Paediatric Sepsis Series — Revised Pathway Part 2

Transcript

Okay, cool.

Well, I'm happy lunch time everyone. I'm

Paula Lister and I'm the medical co-chair

of the Queensland pediatric

sepsis project and thank you for joining us.

We're we're doing a sepsis series and

this is the first of that series talking about our new

revised pathway. So I'm going to kind of

go through the rationale for doing that before we

before we start

Oh.

You want to there we go.

Before we start I just wanted to do the

acknowledgment of country and acknowledge a traditional custodians of

the lands on which we meet which we'll meet today at Sunny

Coast is the Gabby Gabi people and power respects

to Elders past present and emerging.

And I wanted to say a big thank you to all of you who've

given up your time to and especially on

a lunchtime on Wednesday to come and listen to

is fantastic and it's a

really diverse group of people ranging from

Frontline clinicians who would kind

of expect through to Allied Health Partners through to

even management and patient safety and Executives

and we're really pleased

that we've got such a diverse group who logged in

but also they come from all over Queensland far North

Queensland as well. And that's really important because the

old adage of it takes a village to raise a child

is really

true also in sepsis. It takes all of

those clinicians those diverse those

divert that diversity in order to provide good

high quality care to children who present with sepsis

or up in the time of the presentation to going home. And

in order to do that sustainably and

time after time again, so there's no variation

in case so we do need all of you to be

involved in the pathway and and

to know that this presentation and the revised pathway actually

is relevant and for you

So how did this all start? Well, it started

it's been going, you know, International sepsis guidelines have been

going really since the since the 90s and this

is the latest iteration on the screen at night

the 2020 and surviving steps is guidelines

and and they all have some bits in

common and that is firstly we recommend children are screened

for sepsis. So we identify those

children who have infection plus all infection related organ

dysfunction.

And that secondly when we identify sepsis that

we manage them according to a systematic clinical management plan

that involves antimicrobial stewardship.

And for the first time in the last couple of iterations, we've introduced

this idea of clinical certainty or indeed

clinical uncertainty or diagnostic uncertainty.

So those where you are pretty sure this is definitely Services

than children are shocked. You've got an hours window to

get a treatment bundle in and those where you're not quite sure yet.

You've got a little bit more time and to investigate

and do a more and it extensive evaluation

to determine whether you think this is sepsis or

not.

That all leads you into an acute treatment bundle which involves

you will all be aware blood cultures antibiotics lactate

and fluids and possibly anotreps and

then after that the the international guidance

really goes on about recommendations for

picu how you do your organs support

the sort of ama's principles and they kind

of stops there. It doesn't go anywhere beyond the

ICU stay and it also

doesn't include parent support or indeed the

role of parents and partnering in their child's care. And it also

doesn't actually involve any parents in the development of

the guidance, which I think is this is a real limitation.

So Australia was an earlier doctor of the who resolution

and back in 2019. We

developed the Pediatric sepsis pathway, which

many of you will be familiar with and that's what it looked like at the time

and we used a lot of the of the

similar features. We have a screening and recognition

tool which wasn't a screening tool for steps.

It's because we know that there are no specific features

of sepsis all the symptoms and signs overlap with

many other conditions.

So what we did was we developed a screening tool

to identify a cohort of children

who had features of moderate or severe illness that you

could get a senior clinician to look at quickly because we

know that experience conditions we've

seen sepsis before probably the best people the

user this as a Gestalt in

order to diagnose sepsis and that you can't replace

that with any single test and we know we

need to be diagnosed nosing steps as early, you know there

when we have less and less information on which to do

it. So that clinician experience becomes really important.

Once you once and after that,

we went through an escalation de-escalation pathway,

so there were no features of sepsis de-escolletical

patient of the pathway and there was

a tear off information sheet for parents to go homeless

so that if they spotted any of the sun sentence developing

they could come back so there was an education tool and then

if we wove that

idea of uncertainty or certainty

and diagnosis into the into the

pathway here saying that if you think they may have sepsis but

they are certain you've got a

little bit of time to to investigate further and then

we had those that you did diagnosis of

sepsis and they went on to have a treatment bundle

there on the on the right

hand side, which will be familiar with with IV access

blood cultures antibiotics fluids.

That's all minus support and

that's pretty much where it's

came to an end. We did

attach antimicrobial guidelines according to

your presumed source of infection with dosing guidelines.

And what was really really very popular with the antimicrobial

Administration guidelines helping and nurses to

administer doses to to

children.

And I just want to emphasize that that

idea of screening tool not

screening processes, but screening for a cohort of

children who had features of severe disease and and

then using clinical expertise to decide

whether this was Simpson or not. So effectively we weren't asking

the question how skeptic are they we were asking how sick

with these children then asking our clinicians to go and tease

out those ones that they thought were stepsisters and

it turned out when we looked at our results that our senior

Edie clinicians are very good at doing

this. So of the three and a half thousand children that they screened of

those they thought sips this wasn't likely which was

just just under half they missed

very few cases of Simpsons. And in those where

they thought service was likely they were correct in

about nearly half of the cases and they

instituted treatment now that doesn't mean that the other half the cases

they were incorrect. Those may have been children with bacteria infection

who needed antibiotics and things anyway,

so it's not an incorrect diagnosis just they absolutely

nailed it on on about half

of the half of the patients. They thought were sepsis very

early on in the piece. So I think

our approach is correct and to continue

to ask for senior medical review and

and I think our approach in terms of

screening not trying to screen for steps as we're trying to screen for a

sticker called children is is correct.

And again, we have woven this idea

of clinical uncertainty into the pathway

because this is in all of the international guidelines and

it's it's the concept of understanding that when

you have infection in your develop organ dysfunction, you're not find one minute

and and septic the next it is there. It is a gradual onset

and there are

and and patients will present at different

different points in there in their journey

and some and particular bacteria or

some host and characteristics will mean that it has

more likely to happen quicker or more obviously than

others so we know that this is a spectrum and

we've built that into the guidance so and this

is beautifully demonstrated in the most recent in this

diagram for the most recent adult surviving steps as guidance

where if you are pretty sure that's on the

information that you have that safe is definitely a photographers

present but even a shock is absent then you should get antibodies and

treatment in within an hour.

If there is shock present, you should do it. Anyway, even

if you're not particularly sure.

But in those other patients where you don't have shock,

you have a bit of time to investigate further and

if at the end of three hours is still not sure actually you

should just get on treatment. So I think that that's a

useful thing to to have woven into the guidance following the

the services collaborative.

We then reviewed all of our data and all

the feedback. We we had from lots of clinicians and we

we managed to adjust the screening tool

to make it fast simpler.

So we kind of have the number of characteristics that we needed

to look at and that was very useful because

it made it the tool that's complicated to use

but we still were having as much success and

in the area under the curve for the for the screening tool remained

high so we have actually adjusted the

screening tool on data and that

And accepts pathway was was version two,

which was relaunched. I think in 2021.

right

So moving on from there.

I've got it might be useful just to to review

what do we actually know about Pediatrics is that

we really should reflect in our pathway and

there are a couple of things that I think would probably really do need

in there. And the first

of those is is really understanding that.

Pediatric Services causes morbidity and mortality now. This

is a study which is almost 10 years old. Now. It's a

point prevalence study technical life. They put days and 128

psus in 26 country

and it was just measuring a number of patients on

the unit on those days that had sepsis and turns out

for most PS use across the world. It's around about

10% of our workload. So it is the

It's fairly bread and butter for us. It's something we're fairly familiar with and these

kids are pretty sick, you know, they run about

60% of them have have multi-organist function

on admission and a further 40% of them will

develop new or Progressive multi open dysfunction, not surprisingly these

patients have a high

Hospital mortality into the about 25% When

you consider the whole world when we look at

specifically and Australian data, it's sitted around 17 to

18% for services and septic shock

and and while that

isn't as high as you would expect for adult patients when

you consider that all cause mortality of children

in ICU, so whether you come

in with a scrambled heart and he had a severe head

injury whether you come and Childhood Cancer all

cause mortality is running runs internationally

between three and five percent.

So census increases your mortality rate

by five times.

And in Australia, our mortality rates

are low pick use it's about 2.5% and but

what's really interesting is when we look at our vulnerable population

particular Aboriginal Torres Strait Islander communities.

The substance the mortality from sepsis is two and a

half times greater in those children than it is for non-indigenous children.

So it's a big cause of

mortality in children and in Australia and

And what what really did surprise me about this date? It was

not so much the mortality.

But the amount of disability so only a third

of children will get through a safety episode unscathed and

about 40% of them were either dial have a very severe or

all moderate and disability. So that was

news for us. So it causes mortality and

morbidity.

The next thing that needs to be considered in our guidelines

is that if children die from sepsis, they do it

pretty quickly. So 50% of the children who die

from sepsis die within and within

it within 24 hours. Now, this is

in the north Thames area. So my old

stomping ground who retrieversips to icus and

they would followed up and of those who

died 50% of them died within 24 hours and

what that means for us clinicians is that our

window of opportunity is extremely narrow to get

in there with treatments to try and prevent maternity

to try and prevent morbidity. It's quick.

So so Simpsons rapid and treatments need

to be time critical.

and the

other

key bit of information I think is is acknowledging the

role of experts in in the outcomes

of children with and with sepsis.

So our retrieval team and then this is the same

data from another retrieval service in the north terms and the

retrieval service. There is pretty similar to the RSQ retrieval

service here at time point R. You have

a referral of a patient and at that time and

consultant will be giving the home team referring teams

and information and advice over the phone to Institute

treatments whilst waiting for the retrieval team

to get there in these graphs at Point

a the retrieval team comes on site and then point

p is when the child is admitted to pick you and you can see that

in both taken to to random physiological

signs here heart rate

and blood pressure. You can see that when the team

actually physically lands on

physically sees a child that actually that's when

the most impact is on the physiological signs

of

out so there is something about having experts

on the ground seeing patients that actually

impacts their outcomes and the role

of experts I think cannot be underestimated the teams

and

Made it in the north Thames region of

similar to the teams here. Although perhaps

a bit more consultant delivered.

On occasion, but I think the key thing here

is that the nursing teams in both are extremely experienced. Even

if sometimes the registrars might

not be as experienced and as consultants

and the nursing staff are

so it is it is the experience of the team. I think that is

important.

So when we think about those three still those two

three points down what should be in the pathway. Something

is knowing that Seth has caused us mortality and Mobility knowing

that poor sepsis art comes can happen really

quickly and that experts can be useful and in

managing patients the next

Big thing to consider is is understanding that recognizing pediatric service

can be extraordinarily difficult. So the

signs of late sectors are really easy to

see but as we discussed if you only recognize this

late your window of opportunity for turning it around

is is probably gone and many of

these children will therefore have poorer comes.

So these are the children on the right lots of

capillary League.

So what we need to be doing is diagnosing these children

earlier, but we know sometimes a deterioration is

extraordinary Rapids. So you don't have a long time to do it. But we

also know that infection is extremely common in children.

So you have loads of children out there with with

common sometimes and

symptoms and it's how do you pick the one out of all of

those children who's going to deteriorate quickly into sepsis and

we know that we need to do it early because that's

when our treatment works. So it is a it

is a difficult conundrum for us.

And part of the solution will be empowering parents

in healthcare empowering parents to

seek Healthcare early and to be partners

in their health care.

Problem with that is that many parents don't actually know about

steps and this is a survey of the George

Institute. They do repeat them every few years, but

this is a survey from 2020 which was

in the middle of a pandemic when every news story

and use the head stories about

Covid sepsis and patients dying

of infection even in the midst of that only

60% people in Australia has heard of sepsis.

And compared to about 80 or 83%

who'd heard of HIV and even more would her

breast cancer.

and when we looked

at Australians of parenting age that number dropped

to 45% and very few of them could actually

name a symptom of sepsis and the

common symptoms being fever.

So we need to educate parents but we also as

clinicians need to value and the

information that parents were giving us

about their children and we need to listen and where that

sometimes becomes difficult. We also need to have Health

Care Systems that facilitate escalation of

parents feel that concerns are not being listened to

so that's an important part of recognizing this early.

And the other part is just remembering context and

it's getting back to this idea of how of your

pretest probability so many Pediatric intensivists

and pediatric Critical Care nurses. It is

it is a kind of familiar condition for

them one in their ten patients will will have sepsis that

they deal with in their workload for Ed Physicians

that falls down to about one and one from our

data in Queensland to one and about a thousand patients.

So you they need to have seen a lot of patients? So they're

probably going to be slightly and higher up

the seniority chain for them to be his experienced

in experience and having seen steps

as before but we'd also need to remember that Primary Care Health Care

physicians may never ever see a census case in

their career. So

the confirmation bias at the approaching children with

is there that this is probably not Texas and it's

probably just a common cold and we

need to be that in mind and try to provide tools to clinicians to

make it easier to remember sepsis, which

is a rare condition and

So the other things we know is that if you treat if you

delay your treatment in terms of antibiotics to

safety children, they mortality rate goes up. This is very that

this has been proven several times over but this is original

date of from several years many years ago 2013, I

think from chop and where they

showed that your your odds of

mortality increase to nearly five times and

if five times if you delayed your your antibiotic

and Delivery for three hours,

then if you didn't and that's in a case makes adjusted population.

So it's very important to get your antibiotics in

without delay.

And the other thing we know and this is data from

New York state is that if you deliver your bundle of

care and a timely way so within the hours framework in

your sepsis patients that actually you reduce

mortality. So they had a reduction in an odds

reduction in maternity of nearly 0.6 that is

significant. So just to just to

remind you about New York state that is that is a

As a consequence of the death of a child called apocalypse name

now Ryan who died of cellulitis.

The whole state became it became a statutory and

mandated.

And necessity to have a

sepsis policy in every hospital and every

hospital every year or twice the year has

to report their performance against those that

policy and their performance in terms of managing sectors. So

this is a legal requirement that they have to do this

and that that shows

that actually if you if you do do it that you

improve outcomes. We showed with our own data

here in Queensland that you improved

you the correct our antibiotic Progressive

appropriateness. If you used a

bundle of care or treatment bundle, so we improve the

the number of

times the correct choice of antibiotic was given and for

the presume sort of services at least what twice

over and we improve the dosage of

that antibiotics. So there was given in

the correct does more frequently than if

they then prior to the introduction of

We had other positive effects as well, but we've outlined

those in previous and seminars. So

to summarize that Pediatric Services is

difficult to recognize we really shouldn't be partnering with our parents

to recognize it earlier and Pathways and

treatment bundles improve outcomes.

So the next bit of the story is is trying

to understand.

Why don't we use Pathways and and we know that there

is poor compliance with Pathways. And when

we looked at the New York data, which I showed you just now where

it is a legal requirement to be compliant with

a pathway and I showed you that that lovely reduction

and mortality that had when you actually looked at the 54

hospitals involved. The average compliance

was 20 25%

The best compliance of the very best hospitals are

here in the yellow was just over 40%

to start off with I find astonishing their manager shows such a

big effect despite being so few of them being

compliant. And the other thing to notice here is that these yellow

dots are the Pediatric Hospital. So

these are hospitals that have a pediatric cardiac center. So they're

definitely tertiary Institutions and they are

some of the best performing but they're also some of the worst performing and

these blue dots are whole of they have clinicians who

treat the whole of life. So good luck our

next Ed's. So New York

state had really terrible compliance and and here in Queensland

after a huge, you know collaborative, which

was a massive quality improvement project in 16

EDS across the state both adult and

pediatric. We thought we were going to do much better and we

didn't

so despite that huge effort in the huge input

of you know, increased Workforce in

each place and

we achieved 30% compliance in

septic shock.

And 40% compliance in those where you had

to get the mantle in in three hours.

Which is which is kind of deflating when you when

you work so hard to get it done.

But we thought well, is it the same in adults and it's not

and I think that's the key. So when we look at the New York

State data, which is here on the left. So this is the adults equivalent

of that pediatric trial. So this

at all of their hospitals, they're definitely showed that there

was a reduction in mortality if you've

got your bundle in within the predicted three hours.

But 82% of the hospitals were compliant with getting that

bundle done.

And yet they could only get 24% compliance

in children.

And some of those hospitals were doing both both these

things at the same time adults and children. So it's not like

they didn't know about sepsis. It's not like it wasn't part of their work ethic

and similarly here in Queensland. Our adult colleagues

showed a mortality benefit if you

were complied with the pathway and well, if you if you

use after the pathway introduction and 60% of

the patient episodes were compliant. So say

there's only one Children's Hospital here that

was separate all of the other hospitals treat children and adults. So

in the same departments you

with 60% treating adults, but only 30

or 40% compliant treating children. So

there is something about children that makes

life difficult.

And we are doing some research to try and understand it. So if we

think about all those things that need to be reflected in a pathway,

I would add those in that despite having knowing

that sex is difficult to recognize

and and that Pathways and bundles improve outcomes.

We still poorly compliant with them and there is still variation

and Care between adults and Pediatrics and there is still variation

care across Queensland was and second

one events insect two events being over represented in

remote areas and and our

parents and families require support through this process that's

data. I haven't I haven't shown here because

we haven't quite published it yet.

and this leads us on to the the sepsis

standard that was published them towards the middle

of last year and this is the Australian commission

who have

who commissioned this piece of work looking at?

The standards that should be achieved in providing sets

of care right from admission all the

way through to recovery and Beyond being discharged

home and when their commissioned this piece

of work, there was an awful lot of consumer involvement and

I think they identified big gaps

and care that that perhaps as clinicians where

we were concentrating more on the recognition and resuscitation and possibly

a bit of the resolution and we hadn't been

thinking so much about the getting home and back to your normal life.

The consumers have identified big gaps and and holes in

in care and that we need to we need to be filling.

So remembering that the sepsis standard

applies to every patient

who has just been born all the way through to patients

who are dying of old age and it applies

to every facility whether it's free

hospital, whether it's private or public and and

to every type of care whether it's pre-hospital or hospital and more

remote Metropolitan. So it

applies everywhere. So the scope is huge and it

does mean that not every aspect of the of

the pathway will be too directly but there

will be aspects that another part of

the standard but there will be aspects of the standard that you need to

to take on board for where you are working and

the standard is really divided into three bits. This early

recognition and Rapid treatment is all around sort of

the immediate the steps as

policies making sure that they are implemented and

put stuff educated that there's time

critical management and that we comply with antimicrobial stewardship

principles, but then there's this new a

bit around coordinated patient and family care, which is

making sure that there is a multidisciplinary approach to care and that

families get the support and education and information that

they need and then there is proper planning

for after hospital and there is hand over

to Primary Health and that there is

You know ongoing care for patients in the community.

And and when you look at that from our perspective growth

in terms of the guidelines, but also the part

the pathway would also in terms of what the care we provide

so far. We have done quite a bit of this

guideline and talk to tools and treatment bundles and guidance and

antimicrobial stewardship. What we

haven't really put in there before is this coordination of

care, there's multidisciplinary care that needs to be coordinated and

ensuring we've provided some information early

on but making sure that parents have enough information and support

and that we monitor the experience. What is

key part of the standards are some Workforce implication. There

is a need for a sepsis expert to be identified 24/7

who can review patients now

for

For us in Pediatrics, if you are in a

hospital where you are lucky enough to have a picture then that's

that's easy for all the

rest of the places. Then it is likely that you will

use your Ed staff who would have seen a lot

of services they wish we've shown that they have and significant

expertise and

But for our moron remote areas who

don't have pediatricians or Ed staff on site.

We do probably need to be going through RSQ to

to be able to access the pediatric medical

coordinator and that needs to be reflected in your policies.

And then there's other role of coordination of

care and that's probably a nursing a nursing role

where they're not there at all hours of

the day, but they are there to make sure that we're no amount of teams involved that

there's teams are communicating with the parents are communicated with

as well and that they also have

a significant role in monitoring performance monitoring how

patients with sips are being treated in

the hospital and what they experience of their services care

has been so when we

get to our revised pathway, we've got to include all of this

we've managed to we had an ed

pathway or impatient pathway or remote

facility pathway. We have got rid of the secret Pathways

and put them all into one. So there was only

one pediatric pathway from now on and the pathway

we are trying to cover the whole services for presentation.

Hospital to discharge home, so it

doesn't cover Beyond discharge, but it

does covered to discharge home and linking in with Primary Health

Care.

and the

the pathway we've had widespread and

repeated consultation across the state much like we

did with the development of the first pathway. We have

had clinicians from

loads of different disciplines contribute and we've had clinicians

from across the

state from the far north all the way down to to Brisbane and

contribute as well and it has been

very much co-designed and with our consumer

partners and I just wanted to say a

huge thank you everyone who's who's provided feedback and

because with that feedback we've been

able to create a tool that fits everywhere in

the state no matter where you are and if it's

all the discipline, so you everybody has

a

And checklist or or a guidance

to to help them provide high quality sustainable and

repeatable high quality care for

children across the state. So thank you all we we really

couldn't have done it without you. So thank you. We've also

had a human factors review. So you'll see it's a little bit easier to

to use and to look at and we've had it

reviewed for completeness against this episode standard. So if you use this

pathway, you will complete everything you need to complete within

the sips of standard and so it's take

that box for you.

So the first page is pretty much

the same and I'm going to walk you through

the pathways. I hope that's okay. The first part is pretty

much the same you can see it's just the Pediatric sets

of pathway. We've taken off the different and areas the

screening tool is exactly the same and the

so so

that's no no different and we again woven in

the senior clinician review and you can

be de-escalated off as

pathway in the same way. You don't have any features of

severe disease or your clinic clinical review things that

this isn't and same so you escalated off and

similarly to previously we have

the patient information leaflet that

you can send your patient home with which is even if

they don't have sexes.

Is give it is educating them as we said earlier. We do

need to be educating parents about tips to partner with

us in treating their children. And Please be aware

that we do have these available in

different languages. They tend different languages and you

can just download them from the internet and print them off if your

family don't speak English, so please be aware that

they are available.

So, however, if you decide that this patient does have sepsis

you'll see that our treatment page is very

similar to to what it used to look like.

We have this and looking at the top, but first

we have this.

That we've brought in this diagnostic uncertainty

and rule in here and that's really make sure

that we treat people who need to be treated but also

that we're not overtreating people over tweeting

patients that we think might not have said so it's that

balance of benefit versus harm

for the patient. The rest is pretty much

identical and it has the appropriate escalation to

and pick you up you are as

cute as a required.

But then it all starts to to look a little different. And

so the first thing the the next

the next part of the box is this is this bereavement

episode and we have deliberately placed

it here many people found that a little jarring but

we've deliberately pasted here because we know that of

the children who die

Proper than they die in the first day. So it

is putting it somewhere accessible and a reminder

for clinicians. The wording has changed since we've

had some feedback, but we just wanted to emphasize that.

You involve your if a child does

the new department that you allow time your your

family's time with a child because that is an important and private

grieving process that you involve your Allied Health and partners

particularly social workers. Who even if

it is after hours, let them know the next day because they can follow up

and also that you let your steps as chord and

later. No because they will work with the the social workers

to make sure that this family followed up and please remember that the

CH Q bereavement service is not just for people

in Brisbane. It is a Statewide service

and they will and support families who've

lost children and

outside of Brisbane so important to know that the next

part of it of the of that page is

about the the reassessment and we've stem

that down a bit and

Put in the factors that you definitely need to be reassessing. And

then on the basis of

that reassessment you're going to be making a decision, you know,

this patient is is definitely getting better. So

actually at some point we can move out

of a critical care area to an

inpatient audio because they are becoming stable.

So they've

They're in the sort of pink group. They're resolving sepsis.

We can call them in the pink and and

then we have the other group who are either.

Deteriorating or have the system signs of sepsis, and so they

need to stay in a critical care area. And actually they

need to escalate care and depending on where you are in the

state. If you have an ICU available, your ICU is going to come down and help you

if you

If you aren't you're going to be calling retrieval services, so

those those are those patients that are

there.

And now we have a completely two

new pages and I'm going to go through these in a

bit more detail. But this is the next part of the plan and

what we've decided to do is

then divide our patients up according to their Acuity

and how you would manage them according

to their Acuity. So the patients in

the pink or the patients who have responded and have to

treat and and have resolving signs

and symptoms how you do escalate your

care over the coming days and the things that you look for.

And but also understanding that at any point

the patient can deteriorate and that

can jump over into the purple side. So these two

groups are not exclusive there is talk between them and

it is possible for patients to jump from one to the other the people

side are the side we the patients and these

patients for example, maybe being managed

in your Ed waiting for retrieval service. So

this is a guide as to how you should monitor them. What you

should be saying to the parents what else you should be doing in their care.

So there's a little bit of additional information for

those for those patients who you have escalated. Okay.

So going into a little bit more detail. Our consumers

were very keen at the first bit of information was

how you communicate with this family and what you are communicating with

them and we have design and

another information sheet for parents. So

this is also a

terror of she but this is for sure. These are this is for children who are going to

be admitted. They are diagnosed receptors. They're going to

admitted receptors. So we're going down.

What it is going to be like for that family having sex so

there's a little bit more written information for them. And

so with worth while having a read through of that and

it is also making sure that you involved your

ally your Allied Health Partners your social work your

if it's an Aboriginal torture calendar family

that that you involve your indigenous liaison officers

interpreters and so on and just a little

reminder that there are lots of resources out there to

for you when you when you are supporting families. So if you go to

the our website, there is a video

series that parents can watch and which

takes you through each step of of the of

the journey that they undergoing and we also

have a peer mental program that they can sign up to and on

this family support network there where if

they want to talk to a

another family who have gone through

the same thing.

We have some some consumers who've gone through

some training who are now able to support people going

through the acute phase themselves. So and

that is that that it

came about because our consumers told

us or sometimes. All they wanted to do is to talk

to someone else who lived through the same thing who would understand

what they were feeling because clinicians just we

don't

So once you've gone through your communication with

we then very much looking at what monitoring

you should do and how frequently you

should do it and obviously that is more intense in the

patients who are purple or deteriorating or

have persistent sets us and less frequent and

less and and sort of reducing in

those patients who are improving but when

you've got that monitoring going on we do need

to be reassessing those observations and in the

purple group discussing those reassessments with

your escalated and whoever you

escalated to whether it's your right to you or your

or RSQ understanding what

those assessments mean and what the next interventions will be.

And if you're on the ward making sure that when you're

doing your observations and you assess that the patient is genuinely

still improving and not possibly deteriorating and

jumping back into the purple. So a

little bit of help on that.

and then we have an

Looking at making sure that our we've completed

our investigations and we've optimized our antimicrobials

now particularly in the

deteriorating patient. We want to make

sure where we can we thought about Source control.

We've had a lot of comments about CSF appearing

here and it is correct in deteriorating patients quickly

or patients. We often won't do CSF, but

it's there to consider and and making

sure that if even if you don't do it at that point that you hand over

when the patient is stable that that needs to

be done and it's also important in editorating patient,

especially that you discuss your

microbiology results either with the

lab or with you seek ID expert

and expertise and input

Then following that we need to think about making sure

we document things clearly and that is something that the standard

is very particular about. So making sure that we've documented

everything that you should be to be

documented and then in the Handover and discharge

columns, so our deteriorating patients

when we will be handing over possibly from Edie

to retrieval services

retrieval services to ICU and eventually at

some point when the patient is better from our to you to the wards that

each of those transitions of care and the

creative information is transferred that the parents are

involved in Us in those handovers of care that the

treatment plan and for what it's expected over.

The next few days is correctly handed over. I know

that what we've written there has has changed in

in the most in the most recent but

since we've had some recent feedback so so don't

don't look at that think that's all we're doing

that has changed a little bit.

So hand over and discharge is is very important. And then

when we're thinking about discharge planning making sure that

the Primary Health Care is involved and understanding

the needs of the child as well as the needs of

the family and that they're not just launched out of hospital

that there is a continuity there that there

are people that they can contact what they run into difficulty.

And understanding their experiences important. So that's just a

little reminder of what the additional.

additional Pages look like and we still

have kept the antibiotic guidance

and both in terms of

your antibiotic Choice how your

dose recommendations according to the age of

the child and the administration guidelines

for nurse for the

nurses administering the antibiotics and so those

of say that they've been updated and decluttered so

they look a little bit different so I can see we're

almost out of time. So I just wanted to

acknowledge our wonderful team, especially our

fabulous consumers who've given us so much

help with us, but particularly also to those

of you who have contributed to make this another say

at all that is football purpose across

the state and we're really

so grateful and for your

help in this and as ever these youngsters

have been inspiration for

doing the work that we do and they continue to be

a inspiration because they're the whole reason why we

so I'm going to stop sharing my screen now and

I'm hoping that

Sarah the lovely Sarah who's been listening in and Alana

who's from our team of advanced social worker are

here to answer any questions that you may have had.

in the chat

There was there anything that I needed to we don't have any

questions in the chat, but if anyone has anything, please feel

free to pop it in or if you raise your hand

maybe able to see it all the people online.

And Alana, was there anything from a social work perspective

that you wanted to add?

No, I think you covered it. Absolutely. Beautifully. I think

in a lot of ways the so much about our family support

program, please if you don't know about that, it's all on the website.

So if you can have a look at the families tab on our sepsis

and children website, which is housed in the children's health Queensland

page. There's so much detail about all the

different things that we offer families. And as Paula said

the video series is there and links to our peer mental program is there

which is for families who are bereaved as well as

families who are currently affected by sepsis. So

yeah, please talk to families about those resources.

And we do have a question about the go live date puller do

we know when that is not not exactly but

we're hoping it's within a month or so. So we will

we will let you all know and there is another second

part to this webinar series, which is Amanda really

doing a very practical session

of walking a patient through the pathway and with

Alana and so so that you

get the nitty gritty and then following that the pathway will be

launched now. We have a question about the digital pathway.

And so at the moment it is on paper.

We have hit a major roadblock with and

sooner who are the company who run

IMR and

whilst we're working our way through it. They

Are not the fastest so we are we are

having to go at a bit of a slow speed. It's not going to

appear and IMR. We don't think for at least

a year.

So I do apologize because there is

a I know that from a workflow perspective and

going away featuring a paper pathway is

is Nightmare if you if you're

on a digital system, but

Don't lose hope we we are we are and we're

on to it.

and

Jade has who's one of

our fabulous team members has just said it will be available on wink.

And through the standard processes with all

that and the tariffs. That's we've put

the parent check sheet, which is

you know, the tick button this at the back. So that's could you gonna tear

that off most of your patients don't have steps to see you're gonna

turn it off more frequently. And then before then

it's going to be the parent and carer information leaflet,

which is for the limited patients which gives

a little bit more nitty-gritty about water hospital admission looks

like and what to ask your Consultants when they

come and check to you.

Thanks Fuller. So we have recorded this today and I

will share it with everyone who registered. I'll also

share the link to the next session so you can register and attend

that on the 23rd of February. If you're

able to that will also be recorded and available online following

it's completion.

And oh, we have a handout we

do.

Ruby hello. Thank you and Ruby here

from westmorton and I've got some of my pediatric Ed team

in with me. What is your

suggested solution for is two

questions for Health Services who don't

have the luxury of having

a coordinator who can

also follow these patients upon discharge. And

what is the suggested solution

for areas where

GPS are now charging, you know,

70 75 dollars a consult communities here

that lower socioeconomic communities

like where we are families here

that they will not take their child to

a GP to have that necessary follow

up with a printed out piece of information that gets

to the GP before discharge summary,

which might take you know, 17 14 days if

it gets done,

That's like that feels like a risk for

us.

So there's this to the first bit of that is and

look we all have to

Figure out for our facility how we're going to meet matchstanders and

I what we've sort of said to patient safety

and is that a lot of that some

of their care coordination monitoring can go

to patient safety and in smaller

areas. It's it's often been if the

patients are retrieved from you that coordinating

role in terms of clinical coordination is

smaller. And because where

is it if you're in a in a hospital with

lots of impatient work that clinical coordination might

be bigger.

So that clinical coordination some areas. I've had

some hospitals thinking that the Ed staff who does

patient safety might be interested in doing that. There

is no

blanket solution

and so that coordination role has two bits one

is the clinical bit and the other is the monitoring and it's

it's trying to figure out in your facility

how much the clinical how much will be more

ordered based and depending on

how much that is you might make it

more patient safety based. Does that make sense?

Now with regards to the other question, I'm going

to probably hand over to liner, but I would think we are

developing a model of care and that is something that we are

going to be asking questions so line if you want to take that.

Yeah, thank you. I yeah,

I just wanted to mention that we I'm currently in

the process of you may have receive some emails about it where we

fully recognize that there's such different needs in

different communities. And in order to ensure that we and there

is no standard guidelines for postpsis care and

there are all these challenges in terms of GPS and access

to Primary Health and all the rest. So I am currently the

process of running focus groups and I'd love

for you to sign up for those if you don't have the link already. I'm really happy to send it

through you. Actually I might have been put in the chat and then people can

actually sign up for these focus groups so that we can

hear from you directly. What are the challenges that you're having

and how do we look at developing a model of care and some guidelines that

actually meet those challenges because there's no point saying, you

know, we'll go to your GP. And as you say people then can't go to the

GP or can't afford to go. So I really need your input to help

us to understand. How do we set this up in a way that meets all those needs and

the last resources in places

a lot less Morton lack of resources. We're not

Spray and we do do a very good

job of Pediatrics. I can say that and but and we

haven't got the tools even with them

to do get the job done as much as what we

really like to. Yeah, and I think

the yeah the color one from all of this is that if we

get it right for sets of and the model of care for and posts

it's his care if

we get that right actually we'll it'll work

for any any number of other posts, you

know Hospital complicated kit. And so it's

a real opportunity for us to get it

right into here your voice. So please do sign up

for

and

I've noticed that Jade has put in the chat feedback

for evaluation form for this and so

please do follow that in because if you've got

any other questions I can also go in there Alana your hand

still up is it?

Just the same hand.

Does anyone else have any questions there is one

more question in the chat about educational material for

departments to use when the pathway does go live. This recording

will be the main piece of

Education use as well as Amanda's upcoming session walking

through a patient through the pathway. Once it

does go live. It'll also be available on the ceq and

chq website so you can have a look at it and use it

for your own education sessions at any time.

And we will be updating all of our existing

education. So any you know, and I

learn and part of stalk

and those modules those will all in time

be updated with this new pathway. And so

it's coming.

Another hand up from Jolinda.

Hi, we're just up in Cairns and we were just

wondering where the session two will cover the changes in antibiotics recommendations

in the new version We noted that there's no

that the marepin appears to have come off for

here with tropical. Yeah, so it says

interesting that you pick that up and the literally this

week. We've had chats with the ID guys

up in Cairns and so on and we're going to put it back

on.

Fabulous. So yeah, it's going back on the numbers

of set this and of

milio. It sepsis are very very

low which is why they that it's fewer than

12 kids and all fewer than 20 kids

in 12 years or so. I don't know. It was really not I go I'm I could

get the numbers wrong and so they wanted to take

it off, but then the risk was high so

it's gone back on.

So it it is back on.

Fabulous. Thank you.

I think that's all the way of questions that I can see. Yeah.

See Danielle's just sent a question. I'm not sure what's

happening with the adult pathway. You'd have to check in with them and Danielle.

Lovely, thanks, Paula.

Well, thank you everybody. We really appreciate the fact

that you've given up your your lunch time.

I hope you do get some food and and get

a break. So thank you all very

much.

Oh, no, there's one more hand.

To Linda is your hand still up or is it a new question?

Oh, no God, it's Celine

here from caboolture. I just wanted to say the adult pathway. We're

actually working it rolling that out this year

before June.

Cool for the impatience. Yes.

Oh, baby, that's great.

Thank you. Oh Statewide.

Alrighty. Thanks everybody. Thank you.

Thank

here. So yeah just a bit

so that does still exist. Okay speak to

this too. Yeah. Hi Jenny. Sorry. I've been scrolling away

underneath. I'm the manager for the Pediatric success team

and excuse my voice at the moment. But yes, there is considerations and

the antimicrobial guidelines. If

you have a look specifically on the septic shock

line, there's a specific line that says except for

final Queensland during the wet.

Wet seasons, and then it has specific recommendations for you, and we

do have some great consultation with our colleagues up

in Far North Queensland, and you might have seen a draft version it

that wasn't included. But this vinyl version.

It's definitely included in there fabulous. Thank you. You're welcome.

Just one more of the chat Amanda do we know or is

there some way for people to find out who the steps is coordinated are

for each hospital and Health Service or site. Yeah. So

my recommendation there would be to speak

to patients' safety and would be

my first Port of call around that. So this is quite a

the clinical Care standard obviously recently came out

and but those facilities are

probably up and getting wheels around organizing those

sorts of things. So I would Link in

with patient safety at your respective facility wherever that is

and or also your perhaps and

nurturing management or your assistant director of

nursing wherever you are. Obviously, let's be slightly

different Pathways, but they would be the people I would ask who

maybe around have a bit of knowledge around that or if you've

got a standard eight working group. They also maybe

able to point you in the right direction. But yeah,

very hospital is slightly different governance it up on

Who would know those answers, but I think one of those three

People depending on where you are would be at a point in the right

direction and don't be surprised if the answers. Well,

we actually haven't thought about it or we don't have one. This is

a really great opportunity to get those Wheels in Motion

and start to figure out how can we make these people

exist Within These facilities?

So later, you have something to add probably.

Oh, no, great. Great presentation guys fantastic as always.

Um, just a question now. Am

I understand this pathway is for Ed and the

wards as well. So it's a one one pathway. Thank goodness. Thank

you. That's brilliant. So now I'm just going to be starting to

do some more education on our Wards and nades just

to make sure there's the same

wink code.

No, it's a different wink code Celine. I'll

post in the chat those fact sheets and frequently Asked question

guides now which have the wink code on there. So yeah,

so the old the two wink codes for

the rule and remote and the old Ed one will expire.

So they won't appear on the catalog anymore. So there is a new wink code

for this revised pathway. I'll post it in the chat lovely. Thank

you.

And also Selena just to confirm for anybody who isn't from

Metro areas. This Papo is

also for real and remote sites as well. So we've had extensive consultation

with Rural and remote clinicians to make sure that it's applicable for

their sites to

I just want to comment on a comment the

same mobile Fiona Thompson in the chat another question, but a

comment Amanda you mentioned that sometimes despite optimal early

recognition and aggressive treatment with the bundle these patients deteriorate,

of course on a rational level. We know this, but the

clinician guilt and grief can be profound and I think it's great to acknowledge

that I think that's something that was certainly all very well and Amanda. I

wonder if you just want to make comment about the possible referral for

services for support through our referral form in you

know, in terms of accessing support from our team when a particular

incident does occur.

Yeah, absolutely. Yeah. No, thank you Fiona. I'm

glad that's being said.

I hope yeah, that's exactly I hope to put that

in there and get that across in the presentation because yeah time

and time again, we do things really really well and unfortunately,

it's just the nature of sepsis and we rack ourselves

and just yeah, it's awful. So thank

you for also, yeah reiterating that mention so

I think given that it's helpful sometimes

to discuss things to walk through things to

review cases. Obviously each hospital has different processes around

doing that but certainly as the sepsis

Pediatric Services Program. We also

here to support through that if that is what you would like. Okay,

of course, we don't know about these unless unless

you reach out to us and that

has certainly been done in the past. But very very

happy this this really is important and supporting

clinicians through this process is really

really important and something close to my heart as well.

So we do have a referral in place

around that and I might go through

sticks

the latest version

Yeah, sure. Once again, if you go to our sepsis page,

there's a link there request for QPS P support and

basically it's an online form. So people are

now pretty familiar with teams and office. I

think so, there's an online form that we just asked for a little bit of information in terms

of what pathway you're currently using what kind of

governance and structures you currently have in place and

there's no right or wrong answer. It's really just allows us to kind of

see where you're at in terms of implementation and how we may be able to support you

and you can obviously select what level of

support you want. You might want education you might want, you know

family support you might want just a question on what pathway

we're up to. So there is the option for just providing

a little bit more detail on how we can support you.

And I think in your brain as well exactly that you go. I know

I did everything I possibly could.

But just having someone to discuss that to review to

look at pointers all of all those little things

and to go you know, what this this outcome may

not have been able to be changed and this is

affects our practice for years to come and

so really discussing that I find helpful

and being able to move forward and not

getting a bias and a whole different sort of a way. Thanks

for you.

I would just add a quick plug if I may that I'm

also in that same area which you can find on quips

as well is that you there's now referral form directly. If you'd

like to refer a family through to the QPS P

who to then access support in

terms of being connected with other families accessing information

and resources and being able to have direct contact with myself

and my colleague as social workers on the team to offer

that ongoing support to families. So have a

look for that as well.

Any other questions?

Just one in the chat about is there a wink code for the

sepsis checklist and parent and Care information sheet.

Not that I'm aware of. Hey, did we

have one for the old checklist? And are we

intending to do it for the information sheet or would we just expect sites to

print that offline and question? Yeah.

There's a question. There's no direct Wing code for those resources.

They are they are part of the pathway. So

when you order the path where you'll get the resources, and if you

just want the resources to sit by themselves, they're available on our website

to print and users your place.

Thanks, Karen. Alright, we might come to

a close. They're five minutes overtime, but really valuable conversation

and discussion there at the end. So thanks everybody for

joining. We'll get Sarah once again to send out the recording

link and the slides from today and we

might get her to kind of summarize all of the resources. We've been

putting in the chat because there are quite a few there.

You know that you can use that at any point. Once again just you know,

email pediatric acceptance at health docqid.gov.au for

any other questions or support and we have posted the evaluation

survey in the chat as well, which would be really wonderful if

you could could complete that.

There's no other questions. Oh, yeah.

It's off. Thanks everyone for joining. Thank you

everyone. Good luck.

Thanks. No. Thank you. Thanks.

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.