Board Meeting Agenda July 2012 - Birmingham Children's Hospital

Ref. Item Action
• Respiratory arrests, Acute Life Threatening Events and Unplanned
Admissions to ICU: The data shows an increase in Cardiac Arrests, as we
are now including arrests in ICU. We will be separating this data from arrests
on wards to provide clarity. On the wards they have monitoring to prevent
cardiac arrests, so we should see a low incidence but on PICU there are
occasions where the heart may stop suddenly due to the severe nature of the
patient’s condition or where the patient is recovering from surgery. As yet we
don’t fully understand the measures we can put in place to prevent those
cases from happening. This is the same in children’s hospitals worldwide.
• Pressure sores: we are focusing on reducing grade 2 pressure sores and we
are working to ensure we have the correct data to make sure the grading is
done correctly.
• We had two incidents on PICU over recent months, where antibiotics were
not administered until a few hours after diagnosis. In response, as part of a
National Campaign called ‘Surviving Sepsis’ we are piloting an Antibiotic
Care Bundle in ED before roll out to more complex clinical areas. The
process is appended to the report.
KL queried the selection of ED for the pilot rather than a more complex area
where the incidents occurred. VD responded that it was important to test the
scheme in a lower risk environment to ensure it is safe.
• Handover: VD and his team will be speaking at the National Patient Safety
Congress on the work they are doing to improve the quality of handover.
This is a good opportunity to highlight the Trust’s work on patient safety and
for BCH to learn from other organisations.
The Board received and noted the report.
There were no questions from the Public.
12.087 Paediatric Safety Thermometer
MM gave a presentation to the Board, with the following highlights:
The Safety Thermometer was launched across the region in March 2012. This is a
tool which measures harm in 4 areas on one day each month:
• Pressure sores
• Urinary Tract Infections
• VTE
• Falls
We piloted the scheme last year and the clinical teams felt that the process could be
valuable. The SHA have now agreed to support the development of a Safety
Thermometer more pertinent to paediatrics.
MM’s team worked with Governance and VD’s team to identify our top 4 areas of
harm and how they could be measured. The SHA then hosted an event to open the
debate to a wider national audience. All organisations identified pressure sores and
extravasation injuries as vital areas, and additionally agreed a measure for ‘no
avoidable pain’. The group also discussed medication omissions but it was felt that
more time is needed to produce a definition for this measure. The group therefore
agreed that the fourth measure will be the paediatric early warning system (PEWS)
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