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BackgroundChronic obstructive pulmonary disease (COPD) is the the most common disease-specific cause of adult emergency hospital admissions in Ireland. Preliminary groundwork indicated that treatment of acute exacerbations of COPD (AECOPD) in Ireland is not standardised between public hospitals. Applying Institute for Healthcare Improvement Breakthrough Series and Model for Improvement methodologies, Royal College of Physicians of Ireland designed and conducted a novel flexible and adaptive quality improvement (QI) collaborative which, using embedded evaluation, aimed to deliver QI teaching to enable teams to implement bespoke, locally applicable changes to improve and standardise acute COPD care at presentation, admission and discharge stages within their hospitals.MethodsEighteen teams from 19 hospitals across Ireland participated over 13 months. QI teaching was facilitated through inperson learning sessions, site visits, programme manager and coaching support. Teams submitted monthly anonymised patient data (n=10) for 22 measures of AECOPD care for ongoing QI evaluation. A mixed-methods survey was administered at the final learning session to retrospectively evaluate participants’ experiences of QI learning and patient care changes.ResultsParticipants reported that they learnt QI and improved patient care during the collaborative. Barriers included increased workload and lack of stakeholder buy-in. Statistically significant improvements (mean±SD) were seen for ‘documented dyspnoea, eosinopenia, consolidation, acidaemia and atrial Fibrillation (DECAF) assessment’ (7.3 (±14.4)% month(M)1 (n=15 sites); 49.6 (±37.7)% M13 (n=16 sites); p<0.001, 95% CI (14.3 to 66.7)), ‘Documented diagnosis - spirometry’ (42.5 (± 30.0)% M1 (n=16 sites); 69.1 (±29.9)% M13 (n=16 sites); p=0.0176, 95% CI 5.0 to 48.2) and ‘inhaler technique review completed’ (45.6 (± 34.1)% M1 (n=16 sites); 76.3 (±33.7)% M13 (n=16 sites); p=0.0131, 95% CI 10.0 to 65.0). ‘First respiratory review’ demonstrated improved standardisation.ConclusionThis flexible QI collaborative provided adaptive collaborative learning that facilitated participating teams to improve AECOPD patient care based on the unique context of their own hospitals. Findings indicate that involvement in the QI collaborative facilitated teams in achieving their improvements.

Aim This scoping review will gather existing evidence on specific interventions at presentation and discharge which aim to standardize care and/or reduce unnecessary admissions and/or readmissions to hospital for patients presenting with acute exacerbation of chronic obstructive pulmonary (airways) disease. Design Scoping review of relevant literature from January 2000–March 2019. Methods Database searches for primary evidence in peer‐reviewed journals will be conducted electronically using Web of Science, EMBASE (Elsevier) and PUBMED. Eligibility criteria will include hospital‐based interventions for presentations of acute exacerbation of chronic obstructive pulmonary disease with outcomes specific to standardizing care or reducing unnecessary admissions or readmissions. , full‐text screening and data extraction will be completed independently by a panel of expert reviewers. Results We aim to identify current interventions and improvement approaches in acute exacerbation of chronic obstructive pulmonary (airways) disease care that have an impact on admission and discharge processes or readmissions. Recommendations as a result of this review will aid the design and development of future improvement intervention.

ObjectiveTo systematically review the available evidence on paediatric early warning systems (PEWS) for use in acute paediatric healthcare settings for the detection of, and timely response to, clinical deterioration in children.MethodThe electronic databases PubMed, MEDLINE, CINAHL, EMBASE and Cochrane were searched systematically from inception up to August 2016. Eligible studies had to refer to PEWS, inclusive of rapid response systems and teams. Outcomes had to be specific to the identification of and/or response to clinical deterioration in children (including neonates) in paediatric hospital settings (including emergency departments). 2 review authors independently completed the screening and selection process, the quality appraisal of the retrieved evidence and data extraction; with a third reviewer resolving any discrepancies, as required. Results were narratively synthesised.ResultsFrom a total screening of 2742 papers, 90 papers, of varied designs, were identified as eligible for inclusion in the review. Findings revealed that PEWS are extensively used internationally in paediatric inpatient hospital settings. However, robust empirical evidence on which PEWS is most effective was limited. The studies examined did however highlight some evidence of positive directional trends in improving clinical and process-based outcomes for clinically deteriorating children. Favourable outcomes were also identified for enhanced multidisciplinary team work, communication and confidence in recognising, reporting and making decisions about child clinical deterioration.ConclusionsDespite many studies reporting on the complexity and multifaceted nature of PEWS, no evidence was sourced which examined PEWS as a complex healthcare intervention. Future research needs to investigate PEWS as a complex multifaceted sociotechnical system that is embedded in a wider safety culture influenced by many organisational and human factors. PEWS should be embraced as a part of a larger multifaceted safety framework that will develop and grow over time with strong governance and leadership, targeted training, ongoing support and continuous improvement.

IntroductionChronic obstructive pulmonary disease (COPD) is a chronic respiratory disease that may be punctuated by episodes of worsening symptoms, called exacerbations. Acute exacerbations of COPD (AECOPD) are detrimental to clinical outcomes, reduce patient quality of life and often result in hospitalisation and cost for the health system. Improved diagnosis and management of COPD may reduce the incidence of hospitalisation and death among this population. This scoping review aims to identify improvement interventions designed to standardise the hospital care of patients with AECOPD at presentation, admission and discharge, and/or aim to reduce unnecessary admissions/readmissions.MethodsThe review followed a published protocol based on methodology set out by Arksey and O’Malley and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Electronic database searches for peer-reviewed primary evidence were conducted in Web of Science, EMBASE (Elsevier) and PubMed. Abstract, full-text screening and data extraction were completed independently by a panel of expert reviewers. Data on type of intervention, implementation supports and clinical outcomes were extracted. Findings were grouped by theme and are presented descriptively.Results21 articles met the inclusion criteria. Eight implemented a clinical intervention bundle at admission and/or discharge; six used a multidisciplinary care pathway; five used coordinated case management and two ran a health coaching intervention with patients.ConclusionThe findings indicate that when executed reliably, improvement initiatives are associated with positive outcomes, such as reduction in length of stay, readmissions or use of health resources. Most of the studies reported an improvement in staff compliance with the initiatives and in the patient’s understanding of their disease. Implementation supports varied and included quality improvement methodology, multidisciplinary team engagement, staff education and development of written or in-person delivery of patient information. Consideration of the implementation strategy and methods of support will be necessary to enhance the likelihood of success in any future intervention.

BackgroundThe Irish Paediatric Early Warning System (I-PEWS) and associated National Clinical Guideline No.12 was developed in response to a ministerial mandate as a funded workstream of the National Clinical Programme for Paediatrics. I-PEWS is a multifaceted approach to improving patient safety and clinical outcomes, based upon the implementation of several complementary interventions, including 5 age-specific paediatric observation charts incorporating a PEWS scoring tool and escalation guide, promotion of effective communication using the national standard (ISBAR communication tool for patient deterioration), timely nursing and medical input, and clear documentation of management plans.ObjectivesI-PEWS was developed to improve prevention, recognition and response to children at risk of inpatient clinical deterioration in Ireland. For a defined period, national implementation was overseen by a Working Group of stakeholders and supported by a National Coordinator.Implementation strategyOver a three-year period, we piloted and refined the PEWS charts and associated education resources and facilitated national implementation of the Irish PEWS in 29 public hospitals. We developed a centrally-delivered, standardised training programme to establish hospital-level PEWS Trainers. Locally nominated PEWS Leads and Trainers were supported by regular communications, site visits and remote support culminating in a paediatric patient safety celebration day to mark the conclusion of the Working Group and Coordinator involvement. National Key Performance Indicators (KPI) were developed to demonstrate adherence to National Clinical Guideline recommendations by the local governance bodies to include development of locally applicable continuous education standards and regular audit to promote frontline ownership of the change.ResultsImplementation of PEWS was challenging due to the number of sites involved and the different specialties, resources and levels of engagement within each. The four quarterly KPI reports from 2018 demonstrate inconsistency in implementation and embedding of PEWS.21 of 29 (72%) hospitals overall report full compliance with the standards set out in the KPI suite. Issues include (ranges indicate variance in reporting across quarters): no local governance group (33%) no provision for continuous education programme for nurses (1–4 hospitals) or doctors (3–5 hospitals) all admitted children are not monitored using PEWS (1–2 hospitals) audit practices are not as recommended (1–3 hospitals) outcome data is not being collected (4–6 hospitals)LearningImplementing a national QI initiative is complex. The flexibility for locally relevant adaptations is essential for applicability and buy-in. The KPI data demonstrates a deficit in implementation standards and should be addressed by the Irish health service.

Situation Awareness for Everyone (SAFE) is a collaborative programme developed by the Royal College of Paediatrics and Child Health UK to support clinical teams to improve communication, build a safety based culture and deliver better outcomes for children and young people.The programme includes Quality Improvement (QI) theory, situation awareness methodology and planning of safety huddles on the wards. It has been implemented in over 50 teams across the UK and the Quality Improvement Department of the Royal College of Physicians of Ireland are delighted to bring this initiative to Ireland.A National Paediatric Early Warning System (PEWS) was endorsed by the Irish Minister for Health in December 2015. The supporting National Clinical Guideline recommends that hospitals ‘support additional safety practices that enhance the PEWS and lead to greater situation awareness among clinicians and multidisciplinary teams, such as incorporating briefings, safety pause and huddles into practice’. Programmes such as SAFE that use quality improvement methods and patient safety science were specified as appropriate to assist hospitals to collaborate in addressing these challenges.11 consultant-led teams from across Ireland are participating in this SAFE Collaborative. Teams consist mostly of frontline paediatric clinical care providers (Consultants in Paediatric Medicine, Paediatric Nurses, Pharmacists, Dieticians, Hospital Senior Management and Non-Consultant Hospital Doctors). At a series of face-to-face sessions, teams receive mentoring in QI methodology by RCPI QI Faculty, through the IHI Breakthrough Series Collaborative Model, to develop local SAFE improvement projects impacting onReducing avoidable error and harm to acutely unwell childrenImproving communication between all individuals involved in a child’s careImproving working culture for healthcare staff providing care to childrenIncreasing involvement of parents, children and young people in their care.The teaching faculty includes active patient representation through parent involvement. Participating teams are encouraged to engage with children, parents and carers to guide their improvement efforts.Teams collect a concise monthly dataset to facilitate aggregate and comparative measures on paediatric clinical outcomes. Teams are encouraged to use this data, and to collect other necessary data to inform the outcome, process and balancing measures pertinent to the areas upon which they are focusing their improvement efforts.The National SAFE Improvement Collaborative is in its early stages. However, at this point, experience with similar national collaborative projects indicates that QI methodology will be used effectively to generate improvements to positively impact paediatric patient safety outcomes, through site specific changes.

Outlining the experience of implementing a paediatric early warning system (PEWS) for Upendo Paediatric Oncology Ward at Muhimbili National Hospital (MNH), Dar Es Salaam, Tanzania.BackgroundChildren on the paediatric oncology ward in Muhimbili National Hospital, Dar es Salaam, were experiencing poor clinical outcomes after common emergencies with 100% mortality rates for any child requiring CPR. From 2012 to 2015, a team of Irish paediatric specialists, supported by a Tanzanian NGO called Tumaini la Maisha, provided an annual standard paediatric resuscitation training programme.Despite these efforts, staff knowledge, skill retention and clinical outcomes did not improve. An observational analysis in 2016 revealed poor vital sign assessment practices, lack of documentation and examples of failure to detect, escalate and respond to child clinical deterioration.InterventionWe designed five bespoke age-specific paediatric observation charts with inbuilt vital sign triggers, escalation pathway, communication guide, ‘event record’ and a locally appropriate resuscitation course to suit the specific needs of the ward.Implementation StrategyOver three annual visits from 2016–2018, PEWS was introduced to Upendo ward with the tailored education programme for medical and nursing staff. Resources including pdf charts, posters, training slide-set and a PEWS implementation policy were provided to facilitate local ownership of the PEWS. Local champions were identified to act as trainers and peer support during the time between visiting faculty visits. In 2018, Paediatric Pocket Guides were introduced as additional aide-mémoires for oncology guidelines and PEWS reference ranges.ChallengesChallenges to implementation of the new charts and escalation behaviours included lack of availability of basic monitoring equipment, low staffing ratios, weekly turnover of medical interns, and insufficient acute care facilities. Ward nursing culture of task-based rather than patient-based care, non-structured handover practices and lack of integrated communication between nurses and the medical team presented the greatest challenge to embedding PEWS.Successes and LearningBy 2018 two new specifically designed courses were developed for MNH. The Paediatric Assessment of Illness, Resuscitation and Stabilisation (PAIRS) and 8-week paediatric oncology nursing course were conducted. PEWS training was central to the ethos of both courses and removed most of the cultural barriers identified above. PEWS and patient-centred care are now standard on the ward with all staff utilising the Paediatric Pocket Guides to supplement their knowledge of PEWS. Early recognition of the acutely unwell and deteriorating child is now a well understood goal of all staff. This initiative shows the importance of audit and local engagement to bring about successful clinical change.

We have developed and tested a dynamic, context-specific paediatric resuscitation course with tiered level of complexity with targeting different levels of healthcare workers in limited resource healthcare settings. The PAIRS course is now established in Dar Es Salaam, Tanzania with a plan for spread to Uganda and Nigeria in 2019.In 2012, under a joint initiative between the Paediatric Oncology Unit at Muhimbili National Hospital and the Tanzanian children’s cancer charity, Their Lives Matter (TLM), a team of Irish paediatric resuscitation specialists was invited to train the oncology staff. This early enterprise has matured into provision of an annual training programme by a dedicated paediatric faculty, with course content specifically designed for use in a limited resource setting and expanded to involve clinical staff from any specialty, with interest from all paediatric settings and from adult, maternity and neonatal specialties.Children on the paediatric oncology ward were experiencing poor clinical outcomes after common oncological emergencies and inter-current illnesses. Deterioration was sometimes slow to detect with 100% mortality rates for any child requiring CPR. Multifactorial issues were identified including:Poor team approach to resuscitationLow knowledge of basic and advanced life supportNon–availability of emergency equipmentNo access to paediatric intensive care supportAdditional hurdles related to culture, communication and infrastructureEstablished internationally recognised resuscitation courses were trialled over the years, but none was deemed appropriate for the setting.The one-day Paediatric Assessment of Illness, Recognition and Resuscitation (PAIRS) course was designed to build foundational skills and knowledge of any nurse or doctor working with children in a limited resource setting. A further one-day PAIRS + module was developed for paediatric doctors and senior nurses.The three-pronged implementation strategy consists ofa massive rollout of the course, targeting the entire paediatric community of the hospital, championed by local nursing and medical managementlocal endorsement and accreditationestablishment of local faculty and national accreditation of the course with the aim of handing over to the local faculty after 5 years of sustained annual training.A variety of engagement strategies are necessary to influence behaviour and drive change. In order to achieve active buy-in for sustainability, it is essential to engage with local stakeholders, foster cooperative relationships and adapt, adopt or generate training programmes that reflect the real-life needs of the clinical team and setting are critical success factors that influence sustainability, scale and spread.