Recognition of, and response to, acute deterioration in children is difficult due to number of factors.
Why does this standard need special consideration by health service organisations that provide care for children?
There are several physiological differences between children and adults. For example, a young child’s airway is shaped in a way that can make intubation more difficult, they have a relatively higher metabolic and oxygen consumption rate, their circulating blood volume is higher, and stroke volume is small and relatively fixed.67
As we age, our vital signs mature, and the way that our bodies cope with acute illness or injury changes. Recognition of, and response to, acute deterioration in children is difficult because:
- Children’s physiological responses to critical illnesses and treatments differ from those of adults
- During the progress of an acute illness, children may look relatively well before deteriorating very suddenly
- Even when children present with relatively minor illnesses, deterioration can occur rapidly.68
These factors have implications for clinicians who provide care for children.
Criterion: Clinical governance and quality improvement to support recognition and response systems
Organisation-wide systems are used to support and promote detection and recognition of acute deterioration, and the response to patients whose condition acutely deteriorates.
Integrating clinical governance
Although the National Consensus Statement: Essential elements for recognising and responding to deterioration in a person’s mental state71 applies broadly across all healthcare services and age categories, it was developed with input from health service organisations providing care for children and should be applied in services providing care for children. It describes the processes of care, therapeutic practices and organisational supports required to detect and respond to deterioration in the mental health of a child.
Health service organisations that provide care for children rely on safety and quality systems, and clinical governance frameworks that ensure safe and appropriate recognition of, and response to, acute deterioration. Ideally, these systems should take into account the differing parameters required to recognise and respond to deterioration in various age groups so as to monitor risks, trends and changes over time. Suggested approaches to do this include designing a system that:
- Is based on best-practice guidelines and current evidence
- Is consistent with state or territory directives
- Includes requirements for the use of age-appropriate early warning observation charts
- Is tailored to the specific needs of children, including nominating clinicians with expertise in the most appropriate field to respond to instances of clinical deterioration
- Outlines governance arrangements, including specific roles, responsibilities and accountabilities for clinical leaders, executive sponsors and governing committees
- Is regularly reviewed by the relevant committee or group using performance information and feedback.
The training of clinicians responsible for providing care for children may include training in:
- Clinical assessment of the specified demographic
- Measurement and recording of vital signs using approved age-appropriate observation charts and equipment
- Basic and advanced paediatric and neonatal life support, if appropriate, or the ability to call such members of the workforce if required.
Criterion: Detecting and recognising acute deterioration, and escalating care
Acute deterioration is detected and recognised, and action is taken to escalate care.
To ensure the appropriate escalation of care of children, health service organisations may consider specifying the following in their policies and procedures:
- Criteria for triggering a clinical review or medical emergency response
- Members of the workforce who are required to respond to calls for emergency response for specific age groups
- Mechanisms to contact suitably qualified and skilled resuscitation teams, such as paediatric or neonatal resuscitation teams
- Actions the workforce should take when responding to acute deterioration
- Processes for transfer (if required) to other healthcare facilities
- Arrangements with external organisations that form a part of the medical emergency response system
- Processes for escalating the care of children experiencing mental health issues
- Processes for monitoring and evaluating the efficacy of the recognition and response system specific to the age group.
Health service organisations should consider implementing a family-activated rapid response program, including for times when the family is concerned that ‘something is not right’ with their child. To ensure that family members can effectively use escalation systems, health service organisations may consider:
- Having a set of agreed triggers or reasons for families and children to escalate care
- Clearly identifying methods for activating the system
- Identifying clinicians responsible for responding to family and child concerns
- Describing the responding clinicians’ roles and responsibilities
- Implementing measures and processes for evaluating the effectiveness of the system.
To support family involvement in escalation of care, families should be empowered and educated to use an escalation system. This may include:
- Providing education and orientation on admission
- Placing printed brochures or posters in prominent locations
- Broadcasting information about the system on television and audio services throughout the health service organisation
- Auditing the effectiveness of communication strategies to empower families to trigger the escalation process.
Criterion: Responding to acute deterioration
Appropriate and timely care is provided to patients whose condition is acutely deteriorating.
Responding to deterioration
Equipment used during medical emergencies that involve children should be available in all areas where they receive care. The equipment should be:
- Available in a range of sizes appropriate to the demographic being treated
- Regularly checked and maintained as fit for purpose.
In addition, paediatric-specific dosing guidance should be available in the case of a child experiencing acute deterioration.