Paediatric Sepsis Series — Sepsis Clinical Care Standard

Transcript

Good afternoon, everybody. It's 2PM. So

we will kick off. My name is Sarah and

I'm from the Queensland pediatric sepsis program. Welcome and

thank you for joining the Pediatric pediatric. Sorry

sepsis Series. This is the first of a

series of monthly Services education sessions running from now

until the end of the year.

I'll just share my screen with you. I

will start by acknowledging the traditional

owners of the land of which we're meeting today for

me on the Sunshine Coast. It is the

Gabba gabbi people.

Can you guys see me?

But I just do it I think.

We can see we can see the slide. Okay, great.

Excellent. Um, sorry, so I'm on

the Sunshine Coast and the traditional owners are the Gabba Gabbie people. We

pay our respects as to Elders past emerging and present.

I'd also like to ignore acknowledge Sherry

skill a proud big Jara woman from Southwest Queensland.

She's created the artwork for our

program titled healing Journey the design

reflects the Circle of Care and the lines and symbols

tell a story about the struggles setbacks and people involved

on a journey with sepsis.

Today, of course, we meeting to discuss the sepsis clinical

Care standard. The session will be

led by sepsis expert associate professor Paul allister.

Paula was an advisor to the Australian Commission on safety

and quality and healthcare for the development of the sepsis clinical

Care standard. She is also the director of the

Pediatric Critical Care Unit at Sunshine Coast University Hospital

and medical co-chair for the

Queensland Pediatric Services Program.

Having been involved in the development of the standard and also the

development of the Pediatric sepsis pathway that aligns

with the standard makes her an incredibly valuable and

knowledgeable resource to deliver the session for us today.

There is a load of information to get through so we

are recording the presentation and you'll be able to view it

at a later date time permitting. We will have

a Q&A at the end. But if you think of any questions along the

way pop them in the chat and we'll get to them if we

can and also just a reminder to keep yourself

on mute. So we don't get any feedback from you guys throughout

and just a reminder if your

unit needs support with anything sepsis. Please reach out to

the Pediatric Services Program or that there's also an adult

Services Program who'll be more than happy to assist you where we

can I'll hand over to Paula now to get

started. Let me stop here on my

screen.

Thank you Sarah. That was great. Right? Let

me show my screen. There we

go.

Great. Can you guys see the slides?

Yes.

Lovely, thank you. And so, um

Thanks. Thanks for for joining and I

just want to say this is a fairly longer hour and

it's really content rich and it is a little bit dry. So I

hope I don't lose you along the way but I

think it is really important for us all

to understand what this clinical sits us with this

Care standard means for us while we

try and improve the care that we give our patients forceps.

So what I'm hoping to go through

is it's sort of a brief overview of the standard a reminder

of our team and what we can do for you and particularly

what is already what we've

already done in terms of resources to help you straight off

the shelf and then what's coming up the pipeline to

give you a hand.

Right. So we're this

is our team. We have a couple

of new members as well now, but we're

a multidisciplinary team and we've got

Advanced social workers particularly Elon

or Megs there in the front. And Alana is leading

on the model of care for a long term and patience longer

term patients. It makes it's very involved in the acute

care side of things. We've got wonderful pharmacists

the new the new AMS pharmacist is

malcol green and a particularly put her up the front

and center because she will be contacting your just to make

sure that you've got access to and the antimicrobials that

we recommend in our guidance.

There's a couple of Medics at

the back there and Amanda's are sepsis CNC

who's leading on our education which I'll

showcase a little bit later on myself sigh and

Adam are the medical cohort and who support

the rest of the team and we've

got all of our wonderful and administration office

Sarah who leads on communication Jade, he's leading

inpatient project Emma who's helping with various

other projects that we're doing in the moment and not to

leave out the phobia's Bruce who's LED on our digital work,

which I'll be able to showcase for you. The importance

of all of the work that we're doing is that we can actually help you

achieve some of the indicators that

are that are there for the for the census

Care standard.

And this is our programs and five year

roadmap. This is where we want to get to and you and the

reason I'm showcasing. This is that it's pretty much

aligned to the sets of standards that we're going to talk about. We're told

we want to achieve standardized practice across the

state for for children who present pediatric sepsis.

We want to improve our AMS standards and

we want to reduce the morbidity and mortality

associated with sepsis. And and

we want to make sure that all of our healthcare workers feel

well educated and able to respond but increasingly

we want to ensure that our families are

empowered and that they have the

correct support that they need when dealing with children with sepsis

and that comes with a

several sort of buckets of tasks

if you like and particularly there we want to concentrate and

As well as pulley as as providing support

for our and vulnerable and more populations

who include the Aboriginal Torres

Strait Islander populations and other culturally in

English translation. So we want to ensure that we are supporting them

as well as we can we want to improve our Coordinated Care

and and most of that coordination

and Improvement. We can actually do through

a digital solution to support

the workflow in your your workplace and make

it easier to do and and behind

all of this is a dedicated team. So we're

there to help so please do calling us.

So when we look at the sepsis clinical Care standard, we'll

see that a lot of that dovetails with what we're trying to do and

as a pediatric sepsis program in

Queensland and the importance thing about this Care

standard is to realize it is not a sepsis guideline

it it's not going to walk you

through how to manage successes. It's not

that at all what it has done is it is identified

areas, where if we

improve the care in those areas, we

would have a big impact on outcomes forceps.

So it's prioritized areas for

us to concentrate on with our quality

improvement works. So those have been

whittled down to seven quality statements seven key

areas, where if we concentrate on improving those areas,

we will get the most bank for our back in terms of improving outcomes

for our patients and their families.

they also give us a list of indicators and what indicators are

and

things we can measure to show that we are improving in

those seven key areas and they're provided a number of resources

for us to use for example how to do

lactate discharge and litter templates

Etc. So worth having a look at that on their

website.

It's also important to think about what the scope

of this and of the sepsis

guideline and understand that not every single bit of it

will apply to every workplace because it

is going from the whole of life from nearness all the

way up to the elderly and includes and particular

attention to our vulnerable communities including Aboriginal

Torres Strait Islander communities. It's looking

at the whole of healthcare pretty Hospital primary Community

private public.

And it starts right at symptoms onset all

the way through resuscitation hospital care discharge

and cervantages. So where you are

and where your health and the level of

care that your health care facility and provides will

be different to somewhere else. And therefore there will be

some aspects of this and Care standard that apply very much

to you and other aspects which don't and and

you need to be using the indicator to to share

quality improvement in the areas that affect

your current your type of facility and

your level of care and and not worry too

much about those areas where you don't so it's just

trying to understand the scope of it's not it's not

a fully applicable to everywhere.

so do we have a problem with variation and standards across

the state and the answer is yes, so we know from the data

collected by the quality pediatric

quality Council in this report in from 2016

and 17 when they looked

exact one events, and those are events with

Healthcare is reported to Queensland Health

as Charles has suffered but harm or

death and they've reviewed okay.

of the 12 cases eight of

them involved children who had sex

And then further to involved Healthcare Associated

infections, so maybe we could put those under

the same Banner. So we definitely do have a problem variation

of care. We also know that in in amongst

those second events. There was over-representation of our

regional and remote setting and we

know that there's a whole wealth of reasons why children present

later difficult access to care and difficult

access to escalation in those Rule and

motivations and it will you know, it has

continued afterwards. This is a more recent Ombudsman

reporting to a child the sits Us in them again.

So when we're talking about this census Care

Center, I want you to try and just have in your head the patient

and family experience of sepsis. So

right at the beginning we often find that these families

have sought help sort medical expertise.

On a couple of occasions before presenting to hospital.

So it's not unusual that the families taking the

child to the GP once at least once before coming to Ed or

possibly even more than that all they've come to Ed

and be sent away and come back again. So representation is

is part of recognition one steps is

recognized. They're usually in a sort

of a more acute setting and

once it is recognized we know that there is certain treatments

that we need to get going urgently in order

to treat the sepsis and to reduce morbidity

and mortality and we should at

that stage be involving the family both in the

early recognition of steps as because we know and listening to

parental concern around their child's

behavior is important in diagnosing Services early

and but we may actually also be

involved in handing the patient over

to different teams once they've been resuscitated and

maybe going to the ward or indeed. There may be a problem that we

need to

Like can you escalate to different team or

indeed you escalate to a different facility? So escalation

of care needs to be built into into that.

Then once the patient's been treated and they start

their sepsis and starts to resolve. They're usually

an awards hitting and which may be

in the original hospital or a higher and higher level

of care hospital. And again, there's lots of handovers between

teens and newer teams may become involved particularly

around Allied Health, whether they be speech and

language or physios or occupational therapists

and indeed we may start to involve other suspicious teams

such as Orthopedics and or general

surgeons and all of that care needs to be coordinated and

all of that and Care planning needs

to be to try and communicated to

the parents. So then they understand what's going on.

and then eventually the child will be discharged home and they may

or may not have suffered some long-term morbidity from

sepsis and that hand

of needs to happen to the primary

health care and provider for the family and

the family need to know what to expect and from

from their recovery and where to access

help so that if you hold that in in your

head is the long journey you can see there are a

number of pinch points here where

Things could go wrong where information could be not handed over

where and things could possibly be

done better. And that's where the seven areas have

been prioritized to improve patient outcome in

the census standard and I'll Point those out as we go.

So the seven key areas really are the

seven quality statements for fall into for me

and three key areas. There's the early recognition

and Rapid treatment. So good quality Care around

early recognition and Rapid treatment will reduce

mobility and mortality and the key the

key that's here are recognizing and being

able to recognize that it is sepsis that you have a

management plan that is urgent. It's time

critical and that first acute and 13

and that there's appropriate management

of antimicrobial therapy both in the appropriateness of

it in the timing of giving of it and in the

observing AMS principles that's following

followed by making sure that patient

and family centered Coordinated Care

happens and that that is marketed disciplinary and

that happens.

Schedule and that the family and carers are given

as much education information as they need around that

time and then we need to plan for discharge home

and those transitions of care. It's critical

that we have a clear communication and

and we look at care after being discharged

from Home Hospital.

So why is pediatric census such a particular

Challenge and and it's really simple it's because

we know that you know this time of year

you use a full of children who have infection childhood infection

is commonly commonly presents to healthcare

providers.

And but we know that sepsis pediatric

sepsis at least is relatively rare in

comparison. So how do you pick that child

who in amongst? All of these children with common

infections is going to deteriorate interceptors and it's

difficult.

The other worrying problem is that when they

deteriorate these children can deteriorate really rapidly so

when we looked at our data

and when I was in London, we we found

out of the children who died with physics.

50% of them will die within 24 hours.

now that means that for us as

clinicians and we have a

very short window of opportunity to get in there with our

Therapeutics leader antimicrobials or any

intervention in order to stop that sepsis deteriorating

all the way down into into civilian mobility

and mortality. So the time window is

short to turn it around. So that means that we

need to recognize this as early as possible.

Difficulty with that is we know that late sepsis

is really easy to recognize we can see the pictures of these

children with meningococcal sepsis. Nobody would miss that as

being sets us. It's very easy to see

but it's actually really difficult to diagnose census only

because the early signs are often behavioral and we need

and

our parents to be telling us that behavior has changed because we

as clinicians wouldn't necessarily pick it in in children,

you know in particular children because we don't know those particular children

and then individual characteristics. So early

recognition is key and remembering that sepsis is

a Time critical and in the emergency because

the deterioration

can be so quick.

and to put that into context

for myself as a Pediatric Intensive that any one time

and 10% of my patients have sepsis. So

for me, it is actually quite a common thing in something. I'm

very used to dealing with something very used to recognizing but

for the vast majority of our edu Physicians particularly those

who treat the whole of life and

only 0.1% of their practice is Pediatric Services.

a turret into sepsis. So

it is a pretty rare event for them and for our primary health

care givers they may go their whole career and never see a patient with pediatric

sepsis. So it is vital that we

Help the helper Frontline colleagues as

much as we can with various tools to help

them to recognize services.

So these first three quality statements around early

recognition of Rapid treatment and are around

making sure we've got a locally approved

Services guideline in every facility with sepsis may

present or occur and that

by locally approved what they mean, is that the entire hospital

so from the executive down through the

governance process has approved a guideline for

use within that facility and part

of that guideline is to ensure that an

appropriate support tool is used to recognize sepsis.

So that's the key that's thinking about could the

species.

and then there is a Time critical management

element to to the

guy to the gardens and that is is treating patients

with the suspected sepsis and

just just as a recap just to remind you that that's

this is infection with organ

dysfunction septic shock is

sepsis where the organ that is dysfunctional is

the circulatory system. So septic shock is a

subset of sepsis and we we do differentiate that

one because those patients do have a

higher mortality and morbidity rate.

The problem with sepsis is it is a clinical diagnosis.

And apart from using lactate it is otherwise clinically

diagnosed and we're trying to clinically diagnose

organ dysfunction.

Now some children it is pretty easy to diagnose and

you can sort of say it's known sepsis or confirmed or highly

likely sense of so, for example, the pictures of the children's

meaning of cock or purpura.

Pretty easy to to diagnose no one's going

to argue with with that. There is highly likely or confirmed steps.

The problem is that this doesn't

presented different types is differently not Simpsons

is always the Spectrum in between and there

will be some some children where

you just not quite sure.

Do they have organ dysfunction or not? And those are the suspected

possible?

So there is a spectrum of certainty with

which you are making this diagnosis clinically about all business

function. And the reason I'm talking about this is

because up here in the highly likely or the

confirmed and area of certainty. We

will be giving antibiotics and responding much

quicker than if we are here in just the

suspected site. So in the highly likely group, we will

give antibodies within 60 minutes and that is a recommendation

from the standard. Whereas those where

we're still not sure you've got a bit more time to do a bit

more investigation and if it's three hours, you're still not sure but you

think infection and sepsis is likely or is it

is a distinct possibility. You probably should be getting antibiotics and

you've got a little bit more time to think about it.

So in those patients with suspected tips

as well whether you're no matter what your certainty is.

You need to be giving them you need to be treating them according to the guideline

and we need to be taking blood cultures as

well as there's no delay in and treating them

with antimicrobials. If you're in a likely

group or the confirmed group, you give them the appropriate antimicrobials within

16 minutes. But if you're in the list certain

group you probably you've got a little bit more time. Maybe

three hours to get in.

you making sure that if your patient isn't responding or

is it presented at an Acuity

that is above the level of care your facility

normally provides that you have

a framework for escalation and that

is associated within that with a time

frame to make sure that the time critical management of services Carries

On

and Beyond the immediate giving

of the antimicrobials that they are

managed according to the antimicrobial stewardship standard.

So that means their appropriate you're given in the

correct. Does they give in by the correct route

and that's 48 hours and there you review

those antibodies according to the information you're getting

back from your

cultures and other investigations

and the next the next bit is something you most of

us are familiar with with the you know with what the acute

management is, but the next bit that we're standard is recommending is

new and that is that there is a clinician experience

in sepsis management involved in the case and

available 24/7 now

You for most of us. This is actually the edsmo

on or the Pediatric Smo

who's on call for the ward

or a few nice. You'll be the pediatrician. So this is the

most so they usually is someone around in the bigger

hospitals who would fit this role and and for

the for them for the more remote

areas. This could very easily

be filled by the pediatric medical coordinator who's

available through RSQ. So bear then

in mind that that may need to be written into

your local guideline.

For how you is gonna Care Now, do

do these do these do these acute treatment

bundles work and the answer is yes,

they do. So if we look at the New York state which is the biggest and

publication of

over a thousand Pediatric Services patients

and

New York state has

Following the death of a little boy called Roy Staunton has

made it made it as a legal requirement for every

hospital to have a local guideline and to report the

results when we look at the Pediatric sepsis

group. We find that

and

they improved mortality from from pediatric

sepsis in those

children who received the bundle of care and the

bundle of care was elected antibiotics and fluid.

And when we looked at how compliant they were getting that

done within an hour, which is what it should be done. And actually they

would pretty non-compliant only 24% of

hospitals were able to complete the

one-hour bundle in time. So that is

to fix that. Those are two key

messages. I want to get across it one is that it's

Really difficult for hospitals to be compliant within one

hour bundle in children for some reason. So the adult

equivalent this was 86 compliance. But even when

the only 24% client there

was a massive Improvement in sepsis Mobility

immortality. So imagine if we all did what

we should do and get treatment done in an

hour. That effect would probably be higher.

So when we look at our own experience in Queensland,

we were similarly and rather depressed and

in 2019 after we did

the Pediatric collaborative that we had only completed

our compliant with our bundle and

septic shock patients 30% of the time and 40% of

the time in those without shock and that only 47%

of our patients were septic shock

received their antibodies in the correct time frame.

So there's a lot of work that we still need to do in order to

be compliant with the recommended and since this

guidance, but what we did notice is that our antibiotic AMS

balancing outcomes really did

improve we had a improved appropriate choice

of antibiotics using our guidelines and

the dose was correct. It

was the correct us for the weight of the child and that

also improved but we did notice that

there was a signal that we were increasing our

antibiotic use. This is purely data from the

children's hospital, but it showed that there was

a slight uptick in the amount of taxing being

used in the Ed which was the equivalent of one

additional child on therapy daily. Now, we do need to keep an

eye on this because we know that

And one of the criticisms of any senseless

guidelines is that some children

may be unnecessarily treated.

At the stage that may be true, but it

doesn't seem to be many and this is something we need to

keep an eye on.

So the reason I've run through all of that is to

is to and emphasize that

actually we already have a Pediatric

Services pathway in Queensland in Ed more

and remote and inpatient areas not all possibilities

use it but it is available and

ready to use in for for everybody and

and just to reassure you. It has

multi disciplinary and consumer stakeholders

design and it's gone through an iterative

process with the formal evaluation in 2020

and adjustments.

Following that in a tad still has a pretty good

area under the curve in terms of picking out those children

within the cohort of children who present to Ed those with

severe features of illness and the

purpose of picking out that

cold water children is that those are the ones we want the senior eyes

to review the child to see whether this child

might have sex is it's been appropriately endorsed

by the sort of the bodies in control

in Queensland, and that's the mentions advisory

Community the Children's Hospital the child and youth clinical Network

and quad set and is available to order.

Through wink now the pathway has

on the front here, which I'll

go through in a bit more detail both the screening and

recognition tool. It has a treatment bundle. It has

antibiotic prescription dosing and administration

guidelines and a parental and information leaflet.

So as I said our screening and recognition tool

is all about picking out a cohort of children with

features of severe illness and getting

those and under the nose and under reviewed by

senior medical staff because we know that

sepsis is really substances difficult to pick and

we know that people who are best and placed and

with the most experience in sepsis other

ones who are in the senior position

and they are able to diagnosis more readily so involving

the senior medical team earlier means

that you can you can and as

you can see here with this Arrow.

Deflect children with outsets is off

the pathway so that there are reducing the amount of unnecessary treatment.

But those where you do think they have sepsis

you can start the treatment bundle early

and and that includes as as

the standard once has to

do blood cultures.

Lactate levels and commencing appropriate

antibiotics as soon as possible and those

appropriate antibiotics you choose according

to the source of infection. And then

the pathway leads you on to making sure that you reassess

and monitor and if

you are not if the patient is not improving or continue to

show the signs of severe illnesses listed here.

Then you escalate according to your local escalation

pathway, which may very

well involve phoning RSQ and getting the pediatric

medical coordinator on the phone to advise

as necessary. As I

mentioned. There are people there are prescribing guidelines and

these are suitable for the whole state including

far North Queensland and takes

into account and resistance patterns

for for the community.

There are also dosing recommendations. So

depending on the size of the child and as

well as Administration guidelines for the nursing staff

who who are administering, you

know doses to smaller children.

And already so that is all existing and

ready to be used and will answer many of

those quality.

And statements that the Care standard has listed

and we also have up and running this

website, which I would advise you to go and have a look at if

you haven't in the carton particularly here under the healthcare professional there

is a lot of clinical guidance and education and

information that you can give to the parents.

There are is also a hollow information for families,

which I'll go through the later on and it also talks about

the research projects. We're busy doing so under education.

All of this is currently available. We've

got courses in webinars and the

important, you know courses here are The Optimist bonus

stimulation package and the prime and as well

as the pathway education clinical education and awareness and

what they look like is I've tried to highlight here

pathway education does teach you about what's on

the pathway how to use it how to fill it in

clinical education is around those thorny issues about

how to do a lactate how to prepare an adrenal and infusion how

to do a blood culture and

Awareness is just all of our

education that we've done today to on.

managing and recognizing sepsis

And what's coming very soon so in the next couple of

months is help for those sites

who really like the look of what I've just gone

through because it makes your life a whole lot easier but haven't actually

implemented it as well as a resourceful those

places who have already implemented the sexist

pathway just to refresh the memory. So we

we've created we are creating an implementation talk

it and what that does is helps you work through

the steps of implementing a change in practice and

then involves understanding what you're trying to accomplish planning

in detail how you do that recognizing who

your steps as Champions might be

What the roles are around that where you're going to get the

information you required to audit your practice who's going

to be auditing how much you can you can audit

maybe concentrating on just one or two key elements

of ordered making sure that you educate everybody

and about the

new pathway and what's involved in it. And then

how you sustain that change in practice

over time, which is the hardest part. So

all of that information is coming and

this is a this is an idea of the

website all of those and steps outlined

with each step. There's information as well

as resources available to you including things

that's such as a data collection tool and our

ability to help you with that.

So what are the indicators to

for that the commissioner suggesting

that we collect in order to show that we are reaching those

quality statements and they're saying the proportion of

patients with census and that have

a screening lactate.

showing that you've got evidence of a pathway your local arrangements

to show that you've got access to all the required

Diagnostics and we can definitely help you

with that and

making sure that part of your pathway has a clinician available with sepsis

experience showing your education both

in induction and continuing practice

development and audit of

your performance time to antibiotics for example, as well

as in order of your family experience and what you could

use there is any kind of order that you have of your pediatric family

experience and

Put would probably suffice there the proportion

of patients with sepsis treated according

to the pathway. And for that this is the ICT 10 codes.

So you identify these patients and

and then retrospectively see

that they were treated according to the pathway. You don't have to do every

patient. You could maybe choose one week and four one

week in age or to a random selection of five

patients. You don't have to do every single patient. Just some ordered

would be useful and those ones you can

look at their time to to empty microbials

and perhaps those that had blood cultures.

So things that we think probably should be included

that include there's maybe the proportion of patients

on with an ICD-10 code who are screened

and we have a and going

back to the education. We have a which is in implementation

toolkit that's coming as sepsis knowledge

survey that you can just download and use

and maybe use it prior to education and then

perhaps use it after after the education. It

shows an increase in understanding citizens

and confidence and treat your staff and

And particularly around the antimicrobial therapy. I

just wanted to highlight the Naps or the national antimicrobial prescribing

survey. So this is a server that's

run for by the commission anyway, and it would

do both jobs. It would do the job of the

AMS Center but would also do the job of this. So you'd be

killing two birds with one stone with the service. So I think

it's worthwhile looking into doing I noticed

that only a third of Queensland and

Healthcare facilities actually

kind of contribute to this. So it may

be worth looking to see whether you can do that because the sorts

of information that you get from it are were

antibiotics and appropriate and optimal

and did you follow local guidelines? There we go. You're taking

both boxes with with one with one

survey. And again like with

the steps of Care standard. This survey is one of

those ones where you can do a point prevalence, you

can do two weeks and four two days and

30 or you could do a random selection of patients

and you don't have to do every patient you can you can you can

adjust it to how to your

facility.

So I'm going to put a pretty complicated slide

now. That's kind of shows everything that I've just

talked about. If you go back to this patient Journey here at

the bottom.

The sorts of things that we that are

covered in the quality statements are both the

sepsis treatment. So the recognition tool the lactate the

antimicrobials of blood cultures the arrangements for escalation of

care.

And those are all green stars because as pathway

already does that for you if you have our pathway in

place and implemented that will be

your system support of the whole sepsis Care

standard.

We've got all the education tools there for your clinical

education program which needs to be part of your local governments, and

we will be helping you with access to Diagnostics knowing

knowing what's available and

helping you to get there. So we will have helped with a

considerable number of the standard that

you need to meet and

The clinical expert is available 24/7 and at

least through the PMC if required.

so there's an awful lot that we have already done for

you and and

in terms of the audit of performance.

We've made some suggestions about how that can happen and our

data collection tool for paper science will

be useful, but I'm going to show you the ones in yellow are

things that are coming up and I think those are the things in about

a year we'll be able to do for you digitally without

you having to put in any effort at all.

So that's really important.

So for iemr site,

so this is really only those sites who are digital IMR.

We should have a care pathway, which is the equivalent

of our of a power and plan

or power chart but it is much more user-friendly.

I'll show you how and in the next in the next

slide and based on that care pathway.

We'll be able to pull out information from the

iemr which will create such dashboards

and we're already up and running with a qch and then

more than two years away. We'll we'll be able to we're

hoping to work on algorithms to create automatic alerts to

alert clinicians that there's a patient is

observations of become normal. We

need to go and think with the specifics. I think

that's a while away. So I wouldn't I wouldn't

be betting on that for the moment but the care pathway and sets

of dashboard we will be able to use fairly, you know

in not too distant future. So if you think about if

we had a power chart and wanted to write up give

a text theme for our patient. This is the whole list of

kids that you have to choose from the

With the care pathway is

that it steps you through an algorithm. So

and it will automatically pull in

information about patient's age. The patient's weight

where they are there in final Queensland or

not, and it will pull in information about

and MRSA status

for example, really anything like that

as well as asking you and once it's pulled all

that information in it will lead you directly to

the three antibiotics that you need to describe and so

it will make your life a whole lot

easier in terms of workflow and actually doing it.

And once that information is in the

IMR. We will have this dashboard that sits on

top which will give us things like process measures.

So you're bundle compliance within you've

taken blood cultures prior to antimicrobials your

fluid viruses your timely and to microbials

whether you're pathway was used in this patient

receptors and with a lactate was connected we

can give you all of that that Pro,

measurements

automatically and what we can also do

is a summary of your quality improvement

so you can see here. For example, this is

your change from the previous quarter. So this quarter how

much you've changed from the last quarter. So say you'd put

in a big effort into using the pathway. You can see

here that you had a a 2.4% increase

in pathway utilization and

and that you reduce your mean Hospital length of stay because of that. So

this would be a really useful tool to help

your quality improvement process and it

can be be drilled down

into a lot of different and detail with

a you just want to look at shocked patients with you. Just

want to look at patients from this year patients only from

this month whether you actually want

to drill down into individual patients now,

All of this information will not be available to everyone

in the state. They we still need to come to agreement as

to what information will be Statewide viewing and

what information will be local but this this is possible to

be coming to you and just to say that this is mock data.

So not not real data from PCH but we

have got it up and running there and lastly it

will give us antimicrobial stewardship information. These are antimicrobialism

therapy and give us some idea of

what we're doing with our and to

microbials and so this is indement and

we'll be coming so in a year's time.

your collection of data in digital sites

will be a lot easier and while it doesn't

help the science, we do know that there are

on the whole few children and

per month that present to to paper so maybe

slightly more manageable process to get some of

the data and in this in those paper sites

and what we what we are going to be investigating when

we get to that Statewide level is whether they would

be an opportunity for you to upload your data into something

like this for us to so that you couldn't visualize

it in some way. So we will

be working with with you on that and when we

get to that point

so that

brings us back to where we were now we're going to move on to

the last four care standards and

there really is not very much in existence

at the moment to to cover these and the

reason that that the commission is so has invested so

much in these last four pinch points. And in

terms of delivering quality Care is that

this is what we've been told by consumers that was

massively important to them and made their

love so much to more difficult because they were

gaps in this area. And so the

first the first of these is that this MDT coordination of

care and that the families are educated and have all

the information they need and so this means that

we need to each Health Care Facility needs to nominate a

clinician experience in sepsis to coordinate

the master disciplinary care plan now,

This role will look different depending on

your level of care and the size of your facilities. So

in a in a bigger Center, this might look

like a CNC or a nurse navigated type of

role and while in a smaller area may even

be said for example an extended role for

an Eden nurse. So this role will look different

depending on the size of the institution and

its level of care.

But what is important is is that the multidisciplinary care

is coordinated by somebody and that

that somebody also has a responsibility for

managing the audit of sepsis.

And and parent parents and

families need to be kept informed about their diagnosis and treatments and

the potential long-term effects. It was shocking to me when as

part of this process. I find out that some of the consumers

didn't even know they had a diagnosis of sepsis until

they got home and read the discharge letter.

We so often used different languages we talk about infection. We

have an ammonia you have an ammonia with a bit of blood pressure

trouble, you know, we don't use the language of

sense and if we don't use them then we just so much

harder for those patients age to know what happens to

them and be to access care afterwards.

And it's important that there is a documented Handover

transitions of care and that the families included

in those and what the standard is doing is it's itemizing what

needs to be part of that documented hand over

and then following that that there is coordinated and

individualized processes care.

Scholars them in their discharge that optimizes their

outcomes stops their readmissions into hospital

with and since this often because the

immune system is not a good biasis and

you're more prone to developing it again in a few months afterwards.

And emergency readmissions are common

in patients should be in distressed. So their Coordinated Care

to try and reduce that and there needs to

be proper support and information for families bereaved and

biceps.

and

so I think I've these are these

are the indicators that the commission is saying we should

use so that the there

is some advice about what the role the

the job description might look like for this coordinator role,

but I think that they're really does need

to be individualized to each and facility.

There is in terms of finding out if the parents

carers had enough information. There is

a question on the Australian Hospital patient experience question

set about this but it

is for adult patients only as far as I know the commission is trialing a

pediatric version of this in Perth. So

hopefully coming soon and we'll try

and be involved in that and looking at

transitions of care the proportion patient just sits

us on their discharge summary. That's a very quick order that

the can be done and a portion of sepsis

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.