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To deliver safe care for children we need to be able to correctly identify clinical deterioration and appropriately respond to it. The evidence suggests we do not do this consistently and this should be a prime focus for improvement efforts. Yet, the systems in which we work are complex and change is often daunting. In this article we will look at how a quality improvement approach, using well-established methodologies, can be used to try to address a problem such as identifying the deteriorating child. It will look at large- and small-scale examples and will explore some of the approaches that can make a challenging task into a measurable improvement in care for children and young people (boxes 1 and 2).
QI in practice: identifying the deteriorating child
From the driver diagram in figure 2, we can see that there are multiple factors involved in reducing inpatient cardiorespiratory arrest. One important area to look at is the use of early warning scores to identify deterioration.
One of the UK CEMACH recommendations for hospital paediatric care was a ‘standardised and rational monitoring system with embedded early identification systems for children developing critical illness’.7 The exact nature of the chart used should depend on local context but it is clear that a means of documenting and flagging up signs of clinical deterioration is important.
In order to introduce a PEWS (Paediatric Early Warning Score) chart, a QI approach, using plan-so-study-act (PDSA) cycles, can be helpful:
Plan: Meet with colleagues and brainstorm ideas for implementing PEWS on your ward. Choose an idea that the team can support, for example, trialling a new observations chart.
Do: Trial chart for 10 patients.
Study: Look at chart completion rates and get feedback from nurses about ease of use, look at clinical outcomes, for …
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