The simulated case: 
Adam is in his 70s and has presented with shortness of breath, fever and productive cough. He has been brought to the Plym (?COVID) area of the emergency department. 

What considerations are there in where and how we care for patients like this? What is helpful to prepare before the patient's arrival?​
​

What did we think? 
In debrief we discussed:

Differences in the environment of Plym theatres to be aware of e.g. how to attach oxygen and how to access help. In particular we noted that the tannoy is different to the one for the rest of the department. To seek help one needs to use the white tannoy on the wall to tannoy to the “green desk” of Plym where they can relay the tannoy to the rest of the department if required. Reflecting on the sim perhaps walkie-talkies to facilitate two-way communications between those in resus and those in the green areas would be helpful, especially if the potential runner might be moving around and completing other tasks. It was noted that often the staffing level does not allow for an additional person to be a runner, so perhaps a walkie-talkie worn by a designated person would aid in making sure someone is available when needed. 

We discussed the difficulty of requesting a doctor to Plym if there is not someone already present. It is generally done through tannoying for “a doctor”. Perhaps if there was a named person each day that can be tannoyed they would be more likely to respond promptly. 

In terms of collecting samples like the throat swab or blood bottles, we talked about double bag techniques to pass the samples to the green runner. In this case resus was an amber area as was the nearby corridor so a VBG could have been taken directly to the machine still within amber, however blood tests would have needed ICM stickers applied within the area before they were bagged once, and dropped into a second bag held by someone in the green area.

We reviewed the geography of Plym including where to don and doff. 

The guidelines:
The choice of antibiotic in potential community acquired pneumonia can be found on our “RxGuidelines” mobile app. 

See last week’s blog post for the criteria that determine the need for a patient to go to Plym rather than the main ED. 

To do:
Consider going to Plym and conducting a mental run-through of how you would act with a patient in Plym area if you needed to don PPE/collect samples/call specialties/doff without contaminating clean areas  [  ]

Have a look at the tannoys on the wall of Plym resus and make sure you know how you would access help from there if you needed it  [  ]

If you took part in the sim, you can use this blog as a starter to reflect on your own experience of it   [  ]


James Keitley - ED Sim Fellow

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For clinical decisions please refer directly to the guidance. This blog may not be updated.

​What did we think? 
In debrief we discussed:

• Technical
  • The guideline and where to find it - see below. 
  • Neurological observations important in case of developing cerebral oedema.
  • VBGs: for efficiency it’s a good idea to take a capillary blood gas at the same time as the blood sugar level, in case there are delays with obtaining venous access.
• Non-technical
  • Maintaining communication lines by keeping the team leader at the end of the bed where possible. 
  • Remembering to start handovers with the “S” in SBAR. 

We discussed in debrief the latest shift in DKA management, from a previous intention to restrict fluid input due to concern of causing cerebral oedema, to a stance of greater fluid administration. The weight of evidence indicates that cerebral oedema develops out of the disease process itself rather than related to fluid-giving. The local guideline (see below) gives clear instruction of the fluid required in this case. 

We talked through the balance required in keeping the parent informed about what is happening whilst ensuring no delay with immediate care needs. 

We briefly touched upon the PACE model of assertiveness. This blog describes the challenges of speaking up and how PACE can be used to gradually but assertively escalate your concern to a colleague - you can scroll down to where the example of this is given. Here is a case study of it being used by a “junior” colleague to make suggestions to a “senior” during the resuscitation of a child. 

Feedback from the sim participants noted the difficulty for adult-trained nurses to be familiar with the paediatric area and equipment - we can aim to pair a paediatric and adult nurse during scenarios. It was suggested we should have more speech directly from the mannequin - we can aim to do this if a facilitator remains outside of the room in future. 

The guidelines:
On the ED browser page you can find two paeds DKA links - the documentation and an appendix for further information. The documentation link is a complete booklet that allows you to write in your results as it guides you through the process and the calculations. You can take a look at the same document on the British Society for Endocrinology and Diabetes page here. It is a good idea to print this off early in the process so it can guide you. I am going to look into whether we can have a few full-colour versions available.

This guideline was brought out in March 2020 and represents some significant changes on previous versions that are worth being aware of. As mentioned above, the fluid strategy is now more permissive rather than restrictive, with all patients receiving a fluid bolus of 10mL/kg 0.9% saline, with an extra 10mL/kg (i.e. 20mL/kg total) for those in shock (Tasker 2020). Inadequate fluid resuscitation is noted as one of the key contributors to death in DKA resulting from inadequate cerebral perfusion (BDPED).  

Have a look at page 5 (and a little at the top of page 7) of the appendix document, also to be found here. This gives a (virtually) single-page overview of what we need to achieve for these patients in the ED. However when you are looking after a patient with DKA you should use the full guideline above.

Some more detail on this change in guidance, by Dr Tom Siese: 
The latest thinking is that rather than the cerebral injury in DKA being simply related to osmotic shifts due to over-rapid fluid treatment, there is increasing evidence which points towards a state of metabolic acidosis and dehydration which then paves the way for a “hyperinflammatory state”.  The results from the recent randomised controlled PECARN DKA Fluid Trial (Kuppermann et al 2018) supports the return of permissive fluid boluses in paediatric DKA.
 
At time of writing, the latest editorial in the Archives of Disease in Childhood (Tasker 2020) notes caution in treating cases with altered consciousness, as only 2% of study participants in the above trial had a GCS<14.  Therefore the bottom line is don’t be afraid to rehydrate children with DKA, but all cases will still need discussing with a senior member of the paediatric team from an early stage.
​

To do:

If it’s been a while since you worked in the paeds area, ask someone who is regularly there to show you where key items are, and if you have supernumerary time you could spend some of it in paediatrics   [  ]

Have a look at the main guideline document either on our ED browser or via the link above, plus page 5-7 of the appendix document  [  ]

If you took part in the sim, you can use this blog as a starter to reflect on your own experience of it   [  ]


James Keitley - ED sim fellow
On behalf of the faculty behind this sim Hana Bashir, Andy Robinson, Thomas Siese, Rachel Garlick

References:
-  British Society for Paediatric Endocrinology and Diabetes [BSPED]. 2020. Integrated care pathway for the management of children and young people with diabetic ketoacidosis. Available from: https://www.bsped.org.uk/media/1742/dka-icp-2020-v1_1.pdf. 
-  British Society for Paediatric Endocrinology and Diabetes. 2020. BSPED Interim Guideline for the Management of Children and Young People under the age of 18 years with Diabetic Ketoacidosis. Available from: https://www.sort.nhs.uk/Media/Guidelines/BSPED-DKA-guideline-2020-update.pdf. 
-  Kuppermann et al. 2018. Clinical Trial of fluid infusion rates for paediatric DKA. NEJM; 378:2275-2287. www.nejm.org/doi/full/10.1056/nejmoa1716816  
-  Nickson C. 2019. Speaking Up. LifeInTheFastLane blog. Available from: https://litfl.com/speaking-up/. 
-  Tasker R C. 2020. Fluid Management during DKA in children: guidelines, consensus, recommendations and clinical judgement. ADC; 105: 917-918. pubmed.ncbi.nlm.nih.gov/32847796/
-  Yianni L, Rodd IG236(P) Pace – ‘Probe, Alert, Challenge, Escalate’ Model of Graded Assertiveness Used in Paediatric ResuscitationArchives of Disease in Childhood 2017;102:A93.

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For clinical decisions please refer directly to the guidance. This blog will not be updated.

What happened?
The nurse assessed James and noted he’d been out drinking with older teenagers and had an injury to his head. They noted normal observations, GCS14 (E4V4M6), and no serious concerns at this point. 

The doctor’s assessment was interrupted by the arrival of James’ mother. She was unhappy and keen to remove James from the ED. The team attempted to engage with her on the importance of staying with James while he is assessed and treated. 

It was noted that James met the criteria for a CT of his head. 


What did we think? 
In debrief we discussed:

• Safeguarding: use the Salus referral but also if very concerned can phone too.
• Parent should stay, encourage but if they do insist on leaving include on Salus referral.
• Discussed the NICE CT pathway, but sometimes deviation needed -> speak to a senior.
• Consent in children: see “guideline” below. 

Feedback from the participants noted that greater staffing might make the care of patients like this easier. It was noted that this sim being in the Stewart room rather than in situ meant a reduction in realism. For the next sim we will ensure the room is better kitted out with the equipment necessary.

​
The guidelines:
Consent in children:

The mental capacity act doesn’t apply to children under 16. Children under 16 can give affirmative consent if they are deemed “Gillick competent” - see link.

If the parents disagree with treatment like they did in this sim:

For our first month of SimFridays we’re looking at paediatrics, and if you couldn’t join us for the first session (4th September) this blog covers some of the learning points. We will be aiming to run simulations every Friday at 11am - go to derriforded.com/sim particularly if you have suggestions of what we should cover!​

​What did we think? 
We talked through the scenario in debrief. Key points were: 

• Early oxygen and nebs
• If you’re an adult-trained nurse, to know where to find key equipment and drugs in the paediatrics area
• Know where the guideline is
• Early escalation
• Kids can improve rapidly, but keep treatment going after referral

We noted that in reality in our ED the tannoy system is used to request urgent reviews. This has the potential to be impersonal “can a doctor come to…” and there is some risk of bystander effect with it. Do we assume someone else will go? 

Very early on the question of whether to move to resus was raised. To arrange this, one would need to speak to the team in Majors - when is a good time to leave the patient if this is what is needed?

We discussed the usefulness of having a capillary blood gas if possible when discussing with the paediatric team. 

We discussed that the paediatric team may be far away, both in time and in space! So it’s important to highlight sick people to seniors within ED too, and keep treatment/monitoring going to make sure they’re still improving.

In the feedback for the session it was raised whether doctors should rotate through allocated paediatric ED days. It was also asked about how to access asthma action plans - see the “to do” section below for this. 


The guideline:
I can’t post the asthma guideline here but you can find it on the ED browser under children’s guidelines. It’s split into pdfs for each age range, and it’s a really straightforward single-page sheet. You can see how to grade the child’s observations into the severity of asthma attack, and there are clear treatment options. 

There is also an advice sheet for parents under the patient information leaflets section.

Here is the BTS/SIGN equivalent in how to grade moderate vs severe vs life-threatening attacks (BTS/SIGN 2019) - the full guideline is under the “to do” section below.
​

Key steps in child >5 years old: 

• Salbutamol 5mg via nebuliser, plus ipratropium 250 microgram if life-threatening or poor response
• Oxygen
• Ametop ready for access
• Capillary gas
• Oral prednisolone 30-40mg or IV hydrocortisone
• If dischargeable, a written asthma action plan: see “to do” below.

To do:
If it’s been a while since you worked in the paeds area, ask someone who is regularly there to show you where key items are   [  ]

The SIGN asthma guideline here  [  ]

Check out the asthma plans that can be downloaded from Asthma UK here   [  ]

If you took part in the sim, you can use this blog as a starter to reflect on your own experience of it   [  ]

See you at the next one!
James Keitley - ED sim fellow

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References: 
British Thoracic Society and Scottish Intercollegiate Guidelines Network (2019). British guideline on the management of asthma: quick reference guide. Available from: https://www.brit-thoracic.org.uk/document-library/guidelines/asthma/btssign-asthma-guideline-quick-reference-guide-2016. Viewed 09/09/20. 

Photos either taken by the author or copyright- and attribution-free in the public domain.

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For clinical decisions please refer directly to appropriate guidance. This blog will not be updated.