are a lot greater. Um, and in the very, very,

very severely septic child who's already got their sympathetic system working

maximally, um,

almost any type of induction can potentially push them over the edge.

And even ketamine, which is, you know, a favored drug, um, you know,

that that also gives them little bit of sympathetic stimulation.

It might just be too much to push them over the edge. So normally the um,

the normal usefulness of ketamine might not work in this situation,

but that's something to discuss with the pmc. I think that's a,

a high level discussion case by case basis. Um,

of course you're gonna pick the most experienced staff member to do it and

because of the CPR risk you probably should be allocating roles to who's gonna

do jump on the chest if it does go bad.

And you don't wanna find out if the blood pressure does start to slide when you

induce them that you can't find your push dose presser.

You don't wanna be slapping your pockets looking for it.

You want it in your hand of the drug doctor or whatever ready to go.

Um, a couple of quick mentions about, um,

ET tubes and ventilation in retrievals. Um,

I would say everybody who intubates a child in my experience,

always pushes it in too far and I include myself in that. Um,

but I know I do it. So once I've intubated,

I then pull it back a little bit under direct vision and make sure it's in the

right place. Um,

I think that's probably the most common thing we see is with ET tubes,

they go in too far. And that's not a problem as long as it's recognized early.

The problem is if you don't do the x-ray for a while and then, um, you know,

three quarters of the lungs have collapsed by the time you get the x-ray,

then that's a problem. So just remember you've probably pushed in too far.

It's a very stressful situation, well done for getting it in,

but just make sure it's in the right place, um, sooner rather than later.

Ventilation in sepsis can be an issue.

It's not normally as bad as in a bronchiolitic where your problems have just

gotten worse now that you've intubated them. Um, but again,

these are the sort of things that it's hard to give, um, you know,

general advice about that, sort of the case by case over chat.

Then advanced lines do you muck around putting in your art line and your central

line if you've got that capability?

We don't generally advocate that teams do that unless they've got a very,

very long trip. If it's a very long retrieval, then that might be, you know,

it's a risk versus benefit.

The thing about sepsis is you might have a window of opportunity

for moving them. You know, some of these sepsis, it's, you know, it's a very,

very small number,

but some of them are going to not be supportable medically and we'll need

mechanical support.

And so that's the ecmo and that's only gonna happen at Q C H. And so, um,

you know, we're gonna want to get them there as soon as possible. And so it's a,

you know, if, if it's gonna take you an hour or so or whatever to put the lines,

if you put the lines in while the team are coming, then that's excellent. Um,

but it's, it, you know,

I'm very happy if it's two iOS in the legs and a scoop and running off we go and

then we sort it out when you get back to base and you know you've got the

backup. Alright, next.

Um, so there is a thing on the, uh,

EK where there's a button that we saw earlier where this brings up this

retrieval checklist. It has stuff for the intubated ventilator,

it just has a little laid memoir about this stuff. Um,

I just wanna say the main things are do tell the family that they are going and

hopefully the PMC will find you a picky bed and hopefully it's somewhere that,

that they would normally expect to go.

But picky beds during the winter can be at a premium and so it might not be

where you think you're going.

And so it's nice if you can manage the family's expectation.

The other thing is don't promise that they can travel with the patient.

We do make every effort to make that happen, particularly in the sicker ones.

Um, but we can't a hundred percent guarantee it. It's, um, it's at the,

uh, the,

the person in charge of the vehicle determines who travels on the vehicle.

And so it's not within our, um, scope to,

to always approve that. Um,

there is an in-hospital transfer form that'll need to be done at some point by

someone. Um,

and if we've had a phone call and you are concerned,

just call back via rsq, all calls should go through RS Q. Um,

if you're happier and you wanna let us know, that's great. Um,

it doesn't mean we'll cancel the retrieval. Um, but if they're getting worse,

then definitely call back and we can talk you through the next sort of steps.

Um, make sure we've got all the documents printed ready to go.

And then when we get there, it's nice to,

to be met by yourselves and talk to us. Um, you'll hand handover is important.

Okay. Next. Oh yeah, this picture. Okay, we'll skip over that.

So checkers, um, here we get, it's compulsory,

I have to put it in every talk in the contract. Um,

so Checkers is based at the Queensland Children's Hospital.

It's a hybrid retrieval service. Um, so it's not run out of the picu,

but it's run next door to the PICU and featuring many of the same staff. Um,

we provide advice via fail. We can do telehealth, we can dial in all the pmcs,

um, do have portable telehealth, although it's Cisco Jabber,

which is about a decade out of date, so it can be a bit temperamental. Um,

and so we coordinate retrievals, so it goes via rsq and then they call us,

um, throughout Queensland, Northern New South Wales.

We do do some interstate stuff. Um,

the direction is to try and do care closer to home where possible. Um,

and obviously as I said, picky beds, wherever the picky beds are if you need it.

We don't do premature babies or newborns,

obviously we've got near rescue and ants and cue to do that.

We don't do primaries, so we're not winching people off yachts or whatever. Um,

and we don't do international retrievals. Um, so we have checkers teams,

we have a clinical nurse and medical officer.

Two available during the day and one and a half sort of overnight with on call.

Uh, yep. Next we do have some flexibility obviously cuz we've got, um,

SMOs around. So we can always, you know, if someone's very sick, we can,

we can try and send a fellow or an s o as well.

So we're not locked into a team as such. We, we try and, um,

deliver a match the, the, the team composition to the patient needs,

but it's not always possible.

Sometimes teams are redirected or the patient that they went for isn't the one

that you're now referring.

Sometimes it's the one in the bed next and it's gone off. That happens anyway.

So, um, thanks to Katie Cashman, our data officer manager who's,

um, put together some data for us. So this is from the first of Jan,

2020 until, uh,

the end of May 23. Um,

so we had, uh, these,

so these are listed as sepsis cases, so it's 311,

um, were labeled as sepsis. Now this is what, what they're referred as,

it's about 5%. And then the of the checkers,

team retrievals, they're doing not quite half of those. Um,

and then the non checkers, that's your life flight,

R F D S or referring clinicians. And then 30 and required advice.

And if you look at this, um, chart on the side, oh, sorry,

I was just gonna do the previous one. Um,

you can see these are sort of the top referrers for sepsis.

Um, d be interestingly, um, coming in a second.

Um, so this isn't quite the same distribution that we normally see for,

I would've been inter I should put that next to it actually. What the, the,

the overall and then how sepsis differs. But these are still, so, um,

the top referrers overall are, uh, Logan Ipwich, the Prince, Charles,

Caboolture, Redcliffe, and Redlands.

You can see they're sort of scattered through that.

So it looks like query sepsis is appearing more so from some of the other ones.

Okay? Yep. And yep.

So here we have, and this is where, um, the receiving facility,

so this is where we're taking them.

Green is a Checkers team and Blue are the other teams. Um,

so obviously there's a big chunk going to Q C H and also Sunshine Coast and Gold

Coast. Um, and then, uh, Toowoomba,

um, Rockhamptons getting a few and then sort of Townsville, Cairns,

um, even Logan. Okay. Um,

so for the Checkers team retrievals,

you can see the vast majority actually is self ventilating. Um,

and then the next chunk are invasively, ventilated.

And then there's a small number on high flow. Um, so normal retrievals,

we have a lot self ventilating.

And then the next biggest chunk is usually high flow. So, um,

and then invasive ventilation's normally about sort of 13%.

Here you can see it's a bigger proportion. Um,

the blue lines are the other teams that's life flight, R F D S nurse only.

And then you can see there's paramedics and then referring hospital teams, rf,

d s, nets and tonsil.

And then here's probably the interesting thing.

Median length of retrieval with a diagnosis of sepsis is

shorter than the average. Um, but it's still quite long. So six hours.

So, uh, average length of a road retrieval is about five hour mark.

Um, for rotary sort of six to eight. And for fixed wing,

the total duration is sort of eight to 12. Um,

and so if you're thinking how long is it gonna be before a team gets to you,

it can be some hours worse if there's a weather event or problems with,

um, you know, availability of our medical assets.

Here you can see the outcomes for the patients that we looked at. Um,

uh, died at the receiving hospital is six, um,

died before team arrival is one. Um,

I'll bow out.

Thanks Paul. Questions at the end, Paul? We'll,

we'll do questions right at the end if that's okay. Um, Greg, you're, you're up.

Just let me know when you want me to advance.

Thanks, Porto, can you hear me okay?

Yes, we can.

Thank you very much. Um, I think, uh, my name's Greg. I work in, um,

Townsville, north Queensland, and, um, we've heard a,

a great talk about the new sex sepsis,

sexy sepsis guideline and, um, and the retrieval service.

And I guess just to overlay that on how I might approach someone

presenting in,

in the area north of US or or west of us, really.

And this is an overlay of the guidelines,

so using what we know about in the guideline, what we might be thinking about.

Thanks Paula. So I guess the area covers p and g and the top end of, um,

of Australia, um, the Cape York up, um,

to Thursday Island and all the Torres Strait Islanders and then the, um,

far north Queensland area from, uh, Bamaga,

which is on the mainland all the way down to, um, to Cairns on the east coast.

Um, and then west, the Brown Circle really includes, uh,

what's Northwest Mount is as the central hospital and um,

and a lot of hospitals around that. And down the east coast,

I guess the bigger HHS is with Cairns mackay and,

and towns boards dragging many of those patients into their, um,

pediatric departments and support. Thanks Paula.

Um, so I guess we've spoken about what might, what,

um, we might be able to use, but, um,

I know a lot of areas where,

where I work have very small little hospitals with, um,

either a GP visiting doctor locum or, um, nurses only available,

um, after hours. So really important to help everyone,

crisis resource manage, and knowing, knowing your environment, um,

who is local,

who can you call now who lives down the road and maybe your next

hospital down the line or the next area where you refer to is,

is really important to know. And then as Paul's alluded to, um, and Paula,

the,

the way of getting hold of them through R S Q contact numbers and transfers

and using some way of,

of communicating your concerns and whether that's a spa or segway,

whatever the, um,

the thing is that your hospital or or community might use to, to, to,

to communicate. And Paula, can you hit the next, um,

one button now? Um, I guess I, I think if you saw the check, the, uh,

guideline, I think it's a, a beautiful, um,

checklist of what we can tick off, what we've can tick off that we've done and,

and also what's coming up ahead and what might we be looking out for.

So it's a, it's a great reference. Um, even multi-day stays,

um, in along the sepsis pathway.

And I think what's really important is to realize that, um,

you're part of a team of people who will be, um,

kind to look after this, um, child. So from the very local team,

um, and people on the ground next door to, um,

the receiving hospital and R S Q in between, um, connecting the dots.

And that's really important to, I guess,

perceive that there's a lot of people that are trying to work together to get,

um, get, get the best for the crisis in front of you,

which is sepsis. Thanks Paula.

So I guess in my area I would be thinking quite carefully

if, uh, there's a possible sepsis, where do they come from?

Exactly. Um,

what's the weather been like and what season are we in at the moment? Uh,

we tend to only have wet or dry seasons. Um,

but those are really important questions as I'll, I'll show you in a moment.

But I guess the, the normal things of what's the age and sex of the patient, um,

and are there any disease patterns or, um,

resistance patterns that we do know about that might alter what we might do with

the, with the guideline? And I think what's really handy is from the start,

trying to get a picture of what you're looking at and being able to describe it.

Do we think they've got a central nervous system or meningitis type of sepsis

or chest?

Are they coughing or is it undefined or do they have a cut on their foot and

they live on an island somewhere or, and, or do they come from a little,

um,

a little station cattle station hours away from a,

a, um, a northwest and, um, town. Thanks Paula.

And I think to highlight the pattern that we might see in

different, um, presentations of sepsis like diseases, this is,

um, the red being the rainfall and the,

and the cases of Melo doses presenting to North Queensland, um,

areas.

And you can see that the cases follow very directly with the rainfall

and, and therefore really the season.

So understanding that what's been happening in areas where they present is,

is really important. Thanks Paul.

And again, yeah, thanks. And, and I,

I guess the specifics of, of infections, um,

which may be a little bit rarer down south than they are north at the far

tip is that the Torres Strait has an incidence of meiosis,

which is very close to the highest in the world with Thailand being 50 per

hundred thousand. And, and this is 33 per hundred thousand.

So sepsis presenting in that area should almost always be,

um, have a concern or raise a concern of, of myosis even,

even in the a slightly off dry season. Thanks Bolen.

And again,

so we've spoken a little bit about the far north and, um, and p and g and I,

and I guess, uh, alluding to the last slide, am myosis in the wet is,

is almost, um,

should empirically be miropenem in most cases now. And,

and through a number of coronial cases,

we've got that available through on even small islands to,

to have and be able to be given by, um, by the,

uh, clinic clinics in those areas. But I think in the past, um,

COVID has changed our, our profile of, of diseases we get. But um,

we used to get a number of patients down from Papua New Guinea with severe, um,

gastrointestinal or a third world type of presentations of sepsis. Um,

and then adults are seeing more and more, um,

infections related to living near the sea,

cuts in your legs becoming severe sepsis with multiorgan, uh,

dysfunction and, um, sort of breakdown of tissue or,

or cellulitis, um, and with nasty infections.

And, and I guess on these occasions, um,

my approach would be to use the guideline to add in

what we've already spoken about, um,

meropenum being the most important and seek i d advice.

And I think there will show where that fits into the guideline in a moment.

Thanks, Paula. And I,

I guess this slide really just shows that, um,

in media doses as a specific type of infection case, um,

if you get it as a child or less than 18 year old,

your risk of dying is really high.

And it's not that you've got lots of comorbidities.

Most of these children don't have much in the way of comorbidities,

but potentially unrecognized, potentially unavailable, um,

appropriate medications and, uh, uh,

we are not quite sure why, but they usually present, um,

if they're gonna present with sepsis, with a very severe sepsis,

needing significant, significant, um,

intervention and, and the risk of of dying is reasonably high.

So thinking about it early, getting the antibiotics in early,

and then starting to think about what else could it be. And in this case, um,

specific infections to seasonal changes is important. Thanks Paula.

And if we relate that to our sepsis guideline,

just to highlight the success suspected source of infections at the bottom

gray area, trying to create a picture to the PMC or,

or the coordinator of what,

what you're seeing might be helpful in trying to decide what we are gonna give.

And if you can get the next, um,

slide and just to highlight that in, um,

north Queensland and beyond defo North Queensland media doses, um,

should be added and it's specifically on the guideline, um, in that area.

Thanks. Next one, Paula.

Out west. Um, I think it's important to think of two things that, you know,

depending on presentation is really, uh, critical. Um,

the first is that there's a clone of M R S A, um,

non-hospital acquired M R S A, um, non, sorry,

non multi-resistant M R S A,

which is around about 50% of all staff presentations in that

area now.

So although Vancomycin is for severely ill

patients, it is important to think about children with multifocal or severe

illness to very early start and think about vancomycin

as a, a specific, um,

antibiotic for these children and very rare but to

highlight that, um,

not all things will be at all treated by the um, um,

guideline.

And we need to think about who else do we call along the way is children

presenting from, uh, rural properties, um,

who don't have town water and chlorinated water or have been camping out in the

bush, um, jumping into billabongs and things like that where, um,

some of these kids should be moved very quickly towards, um, uh,

an I C U and neurosurgical capabilities for, um, aic,

mening Meningoencephalitis. Thanks Paula. The next one.

So I think in the guideline there's an area where we can,

in the purple box,

we can think about are we really giving what we think we should be giving and

is there anything we can do to optimize our antibiotics?

And so consider getting a local or um, a d uh,

expert guidance as to what's going around,

what should we thinking about in this area? And there's a number there to call,

um, if you should need to thanks Paula

and really out of the funny areas,

but we can use this guideline beautifully here. Uh, most of the time is, um,

the, uh, east coast Cairns really down to Mackay where, um,

although we do have seasonal osis,

it's really rare and we need to search and think quite carefully about it.

But there is still a higher incidence of umm R s A in the

community. And um,

so moving towards and thinking about adding specific antis,

um, antibiotics early if they're not responding is, is important.

And I think what is important there is the capacity to locally escalate and, um,

in the guideline you'd have seen a number of references to locally escalating

patients and, um, the ICUs, they,

the adult ICUs are comfortable and capable of admitting and,

um, supporting children with sepsis and will would like to be, uh,

involved as early as possible in managing, um, these children.

Thanks Paula.

So I think in summary for us on the far north and Will or North Queensland

guidelines are very useful resource, please do use it. Um,

getting onto it sometimes can be tricky, um,

but recognizing that sepsis is a possibility and that, um,

the earlier we treat it, uh,

the better the outcomes is u are usually gonna be is really important.

I'd like to suggest we all consider our environment that we work in and get to

know it where, where do I find the fluid, where do I find help,

um, where do I find resources online, paper, telephonic, um,

and because a lot of the doctors and staff,

they are locums and may not be aware of that,

that should be really part of an orientation for them as well.

And then ask early how you could get help and, and how you get, um, um,

who you can get on the phone to help and specifically Id, um,

advice which is related to the, the local, where the patient came from.

And then obviously we've got, um, R S Q going through to, um,

to the pmcs and, and uh, medical coordinators.

Thanks Paula. I think that's it.

Thanks Greg. Um, and Paul, thank you both very much and just wanted to, um,

show sort of resources page.

So our sepsis website, uh,

children's Health Queensland is full of a whole lot of resources. The,

the pathway itself does, um, point towards, uh,

where you can find some of these resources.

And of course the Australian Commission, uh, sepsis standard,

there are some resources available there too.

So we've got about five minutes left, uh,

for us to, to maybe take some questions and answers. Um,

and if, I don't know if there's any in the chat, but just before I, I I leave,

well, before we go to that, I just wanted to let you know that these,

these kids have been our inspiration for developing this pathway and,

and seeing it on through. Um, so thanks to them cause they keep us going.

I'm gonna stop sharing now.

with an unplanned readmission within 30 days. So those

are the types of order that they are recommending you do.

And so from our perspective the other things that you

could do instead are looking

at the number of patients given the sepsis in children leaflet.

So this is this leaflet here, which is

available.

Both to print off from the homicide or

if you contact us at peace status, we will

send you these leaflets and important thing about these leaflets is

that they and allow the parents to then go to

our website and see our wealth of information for

them. So on our website we have this

Through the acute care no longer term recovery. We have

a family support network that they can sign up

to and that puts it in contact with our Advanced social workers. And

we also have this journey through

sepsis video series, which is actually led by

our wonderful consumers. You've lent us

their time and advocating for improved and

census care. So they have

talked us through what it was like for them to go

through the ICU but of services when

you were being transferred when you were in the world the worrying bit about

being discharged from the Ward to rehab for example or being

discharged from the Ward to home and

then having to access care from

home with things we're a little bit tricky how to do that

how to navigate all of that and we we did this because

we found out from our research that parents who

are going through sex is feel very alone feel very isolated and

as well as just not having enough

information and

They did ask you know that that and if

only they could talk to someone who lived the experience

then that that would be

invaluable to them. So part of the video series is making

sure that consumers are talking directly to Consumers and

on the back of that what we've developed is this

peer mentor program which they can access through

our family support network just by contacting us and when

you give them this leaflet and this is these the

main Tools in this program are

and parents who have lived through

having a child reception have they been undergone some

training and and they then become they

then Mentor families who are acutely going through

sexist at the time so that those families are getting

the direct and ability to talk to

somebody who's lived their experience and to get support

through that so we have an awful lot available

for for patients with sets us and that

peer mental program is virtual.

If you happen to be in Rockhampton or you happen to be in Townsville

and your parents there can still

access this Mentor program because it is all either over

the phone or and virtual other teams or

whatever.

So so those resources are

available and we also have all of our do you

know the signs of sepsis translated into any number

of languages? Which downloadable from the

from our website

The other the other bit, I thought

might that we could provide service force is if you

if the child is if a family is bereaved and through Pediatric

Services many of our children many of those families would

be referred to the chq and bereavement services

and we could follow them through that so

that's worth bearing in mind.

So what are we doing in the near future? So the

next three to six months we are going to be having a new look pediatric

sepsis Pathways. So instead of

having an ed Rural and remote and impatient pathway, which

are almost identical but not quite we're going

to make it into one. So there's only one pathway across the

whole state and it's going to go beyond that

a cute treatment bundle. So at the

moment it's sort of ends there with a little bit of monitoring and

what to do if things are aren't improving but we're

actually going to go beyond there looking at the acute treatment

to the first 24 hours and then beyond the first 24 hours and so

we're going into the resolution of sepsis the recovery

and tips and also if there is a

simp and we will be making sure

that the checkpoints that are

in there match this hipster standards so

that if you do this you will be able to order it and

show that you are meeting the quality Care

standard and the digital path.

They can and pathway then will match that

so they will be able to pull that information from IMR and

clearly the dashboard will be adjusted to follow

on from that. So and digital signs

will be able to do this digitally so that is coming and it's

not coming in paper very soon and obviously

in electronically in about a year's time,

but also we're spending quite a lot of time developing and

our post-stepsis model of care and that's

been led by Alana one

of our Advanced social workers. And this is

very much being co-designed by consumers from

all over the stage. And we we

are also involving the older

patients who have experiences who may

be able to help us teenagers and obviously

Healthcare professionals from across

the state who are delivering this okay, and then we'll come

up with a model of care that will go through and feedback sessions

with with the stakeholder group.

in the state prior to implementation and and

I think they the key the

key thing for us with this

is that we

this is what the consumers are saying that they desperately need and

we hope that it will help Healthcare

professionals to understand that we don't want to

reinvent the wheel we want to build on services that are

already existing. We just want to streamline things so

that we match what consumers need but also don't

overload our Healthcare professional. So I'm pretty sure

that we will be able to deliver something that walks

a very nice Road in the middle of that without

creating a whole lot of new work which

is which when you first read the Care standard

you think are this of our stuff we have we're not doing actually are

doing a lot of it. It's just not coordinated. And so I'm hoping

that this model of care will make

that obvious and so make your lives easier

and

In Men in coping with these patients who are who are

have lived through this and need a little bit of extra help

thereafter.

So that's what

the algorithm looks like at the end of the day lots

of stars. Lots of things. We need to collect. We don't need to

connect them all all of the time. You don't even need to connect everything and

in that in that line,

but we do need to highlight those areas where we know if

we improve the quality of care that we give

we're going to improve outcomes for our

patients and families. And these

are them these wonderful people

have been incredible Advocates they've lived they've lived

the life of Simpsons which is being very different. Some of

them have been believed and they've taken

the time out to tell us about the experience and

what was good and what was bad and they're

incredibly inspiring because all of us

want to come to work and to do good work

and these guys keep us on the straight and narrow and

I keep our feet firmly planted on the ground. So we we are

very grateful to them and their time and their

effort and lastly. I'm very grateful.

You are lovely team who are listed or

there who are award-winning and you know internationally for

the work that they're doing but our key

message here is that we are here to help. Please don't

see the sips of standard as yet. Another

thing that you have to do. It's a wonderful

tool to help us live a really

really good care most of it we're doing already and

and we can show that we're doing it already who work

together. And for those of you who haven't yet implemented the

steps to part where we can help you to do that. For those

of you having struggling to connect data, we can help you

to do that. I'm hoping that within a year to two

years for the digital side, at least that will

be seamless and we'll be able to suck it out the back of

our and then we can concentrate and what we can do for the

paper science to see how we can get that sort of data into

the Statewide system as well. So you can be you know

benchmark yourself if you want to

so I'm going to leave it there

and

I hope there's a little bit of time left.

for

for questions

Thanks, Paula. I think we've got about six

minutes. So we've got definitely a chance for some

questions if people want to put anything in the

chat, we can moderate it that way.

I've got one. Yeah, and

I just thought of as you're presenting so lots

of information and lots

lots to digest there. I think in terms of the national

casting but like you said it's a it's a really exciting piece

of work and it's been in the works for

some time. So I think it's going to just standardize and make everybody's as

you said, you know the outcomes for children and better

I suppose. My question is you

talked about

them like the key messages and stuff. But what would your call to

action be for people who are online today? So to digest

all that information, what would you say would be the next step? Where

should they go for more information or what would kind

of be the first two things that you was suggest people

do because I mean, it's everybody's responsibility

isn't it to get this standard happening it is,

so, thank you.

I think if you're thinking about and

you know, if you are more of a managerial level

or senior leadership level and I

would go to the website and actually read the standard because

It I know it's a number of pages but it's actually really easy to

to read and and particularly the

beautiful clinicians and a bit of the system and and

you're not alone. So if this will

need to be implemented, so the only

Children's Hospital is it's the one done in Brisbane. The

rest of us are all in mixed hospitals. And so this

is being done in adults as well as Pediatrics and

will be your go to are your

patient safety and team in your facility. So

I would I would go to them and say how do we

how do we how are we going to tackle this for both adults

and children? And then how do we as if

you have inpatient facilities, how do we pediatricians

uniquely contribute to that? So I think initially for

those leadership levels read the standard

and for for people who don't need

to know everything I would go to our website. There's

a lot of information on our website in

terms of what you need to know as a clinician and in

order to deliver good care and for

all our clinicians online if you

haven't

Done the video series journey through

sepsis which is our consumers experience. It's

really it's really worth it

it just

and it's you between the eyes what these families go through and I

think it's really important and and it's important

that their galvanizes you to do. Well and the

fact is that most of the time we do a really good job all of

us.

And just every now and again it becomes a

bit tricky.

A novel. Thanks Paula. Okay, cool. We've got some questions

coming through. Thanks everybody. We just

got a comment here before I read out a question, but we've

got a comment and from Celine Hill that she's a received great

feedback from the Ed nurses and we do hear

this a lot that they do love the antimicrobial Administration

guidance. And I think that's what makes Queensland unique

too. I don't think New South Wales have that in their pathway and

that's something that we've learned from them that they're a

little bit envious I think because we do here from the

staff that they do really find that useful.

we have a question from and

at this stage what percentage of children on the sepsis pathway

have sepsis have we done any analysis of that Paula and

not sure if you'll have it on the top of your head, but we could potentially get

it to end we have so it depends what you mean by

on the pathway. So if

you are screened as heading thickness,

if you are if you go through the screening program

and then they ask you

to

It's enough to trigger a review by

a senior medical officer that is about of

that presented to the Eds in Queensland.

thing of their features of severe disease,

I think I need to get a senior smile to see them and the

senior is the most they decided this could

be sepsis. There were about 350 something

like that.

So very very very few actually screened.

Seen by senior clinician and then we're

treated as sepsis now of those where the

scenic clinician said. I think this is sepsis.

How many actually in the end ended up having sepsis

44% so our senior

clinicians are pretty good at picking it.

So when by the time they see the child and

they decided is, Texas.

They're any good at wrong one into which is which is fabulous.

And because it's a really difficult

diagnosis to get right early and it doesn't

it doesn't mean that it was wrong for those other children to have

antibiotics. They may have had an invasive infection for example,

but not quite deteriorated into organ dysfunction. So maybe appropriate for

them to have antibodies Etc.

Of the patients where the tradition said.

I don't think this is sexist very few

of them. Then went on to have sex as it

was like 3% So clinicians are really good and they

have the ability to

pull in that constellation of of signs

and symptoms and digest it because they've seen

such as before.

They're able to actually make the diagnosis and that's the key.

and

Hey, alright, we might have.

Time for one more quick question. I'm just

looking here.

Does the clinical expert you

spoke about before need to be on site 24 hours

per day, so there's and so

the clinical expert.

And in the acute management

and for say for

a tertiary institution would likely be the

edsmo because they would be able to be recalled within

a reasonable time frame anyway, so

so keep you know for kids in Ed, that

would be fine for your inpatient Wards. I

think whether you decide it's your senior.

senior registrar for kids

your pediatric is the moment of them are on what we

call within 30 minutes. I think that you know, that's all within

the the it

would just need to be worked through so that if for you

in your circumstances could be worked for you through if you're

a more remote site where you don't have

that backup, that's what the pediatric medical

coordinator and Telehealth is full.

So I think what what the what the standard

is not doing is being prescriptive about what you in

your facility does what it is being prescriptive about is that

you've thought about it you've had an agree guideline and

that has gone through governments so that if it fails

you can then pull

And say oh hang on a minute, you know, somebody wasn't

on the roster for that day or somebody wasn't nominated on

that day to do it. We just need to have thought about it. So

it's done.

fantastic

All right. Thank you Paula. I think we are bang on three

o'clock. So any questions we didn't get to guys we'll definitely

Endeavor to to summarize them and send

an email or of course. Feel free to reach out by the Pediatric sepsis

account. Thanks all

so much for joining. I just want to plug our next

session as well. This is a monthly series

that we're now running is Sarah said at the start of the session. So

obviously the July Focus was on the

standard next month on August. We're running

a session on the 11th of August and on the

25th, it'll be advertised through the same channels that

you found this or you can also follow the Eventbrite

page, which I will post in the chat. Matt session

will be all about data and metrics so a

good follow-on session from this in terms of how how we

can help you collect information

and the local monitoring and the importance

of that and also talking about documentation matters and

and documenting sepsis and the ICD-10.

And that will be led by our wonderful AMS pharmacist Mel

and other medical lead Adam Irwin. So

thanks everyone for joining reach out if

you have any questions, but just to reiterate what Paula said we're here

to support you through this. So any any questions,

please reach out. Thanks everybody. Thanks everyone.

Good luck.