Identifying areas for improvement in paediatric trauma care in NSW Australia using a clinical, system and human factors peer-review tool

Abstract

Background: There is known variability in the quality of care delivered to injured children. Identifying where care improvement can be made is critical. This study aimed to review paediatric trauma cases across the most populous Australian State to identify factors contributing to clinical incidents. Methods: Medical records from three New South Wales Paediatric Trauma Centres were reviewed for children <16 years requiring intensive care; with an injury severity score of 9, or who died following injury between July 2015 and September 2016. Records were peer-reviewed by nurse surveyors who identified cases that might not meet the expected standard of care or where the child died following the injury. A multidisciplinary panel conducted the peer-review using a major trauma peer-review tool. Records were reviewed independently, then discussed to establish consensus. Results: A total 535 records were reviewed and 41 cases were peer-reviewed. The median (IQR) age was 7 (2-12) years, the median ISS was 25 (IQR 16-30). The peer-review identified a combination of clinical (85%), systems (51%) and communication (12%) problems that contributed to difficulties in care delivery. In 85% of records, staff actions were identified to contribute to events; with medical task failure the most frequently identified cause (89%). Conclusion:The peer-review of paediatric trauma cases assisted in the identification of contributing factors to clinical incidents in trauma care resulting in 26 recommendations for change. The prioritisation and implementation of these recommendations, alongside a uniform State-wide trauma case review process with consistent criteria (definitions), performance indicators, monitoring and reporting would facilitate improvement in health service delivery to children sustaining severe injury.

Prehospital care and transport costs of severely injured children in NSW Australia

“…NSW Ambulance intensive care paramedics are trained for non-drug assisted intubation ('cold' intubation in cardiac arrest), which further reduces the number of children for whom paramedics are likely to perform an intubation. This low exposure potentially contributed to the number of clinical incidents relating to airway management in the prehospital setting identified during peer-review of these cases [25] . This finding is similar to other research that report low incidence of paediatric intubation for EMS providers [6,24,26,27] , with higher rates of complications when performed by non-physician led providers [9,28,29] .…”

“…Previous work in the aeromedical setting in Australia, where there is strict governance processes with structured education and compulsory certification of skill currency, demonstrated overall high first pass success rates (91%) among providers for paediatric intubation, these success rates reflect that of primarily physicians [10] . Following review of paediatric trauma cases, an expert panel identified the need for similar targeted education and training on infrequently performed critical tasks in paediatric trauma care for paramedics [25] . The panel also recommended the development and implementation of guidelines to improve pre-hospital airway management practices, following review identifying a large proportion of airway management problems, were in prehospital setting [25] , with the focus of training and airway management policy to be around perfecting basic airway manoeuvres such as airway opening/adjuncts, bag valve mask ventilation and supraglottic airway insertion where indicated .…”

“…Following review of paediatric trauma cases, an expert panel identified the need for similar targeted education and training on infrequently performed critical tasks in paediatric trauma care for paramedics [25] . The panel also recommended the development and implementation of guidelines to improve pre-hospital airway management practices, following review identifying a large proportion of airway management problems, were in prehospital setting [25] , with the focus of training and airway management policy to be around perfecting basic airway manoeuvres such as airway opening/adjuncts, bag valve mask ventilation and supraglottic airway insertion where indicated . Skill retention for bag valve mask is maintained at a higher rate than endotracheal intubation over time following training [30] , and more favourable outcomes have been reported for paediatric patients provided with basic airway interventions when compared with those who received advanced airway interventions pre-hospital [31,32] .…”

Cause, treatment costs and 12-month functional outcomes of children with major injury in NSW, Australia

“…This study did not demonstrate a survival benefit for children who received definitive care at non-PTCs versus PTCs. The peerreview of deaths during the study period did not find any preventable deaths [28] . These findings are in contrast to earlier work by Mitchell et al [ 3 , 4 ] who demonstrated a survival benefit for children with an ISS > 15 if treated at a NSW PTC.…”

Pathways and factors that influence time to definitive trauma care for injured children in New South Wales, Australia

“…There was a significant difference in mortality at the PTC between children arriving via IHT and those transported directly following injury at 1.5% and 5.8% respectively, (Chi-sq=5.76, df=1, p=0.016). The children deceased at PTC post transfer were transported by NETS, but a previous peer-review demonstrated these were not preventable deaths 21 . There was no significant difference in the proportion of children with an ISS > 12 (p=0.535), those with polytrauma (p=0.066), significant head injury (AIS >2) (p=0.243), or ICU admission (p=0.092).…”