Shared learning database
Type and Title of Submission
Implementation of a clinical decision-making pathway for the Feverish illness in children: assessment and initial management in children younger than 5 years old (NICE guidance)Description:
Please note that this example was submitted to demonstrate implementation of CG47. This guideline was updated and replaced in May 2013 by CG160. The practice in this example remains consistent with the updated guidance.Category:
ClinicalDoes the submission relate to the general implementation of all NICE guidance?
NoDoes the submission relate to the implementation of a specific piece of NICE guidance?
YesFull title of NICE guidance:
CG160 - Feverish illness in childrenCategory(s) that most closely reflects the nature of the submission:
Is the submission industry-sponsored in any way?
Description of submission
The aim of our project was to implement the NICE guidance in a large UK Paediatric Emergency Department using a clinical decision making pathway. Local dissemination of new clinical information from published national guidance can be challenging. Individual clinicians take time to read and act upon lengthy guidance. Memorising such guidance and putting it into practice is can be difficult for clinicians. The variety of shift patterns worked by clinicians in a large Paediatric Emergency Medicine Department such as ours causes further difficulties implementing new policies, and we aimed to improve implementation of this specific guidance by use of our pathway.Objectives
1. To improve consistency in assessment and management of children with fever to the standard set by NICE, comparing the management of these patients before and after introduction of the clinical decision-making pathway 2. To produce a tool to facilitate audit of implementation of the NICE guideline 3. To use the pathway to support education of junior doctors in training in making a full clinical assessment of potentially seriously ill children with a history of feverContext
Prior to publication of the NICE guidance a group of medical students from the University of Liverpool were attached to the Paediatric Emergency Department and undertook a review of the management of children presenting with fever. The electronic records of 100 such randomly selected patients were interrogated to establish the investigations that had taken place. This preliminary study revealed inconsistencies in investigation and management of these children. The publication of NICE clinical guideline 047 was the trigger to address these inconsistencies and to facilitate the introduction of the NICE guidance by developing a clinical decision making pathway tool. This pathway is based upon the recommended NICE traffic light method of categorising the potential risk of serious illness in a child presenting with fever, and directing the investigation and management accordingly. The pathway was developed by the Trust's Clinical Pathways Coordinator in conjunction with senior medical and nursing staff from the Emergency Department. Prior to implementation formal consultation took place with other senior staff members and paediatricians from elsewhere within the Trust. Implementation was led by an NTN Grid Paediatric Emergency Medicine Specialist Registrar with regular teaching sessions for all staff groups, poster advertising of the pathway and prominent placement of the pathway within clinical areas.Methods
1. To improve consistency in assessment and management of children with fever to the standard set by NICE, comparing the management of these patients before and after introduction of the pathway (see supporting material table of results) 2. To produce a tool to facilitate audit of implementation of the NICE guideline The pathway that was developed provided a convenient and simple way to audit the implementation of the NICE guidance. The department now has a set of case notes where the pathway has been used, for future audit purposes. The department continues to collect the case notes of children who have been placed onto the clinical decision making pathway and, it is planned that the audit cycle will be repeated after a period of one year following implementation. 3. To use the pathway to support education of junior doctors in training in making a full clinical assessment of potentially seriously ill children The pathway and an associated presentation were used to educate junior doctors and nursing staff within the department. Recall of information provided to junior doctors was tested during a fun quiz which they completed after the relevant teaching sessions. The results of the audit show that assessment of potentially seriously ill children improved following introduction of the clinical decision making pathway.Results and evaluation
Progress of implementation was monitored continuously by collecting and reviewing the case notes of children who had been placed on the clinical decision making pathway. An audit took place prior to implementing the pathway, and a re-audit was performed after implementation. The audit cycle was completed by correcting an error in the pathway which would have inappropriately placed older children into the high risk category. In addition to this, further educational sessions were delivered to staff within the department to remind them about the traffic light system criteria. We also produced some coloured summary tables for display around the department, reminding staff of the appropriate investigations and management of children in each category. These are attached to this submission. There was a general lack of documentation of discussions with senior paediatricians for the Intermediate Risk patients, even though our pathway had specific areas for these discussions to be documented. It is clear from review of implementation of the pathway that it did trigger a discussion with a senior doctor, however improvements still need to be made to ensure proper documentation of the results of that discussion. Our department has a senior doctor present performing clinical work for 16 hours each day and the presence of a senior staff member was helpful in ensuring implementation of the NICE guidance. A discharge advice sheet was produced and adapted from the NICE template discharge advice sheet to give to all patients and their carers who were discharged from the department following attendance with fever. It is planned that a further audit will take place approximately twelve months after implementation of the pathway. The pathway and the results of the audit have been shared with primary care commissioners in an attempt to begin the process of standardisation of assessment of management of children with fever, between primary and secondary unplanned care.Key learning points
1. Implementation of a clinical decision-making pathway improved the assessment of children with fever and helped clinicians identify those patients who were at risk of serious illness. We anticipate this will have had a significant impact for patients given the diverse aetiology of fever in children 2. Whilst the pathway was very good at improving recognition of ill children, it is difficult for a pathway to ensure that the next steps (investigations and management) are consistently applied given that subjective clinician preferences can have an impact on the care of children 3. Review of the NICE guideline revealed some inconsistencies and discrepancies that we had to address and agree an interpretation of. Clinicians have difficulty differentiating between pale and pallor. Such differentiation is important within the guidance as it is one of the determinants of whether a patient is low or intermediate risk. 4. There was difficulty in using the NICE guideline criteria of a Capillary Refill Time of >3 seconds to place a patient into the Intermediate Risk group. This was not consistent with other guidance familiar to clinical staff which referred to a capillary refill time of less than 2 seconds as normal. The department therefore decided to use the familiar standard of 2 seconds for this section of the guidance 5. There were difficulties communicating introduction of the pathway to all clinical staff, including those who visited the Emergency Department but who did not routinely work here. This was overcome by presenting the pathway in a number of fora, and using coloured posters around the department to refresh staff memories. The presence of clinically-based senior staff within our Emergency Department for 16 hours out of every 24 helped facilitate implementation of this guidance 6. The Trust employs a dedicated clinical pathways coordinator and this key member of staff makes implementing national guidance significantly easier
View the supporting material
|Job Title:||NICE Guidance Co-ordinator|
|Organisation:||Alder Hey Children's NHS Foundation Trust|
|Address:||Research & Development Dept, 1st Floor Mulberry House, Eaton Road|
|Phone:||0151 228 4811|
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This page was last updated: 26 September 2008